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66 An Introduction to Health Systems

Kunal Chatterjee

Health has been at the centre of human concern since ancient times. Civilisations developed and perished due to wars, conflicts and raging diseases, which left none untouched, save those whose health was taken care of by an organised system. Ancient civilisations that developed in Indus valley, Greece, Rome and Mesopotamia had fairly advanced health systems for their times and the medical practitioners enjoyed a high status in the society due to their practice.

Two renowned medical systems developed in India in ancient times; Ayurveda and Siddha, which were quite similar in concept and practice. Indian systems sought knowledge by which life could be prolonged and some of the popular medical treatises of those times were the Charaka Samhita and the Sushruta Samhita. Medicine practiced in China was based on ‘Yang’ and ‘Yin’ principle and claimed to be the first organised body of medical knowledge. One of the oldest civilisations of the world developed on the banks of river Nile in Egypt. Ancient Egyptian medicine mingled with religion and enjoyed great patronage under their rulers. Nearby in the land between Tigris and Euphrates rivers, the Mesopotamian civilisation emerged, which was called the ‘Cradle of the World’. Medical practice in this land was remarkable for a code of medical ethics created by the King Hammurabi, which though drastic was nevertheless the first of its kind. Greeks and Romans gave the world of medicine its modernity. They taught medical practitioners to think of ‘why’ and ‘how’ and raised medicine to the status of science.

The practice of medicine has come a long way since the time of magic, religion and supernatural thoughts to a modern science following evidence-based practice with a range of services extending from preventive, promotive, curative to rehabilitative offered to the individual and community.

What is a Health System?Health system covers a whole gamut of health activities, health programmes, institutions providing medical care such as hospitals, clinics and primary health care centres and the policies enunciated by governments to provide optimal health care for its citizens. A health system as described by WHO is the “sum total of all the organisations, institutions and resources whose primary purpose is to improve health. ” A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently. The government is ultimately responsible for the overall performance of a country’s health system, however individual institutions, municipalities and regions need also to play an important role in its propagation and maintenance. Health systems affect the socio-economic status of a community in any region and in turn are affected by its poverty, development and stability.

Health systems usually include the following :Development of health policies, plan for their ●implementation and development of a system of regulation of health services. Define and develop the institutional framework to deliver ●the health services within the purview of this system. Allocate and mobilise financial and human resources for ●its functioning. Plan, manage and deliver the health services. ●

Health systems should be accessible, efficient, affordable and of a good quality. They should ultimately aim to improve, maintain and restore the health status of the community at a cost that an individual and the community can afford to spend without substantial change in their financial status.

Goals of a Health SystemA health system has to provide for much more than routine delivery of services. It has to protect the health of its community, treat them with dignity and ensure that it responds fairly to the expectations of the population. The WHO has thus identified three overall goals for the health systems to be effective, responsive and fair :

Effective in contributing to better health throughout the ●entire population.Responsive to people’s expectations, including safeguarding ●patient’s dignity, confidentiality and autonomy and being sensitive to the specific needs and vulnerabilities of all population groups. Fair in how individuals contribute to funding the system ●so that everyone has access to the services available and is protected against potentially impoverishing levels of spending.

Historical EvolutionThe oldest known health system, since the time humans settled down to community living, is the family. Families came together since ancient times to care for the pregnant women, young and elderly and for basic survival needs such as nutrition, safety and care during sickness. The oldest known organised health efforts date back to the time when religion was identified with healing and deities were worshipped for seeking cure of a disease in the community. Some civilisations proffered sacrifices to appease the Gods. Worship, herbal medicines, medicines from animal sources and disciplined lifestyle were integral to the ancient medical systems. Thereafter, in the era when Buddhism and Christianity spread across countries, the first hospitals were constructed for the sick, destitute, old, orphans and lepers. Notable among them were the early sanatoria built by Emperor Ashoka in Indian subcontinent in 2nd century BC. Hospitals remained the domain of religious institutions such as churches till well into the 16th century in most parts of the world. State supported institutions developed subsequently when Europe awoke from the dark ages and superstition and dogma in medicine were challenged. Monarchs also lent their support to health care activities as a pious duty towards their people. In India modern hospitals were started by missionaries and later supported by the colonial government. Industrial revolution in Europe created conditions of overcrowding, rapid urbanisation and even rapid decline in the health of community. It brought

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about an appreciation of the losses incurred by the state due to ill-health, especially of the workforce. This motivated them to work systematically towards improvement of health systems. Health was now perceived as a citizens’ basic right.

The Rise of Modern System of MedicineIn the second half of 19th century, several revolutionary breakthroughs were witnessed in the medical science. They heralded the coming of age of medicine making it one of the most researched sciences. Advances in the medical field continue unabated even today. Newer drugs, modalities of treatment, health systems and research have improved the quality of life of people. Life expectancy has risen, many diseases, which in early days caused significant morbidity and mortality have been controlled and some eradicated. Countries have witnessed an improvement in the health and quality of life indicators, which have added onto the rising economic prosperity.

This rise has however been associated with increase in the cost of newer technologies. Newer and deadlier diseases have emerged throughout the World. Microorganisms are increasingly showing resistance to the routine drug regimes and disease vectors have developed ability to survive in the environment despite using physical, chemical and biological methods to control them. Lifestyles of the human population are found to be associated with various chronic diseases and rising expectations of a relatively healthy and prosperous population have created the demand for immediate relief of illnesses often at the cost of rational drug policies and evidence based interventions. This milieu has created the impression of profitability of health care industry with health care providers, medical equipment manufacturers, insurance and pharmaceutical industry and the corporate world staking its claim of the pie. As a result there is a widening disparity in the quality of medical care being provided to different social status of population in the countries. The cost of medical care is growing out of the reach of common man.

Financing the Modern Health Care SystemThe modern health care systems need funding from the state or citizen sources to create financial viability and enhance responsiveness, efficiency, equality and fairness in the delivery of health care. The following questions need to be asked to describe the financing of health care systems :

Who is financing – Government, finance companies or ●employees?What are the services covered by this payment? ●Which financier pays for how much of the service ●provided?Who are the organisations or individuals receiving this ●funding?What is the basis for this payment – whether it is fee for ●service, capitation charges or both?

The primary source of funds is from the public, whether by direct cash for service or indirectly through the government contribution. There are generally five primary methods of financing health care systems as enumerated below.

Direct or out-of-pocket payments ●General taxation ●

Social health insurance ●Voluntary or private health insurance ●Donations or community health insurance ●

Private out-of-pocket FundsIn most of the low-income countries, people pay a high proportion of their health costs directly to the health care providers out of their own pockets. While in the wealthiest countries in the world, few health care costs are paid by the individuals directly to providers. This system exposes the family in a poor country to exploitation and catastrophe in case of sickness. Some people are deterred from using health services or from continuing treatment because of unaffordability. The people who use these services have to cut expenditure on the more important needs of the family such as nutrition, clothing, housing and education. As per WHO, each year approximately 150 million people in the world are obliged to spend more than 40% of the income available to them on health care, after meeting their basic needs, which drives most of them below poverty line. To this scenario, market forces are added, which move the focus of health care from user benefit to vendor profitability. The formal health systems are thus seriously damaged and perception of effectiveness of a system gets linked to its cost. Traditional and cheaper alternatives are also pushed out. Though the system provides choices and control to the customers and also accelerates competition and research, most often all these efforts are oriented towards increased profitability.

General TaxationIt is the responsibility of the governments to facilitate healthy and prosperous life for its citizens. A variety of functions are included to achieve this goal such as improvement of security, infrastructure, enforcement of laws and spending on education, health and nutrition. The health sector thus needs to compete with the others for resources out of the common government kitty. Governments of different countries have installed mechanisms to tax its citizens in various commodities and services, to fill the treasury from which it allocates a percentage share to develop health of its citizens. It is generally observed that in almost all the developed nations and some underdeveloped nations, governments spend heavily on health, even though a majority of its citizens are in a position to pay for health services. In the rest of the world, government spending is extremely low on healthcare and is unable to meet health needs, even though it remains the largest organised resource pool for health systems.

Health InsuranceHere the basic tenet is that a large group of people are made to share the risk that they may need health care at any point of time, thus creating a ‘risk pool’. The funds dedicated for health care are collected through prepayment and managed in such a way as to ensure that the risk of having to pay for health care is borne by all the members of the pool and not by each contributor individually.

Social Health InsuranceIn this finance scheme contributions targeted specifically for health care are collected from workers, self-employed people, businesses and the government. A pool of funds is thus created

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and health care is financed through this source. The successful implementation of this scheme depends on the contributions of each member of the population. Often the government ends up contributing on behalf of people who cannot afford to pay themselves to this fund. An example of this type of insurance is the Employees State Insurance in India.

Private InsurancePrivate insurance companies operate in fairly big numbers in the developed countries such as USA. These collect contributions from its members and work for high profit margins due to the high insurance coverage amount and incentives that they create to increase appeal of their schemes. As a result the premiums paid for these schemes are also high and hence the private insurance players are more interested in the high income groups. In most countries part of the population is covered directly through general taxes, while others are required to make contributions to a social health insurance fund or another type of health insurance, which may be private.

DonationsDonations play a very important role in the health systems such as during calamities and such emergencies in the affected areas. There is a lack of authentic data regarding the type and source of funds received during these situations especially when such catastrophes occur in lesser-developed countries. Similarly the availability of these funds are unpredictable and depends on the mobilisation and involvement of governments, non governmental organisations, corporate world and private donors.

Health Care System ModelsThe health care systems in different countries are either purely private enterprises following the so called capitalistic model or the public insurance systems which enshrine the fact that health care is a fundamental right of every citizen and a basic responsibility of the government. Most often a country has a mix of the two systems to ensure equitable distribution of quality medical care.

Private SystemsThe purely private enterprises are relatively rare. In some countries where such systems exist, they cater to the requirements of a comparatively economically well-off population subgroup in a developing country. In such places the overall standard of health care is poor and private enterprises in the form of private clinics or nursing homes meet the requirements of wealthy expatriates. In most countries where the government health care system functions to provide health care, a parallel private system is also allowed to operate.

Public SystemsThe other model is the public insurance system where in the state covers the risks involved substantially. Here the citizens do not pay from their pockets to finance their treatment and mostly insurance is the medium of payment for health care. Among the methods of funding enumerated above, governments use taxation, social security measures and donations to fund this method of health care. Public insurance systems include social security model, publicly funded health care model and

the social health insurance models. In the social security model, workers and their families are insured by the state, while the residents of a country are insured by the state in a publicly funded health care model. Social health insurance scheme has been discussed before and includes a system where the population is a member of a sickness company. In India, the Employees State Insurance Corporation is an amalgamation of the social security model and social health insurance scheme. Some of the other social security models are practised in organisations such as Defence and Railways. A publicly health care model works in high-income countries and the small countries where government sources are mobilised to fund for the health care of its population such as in Cuba. A fall out of this model is that the quality of health care is compromised when the governments do not devote adequate resources for health care and private players take over.

Planning & Development of Health SystemsPlanningThe earliest developed planning is where each individual or organisation makes decisions for definition and selection of relevant health problems, establishment of priorities among problems and allocate resources accordingly, establish coordination with other health system personnel and chose daily activities in the use and financing of health services. This is known as the dispersed health planning. Thus each physician selects his patients, area of practice, referral system, standard of performance and relationship with other health care workers and establishments. Similarly the consumer defines his health problem, which needs more priority and investment in time and money and ties up services of medical workers and laboratories and pharmacies he would utilise. A financing organisation also priorities the services, facilities and disabilities for distribution of funds. Thus each individual or organisation balances its own self-interest with the self-interest of other individuals and organisations whose help and cooperation are required. While some important goals and standards are achieved with this planning, it results in creation of gaps and inconsistencies in distribution of health care especially among minority and disadvantaged who have not been able to participate in the planning process. Similarly each provider or consumer needs external help to solve all relevant health problems in the era of specialisation, population expansion, social mobility and rising expectations.

There have thus developed voluntary associations of persons and organisations to solve common problems and collectively attain goals, which were difficult to achieve individually. Such form of planning is known as focused health planning. These associations are established solely for purpose of organising voluntary efforts of persons interested in planning together to solve problems in organisation and financing of health care such as the health and welfare councils or comprehensive health planning councils in certain countries. These do not themselves provide health care nor allocate resources or engage in funding but facilitate the dispersed planning by individuals and organisations. The lack of control of resources, disagreements with those who control finances, domination by self-interest groups have limited the ability of these

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organisations to implement recommendations arising out of planning processes.

The limitations of focused and dispersed planning to deal with certain kinds of issues, have resulted in development of another type of planning called as central health planning. Central health planning refers to the planned use of power controlled by an individual or organisation to force other individuals and organisations to use their own resources in accordance with their plans. Central health planning may be based on the legal or professional authority for health care, such as a physician in a clinical practice, or a health care financing organisation such as the medicare programme or state governments exercising their authority, which requires the hospitals to perform certain activities to improve these institutions.

DevelopmentThe health systems need to respond to a variety of disease conditions, which have themselves been influenced by the social, demographic and epidemiological transition of communities. They require the financial means, organisation and procedures to efficiently manage the diversity of health conditions. Thus for development of health system in a country, the following key issues must be kept in mind that it should aim in :

Improving health status. ●Reducing health inequalities. ●Enhancing responsiveness to legitimate expectations. ●Increasing efficiency. ●Protecting individuals, families and communities from ●financial loss.Enhancing fairness in the financing and delivery of health ●care.

A health system must aim at ensuring universal coverage of all the citizens of its country. To achieve this, the poorest, underprivileged and the sickest have to be reached by health promotion and prevention programmes. They have to be able to reach the nearest health post or clinic for treatment of locally prevalent and common health conditions. It also means that irrespective of the source of funds, the health care system must function like a national health insurance system, prepaid either through tax revenues or through social insurance. In this connection a historic WHO conference in Alma-Ata in 1978 established the goal of Health for All by the year 2000 defining the goal as ‘attainment by all peoples of the world a level of health that permits them to lead a socially and economically productive life’. It suggested the achievement of this level by the extension of basic primary health care services to everyone as the major route to attain this goal.

Efficiency of a health system would vary with the amount of resources allocated to its development out of the total health budget of a country. The health status achieved with this kind of allocation would define efficiency in the macroeconomic terms. Most of the developed countries devote upto 9 percent of Gross Domestic Product for health care, which is considered optimal in view of the fact that the World Bank suggests US $12 be allocated by a country for a combined package of per capita basic preventive and curative interventions. In most of the developing countries such as Cameroon, Sudan, Nigeria the percentage of GDP share for health is upto 2 percent, which

is grossly inadequate. Some countries such as USA spend upto 14 percent of GDP on health, which conversely could be an indicator of inefficiency. The scope of achieving greater efficiency out of the existing resources defines microeconomic efficiency. This includes issues such as overstaffing, spending large amount on health needs of diseases, which are absolutely preventable and so on.

Establishment of priorities in spending health resources is essential to ensure universal access to affordable and effective health care. Clear definition of priorities facilitates planning, training, monitoring and supervision of services in districts with inputs to build capacities at this level. In developed countries guidelines on priorities are debated and while several categories of priority are defined they differ among countries based on the need. In developing countries the debate on establishment of priorities is mostly led by the international agencies such as the focus on malaria control, diarrhoeal diseases or poliomyelitis. In such settings once the common conditions, with the maximum disease burden, are covered then the health facilities could be reorganised for improving patient waiting times, standardised dispensing of drugs and better communication with service users. Thus limited resources could be focused to have the greatest impact on service quality and health outcomes.

Lastly, service quality of a health system is influenced in the way service providers are paid. It is seen that when the providers are paid in the fee-for-service manner, it results in overspending, extravagant and wasteful care due to over-prescription, overuse of diagnostic services and excessive surgical interventions. This leads to an unproductive growth in health expenditure, hence a control on utilisation volume or quality of service is required. This control includes an arrangement between the funding agency, provider and the user. Referral process, profile of the health care personnel, performance and quality of care audit are such important measures to check the economic efficiency of health care. Appropriate incentive-disincentive process should be utilised for supervision of health care providers both in public and private sectors.

Health Care Systems in the WorldFranceThe health care system in France is one of the best in the World. It permits all citizens access to treatment irrespective of their payment capacity, social class or any other disposition. The health care system is a combination of public, private (not for profit) and private profit making system. The doctor-population ratio at 3 : 1000 is among the highest in the world. The social security with regard to health care consists of several public organisations, with separate budgets that refund patients for health care. These budgets are generated by direct and indirect taxes such as that on tobacco and alcohol and contributions. Upto 70 percent of health care costs in most patients and 100 percent in long-term ailments is refunded by the social security. Supplementary insurance is also taken by the citizens, either from their employers or private organisations, mostly non-profit insurers. Insurance is compulsory for all employed and self-employed adults, besides which, social security also protects against economic losses incurred due to sickness and

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provides maternal and child care services at home for women with new-born babies.

United KingdomThe United Kingdom established National Health Service (NHS) under the auspices of Department of Health in 1948 with the basic purpose of providing all British nationals with free physician and hospital services. Most health care facilities are owned by the state and the people working in NHS are employed by the state either directly or as independent contractors. The General Practitioners (GPs) are the mainstay of NHS and every patient has to be routed through them. They are paid by a nationally agreed contract, according to the number of patients registered with them and the range of additional services offered. The GPs refer the patients to specialists or secondary or tertiary level trust hospitals. Hospital staff are salaried employees according to nationally agreed contracts. Financing of health care is mainly through taxes and insurance. Private health care continues parallel to NHS, funded by private insurance and utilised by those who can afford it. The NHS has received its own share of criticism due to poor allocation of funds and long waiting lists despite being considered as the most cost effective health system in Europe.

United States of AmericaThe health care system of USA is alone among developed nations with the absence of universal coverage. It is a mix of public, private and charity hospitals and clinics. Majority of the health care expenses of its citizens are met by health insurance. Yet the US Census Bureau estimates that 16 percent of US population are uninsured, which mostly includes people less than 30 years of age who don’t believe in the need to purchase health care and some eligible people who have not applied for insurance due to escalating costs. Some of the health insurance is provided by the government and includes Medicare covering people aged 65 years and above and those below that age with disabilities, Medicaid for low income groups mostly covering the dependant population and the State Children’s Health Insurance Program (SCHIP) for all children upto 19 years of age. These state insurance schemes and those for serving or retired military personnel cover about 27 percent of population by government financed insurance. Besides this there are almost 50 private insurance companies, which offer medical insurance products to the citizens. The insurance systems in USA follow Diagnosis-Related Group (DRG) concept, that groups patients according to diagnosis, type of treatment, age and other relevant criteria. The health care establishments are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of treatment for the individual.

IndiaHealth is a state subject in India, though the Centre plays an important role as a regulator, advisor and resource provider. The government is obligated to provide health care to every citizen of India. The total share of health costs of the government towards provision of free health care in India today is 17.6 percent, which is a quarter of what a country like USA spends on its citizens. As a result of this dismal spending on health, the government hospitals and primary care institutions are ailing.

There is a large and diverse private health care system including corporate hospitals, nursing homes and private clinics, which exist around urban areas and are utilised by people who can afford the out-of-pocket expenses. Medical insurance in India is in nascent stages and unavailable to majority of population. As a result majority of the lower economic groups cannot afford private health care and depend on government institutions or practitioners of indigenous or alternative health systems.

Alternate systems of health care in India : There is a large share of health practice in the country based on alternate systems of medicines, some indigenous and some, which were brought by the different invaders over the centuries. The scientific basis of these systems have been debated time and again, however it goes without saying that a vast majority of these systems are supporting health care in remote areas, for the disadvantaged groups and the poor who cannot afford the increase in health care costs in the country. Government of India has established a separate Department of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) under the Ministry of Health & Family Welfare, to promote and regulate the practice of alternative medicine in the country. The more common ones are mentioned in the next paragraph.

The term Ayurveda means ‘Science of Life’, which is conceived as the union of body, senses, mind and soul. The living man is considered as a matrix of three humors; Vata, Pitta and Kapha, seven basic tissues and the waste products of the body. Besides this the body is considered to be composed of five basic elements namely earth, fire, water, air and vacuum (ether). Any disturbance in the balance in the matrix or the elements is considered to cause sickness and the aim of Ayurveda is to restore the balance. It employs treatment modalities such as purification treatment, palliative treatment, prescription of various diets, exercises, avoidance of disease causing factors and the use of psychotherapy and ayurvedic medicines. Siddha system of medicine is another ancient Indian system, which takes into account the patient, his surroundings, age, sex, race, habitat, diet, appetite, physical condition etc to arrive at the diagnosis. It uses minerals, metals & alloys and drugs & inorganic compounds to treat the patients. Unani medicine is another alternative system, which was introduced by the Greeks in ancient India. It considers that the body is made up of four basic elements, earth, air, water and fire which in turn form humors, blood, phlegm, yellow bile and black bile. Health is a state of equilibrium among these humors and when this is disturbed a person falls sick. The system treats a patient with diet, pharmacotherapy, exercise, massages and surgery somewhat similar to Ayurveda. Yoga is a tradition evolved over thousands of years by saints and sages. According to yoga, most of the diseases originate through wrong way of thinking, living and eating and its basic approach is to correct the lifestyle by cultivating a rational, positive and spiritual attitude towards all life situations. Among the other alternate systems practised in India is homeopathy, which was created by Dr Hahnemann in Germany and found great popularity in this country. It considers that symptoms are the best possible reaction of body’s defence mechanism to a disease and aims to strengthen these reactions. It tries to find out the best possible

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remedy that would be effective and uses minimum doses of drugs to cure diseases against the principles of dose-response effect.

SummaryA health system as described by WHO is the “sum total of all the organisations, institutions and resources whose primary purpose is to improve health. ” Health systems affect the socio-economic status of a community in any region and in turn are affected by its poverty, development and stability. Health systems usually include - Development of health policies, plan for implementation and regulation of health services; Define and develop the institutional framework to deliver the health services within the purview of this system; Allocate and mobilise financial and human resources for its functioning; Plan, manage and deliver the health services. Health systems should be accessible, efficient, affordable and of a good quality. They should ultimately aim to improve, maintain and restore the health status of the community at a cost that an individual and the community can afford. The WHO has identified three overall goals for the health systems to be effective in contributing to better health; responsive to people’s expectations, fair in how individuals contribute to funding the system.

Most often a country has a mix of the two health care systems, Public and Private, to ensure equitable distribution of quality medical care. The governments use taxation, social security measures and donations to fund public health care system. Public insurance systems include social security model, publicly funded health care model and the social health insurance models. Health insurance is also provided through Private insurance companies.

Health planning is of three types - Dispersed, Focused and Central. Central health planning refers to the planned use of power controlled by an individual or organisation to force other individuals and organisations to use their own resources in accordance with their plans. Planning efforts in a country shift from one type of planning to another as decisions made in one planning context create the need for other types of planning. For development of health system in a country key issues to be considered are improving health status; reducing health inequalities; enhancing responsiveness to legitimate

expectations; increasing efficiency; protecting individuals, families and communities from financial loss; and enhancing fairness in the financing and delivery of health care.

In India Health is a state subject, though the Centre plays an important role as a regulator, advisor and resource provider. The government is obligated to provide health care to every citizen of India. The total share of health costs of the government towards provision of free health care in India today is only 17.6 percent. There is a large and diverse private health care system including corporate hospitals, nursing homes and private clinics, which exist around urban areas and are utilised by people who can afford the out-of-pocket expenses. Medical insurance in India is in nascent stages and unavailable to majority of population. As a result majority of the lower economic groups cannot afford private health care and depend on government institutions or practitioners of indigenous or alternative health systems like Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. In India, the Employees State Insurance corporation is an amalgamation of the social security model and social health insurance scheme. Some of the other social security models are practised in organisations such as Defence and Railways.

Study ExercisesLong Question : Describe the health care system in India

Short Notes : (1) Health Insurance (2) Social security measures (3) Goals of a Health care system

MCQs : 1. The total share of health costs of the government towards

provision of free health care in India today is (a)17% (b) 7% (c) 37% (d) 50%

2. The following is not a method of financing health care systems (a) Direct or out-of-pocket payments (b) General taxation (c) Social health insurance (d) None of the above

3. The type of health planning which refers to the planned use of power controlled by an individual or organisation to force other individuals and organisations to use their own resources in accordance with their plans is (a) dispersed (b) focused (c) central (d) none

Answers : (1) a; (2) d; (3) c.

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67 Assessing “Health Status” and “Health Needs”

Amitava Datta

Assessing “Health Status”Assessing the health of a population is a fundamental part of many public health activities. Performing the assessment correctly is a challenging process as there are usually problems in obtaining the necessary data and in balancing alternative approaches.

Reasons for Assessing Health StatusThe usual circumstances under which assessing of health status of a community is conducted are as follows :

To conduct a “health needs” assessment to establish ●whether particular health problems exist in a given population, describing the problems and identifying the magnitude of mortality and morbidity due to the problem. To conduct an audit into equitable distribution of resources, ●namely provision of health services by establishing the quantitative difference between “need” and “supply” for a defined population/service and bringing about necessary interventions. To assist in conducting a review of existing policy or plans ●to assist policy making decisions by decision-makers either directly or by informing the public, professional groups and other interested parties about the nature and distribution of health challenges and the definition of the problem; this may include a health impact assessment. To enable setting of targets for achievement and decide on ●quantum of resource allocation that is for better planning and implementation of health programs, improving resource allocation, target setting and helping targeting of health and other services. To conduct an evaluation of existing / proposed health ●services /interventions For research purposes by assisting in prioritizing the areas ●where research is needed.

Steps in Assessing the Health Status of a Community/ PopulationAs indicated above, there may be many reasons for conduct of assessment of the health status of a community / population. The methodology varies depending on the objective. However the usual steps in performing a health status assessment are as follows :

Define the purpose of the assessment. ●Define the population concerned including the populations ●which will be compared. Define the aspect / aspects of health to be considered. ●Identify and review existing data sources from which ●information can be obtained. In case good local data is already available or reliable local or national statistics already available or relevant published or unpublished surveys already available, there may be no need to conduct a fresh health assessment survey. The various sources of

secondary data are discussed in detail in the section of epidemiology. Determine the most appropriate existing data which can ●be used. Use of the available data, statistics or survey reports to ●appropriately analyze the aspects needed which includes adjusting for population composition, deriving suitable measures and modeling future trends if required. Determine if any issues / aspects require data to be specially ●collected in which case a special survey may need to be undertaken. Details of undertaking a survey are dealt with in the section on epidemiology. Determine the aspects of comparators which will be ●considered. If so needed issues of confidentiality of information and ●disclosure by the subjects will need consideration besides any ethical issues. Interpret and communicate the results of the assessment. ●Evaluate the results and efforts undertaken ●

Step 1 - Clarity of purpose : The starting point of the health assessment, defining the purpose, is very important. Many a times, a tendency to have an extensive unfocused list of objectives as well as the temptation to examine interesting but irrelevant issues may arise. These must be resisted.

Step 2 - Define the population : Defining the population to be assessed is extremely important. Population size, structure and the period of observation can have major effects on the numbers of cases of disease or disability observed. The data is therefore usually expressed as proportions (e.g. the number of children aged under five per thousand population at a particular point of time) or rates (the number of new cases of tuberculosis per thousand population per year). Adjustment for potential confounding variables (e.g. age, sex, socio-economic status, etc) to allow valid comparison with other populations will be needed. Often geographic locations are used to frame the population studied, for example district boundaries. Problems can arise with population estimates for small areas, especially those projected from a data source that is relatively distant in time. The smaller the areas being studied, the bigger the chance of errors in estimates of population numbers and composition which can result in dramatic but erroneous findings. Step 3 - Define the aspect / aspects of health to be considered : Health as indicated above can have a variety of meanings which can range from the lofty definition of World Health Organization having physical, emotional and social dimensions. In practice a more restrictive definition should be used which can be easily measured, for example a particular group of diseases or certain summary measures of population health.

Step 4 - Review the available data : Comprehensive population health assessments are based on a wide range of data of different types. While local data are required for assessing the health of the local population, they may not be available and so national (or indeed international) data may be used if the local population is felt to be typical of the nation as a whole. Data from similar localities (e.g. from different developing countries sharing common boundaries) or national data may be used for comparative purposes.

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Many data are collected routinely by periodic national census, health service providers, local and central government and others. In addition, some of the many ad hoc studies that have been carried out locally or elsewhere may be relevant to a particular issue. Weaknesses of routine data collection systems include non-standard or inconsistent approaches to coding and data collection and limited availability due to cost and privacy policies. Data can be Quantitative, which usually answer questions such as ‘How many people have a particular condition?’ or Qualitative, when exploring such issues as what it is like to be afflicted with a chronic disease like diabetes, or perceptions about the effects and tolerability of risks from industrial pollutants. Strengths and weaknesses of various data sources are discussed in the section on epidemiology

Step 5 - Select data carefully : At first sight there may seem to be so many data available that assessing health should not be much of a challenge. However, in this connection Finagle’s law is usually proved correct in public health work, which can be roughly stated as, ‘The information you have is not what you want; the information you want is not what you need; the information you need is not what you can get; the information you can get costs more than you want to pay’. Relevant, detailed and accurate data are seldom available directly and so data collected for other purposes have to be used appropriately to give an indirect assessment. In considering the use of any data, one must consider how they have been obtained. People often assume that the quality and relevance of the data is satisfactory for the intended purpose. While recording data consistent terms or criteria may not be used and this can have a major impact. The use of international data needs great care as different countries may use different definitions and data collection processes.

When the data source proposed to be used has been identified the following aspects of the data should be considered before utilizing it :

Validity of data for the assessment : The data must be relevant to the issue, the data items should have been defined, there should be no conceptual biases in the data source (e.g. data collection should not have been structured to benefit the organization that has produced the data), the data should still be relevant as per time and the data should be relevant to the defined population so that the findings can be generalizable.

Technical quality of data : The data should have been properly recorded according to the specified definitions, complete in all aspects (preferably all subjects included or a representative adequate random sample used), be free from classification or selection biases and appropriate for the assessment planned

Quality of the analytic methods : The data should be adjusted for the population structure, e.g. age, sex, social group or ethnic composition and the numbers should be big enough to allow a statistically adequate and precise estimate of the aspects being considered

Other aspects : The relevant use of the data should be possible in spite of confidentiality policies, whether the data is available in computer analyzable form and what the likely cost of obtaining the data is.

Step 6 - Make good use of the existing data - Analyze and interpret the existing data : In progressing from data to information, the purpose of the assessment will determine the nature of the analyses chosen. The results of the health assessment need to be communicated to the concerned people for who the assessment has been designed and executed. The usual aspects which may be planned to be communicated include :

Comparison of findings on health aspects of the population ●with other similar populations or larger populations, or comparing health status observed with that expected for the type of population.Describing the relative heath of groups of the population ●(based on defined areas or social groups) and identifying inequalities.Comparing the health trends over time. ●Estimating the extent of potentially preventable health ●problems or conditions.Describing the likely health impact of environmental and ●social factors.Describing the impact of health problems in terms of ●people’s experience of health problems.

Step 7 - Carry out a local study, if necessary : The health aspect planned to be assessed can be sufficiently important and the available local data so limited that a case may exist for conducting a fresh data collection. At national or state level, this situation arises relatively frequently in the field of public health. Conduct of special survey is however usually constrained by the cost involved. At the local level, a special survey or longitudinal study should only be carried out if time is available and the value of the data likely to be provided justifies the cost. The purpose of the assessment must be clear. Attempting to answer too many interesting questions or record too many findings may become unnecessarily expensive, besides reducing the response rate, if a questionnaire is used which appears too complex. The key features of a successful survey are described in an exclusive chapter in the section on epidemiology.

Step 8 - Consider the use of comparators : Assessing the health of a population may be undertaken to assess what is the actual extent of a health problem and also to determine how it compares with previous years, other areas and other social groupings. For example in examining the need for initiatives to reduce smoking, all that may be required is the number of deaths and extent of ill health associated with smoking locally. Information that locally this data is 10% lower or higher than the national average may well be redundant and indeed may divert attention from the principal data. However on other occasions comparative data will be required to highlight problems that are becoming more important with the passage of time or are particularly acute locally and need to be addressed in ways that are different from those required for most other areas. For example, the proportion of school children smoking in the town surveyed has increased since the previous survey or is more as compared to national average. Comparisons are of particular relevance when considering inequalities and inequities.

Step 9 - Address issues of confidentiality and disclosure : Assessing the health status of a population, especially at a small

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area level, increases the risk of inappropriate and unnecessary disclosure of personal data. For example, the assessment of the HIV positive status of commercial sex workers in a particular area. Social and other discrimination besides loss of clients may result from the publication of the survey results. This is a highly complex and evolving area, as there are both technical and ethical issues, concerning balancing the benefits to society being weighed with the risks to individuals. Informed consent of the participating subjects is an essential pre-requisite to their inclusion in the assessment process.

Step 10 - Communicate results effectively : Occasionally a large set of data is to be produced for reference purposes, for subsequent expert analysis. But usually the information is used to inform the process of identifying opportunities to improve health and while experts may be involved, the information usually needs to be communicated to a general audience. When communicating results, a full description of the analytic methods used together with their limitation and assumptions may well be inappropriate. If so the assessor must take great care to provide a fair assessment and ensure that the typical audience will gain the right impression. The assessor must, however, be prepared and able to justify the methods in detail if requested.

Key points about health status analyses to consider in a written or oral communication are :

Think through its purpose. ●Don’t leave it to the reader to relevant points from a mass ●of data-quote specific data to make a point.Ensure confidentiality for participants in survey and ●ensure this is made clear to everyone.Don’t be too sophisticated-many people in the target ●audience will not have that much background knowledge of the issue.

Step 11 - Evaluate your health status assessment : Those who are engaged in public health need to emphasize the importance of assessment to others. This should begin at home. It is important that our work is assessed using correct tools such as audit.

Assessing Health “Needs”Definition“Health needs assessment” is a systematic method of identifying the unmet health and health-care needs of a population and making changes to meet these unmet needs. Health needs assessment is used to improve health and other service planning, priority setting and policy development. Most doctors are familiar with assessing the health needs of individual patients. Professional training and clinical experience imparts a systematic approach to this assessment before starting treatment that the health professional believes to be effective. Such a systematic approach has often been missing in assessing the health needs of local or practice populations. Case studies have revealed the importance of conducting scientific “health needs assessment” before planning appropriate interventions in society.

Defining NeedAn understanding of health needs assessment requires a

clear definition of need. Need, implies the capacity to benefit from an intervention. ‘To speak of a need is to imply a goal, a measurable deficiency from the goal and a means of achieving the goal. ’

Health needs assessment is not the same as population health status assessment. It incorporates the concept of a capacity to benefit from an intervention. It therefore introduces an assessment of the effectiveness of relevant interventions to supplement the identification of health problems. Health needs assessment should also make explicit what benefits are being pursued by identifying particular interventions.

Health needs may be of two broad categories, viz. normative or professionally assessed needs, which are the needs which the expert health care providers think should be addressed, based on their professional assessment of the community. The second is the “felt needs” which the community feels to be important. Both the view points are important and need to be considered when assessing the health needs of a community.

Approaches to Needs AssessmentVaried approaches to needs assessment have been suggested, which include ‘epidemiologically based’ needs assessment – thereby combining epidemiologic approaches (like specific health status assessments) with assessment of the effectiveness and possibly the cost-effectiveness of the potential interventions. It can also be a comparison of the levels of service receipt between different populations. Determining the demands and wishes of professionals, patients, politicians and other interested parties can also be an effective approach to needs assessment.

The epidemiologic and qualitative approach in determining priorities incorporates aspects of clinical effectiveness, cost-effectiveness and patients’ perspectives. Comparisons of health service usage are commonly used as indicators of need. However, often for unexplained reasons, population-based usage rates typically vary markedly between areas. The relation between usage rates and improved health outcomes is also often hard to demonstrate.

The distinction between individual needs and the wider needs of the community is important to consider when assessing needs. If individual needs are ignored then there is a danger of a top-down approach to providing health and other services, reflecting what a few people perceive to be the needs of the population, rather than what they actually are. In India, the present concept of decentralization through decision making by the panchayati raj institutions and implementation of National Rural Health Mission are clear examples of this concept.

It is important to appreciate that health needs assessment involves the active, explicit and systematic identification of needs rather than a passive, ad hoc, implicit response to demand. For example, evaluation of the pattern of referrals for specialist care from a health centre and then base the recommendation for posting of a particular specialist based on work load, rather than base the recommendation simply based on “demand” of the local politician. The assessment of health needs can be made clearer by classifying the issues into needs, demands and supply, considering that health needs is not restricted to health-care needs. Health needs include wider social and environmental determinants of health

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such as social and economic deprivation, housing, nutrition, education and employment. Health needs should ideally be appropriately addressed (‘met’), but these needs are too often unmet (e.g. waiting lists, undiagnosed anemia, ignored needs of contraception) or ‘over met’ (e.g. prescribing antibiotics for all diarrhea cases).

Assessing of health needs provides the opportunity for : Assessing the population’s health status in terms of the ●patterns of disease or disorders in the local population and the differences from district, regional, or national disease patterns. Learning more about the needs and priorities of patients ●and the local population. Highlighting areas of unmet needs and working towards ●meeting these needs. Deciding rationally and appropriately how to use scarce ●resources to improve the health of the local population in the most effective and efficient way. Influencing government policy, inter-sector collaboration, ●as well as research and development priorities. It also provides a method of monitoring and promoting ●equity in the provision and use of health services and addressing inequalities in health.

Framework for Assessing the Health Needs of a PopulationThere are eight steps involved in a formal health needs assessment project. However every assessment need not follow a simple linear progress through all the steps. Health needs assessment can be approached in much the same way as doing a jigsaw, so that different pieces are put together to give a complete picture of local health problem and thus the “need”. The various steps involved are as follows :

Step 1 : Identify the health problem to be addressed in the defined population.

Step 2 : Carry out a health status assessment for the population, covering the relevant areas of ill-health and/or potential health to determine what is the size and nature of the problem.

Step 3 : Identify the existing services and interventions being delivered, including, where relevant, the service targeting, quality, effectiveness and efficiency.

Step 4 : Identify the interventions by determining what patients, professionals and other stakeholders want.

Step 5 : Identify interventions by reviewing the scientific knowledge and determine the most appropriate and cost-effective solutions.

Step 6 : Determine the resource implications. It may require to choose between competing ways of meeting needs (competing interventions) and decide on competing priorities – resources are always limited.

Step 7 : Enunciate the recommendations and the plan for implementation.

Step 8 : Determine whether assessing need is likely to lead to appropriate change by identifying expected health gains.

Needs Assessment Requires Careful PreparationThe process of needs assessment involves identifying the right

issues, using the right technical methods and managing the process effectively. The task needs to be defined right in the beginning with the objectives as clear, simple and focused as possible. The right project team should be assembled and all relevant stakeholders included, which may include representatives from the likely funding agency, clinicians and the users. Good leadership is important besides providing a clear and effective communication during the project. This aspect is especially important if there are multiple agencies involved in the assessment process. Access to relevant available information and informants should be sought at an early stage.

Identify the Health Problem or IssueThe health problem on which to focus the needs assessment exercise should be clearly identified. A health problem may come to attention from many sources, including the results of a population health status assessment, media reports, input from patients or stakeholders, government priority setting, or the scientific and professional literature.

The definition of the problem may involve a search of the health and social science databases besides review of the published health literature, which will provide a national and international perspective about the health topic and may provide already known methods, case definitions, disease incidence and prevalence, current provision of health services, etc, which may be applicable to the local population. In the absence of reliable published professional literature, a search of unpublished literature sources, for example reports of public health professional bodies and government health department databases, can also provide useful information. After initial analysis, it should become apparent whether the problem justifies a full and systematic needs assessment.

Dimension of the ProblemWith a working definition of the health problems in mind, relevant health data can then be collected by selected methodology – study of records or special survey. Although it would be desirable to be able to estimate the likely number of beneficiaries of the planned interventions, the assessment process should be able to establish the following :

How many people in the studied population are likely to be ●suffering from the target condition or conditions ?What their socio-demographic and other characteristics ●are? To what extent they are already receiving appropriate ●interventions.

Availability of ServicesThere are several sources of data on health care in a locality. Hospital data can provide information on OPD attendance and hospital admissions, diagnoses, length of stay, operations performed and patient characteristics to some extent. Clinical indicators can provide information on the comparative performance of hospitals and health authorities. Health-care provision indicators (e.g. number of doctors and nurses per capita, number of operations per capita) are often compared with national or international norms. There is however rarely evidence of a direct link between provision of health services and positive health outcome.

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What do Professionals, Patients and other Stake Holders wantA wide range of stakeholders can be consulted to describe local health needs. Local health professionals – both private practitioners as well as those in government run health care facilities will have valuable contributions to make about the health needs of their local community. Other stakeholders such as health administrators, local government agencies, local politicians and voluntary groups also provide important contributions. This not only obtains views on their knowledge and beliefs but also engages them in the assessment process and encourages ownership and eventual implementation of the results. It is important to include the general public in decision-making about local health care. With increasing recognition of the importance of obtaining greater public involvement, various methods have been used, including use of panchayati raj institutions in India.

Determining the most Appropriate and Cost-Effective InterventionsAn essential part of a health needs assessment is the review of the clinical effectiveness and cost-effectiveness of interventions that can address the identified health needs. Evidence about the effectiveness of health interventions or services can be found in databases of good-quality systematic reviews such as the Cochrane Library, or peer reviewed publications. Where there is a limited evidence of effectiveness of interventions then professional consensus about best practice may have to be relied on.

Resource ImplicationsIf needs are to be matched to the usually limited available resources so that as much need as possible is met, then economic appraisal, including cost-effectiveness or cost-benefit information, must be considered. This involves :

Determining how resources are currently being spent ●(programme budgeting)Defining options for change by suggesting alternatives : ●

(a) identify potential services which require more resources(b) identify services which could be provided at the same level

of effectiveness but at reduced cost.(c) identify services which are less cost-effective than those

identified.Assessing the costs and benefits of the principal options. ●Decide on the best option, aiming to increase investment ●in (a) and reduce investment in services identified in (b) and (c).

Implementation of RecommendationsIn a needs assessment program, the collected information should be collated, analyzed and presented, usually in a report form. A summary of key findings is very useful in communicating the results to the decision-makers and those who will be affected by the decisions. Reporting results, however, is not an end in itself. Building agreement to a practical implementation plan for meeting the unmet needs is an essential part of needs assessment.

The Demarcation Between Health Needs Assessment (HNA) and Health Impact Assessment (HIA) : Health needs

assessment starts from the health of a defined population and result in proposals (for policy, programmes, strategy, plans or other developments). Health impact assessments (HIAs) and Integrated Impact Assessment (IIA) start from proposals and compare how they may impact on health. HIA has been dealt with in detail in a subsequent chapter in this section.

SummaryAssessing health status of a community is a challenging process but is required for numerous reasons viz- to conduct a health needs assessment; to audit equitable distribution of resources; to assist in conducting review of existing policy; to enable setting of targets for achievement; to evaluate existing / proposed health services / intervention and for research purpose as well. The methodology varies depending on objective; however mentioned steps could be followed to achieve the same. Needs implies the capacity to benefit from an intervention. The concept of felt needs- what people consider and/or say they need, expressed needs - needs expressed by action and normative needs-what health professionals define as need are very important to understand and apply. Health Needs Assessment is a systematic method of identifying the unmet health and health care needs of a population and making changes to meet these unmet needs. Approaches used commonly for need assessment are epidemiological and qualitative in nature. Health needs are not static and therefore any assessment will only provide snapshot of current needs of population concerned. Thus health need assessment is a continuous process which is to be reviewed, updated and evaluate concurrently.

Study ExercisesExercises

(1) Give WHO’s definition of health and its drawback. (2) Enumerate the limitations of hospital based data. (3) What is Finagle’s law in public health work? (4) Name a difficulty with use of international data. (5) What are the aims of health need assessment? (6) Name approaches utilized for needs assessment. (7) State the ethos of health needs assessment.

Answers1. WHO has defined Health as a state of complete physical,

mental and social well being and not merely absence of disease. This is an idealistic definition which does not lend itself easy measurement.

2. (a) Although voluminous, needs to be evaluated with care as not all people with a disease/ disability receive treatment. (b) Data is recorded for clinical purpose rather for analytic purpose. (c) Definition of a condition vary substantially from clinician to clinician, from clinician to researcher. (d) Issues related to patient confidentiality.

3. ‘The information you have is not what you want; the information you want is not what you need; the information you need is not what you get; the information you get costs more than you want to pay’.

4. The use of international data needs great care as different countries may use different definition and data collection processes.

5. (a) To identify unmet health and health care needs of

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68 Assessing the “Health Impact”

Amitava Datta

Definition, Scope and Need for HIAThe word “Impact” in public health parlance means the overall, totalistic effect of an intervention. It does not restrict itself to specific outcomes. For example, the specific outcome measure in the case of an intervention like polio vaccination is reduction in the incidence of paralytic polio cases. However assessment of “impact” will go much beyond this and include wider range of outcomes both positive like, improvements in quality of life, increase in productivity as well as negative outcomes like community apprehensions, misconceptions, etc. Health impact assessment is a combination of procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population and the distribution of those effects within the population. Health impact assessment may focus on projects such as new industry, hospital or health centre, programmes such as women’s empowerment or immunization of children, or policies such as ban on advertisement on tobacco in movies. On an international level, HIA can be employed to assess global public policies in areas such as international trade, war and human rights.

Health Impact Assessment (HIA) is based on four values- Democracy, Equity, Sustainable development and Ethical use of evidence. These values provide the foundation based on which the benefits of HIA can be derived and link HIA to the policy environment in which HIA is being undertaken.

Elucidation of these values explains the concept of HIA. By democracy is meant allowing people to participate in the development and implementation of policies, programmes or projects that may impact on their lives. By assessing the distribution of impact from a proposal or policy on the whole population, with a particular reference to how the proposal will affect vulnerable people (in terms of age, gender, ethnic background and socio-economic status), equity is ensured. By assessing short and long term impacts, sustainable development is ensured. The ethical use of evidence ensures the best available quantitative and qualitative evidence must be identified and used in the assessment. A wide variety of

evidence should be collected using the best possible methods.

Health impact assessment builds on the fact that a wide range of economic, social, psychological, environmental and organizational influences determines a community’s health. It is important to try to estimate these influences on health prospectively and so HIA should precede the start of the project, programme, or policy concerned.

The aims of prospective HIA are : To systematically assess the potential health impacts, ●both positive and negative, of projects, programmes and policies. To improve the quality of public policy decisions by making ●recommendations that are likely to enhance predicted positive health impacts and minimize negative ones.

The key output of a HIA is a set of recommendations for beneficially modifying a proposal so that its overall health impacts are enhanced and any potential health inequalities are minimized.

The Importance of Health Impact Assessment Health impact assessment is an important public health method because of the following reasons :

It promotes equity, sustainability and healthy public ●policies in a world which has unequal and different levels and perceptions of health. The quality of decision-making in health sector and of ●its partner organizations is improved by incorporating into the planning and policy-making process the need to address health issues. It emphasizes social and environmental justice as the ●disadvantaged sections of society and the world suffer the most from negative health impacts. It involves a multidisciplinary approach. ●Participation by the public is encouraged in debates about ●public health, planning and other public policy issues. Gives equal status to qualitative and quantitative ●assessment methods. Makes values and politics explicit and opens all issues to ●scrutiny. Demonstrates that health is a subject which is far broader ●than only health-care issues. Health impact assessment is used in public policy decision- ●making in a wide and rapidly increasing range of developed and less developed countries throughout the world.

a population. (b) To improve health and other service planning, priority setting and policy development.

6. (a) Epidemiologic method. (b) Qualitative method. 7. Health needs assessment starts from the health of a

defined population and result in proposals- for policy, programmes, strategy, plans or other developments.

Further Suggested ReadingAssessing health needs. John Wright and Dee Kyle in Oxford Handbook of 1. Public Health Practice. 2nd ed, 2007. 20-31Assessing health status. Peter Gentle, David Pencheon and Julian Flowers in 2. Oxford Handbook of Public Health Practice. 2nd ed, 2007. 146-159Measuring health needs. Gavin Mooney, Stephen Jan and Virginia Wiseman 3. in Oxford Textbook of Public Health. 4th ed, 2002. 1765-1772

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Methods for Assessing Health ImpactsThere are a wide range of methods used for HIAs which clearly reflect the nature and complexity of the subject. It is very important to use all methods and involve all disciplines that may contribute to the overall tasks. The methods commonly used are :

Analysis of policies. ●Assessing the health profiles of affected areas/ ●populations. Identification of potential positive and negative health ●impacts. Assessment of perceived health risks. ●Quantification and valuation of health impacts. ●Ranking the most important impacts. ●Consideration of alternative options and recommendations ●for management of desired impacts.

Participation in HIAsThe process of HIA requires broad participation of all disciplines and all stake holders to enable obtaining of a comprehensive picture of potential health impacts. Public participation throughout the HIA is essential, both to ensure that local concerns are addressed and for ethical reasons of social justice. The commonly sought participation includes :

Those involved at all levels in the project. ●Those likely to be directly affected by the project. ●Others who have knowledge or information of relevance to ●the project and its outcomesLocal or outside experts whose knowledge is relevant to ●the project. Relevant professionals including medical and paramedical ●workers, social workers or community workers. Voluntary organizations working in the field under ●assessment. Community participation adds value and credibility to HIA ●recommendations. The experiences of the local community are more important than routinely collected statistics. Undue reliance on quantitative methods may oversimplify the complexity of real life situations.

Reasons to Use HIAPromotes cross-sectoral working : The health and wellbeing of people is determined by a wide range of economic, social and environmental influences. Activities in many sectors beyond the health sector influence these determinants of health. HIA is a participatory approach that helps people from multiple sectors to work together. HIA participants consider the impacts of the proposed action on their individual sector and other related sectors – and the potential impact on health from any change. Overlaps with other policy and project initiatives are often identified, providing a more integrated approach to policy making. A participatory approach that values the views of the community : An initial stage within the HIA process is to identify the relevant stakeholders to the HIA. This process usually produces a large number of relevant people, groups and organisations. The HIA can be used as a framework to consult meaningfully with stakeholders, allowing their messages to be heard. The common stakeholders besides those who

commissioned the HIA are network of people and organisations who will carry out the HIA include the local community / public, specially the vulnerable groups, developers, planners, local/national government officials, voluntary agencies / NGOs, health workers at local, national or international levels, employers and representatives of workers’ unions and representatives of other sectors that are affected by the proposal.

The best available evidence provided to decision makers: The purpose of an HIA is to provide decision makers with a set of evidence-based recommendations about the proposal. The decision makers can then make decisions about accepting, rejecting, or amending the proposal secure in the knowledge that they have the best available evidence before them. HIA should consider a range of different types of evidence – going beyond published reviews and research papers, to include the views and opinions of key players who are involved or affected by a proposal. Often, evidence of the quality and quantity demanded by decision makers is not available, this is noted within the HIA and the best available evidence is provided.

Improves health and reduces inequalities : Addressing inequalities and improving the health of its community or population is a goal for many organisations and all Governments. One way of contributing to the planning of policies to improve health and overcome inequalities is through the use of HIA. It also ensures that proposals do not inadvertently damage health or reinforce inequalities. HIA provides a systematic approach for assessing how any new proposal can affect a population - specially, the distribution of those effects among the different subgroups of the population. Recommendations can specifically target improvement of health, particularly for vulnerable groups.

Appropriate for policies, programmes and projects : HIA is suitable for use at many different levels. HIA can be used on projects, programmes and policies, though it has most commonly been used on projects. The flexibility of HIA allows these projects, programmes and policies to be assessed at either a local, regional, national or international level – making HIA suitable for almost any proposal. Therefore, choosing when to carry out an HIA is important.

Timeliness : In order to be able to influence the decision making process, the HIA recommendations must reach the decision makers well before any decisions about the proposal will be made. This basic principle of HIA highlights the practical nature of the approach. Experienced HIA practitioners can work with most timeframes, undertaking comprehensive HIAs, which may take a longer time or a rapid HIAs. Links with sustainable development and resource management : When HIA is undertaken early in the development process of a proposal it can be used as a key tool for sustainable development. For example, for an HIA on road building, it enables the inclusion of health and other sustainability aspects to be built in from the very beginning, such as cycle lanes, noise and speed reduction interventions, crossings, pedestrian over bridges, etc rather than solving the health impacts like accidents at a later date. This enables health objectives to be considered on a par with socio-economic and environmental objectives, bringing sustainable development closer.

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Many people can use HIA : HIA because of being participatory in approach, has many potential users which include decision makers who may use the information for making decisions; Commissioners of the HIA, who use it to consult widely and gather differing views to build capacity and develop strong partnerships; HIA workers, who actually carry out the individual components of the HIA, which may include consultants, local staff from a wide variety of organisations and the community and finally the Stakeholders, who want their views to be considered by decision makers.

The HIA Procedure1. Identifying if an HIA should occur – Screening : It is not possible to carry out an HIA on every project, policy or programme. Therefore screening is used to systematically decide when to do an HIA. Although ideally screening of each planned proposal should be conducted to assess whether an HIA should be conducted, in practice it is usually not followed due to resource and organisational issues. Screening only works when there is organisational commitment to HIA – where management allows the time and resource to screen each project, policy or programme. Typically, the decision to carry out an HIA occurs because a significant project is occurring and someone (the developer, the public, local public health, planners, etc) thinks an HIA would be a good idea. At other times funding is received for carrying out an HIA and a single topic is chosen.

2. Identifying what to do and how to do it - Scoping : Scoping sets the boundaries for and considers how the HIA appraisal stage should be undertaken. Some typical scoping issues which need to be considered are :

Who will do the HIA and who will be in charge. ●Are there any specialists or practitioners who could be ●involved ? What monitoring and evaluation of the HIA will occur. ●When does the HIA have to be done by, to influence key ●decision makers (often influencing the choice of whether a rapid or comprehensive HIA is undertaken). Setting and agreeing the aims and objectives of the HIA ●

The terms of reference for the HIA are often drawn up at this stage to clarify exactly what is expected from whom. The HIA may be conducted as a Rapid HIA where the appraisal stage is carried out quickly (often only in days/weeks) with a limited amount of resource, or else a Comprehensive HIA, in which an extensive appraisal is conducted, where new information is generated, significant literature reviews undertaken and comprehensive involvement of stakeholders often occurs. This may take several months or longer. 3. Identifying the health hazards and considering the evidence of impact - Appraisal : This is where a large amount of HIA work is carried out. The work usually begins with a panel of experts to guide the assessment process who examine the proposal in detail. The panel can draw on a variety of documents that may include information on a number of determinants of health including social and economic issues, besides other relevant issues. Specific health hazards and diseases in the defined area would also need to be listed. The relationships between the determinants of health and key elements of the

proposal are then investigated (often laid out in a table/grid like fashion for clarity). Normal procedures for collecting field data may not be used at all times and improvisations conducted to suit the specific requirements. Normally within an HIA the best available qualitative and quantitative evidence would be collated using a range of methods, including interviews, focus groups, surveys and community profiling. However, if these are not possible for various reasons or constraints, secondary analysis of existing data to estimate the likely number of deaths per year from the most important health and safety risks can be conducted to rank important health risks. Identification and description of the type and size of health impacts (both positive and negative) is typical of the appraisal stage of HIA. 4. Developing recommendations to reduce hazards and / or improvement of health- Reporting : A key output of HIA is the set of recommended changes to the proposal. Recommendations are provided in a formal report to the decision-maker and delivered in good time. The stakeholders’ views are clearly set out within the recommendations made. Decision makers are provided with recommendations that cover all of the possible decisions that could have been taken. If there are any conflicting impacts, these are acknowledged. Consideration is also given to provide a feed back of the outcome of the HIA to the community.

5. Evaluation and monitoring - Monitoring : Evaluating whether the HIA has influenced the decision making process (and the subsequent proposal) is an important component of HIA. As with any intervention, evaluation is required to see if it has worked. Monitoring the implementation of the proposal is critical to ensure that any recommendations that decision-makers agreed to, actually occur. Longer term monitoring of the health of populations is sometimes a component of larger proposals. This long term monitoring can be used to see if the predictions made during the appraisal were accurate and to see if the health, or health promoting behaviours, of the community have improved.

The Impact of HIAHealth impact assessment has now been carried out on a number of major policies, programmes and projects and has had significant influence on policy-making and planning. Examples include the Greater London Assembly’s HIA programme, the Finningley airport study conducted by Doncaster Health Authority (which for the first time in the UK incorporated the establishment of an independent airport health impact group into the regulatory framework for an airport) and the St Helens and Knowsley PFI study which was instrumental in attracting significant additional financial investment in the scheme at reduced interest rates form the European Investment Bank. At a global level, the World Health Organisation has appointed a HIA adviser at its Geneva Headquarters and has published a special issue of its Bulletin on HIA. The WHO has also played a major role in promoting the consideration of health within Strategic Environmental Assessment (SEA). These actions reflect the importance ascribed to HIA in health care management by the world body.

Health impact assessment is also increasingly used by global agencies such as the World Bank and by multinational corporations.

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Even in developing countries, poverty reduction strategies are among the most structured ways of developing investment policies and HIA has been recommended to be an ideal way to support these strategies and integrate economic and social activities with health concerns.

Summary‘Impact’ in public health refers to overall totalistic effect of an intervention. Assessment of health impact combines procedures, methods and tools by which a policy, programme or project may be judged as to its potential effects on the health of a population. HIA is based on 4 values - Democracy, Equity, Sustainable development and Ethical use of evidence. Ideally, HIA should precede start of project, programme or policy concerned. The aims of prospective HIA are to systematically assess potential health impacts and to improve quality of public policy decisions by making suitable recommendations. The methods commonly employed for HIA are- analysis of policies, assessing the health profiles of affected population, identification of potential positive and negative health impacts, assessment of perceived health risks, quantification & valuation of health impacts, ranking impacts and consideration of alternative options. HIA requires broad participation of all disciplines concerned to obtain comprehensive picture of potential health impacts. HIA has now been carried out on number of major policies, program and projects and has had significant influence on policy making and planning. It is being increasingly used by global agencies viz WHO, World Bank and by multinational corporations. HIA has been recommended to be ideal way to support strategies used by most of them.

Study ExercisesMCQs and Exercises1. Which are the four values on which health impact

assessment is based ?2. Enumerate the aims of prospective HIA.

3. What are the possible methods of assessing health impacts?

4. Health Impact assessment is a ______________ approach. 5. Potential users of HIA includes_______________

(a) Decision makers (b) Commissioners of HIA (c) HIA workers (d) Stake holders (e) All the above

6. Highlight the difference between Rapid HIA and Comprehensive HIA

7. Strategic environmental assessment is a concept of HIA implemented by which international organization?

Answers1. Democracy, Equity, Sustainable development and Ethical

use of evidence. 2. (I) Systematic Assessment of potential health impacts

(II) Improve quality of public policy decisions by making suitable recommendations

3. Methods commonly used are : Analysis of policies; Assessing the health profiles of affected areas/ populations; Identification of potential positive and negative health impacts; Assessment of perceived health risks; Quantification and valuation of health impacts; Ranking the most important impacts; Consideration of alternative options; Recommendations for management of desired impacts.

4. Participatory5. e. 6. Rapid HIA is one in which appraisal stage is carried out

quickly- in days and weeks with limited resources where as comprehensive HIA is the one in which extensive appraisal is conducted, new information is generated, significant literature reviews are undertaken and there is comprehensive involvement of stakeholders.

7. WHO.

Further Suggested ReadingAssessing health impacts on a population. Alex Scott-Samuel, Kate Ardern 1. and Martin Birley in Oxford Handbook of Public Health Practice. 2nd ed, 2007. 42-55

69 Community Diagnosis

Amitava Datta

The definition of a community can have many interpretations such as a neighbourhood, or a collection of people in similar geographical circumstances. A community also refers to a group of people who share the same stakes and common interests. Epidemiological methods can be used to assess the condition of the people living in a community or defined geographical area. Indices can be produced of the health and wellbeing and

the character and dimensions of the problems can be charted. The process of diagnosing the health, health related problems and their determinants, in a community is called community diagnosis. In some contexts it has also been considered to be the methods which enable communities in developing a consensus about the priority health problems in their individual communities and developing strategies to address the issues identified. The completion of the Community Diagnosis process should answer the following questions for the community :

Where is the community now? ●Where does it want to be? ●How will it get there? ●

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There are several ways to obtain information for the diagnosis of communities including routine health facility reporting, screening, surveillance, special large scale surveys, contact tracing and population census. These methods vary depending on the objectives, investment and utilities available.

The overall objective of community diagnosis is to estimate the magnitude of the health problems and the determinants as well as to analyse trends and changing paradigms of these problems and determinants. Because the community consists of heterogeneous groups, the overall objective may need to be expanded to include many value laden issues such as health needs and determinants, equity, responsiveness to expectation, efficacy, protection of individuals and fairness. The diagnosis of the state of health of a community must also be dynamic as there are continuous changes happening. The results of the community diagnosis process can then be used as evidence for discussion among the stakeholders in the community, balancing the views of the stakeholders in setting priorities and making decisions for resource allocation which are acceptable to the community. The priorities and decisions for control should take into account not only the current status but also the impact that controls may have on health of future generations. The priorities and decisions for control depend not only on the indicators used for the diagnosis but also on the expressed values of a health system.

Types of Health Information Needed for Planning Health CareHealth situations and needs : Planning of health care of any community will need to start from simple descriptions of the state of health of the community or presence of illnesses. The socio- demographic distribution of the diseases and conditions will help assess the “needs”. Availability of resources to deal with those needs including the various approaches to organizing and financing of the resources : The availability of health resources determines the relative ability to cope with the requirement and “needs” of the community and setting of priorities for allocation of resources.

The accessibility and utilization of existing health resources: This is important to determine the type of services which will be most appropriate for the community and therefore can be considered for provision.

Impact on health outcomes : The planned outcome will play an important role in determining what health services or facilities need to be provisioned. Consequences of health care financing on politics, economy and society as well as on the welfare of the entire population: Health is central to the overall development of any community. The outcomes in the non – health field in a community which can be also expected because of improved health can provide additional bargaining support while requesting for resources for the planned health interventions.

General Framework for Community DiagnosisDefining the community : The first task to be considered when it is planned to define health and disease in a community is to define the target community – country, province, district, or

state but might be a more defined geographical region such as urban inner city or a socially defined group such as poor communities, women in reproductive group, pregnant mothers, infants, young adults, elderly, etc. If not properly defined there may be a chance of over representation of sub groups from who it is easy to obtain data.

Health indicators : Definition of indicators is a pre-requisite for the development of an effective information system in community diagnosis. They should reflect both the positive (as SMPH) and negative (as IMR) aspects of health status. Positive health measures have been less used in developing countries as these populations are more likely to be satisfied with poorer health. Concept of burden of risk can be brought to the notice of public health officers. Mostly the health indicators are oriented to the negative aspect of health because of ease of measurement. Details of various indicators in community health practice are dealt with in another chapter on “measures of health and disease in community health”. Sources of information and the methods that can be used for community diagnosis : A variety of information regarding the health status of a community is available from existing health system records. Depending on the type of information required specific surveys may need to be conducted to gain the desired information if not available from existing health system records. Some of the sources which can be considered for obtaining information about the community are as follows:

Routine reporting from health facilities ●Surveillance – active and passive and sentinel ●surveillanceScreening of the community ●Surveys ●Vital registration of events ●Combination of several methods ●

Trend analysis : Information regarding various health parameters can be obtained and analysed regarding changes over a period of time. Various aspects like demographic transition, urbanization, economic transformation, politics, globalization, etc may impact on the health status of a community. Trend analysis can be conducted to assess the changes in a community of the health situation, burden of illness, prevalence of risk factors and many other factors.

Characteristics of community diagnosis : Basis of Community Diagnosis is to assess the health situation in the community including its dimensions and determinants besides whether the community has achieved the objectives proposed by the health policies and programmes in use. There are several desirable characteristics in the Community Diagnosis process which are enumerated as follows :

Ability to address important community problems which ●are amenable to practical control. Ability to identify most of the targeted health events. ●Adequacy in reflecting changes in distribution of events ●over time, place and person. Having a clearly defined population, data collection, data ●flow, analysis, interpretation and feedback. Orientation towards appropriate action. ●Being participatory, uncomplicated, sensitive, timely and ●inexpensive.

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Sources of Information and Methods for Community DiagnosisThe various important sources of obtaining information have been enumerated above and have been dealt with in detail in an exclusive chapter on “sources of information in epidemiology”. Readers are advised to go through the same.

Steps in Conduct of Community DiagnosisThere are no clearly laid down chronological steps in the conduct of a community diagnosis program. Several short cuts can be easily taken to achieve the desired results. However, when time and resources permit a thorough study, the various steps involved may be considered to be as follows :

Step 1 - Establishing a Community Diagnosis Team : The first step is to establish a Community Diagnosis Team who will lead the assessment process. This group should consist of motivated individuals who can act as advocates for a broad range of community members and can represent appropriately the concerns of various populations within the community.

Step 2 - Analyzing the existing Health Data : The Community Diagnosis Team will compare the community’s health statistics with those of the district, state or national figures to identify possible health problems in the community.

Step 3 - Collecting Community Data : Data will be collected from the community on health issues of interest, especially those that go beyond the information available in the existing community or health system records. The necessary data can be conducted using specially devised Community Health and Opinion Survey Questionnaire, conducting Focus Group Discussions with community members and obtaining data from the Health Resources Inventory (if it exists). Community surveys take a lot of time and it may not be possible to implement all of these data collection efforts before the reporting deadlines. These tools may be employed at any time, since community health assessment should be an ongoing process. Step 4 - Combining existing Health Statistics With Community Data : The Community Diagnosis Team will review the data from Steps 2 and 3 in detail. By the end of this phase, one will have a basic understanding of the community’s major health issues including comparison with other communities.

Step 5 - Choosing Health Priorities : Community Diagnosis Team will determine the priority health issues which will need to be addressed in the community based on the data collected and analysed.

Step 6 - Developing the Community Health Action Plan : Community Diagnosis Team will develop a plan of action for addressing the health issues deemed as priorities in Step 5. Developing of appropriate and effective health interventions and prevention activities is the basic idea behind the community diagnosis exercise.

Step 7 - Measuring Environmental and Policy Changes : The Community Diagnosis Team will do some advance planning about evaluating the success of the interventions developed in Step 6. A particular focus of this step is on collecting community-level indicator data to document the extent to which the community is making changes to improve health.

Step 8 - Creating the Community Diagnosis Document : Community Diagnosis Team will develop a stand-alone report to document the process as well as the findings of the entire assessment effort. The purpose of this report is to share the assessment results and plans with the entire community and other interested stakeholders. At the end of this step, the community will be ready to move from assessment to action by implementing the Community Health Action Plan developed in Step 6.

Limitations of Community DiagnosisThe process of community diagnosis as a solution to assessing the problems of the community and instituting appropriate interventions based on the findings has its limitation in ability to provide valid inputs to enable prioritizing health care facilities and interventions. The effects of health problems of individuals on their relatives cannot be assessed so simply. For example, all deaths are not equal in effect. Death of a person who is the sole earning member in the family has catastrophic effects which cannot be compared with the death of any other member of the family. The community will need to be consulted regarding their perceptions of values to assess the correctness of community diagnosis in these circumstances. The principles of community diagnosis are however valid in laying the foundation for appropriate public health interventions specially in the settings of developing countries where multiple health problems are vying for attention of politicians and health administrators for allocation of scarce resources.

SummaryThe process of diagnosing the health and health related problems of a community is called community diagnosis. The overall objective of community diagnosis is to estimate the magnitude of health problems and the determinants as well as to analyze changing trends of these problems and determinants. There are several ways to obtain information for the diagnosis of communities including routine health facility reporting, screening, surveillance, special large scale surveys, contact tracing and population census. The health information required for planning health care includes information on health situations and needs, available resources, organizational capacity, impact on health outcomes and consequences of health care financing on politics, economy and society as well as on the welfare of entire population. Various sources of information commonly utilized are routine reporting from health facilities, active and passive surveillance, screening of community, special and rapid surveys conducted to obtain same. The priorities for policy decisions should take into account not only the current status but also the impact that policies may have on health of future generations.

Study ExercisesExercises1. The process of diagnosing the health, health related

problems and their determinants, in a community is called _________________ .

2. The overall objective of community diagnosis is to estimate the magnitude of the health problems and the determinants as well as to analyse trends and changing paradigms of

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70 Ethics in Public Health, Health and Human Rights

Amitava Datta

Ethics has been defined as “a set of principles of right conduct”. In the medical sense, it has also been defined as “the principles and norms of proper professional conduct concerning the rights and duties of health care professionals themselves and their conduct toward patients and fellow practitioners, including the actions taken in the care of patients and family members”.

The ethical practice of health dates back to ancient times. The Hippocrates oath administered to all practitioners of medicine was the start of the formalization of ethical medical practice. The concept of “bioethics” however took birth due to the experiences of the Second World War and the atrocities conducted in the name of medical research by Nazis among inmates of concentration camps. The vulnerability of human beings to being subjected to medical research against their wishes was highlighted by the experiences of the inmates and findings of the Allies after Germany surrendered in 1945. A code of conduct for human research, namely the Nuremberg Code was established. In 1964, the World Medical Association Declaration of Helsinki took this process a step further and underscored 12 basic principles for the conduct of human biomedical research (Details are given in Box-1 towards the end of this chapter). However, these principles were largely physician oriented and did not directly address the issue of research in developing countries. The issue of research in developing countries was eventually taken up by the Council for International Organization of Medical Sciences (CIOMS), which in collaboration with WHO, proposed guidelines for international research. The guidelines were further amended in 1993 as the International Ethical Guidelines for Biomedical Research involving human subjects. The rapid advances in medicine, including reproductive health, organ transplantation and genetics, raised questions about the purpose and limits of medical technology. In recent years, there have been efforts to broaden the scope of ethical analysis in health care to focus more directly on public-health issues.

these problems and determinants. True/False3. The diagnosis of the state of health of a community is

static as there are no changes happening. True/False4. Positive health measures have been less used in developing

countries as these populations are more likely to be satisfied with poorer health. True/False

5. Information regarding various health parameters can be obtained and analysed regarding changes over a period of time, this is referred to as

Answers : (1) Community diagnosis; (2) True; (3) False; (4) True; (5) Trend analysis

Further Suggested ReadingReaders are advised to also go through the following chapters in this book

Epidemiological basis of planning and evaluation of a health programme1. Planning a Health Education Programme2. Measuring the level of Health and disease of a Community3. Sources of data in Epidemiology4.

What is Public Health EthicsPublic health ethics can be subdivided into a field of study and a field of practice. As a field of study, public health ethics seeks to understand and clarify principles and values which guide public health actions. Principles and values provide a framework for decision making and a means of justifying decisions. Because public health actions are often undertaken by governments and are directed at the population level, the principles and values which guide public health can differ from those which guide actions in biology and clinical medicine (bioethics and medical ethics) which are more patient or individual-centered.

As a field of practice, public health ethics is the application of relevant principles and values to public health decision making. In applying an ethics framework, public health ethics inquiry carries out three core functions :

Identifying and clarifying the ethical dilemma posed. ●Analyzing it in terms of alternative courses of action and ●their consequences.Resolving the dilemma by deciding which course of action ●best incorporates and balances the guiding principles and values.

Public health ethics thus focuses on the design and implementation of measures to monitor and improve the health of populations. This is in contrast to the traditional emphasis of bio-ethicists on the physician–patient relationship. Public-health ethics also looks beyond health care to consider the structural conditions that promote or inhibit the development of healthy societies.

Issues in Public Health EthicsWho is Responsible for Health?The conflicting views on ethics in the field of public health arise due to differing perceptions regarding responsibility for health. The wide spectrum of views has at one end the view, that it could be purely a matter of individual choice. On the other extreme, responsibility for health could be completely delegated to government. The central dilemma, therefore in public health is to balance respect for individual freedom and liberty with the responsibility of governments to provide their citizens with some degree of protection in relation to health.

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health research system could be regarded as the ‘‘brain’’ of its health system, then ethics would constitute its ‘‘conscience’’. It is imperative that health research systems function to the highest aspirations of ethics and distributive justice.

Responding to the Threat of Infectious Diseases Efforts to contain the spread of infectious diseases raise difficult questions about the appropriateness of restricting individual choices to safeguard other people’s welfare. Examples include the use of isolation and quarantine for tuberculosis, yellow fever, SARS and pandemic influenza.

International Co-operation in Health-Monitoring and Surveillance The international context also matters in the case of infectious diseases, since infections do not respect national borders. Countries also differ in their capacities to monitor and respond to outbreaks. Therefore, developed countries have obligations to assist developing ones, for example in terms of enhancing surveillance capacity. At the same time, developing countries have obligations to cooperate with international surveillance and control efforts. The implementation of the International Health Regulations reflects the commitment of countries to collective action in the face of public-health emergencies. Defining the scope of countries’ obligations to act collectively and determining how those obligations should be enforced, will inevitably raise difficult ethical dilemmas.

Exploitation of Individuals in Low-Income Countries Current practices in medical research, for example, may expose participants to significant risks without a benefit for themselves or their communities. Defining and enforcing foreign research sponsors’ obligations to local participants is therefore a critical ethical issue. In the area of organ transplantation, the growing practice of “transplant tourism” exposes individuals living in poverty to significant health risks while also raising broader questions about the commodification of the human body.

Participation, Transparency and Accountability As an ethical matter, the process by which decisions are made is as important as the outcome of the decisions. In the area of medical research, much attention has been devoted in recent years to strengthening systems for informed consent and community oversight. Once such systems are in place, the next step will be to develop mechanisms for evaluating their effectiveness.

Medical Research in Developing CountriesThe ethical issues in conduct of medical research on public health in developing countries need special attention. This aspect is deliberated in detail in the section on epidemiology and research methodology.

The recent landmark trial in Gadchiroli, India, makes an interesting case in point which clearly elucidates the above concerns. The trial evaluated domiciliary neonatal care with community-based health workers administering oral trimethoprim-sulfamethoxazole and twice-daily gentamicin to newborn infants with suspected sepsis. A control population was used for comparison and the researchers were able to demonstrate a 72% reduction in neonatal mortality using this

The role of the government has been evolving over a period of time. Today, very few would argue against state sponsored fortification of bread or pasteurization of milk. However many of the interventions to prevent the so called “lifestyle choices” leading to arising of risk factors of killer diseases like ischemic heart disease, lung cancer, chronic obstructive pulmonary disease and diabetes mellitus are still contentious depending on the country involved. It is common knowledge that the so called “choices of lifestyle” are often constrained by actions of others like industry and government as well as socio-economic, environmental and genetic factors. In traditional bioethics, much emphasis is placed on the freedom of the individual. However, in public health policy, some measures might constitute minor infringements of a person’s freedom but bring about significant benefit for a large number of people. The western world with democratic traditions would recommend that governments should not coerce their people or restrict their freedom unnecessarily. However, these same governments are also expected to provide the conditions under which people can lead healthy lives. “Tobacco smoking” lends itself easily as an example. By banning advertisements by tobacco companies and restricting the availability to children, the governments are discharging their role in harm reduction to vulnerable citizens while still permitting their citizens their right to smoke tobacco.

Disparities in Health Status in Different Parts of the WorldIt is an accepted fact that resource allocation depends in part on value judgments about the relative importance of small improvements in quality of life for a large portion of the population as compared with a life-saving intervention that would benefit only a few people. Most of the developing countries have very poor state of health of their citizens. They look towards the affluent nations and philanthropic agencies for economic and technological aid to alleviate the sufferings of their citizens. Most inter governmental economic aid is however conditional to the use of services provided through companies of the donor country, which may exploit the situation for economic gain rather than philanthropy. The astronomical and unjustifiable gains of some pharmaceutical companies, from sale of life saving drugs, are well documented. Governmental health policies may become dictated by the donor of funds rather than from perceived need.

Disparities in Access to Quality Health Care and the Benefits of Medical ResearchMany of the clinical researches being conducted in the world have used subjects who may have nothing to gain from the research. Medical research is one of the most contentious issues in public health today. Even in the developed world, discriminations against the deprived communities have been documented in literature and have raised ethical concerns. The existing ethical norms need to be guided more by the need and circumstances of individual nations (especially developing countries) rather than be exceedingly idealistic and moralistic in their approach. The Global Forum for Health Research has pointed out that less than 10% of the world’s research resources are earmarked for 90% of the health problems. If a country’s

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approach. This study would have raised ethical questions by most existing standards, since it involved a control population and also used an experimental protocol, when the “national standard of care” for suspected neonatal sepsis was intravenous antibiotics and supportive care. The authors, Bang et al, went through an elaborate scientific and ethical review process prior to the study, involving national experts and the Indian Council for Medical Research. The researchers were also able to get community concurrence to participate in this study, in a situation where even the national ‘‘standard of care’’ was not available to the participants. The benefits of the study for the local people (in terms of improved neonatal survival) and its impact on national and global programmes for neonatal care have been enormous. Taking an extreme position on the “standards of care” would have required that the study only be conducted with a control arm that received neonatal intensive care and expensive intravenous antibiotics, neither of which are sustainable even in urban settings in India. Thus, the study could not have taken place. The Gadchiroli trial vindicates the position of public health researchers that each developing country deserves the chance to develop health care interventions that suit local socio-cultural and economic means.

Principles of Ethical Public Health PracticeThe Public Health Leadership Society in 2002 has published a code of ethics for the ethical practice of public health based on the definition of heath as advocated by WHO. The salient features which explicitly enunciate the current basic understanding of the ethical practice of public health are as follows. The detailed elaboration of each of these principles is being given in detail subsequently. 1. Public health should address principally the fundamental

causes of disease and requirements for health, aiming to prevent adverse health outcomes.

2. Public health should achieve community health in a way that respects the rights of individuals in the community.

3. Public health policies, programs and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members.

4. Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

5. Public health should seek the information needed to implement effective policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation.

7. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public.

8. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs and cultures in the community.

9. Public health programs and policies should be implemented in a manner that most enhances the physical and social

environment. 10. Public health institutions should protect the confidentiality

of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others.

11. Public health institutions should ensure the professional competence of their employees.

12. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness.

Notes on the Individual Ethical Principles1. This principle gives priority not only to prevention of disease

or promotion of health, but also at the most fundamental levels. Yet the principle acknowledges that public health will also concern itself with some immediate causes and some curative roles. For example, the treatment of curable infections is important to the prevention of transmission of infection to others. The term “public health” is used here and elsewhere in the Code to represent the entire field of public health, including but not limited to government institutions and schools of public health.

2. This principle identifies the common need in public health to weigh the concerns of both the individual and the community. There is no ethical principle that can provide a solution to this perennial tension in public health. We can highlight, however, that the interest of the community is part of the equation and for public health it is the starting place in the equation; it is the primary interest of public health. Still, there remains the need to pay attention to the rights of individuals when exercising the police powers of public health.

3. A process for input can be direct or representative. In either case, it involves processes that work to establish a consensus. While democratic processes can be cumbersome, once a policy is established, public health institutions have the mandate to respond quickly to urgent situations. Input from the community should not end once a policy or program is implemented. There remains a need for the community to evaluate whether the institution is implementing the program as planned and whether it is having the intended effect. The ability for the public to provide this input and sense that it is being heard is critical in the development and maintenance of public trust in the institution.

4. This principle speaks to two issues : Ensuring that all in a community have a voice; and underscoring that public health has a particular interest in those members of a community that are underserved or marginalized. While a society cannot provide resources for health at a level enjoyed by the wealthy, it can ensure a decent minimum standard of resources. The Code cannot prescribe action when it comes to ensuring the health of those who are marginalized because of illegal behaviors. It can only underscore the principle of ensuring the resources necessary for health to all. Each institution must decide for itself what risks it will take to achieve that.

5. This principle is a mandate to seek information to inform

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actions. The importance of information to evaluate programs is also implied.

6. This principle is linked to the third one about democratic processes. Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public. This statement is also the community- level corollary of the individual-level ethical principle of informed consent. Particularly when a program has not been duly developed with evaluation, the community should be informed of the potential risks and benefits and implementation of the program should be premised on the consent of the community (though this principle does not specify how that consent should be obtained).

7. Public health is active rather than passive and information is not to be gathered for idle interest. Yet the ability to act is conditioned by available resources and opportunities and by competing needs. Moreover, the ability to respond to urgent situations depends on having established a mandate to do so through the democratic processes of Ethical Principle number three.

8. Public health programs should have built into them a flexibility that anticipates diversity in those needs and perspectives having a significant impact on the effectiveness of the program. Types of diversity, such as culture and gender, were intentionally not mentioned. Any list would be arbitrary and inadequate.

9. This principle stems from the assumptions of interdependence among people and between people and their physical environment. It is like the ethical principle from medicine, “do no harm”, but it is worded in a positive way.

10. This statement begs the question of which information needs to be protected and what the criteria are for making the information public. The aims of this statement are modest : to state explicitly the responsibility inherent to the “possession” of information. It is the complement to Ethical Principles 6 and 7, about acting on and sharing information.

11. The criteria for professional competence would have to be specified by individual professions, such as epidemiology and health education.

12. This statement underscores the collaborative nature of public health while also stating in a positive way the need to avoid any conflicts of interest that would undermine the trust of the public or the effectiveness of a program.

SummaryEthics has been defined as a ‘set of principles of right conduct’. The landmarks in ethical practice of health dates back to the Hippocratic oath, ‘Concept of Bioethics’ arising out of atrocities of Nazi doctors and Germans during Second World War in the name of medical research, setting up of Nuremberg code for human research, followed by Declaration of Helsinki adopted at World Medical Assembly, Finland, 1964. The Council of International Organization of Medical Sciences (CIOMS) in collaboration with WHO established International Ethical Guidelines for Biomedical Research last amended in

1993. There are 3 core functions of public health ethics viz identifying the ethical dilemma posed, analyzing it in terms of alternative course of action and deciding best course of action. The Public Health Leadership Society in 2002 has published a code of ethics for ethical practice of public health based on definition of health as advocated by WHO constituting the 12 basic principles of ethical public health practice. Ethics has also been at the heart of WHO mission to protect & promote global community health. WHO’s General Dr. Gro Harlem Brunttland created an ‘Ethics and Intelligence Initiative’, which has since served as a focal point for ethics activities throughout the organization.

Study ExercisesMCQs and Exercises1. The Code of conduct for human research is called the __.2. The World Medical association Declaration of Helsinki took

place in : (a)1954 (b) 1964 (c) 1974 (d) 1984.3. The Global forum for health research has pointed out

that < ________ % of the world’s research resources are earmarked for ________ % of the health problems.

4. Clinical research cannot be legitimately carried out unless the importance of the objective is in proportion to the inherent risk to the subject. True/False.

5. The responsibility for clinical research is both for the researcher & the subject once the consent has been obtained from the subject. True/False.

Answers : (1) Nuremberg Code; (2) b; (3) <10%, 90%; (4) True; (5) False.

Further Suggested ReadingHan MT, Shampo MA, Kyle RA. Sun Ssu-Miao (Si miao). 1. JAMA 1981;246 : 1. 2067. PMID : 7026814 doi : 10. 1001/jama. 246. 18. 2067Butterworth2. CE. Medieval Islamic philosophy and the virtue of ethics. 2. Arabica 1987;34 : 221-50. doi : 10. 1163/157005887X00298Kass3. NE. Public health ethics : from foundations and frameworks to 3. justice and global public health. J Law Med Ethics 2004;32 : 232-8. PMID : 15301188 doi : 10. 1111/j. 1748-720X. 2004. tb00470. xResolution4. WHA58. 3. Revision of the International Health 4. Regulations. In : World Health Assembly. Available from : http : //www. who. int/gb/ebwha/pdf_files/WHA58/WHA58_3-en. pdf [accessed on 7 July 2008]. Bioethics homepage. PAHO. Available from : 5. http : //www. paho. org/5. Spanish/bio/home. htm [accessed on 7 July 2008]. Lolas F. Bioethics at the Pan American Health Organization. Origins, 6. 6. developments and challenges. Acta Bioethica 2006;12 : 113-9. Guidance on ethics and equitable access to HIV treatment and care7. Geneva: 7. WHO & UNAIDS; 2004. Available from : http : //www. who. int/ethics/Guidance%20on%20Ethics%20and%20HIV. pdf [accessed on 7 July 2008]. Ethical considerations in developing a public health response to pandemic 8. 8. influenza. Geneva : WHO; 2007. Available from : http : //www. who. int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c. pdf [accessed on 7 July 2008]. Networking for ethics on biomedical research in Africa (NEBRA) : final 9. report, 9. 2006. Available from : http : //www. trree. org/site/en_nebra. phtml [accessed on 7 July 2008]. Engaging for health : 11th general programme of work, 2006-2015 : a global 10. 10. health agenda. Geneva : WHO; 2006. Understanding ethics in public health. Angus Dawson in Oxford Handbook 11. of Public Health Practice. 2nd ed, 2007.64-71Being explicit about values in public health. Nick Steel in Oxford Handbook 12. of Public Health Practice. 2nd ed, 2007. 56-63Ethical principles and ethical issues in public health. K. C. Kalman and R. S. 13. Downie in Oxford Textbook of Public Health. 4th ed, 2002. 387-400. Ethics and Public Health Policy. John M Last in Maxcy-Rosenau-Last. Public 14. Health & Preventive Mediicne. Appleton & Lange. 14th ed, 1998. 1069-1080. 14th ed, 1998. 35-44

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Box - 1 : Declaration of Helsinki

Recommendations Guiding Doctors in Clinical Research

Adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964

It is the mission of the doctor to safeguard the health of the people. His knowledge and conscience are dedicated to the fulfillment of this mission. The Declaration of Geneva of The World Medical Association binds the doctor with the words : “The health of my patient will be my first consideration” and the International Code of Medical Ethics declares that “Any act or advice which could weaken physical or mental resistance of a human being may be used only in his interest. ”

Because it is essential that the results of laboratory experiments be applied to human beings to further scientific knowledge and to help suffering humanity, The World Medical Association has prepared the following recommendations as a guide to each doctor in clinical research. It must be stressed that the standards as drafted 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.

In the field of clinical research a fundamental distinction must be recognized between clinical research in which the aim is essentially therapeutic for a patient and the clinical research, the essential object of which is purely scientific and without therapeutic value to the person subjected to the research.

I. Basic Principles1. Clinical research must conform to the moral and scientific

principles that justify medical research; and should be based on laboratory and animal experiments or other scientifically established facts.

2. Clinical research should be conducted only by scientifically qualified persons and under the supervision of a qualified medical man.

3. Clinical research cannot legitimately be carried out unless the importance of the objective is out of proportion to the inherent risk to the subject.

4. Every clinical research project should be preceded by careful assessment of inherent risks in comparison to foreseeable benefits to the subject or to others.

5. Special caution should be exercised by the doctor in performing clinical research in which the personality of the subject is liable to be altered by drugs or experimental procedure.

II. Clinical Research Combined with Professional Care1. In the treatment of the sick person, the doctor must be

free to use a new therapeutic measure, if in his judgment it offers hope of saving life, reestablishing health, or alleviating suffering.

If at all possible, consistent with patient psychology, the doctor should obtain the patient’s freely given consent after the patient has been given a full explanation. In case of legal incapacity, consent should also be procured from the legal guardian; in case of physical incapacity the permission of the legal guardian replaces that of the patient.

2. The doctor can combine clinical research with professional care, the objective being the acquisition of new medical knowledge, only to the extent that clinical research is justified by its therapeutic value for the patient.

III. Non-Therapeutic Clinical Research1. In the purely scientific application of clinical research

carried out on a human being, it is the duty of the doctor to remain the protector of the life and health of that person on whom clinical research is being carried out.

2. The nature, the purpose and the risk of clinical research must be explained to the subject by the doctor.

3a. Clinical research on a human being cannot be undertaken without his free consent after he has been informed; if he is legally incompetent, the consent of the legal guardian should be procured.

3b. The subject of clinical research should be in such a mental, physical and legal state as to be able to exercise fully his power of choice.

3c. Consent should, as a rule, be obtained in writing. However, the responsibility for clinical research always remains with the research worker; it never falls on the subject even after consent is obtained.

4a. The investigator must respect the right of each individual to safeguard his personal integrity, especially if the subject is in a dependent relationship to the investigator.

4b. At any time during the course of clinical research the subject or his guardian should be free to withdraw permission for research to be continued.

The investigator or the investigating team should discontinue the research if in his or their judgment, it may, if continued, be harmful to the individual.

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71General Principles for Developing Management Information Systems in Public Health Practice

Amitava Datta

Information is the basis for all planning processes and planning of public health measures for a community is no exception. Health information is generated both at the individual level (patient records from hospitals) as well as at the community level (surveillance systems, population surveys, outbreak reports, etc). The clinician requires detailed information about limited number of persons for clinical follow up. The needs of the public health analyst differs from that of his clinical colleague in that he needs information from large number of persons or patients but comparatively limited information about each person or patient. By the word data, we usually mean numerical information that is collected routinely and that is used to monitor health of the populations (surveillance data) or the activity of health-related services. In general, data tends to refer to numerical information which expresses information in terms of ‘how many’ and ‘how much’. However epidemiology has clearly taught us that simply ‘counts’ do not allow meaningful comparisons. Public health data invariably has a numerator and a denominator besides preferably having a time dimension and is expressed as rates to enable comparisons with other communities or periods of time. Information can be considered to be the outcome of processing and evaluating raw data. The degree of processing required to turn data into information may depend on the level of expertise of the recipient.

The term evidence is used mainly in legal terms where it is used to describe the material which shows beyond a reasonable doubt that something has occurred. In public health, it is applied to knowledge obtained from research. It can be used for providing support to theory regarding etiology; for example, does iodine deficiency produce hypothyroidism or to what extent does the absence of fluorine in drinking water lead to dental caries. It can also be providing support for some planned or existing intervention; for example does the fortification of salt with iodine lead to reduction in number of mentally retarded children in a community. Evidence can be a mixture of numbers and words as compared to data which has only numbers. Evidence comes from many sources, is of variable quality and requires interpretation. This is also the case when considering empirical evidence, arising from observation or experiment.

Public health policy makers and health care managers require timely, useful and balanced information which is quantifiable and tangible for the diagnosis of health needs of a community, their trends and determinants with a view to achieve effective planning and monitoring of health care interventions. This information can be of three types - derived from research, that is evidence; derived from routinely collected data, that is statistics or derived from experience either from patients or of fellow professionals or other partner organizations.

Components of Information Systems for Planning Health CareThe major components of health care which will need systematic information for planning activities include information about health situations and needs, availability of resources to deal with those needs, organization and capacity to take those resources and convert them into services (that is conduction of system efficacy, effectiveness, efficiency, quality and decision analysis), variation of use and practice with their implication on equity to access and coverage, impact on health outcome and consequences of health care financing on politics, economy and society as well as on the welfare of the entire population. The users and contributors of information for health planning can be policy analysts, health care providers, epidemiologists, social scientists, economists, etc. Those who provide health services and have the task of being accountable for the services they provide should be involved with the development of information system. There are differences in the emphasis shown to the different components of health information system between developing and developed countries as well as depending upon the political system in the respective country.

Important Considerations in Providing Data and Evidence for Policy MakersIt is common knowledge that in the field of public health, as in other planning processes, there had been many occasions when there has been a mismatch between the generation of evidence and data and their communication to the right people in the right way at the right time. The many known reasons for this incongruity can be overcome with careful organization and preparation.

In the field of public health when we attempt to solve serious problems there is often a wealth of descriptive data about a population (like data obtained from routine surveillance system, data from special survey as well as anecdotal evidence from practitioners or professional bodies). However some times, (especially when a new disease appears), there may be too little information available, for example during the initial stages of the AIDS epidemic. In both circumstances however, rarely is information made available in a way that makes it easy for policy makers to take effective action. Some of the problems which have been identified in providing data and evidence for policy makers and needs consideration are as follows :

Availability of many types of knowledge : Data, evidence and best practice (obtained from professional bodies) often leads to confusion. The present confusion to decide which drugs to use in prevention of parent to child transmission of HIV is clearly an apt example. It is necessary to develop an organized approach to considering problems and suggesting solutions using a combination of ‘content’ and ‘process’. Although there can be different sorts of knowledge, all of which can help in different ways, however, these must be critically evaluated before they are assembled and articulated in a clear balanced way. Anecdotes are powerful ways to raise issues but they need to be validated by data and evidence before they can be used to direct significant policy and action.

Information is not available in time : To be able to plan and implement public health policies information is required within

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manner to address the public health problems. Communication of the information therefore has to be consistent in various presentations.

Communication of evidence in unhelpful ways : Even the most committed policy makers will be unable to generate the required policy change if problems are provided to them in a manner which is not conducive to easy understanding of the seriousness of the problem as well as the quantification of the improvement likely. Technical epidemiological terminology, like ‘absolute risk reduction’ though appropriate when used among professionals may be counter productive if used among not so knowledgeable professionals or non- medical persons. Use of simple terms like ‘how many children out of 1000 immunized with the proposed vaccine will be saved’ is likely to be as effective or even more than use of terminology like ‘risk reduction’. An inappropriate stress on evidence can be as damaging to a desired policy outcome as the wrong dose of a drug to a patient. The full range of available evidence (statistics, charts, meta-analyses, etc. ) does not always need to be marshaled while communicating the seriousness of the public health problem and its suggested solution. The timing of the presentation of evidence is also very important. Provision of ‘exhaustive evidence’ after the negative policy making decision has occurred is of lesser use as compared to ‘adequate evidence’ before the decision making process. It would be appropriate to present the latter form in time rather than wait too long for the ‘perfect evidence’. It will also be pertinent to know who will receive the evidence- a public health specialist, a clinician, non-medical official or politician before deciding how to package and communicate the evidence. This will ensure a better appreciation of the problem at hand by the receiver of evidence.

Poor communication of information : The ability to convert data into evidence and subsequently convey it in an acceptable manner depends on many factors including capability, training, motivation and other interests of the persons responsible. Even though a problem may be considered to be requiring continued communication, there is a real danger of ‘over exposure’. The danger of military commanders becoming immune to the repeated pleas for attention to curb the STD and malaria incidence among soldiers, as documented to have happened during second world war are apt examples of this aspect needing consideration. Unforeseen reactions like some sub-sections of society rebelling and actually increasing their tobacco use only as an expression of their rebellion is also to be warded against. When economic considerations are likely to play an important role in the policy making process, it may be wiser to have fewer experts propounding the issues at regular intervals rather than attempting to rope in as many and diverse personalities. The use of cinema personalities, sports persons, politicians, etc in the campaign against tobacco use can be considered in this light.

Inability to balance harm, benefit and cost explicitly : The method of communicating data, information or evidence needs to be able to clearly elucidate the harm caused by an element, the benefit on removal of the element from society and the costs involved - direct and indirect in the intervention proposed. The most apt example is the continued debate on tobacco use over

stipulated time frame. Most policy makers are constrained by time schedule beyond which the policy making cannot be kept pending. In India for example, wherever governmental funds are to be committed, the information required to formulate policy and commit funds has to start several months before the start of a financial year and in case of major fund requirement, as much as five years before – in case the policy decision is required to be funded through the five year planning system. In the present age of computers, it is sometimes expected that simply on the click of a button, data and evidence will be generated. Unfortunately, this is far from reality except to generate data regarding some highly prevalent communicable diseases. Most public health data are expensive to collect but expense must not be made an excuse not to collect, analyse and present required data.

Lack of consistency in information definitions : The field of public health is extremely dynamic. The common examples are definitions for hypertension and diabetes mellitus. With better understanding of the risk posed, the definition of what is to be considered “hypertension” and “diabetes” needing therapeutic or other interventions has changed over the last decade. What may have been a mild problem in several geographical areas like states has suddenly become a “burning public health issue” once the new definition is applied. Similarly, there are debates and disagreements among professional bodies to arrive at consensus definitions. .

Lack of meaningful comparators : Many public health problems do not have adequate or appropriate comparators or indicators which allow comparison of the state of health due to the condition under consideration. This may be due to basic problems of ethnicity. The lack of protective effect due to BCG vaccine among Indians as compared with the demonstrated protective effect in other countries is based on evidence. The continued use of BCG in the national immunization program based on evidence of “reasonable” protection from childhood forms of tuberculosis provided by certain surveys does not allow for meaningful comparisons as there is paucity of data on this aspect. Comparators can be the crux of any analysis. The presentation of data should clearly indicate whether we need to be increasingly concerned, whether the magnitude of the problem is less or more than other comparable places, whether time trends are available, whether the change if any or rate of change is satisfactory, etc.

Solution-focused approach of knowledge : There are at times attempts to stress the ‘solution’ rather than the ‘problem’ while presenting analysis of data. For example in a bid to introduce Pneumococcal immunization in the national immunization schedule in India, the protective efficacy of one or more vaccines only is projected without assessing the magnitude and determinants of pneumonia in the country. The initiation of debate should have been with an assessment whether Pneumococcal pneumonia is indeed a problem in our country.

Lack of common language to describe domains : Concern for the health of their citizens is common among practitioners of public health as well as policy makers. However they may have different ideas of the relative importance of different health related problems as well as the means of overcoming them. It would be helpful if all concerned could be aligned in a similar

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a period of nearly half a century throughout the world. Tobacco does not cause immediate harm and hence users, lay public and policy makers need to have evidence of the cause and effect relationship of tobacco leading to harm, the gains from cessation of use of tobacco as well as stopping the initiation of tobacco use, besides the costs involved in implementing a policy for stopping the use of tobacco which needs to consider the losses to industry, the tobacco farmers, related industry as well as government (in terms of easy taxes). Similarly charging a token sum for the purchase of highly subsidized condoms in the family planning program needs to be considered before implementation. There is evidence that introducing user charges may reduce inappropriate attendance, but it might lead to an adverse impact on the most disadvantaged. At the clinical level, the well known example of suppressing ventricular ectopics in post myocardial infarction period actually increased the risk of sudden death rather than decreasing it. This was established only after careful research and stressed the importance of considering all potential harm as compared to benefits in any intervention.

Inadequate listening to the users : Many a times, information is provided in a sensational manner which attracts the attention of important community persons as well as policy makers. The discussion of HIV / AIDS among the women of a community who are more concerned about the problem of inadequate child health care facilities in the community is hardly likely to succeed. Similarly discussing the problem of child labour in an area with abject poverty may make for good media coverage to identify industries which employ child labour. This may in fact result in the denial of employment to a child but does nothing to take care of his need for this employment as a means of earning money for his and possibly also his family’s needs. In the absence of organized social security, implementation of such public policies may only harm the individuals concerned and provide for exploitation of needy children. The key issue with data is to choose the right data (with the right comparators) that will change the particular minds (and hearts) of the people to who we communicate. Before planning any health related communication, it is almost always a good investment of time and effort to seek to understand the perspective, anxieties and motivations of the people who are the targeted beneficiaries.

Policy makers often don’t want evidence : In the field of public health especially, evidence may be unwelcome. It would be politically inappropriate for some evidences in the public health domain to be overlooked. However, constraints of funds may not permit allocations and hence delays in even consideration of needed policies. There are various organisations and individuals who focus their research and other activities only on certain fields of public health. The problems of lobbying activities are well established in western countries. Even in India, lobbies for assisted reproductive therapy vie for funds from policy makers in a country where the problem due to too many births is well recognized. However, good-quality evidence, well generated and explicitly disseminated, can make an issue less political as there may be less debate in the face of scientifically generated information. In case the available evidence is clearly against the known beliefs of the policy maker, then it will need careful planning by the public health

specialists about how you change the belief. However, in no case must spurious or biased evidence be fabricated to merely satisfy a policy position.

Evidence and data are usually, though not exclusively, provided to change and improve the quality of decision-making. A public health professional armed with good data and evidence and presenting in a well organized, skillful and confident fashion to raise and debate issues opportunistically, without the need to berate, harangue, or sermonize the audience, can be very effective in bringing about policy change. In the absence of good evidence on how best the available evidence can best be used to effect policy change, it is one of the major challenges in public health.

SummaryInformation is the basis for all planning processes including public health. Health information is generated at the individual & the community level. The Public health analyst needs information from large number of persons, but needs limited information. Data refers to numerical information but to enable comparisons, information can be considered to be the outcome of processing & evaluation of raw data. Evidence refers to knowledge obtained from research, which can be used to provide support to theory regarding etiology or to some planned or existing intervention. It can be a mixture of numbers & words, come from many sources, is of variable quality & requires interpretation. Public health policy makers & health care managers require quantifiable & tangible information in the form of evidence, statistics or experience.

The components of information systems for planning health care need systematic information about health situations & needs, resources, organization, capacity to convert resources into services, impact on health outcome & consequences of health care financing.

In the field of Public health, rarely is information available in a way that it is easy for policy makers to take effective action. The problems that need consideration are :

Availability of many types of knowledge ●Information not available in time ●Lack of consistency in information definitions ●Lack of meaningful comparators ●Solution – focused approach of knowledge ●Lack of common language to describe domains ●Communication of evidence in unhelpful ways ●Poor communication of information ●Inability to balance harm, benefit & cost explicitly ●Inadequate listening to the users ●Policy makers often don’t want evidence ●

Evidence & data are usually provided to change & improve the quality of decision making. One of the major challenges in public health is to effect policy change in the absence of good evidence.

Study ExercisesMCQs & Exercises1. Patient records from the hospitals is health information

generation at community level : True/False

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2. Health information generation at community level includes all except : (a) Surveillance system (b) Population surveys (c) Outbreak reports (d) None

3. Numerical information which expresses information in terms of ‘how many’ & ‘how much’ is referred to as ____

4. The outcome of processing & evaluating raw data is referred to as ______________

5. The knowledge obtained from research is referred to as _______________

6. Information can be in the form of : (a) Evidence (b) Statistics (c) Experience (d) All of the above

7. Information is rarely made available in a way that makes it easy for policy makers to take effective action : True/False

8. Which of the following are powerful ways to raise issues but aren’t valid on their own : (a) Data (b) Evidence (c) Anecdotes (d) Policy

9. Spurious or biased evidence may be fabricated to satisfy a policy position : True/False

10. Policy makers often don’t want evidence : True/False11. ‘Solution-focused’ approach to knowledge is better than

‘Problem-focused’ approach : True/FalseAnswers(1) False; (2) d; (3) Data; (4) Information; (5) Evidence; (6) d; (7) True; (8) c; (9) False; (10) True; (11) False.

Further Suggested ReadingProviding data and evidence for practitioners. Julius Weinberg and David 1. Pencheon in Oxford Handbook of Public Health Practice. 2nd ed, 2007. 194-200

72 Making Public Health Policies

Amitava Datta

A policy is a deliberate plan of action to guide decisions and achieve rational outcomes. The term may apply to government, private sector organizations and groups and individuals. According to the Oxford English Dictionary, policy is ‘a course of action or principle adopted or proposed by a government, party, individual, etc. , or any course of action adopted as advantageous or expedient’. Policy or policy study may also refer to the process of making important organizational decisions, including the identification of different alternatives such as programs or spending priorities and choosing among them on the basis of the impact they will have. Policies can thus be understood as political, management, financial and administrative mechanisms arranged to reach explicit goals.

Policy differs from rules or law. While law can compel or prohibit behaviors (e.g. a law requiring the payment of taxes on income) policy merely guides actions toward those that are most likely to achieve a desired outcome. Science and logic may help to identify public health problems and potential solutions, but emotion and power relationships determine whether anything is done about them.

Public policy-making is accepted to be ‘political’ and seldom driven by public health evidence. To achieve healthy public policy, it is necessary that timing and the relevance of evidence to policy are crucial. Evidence needs to support a practical programme of actions, but much public health research can be criticized for providing elaborate descriptions of problems rather than possible solutions. There is need for public servants who are equipped with critical appraisal skills to use evidence in policy development. The methodology of presenting evidence

for health policy use has been discussed in a different chapter.

Many of the public debate on health issues is converted by the media into simplified notions of what each issue is really about. For example, to public health practitioners in USA, gun control is about saving lives, but to the gun lobby, opposing gun control is about limiting the power of the state and preserving the freedom of the individual. Framing of issues in the media is critical to how they are dealt with and understanding this process and responding directly to an adverse framing of an issue, can be critical to influencing policy and politicians.

Multi-national companies and global organizations can now have major influences on ‘local’ public health problems and public health practitioners must now both think and act locally and globally. Appreciating the full international picture behind modern public health challenges can help us focus on cause rather than symptoms.

Globally, public opinion and the media can be critical to getting public health issues onto the policy agenda and keeping them there. The importance of recognizing the task of influencing policy as a specific challenge of public health practice, as a challenge that requires an understanding of the policy-making process and the adoption of specific attitudes and skills are important considerations in framing public health policy. At most levels, getting public health issues into the mainstream of public debate and influencing public opinion is seen as a major challenge to public health practitioners.

Policy Making ProcessIntended Effects : The goals of policy may vary widely according to the organization and the context in which they are made. Broadly, policies are typically instituted in order to avoid some negative effect that has been noticed in the organization, or to seek some positive benefit.

Policies frequently have side effects or unintended

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consequences. Because the environments that policies seek to influence or manipulate are typically complex adaptive systems (e.g. Governments, societies, large companies), making a policy change can have counter-intuitive results. For example, a government may make a policy decision to raise taxes, in hopes of increasing overall tax revenue. Depending on the size of the tax increase, this may have the overall effect of reducing tax revenue by causing capital flight or by creating a rate so high; citizens may lose incentive to earn the money that is taxed.

The policy formulation process typically includes an attempt to assess as many areas of potential policy impact as possible, to lessen the chances that a given policy will have unexpected or unintended consequences. Because of the nature of some complex adaptive systems such as societies and governments, it may not be possible to assess all possible impacts of a given policy.

Policy cycle : In political science the policy cycle is a tool used for the analyzing of the development of a policy item. It usually includes the following stages :

Agenda setting (Problem identification) ●Policy formulation ●Decision-making ●Policy implementation ●Policy analysis and evaluation (continue or terminate) ●

Agenda setting : Agenda setting, the most crucial step in initiation of new policy, occurs when policy makers identify a problem and develop broad goals to address it. In health care, examples of potential problems include rising health expenditures, an unexpected increase in problems include rising health expenditures, an unexpected increase in infant mortality, or an unexpected increase in the prevalence of a disease (e.g. AIDS). Health-care issues such as these must compete against other policy issues (such as national defence) to become national priorities and specific health issues must compete for attention with other health issues. Policy makers can focus on only a limited number of problems at any one time.

A considerable amount of effort is required to place an issue at the forefront of the policy-making agenda. Although different issues may be influenced by different ways and means, however in general, factors known to help place an issue on the political agenda are the following :

Large number of people perceiving the existence of the ●problem. Perception of the severity of the problem by many. ●If the problem has occurred recently and is very unique or ●novel. Likely to affect individuals personally. ●

Simply generating public interest alone does not guarantee that an issue will be placed on the public agenda. Policy makers should consider that the issue is within the purview of government action and deserving of public attention before they will accept it being placed on the public agenda. Many policy issues that have only long-term consequences or only minor consequences for an individual are unlikely to become health-care policy concerns. Unfortunately, many public health issues fall into this category.

Many different approaches are used to place an issue at the forefront of the public policy agenda. One method is to use ‘Inside access’ to try to influence policy making. This is the aspect which in western countries especially USA, is delegated to lobbyists. Another method is to influence public opinion. This can be done through the media, personal appeals by public officials and celebrities, advertising to raise public awareness and many other approaches including to interest groups and political parties. Public opinion has its greatest impact on government decision-making when people feel strongly about clear-cut preferences. Impact of public opinion is also highest during the period close to elections in democracies. Although government policy usually tends to coincide with public opinion, however if well-organized interest groups intervene, this may not be the case, particularly when public apathy is evident. Special interests can have a particularly important role in technical issues or issues that involve only a few people.

In health care, there is an unequal distribution of information; doctors and other health professionals have specialized knowledge. As a result, individuals must often place their trust in health-care professionals. These health-care professionals who hold and control information have considerable leverage over public opinion.

The media can have a strong influence on public opinion and a short well orchestrated media campaign can provide exceedingly successful results. Interest groups, politicians and others are all trying to influence how the media frame issues and report the news. Favourable media reporting has had very significant impact on decision making. Political leaders and media persons often share a symbiotic relationship. Politicians rely on the media to provide them with information (feedback from their constituency) and to convey their messages to the public. The media, in turn, rely heavily on politicians and public officials for information they use as the basis for their reporting.

Political parties serve as linkages or intermediaries between the citizens and their government. Officially and unofficially political parties have a major role in agenda setting. Party leaders have major roles in determining the agenda of the party in advance of an election and then balancing the conflicting priorities of various interest groups between elections.

Policy formulation : Once it is widely recognized that a problem requires government attention, policy makers must develop a broad policy agenda into specific policy options. Policy formulation involves developing alternative proposals and then collecting, analyzing and communicating the information necessary to assess the alternatives and begin to persuade people to support one proposal or another. The analysis process may involve cost-benefit or cost-effectiveness studies in case the proposals require substantial financial support. Policy formulation involves compromising and bargaining in order to satisfy various interests and build a coalition of support and ideally a consensus among the opposing interests.

Next step involves adoption of specific policies. Known by political scientists as legitimization, government policy must conform to the public’s perception of the proper way to do things to enable its wide acceptance. Frequently, previous policies of the government are good predictors of future policies,

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since people tend to prefer incremental changes over major or revolutionary changes.

In policy formulation, information is gathered, arguments developed and alternatives shaped towards winning the approval of policy makers. Sometimes this is accomplished through rational analyses of the advantages and disadvantages of various alternatives. At other times, policy formulation is a more flexible process that is likely to be influenced by which specific policy maker is involved at specific times and unexpected opportunities to affect change that arise suddenly.

Once the policy has been formulated, statements of government policies and programmes are promulgated. These can be laws, regulations, decisions on resource allocation, court decisions, etc. Equally important, the government can decide that the best alternative is in action.

Policy content : Policies are typically promulgated through official written documents. Policy documents often come with the endorsement or signature of the executive powers within an organization to legitimize the policy and demonstrate that it is considered in force. Such documents often have standard formats that are particular to the organization issuing the policy. While such formats differ in form, policy documents usually contain certain standard components including :

A purpose statement, outlining the reasons for issuing the ●policy and what its desired effect or outcome of the policy should be. Applicability and scope statement, describing who the ●policy affects and which actions are impacted by the policy. An effective date which indicates when the policy comes ●into force. Policies with retrospective effect are rare. A responsibilities section, indicating which parties and ●organizations are responsible for carrying out individual policy statements.

Policy statements indicating the specific regulations, requirements, or modifications to organizational behavior that the policy is creating.

Policy Implementation : Few government policies are self-implementing. Once a policy has been formulated and promulgated, it must be implemented. Even the most brilliantly crafted law, executive order, or court decision will fail to meet the planned goals if it is poorly implemented. Implementation involves three activities directed towards putting a policy into effect. The three activities required for implementation are interpretation, organization and application

Interpretation : It requires the translation of the program language into acceptable and feasible administrative directives. Administrators need to understand the policy-makers intent and fill in the details about how the goals will be accomplished. In many instances, legislation or court decisions are purposefully left somewhat vague to allow administrators wide latitude to respond to changing conditions and conflicting demands.

Organization : This requires the establishment of administrative units and methods necessary to put a program into effect. Resources (money, buildings, staff and equipment) are required to implement a program. Implementers may choose

to organize a new policy through an existing agency, or create a new agency to administer the policy.

Application : Application requires the services to be routinely administered.

The entire process of interpreting policy and designing the organization to implement it is sometimes referred to as ‘strategic planning’. This refers to setting out the broad approaches and methods for achieving the policy goals in practice. It must then be followed by ‘operational planning’ and management in the application phase of implementation.

Policy Evaluation : The last step in Policy formulation is evaluation. The policy is evaluated with the view to assess how well it was implemented including whether the goals and objectives were achieved and what impact was achieved. The results can determine whether the program is to be maintained, expanded, changed, or even terminated. Inputs are provided by the general public, providers and special interest groups. The inputs may range from anecdotal to formal evaluation surveys. The results of the evaluation process will lead to actions similar to that of policy making with the formulation of a revised policy based on the results of the evaluation.

Successful Public Health Policy FormulationPublic health evidence and a population based perspective do not adequately influence public policy in many cases, particularly in sectors other than health. Public health professionals are therefore often frustrated at their apparent failure. Such lack of success should only serve as a motivating factor to generate more support needed from all stakeholders and interest groups to exert a successful influence on the policy makers. Policy making is rarely an event, or even an explicit set of decisions. Policy tends to evolve, subject to continuous review and incremental change. Policy making as it impacts on a large population, is an inherently ‘political process’ and the timing of decisions is usually dictated as much by political considerations as the evidence. As such, policy making requires appraisal of aspects that are scientifically plausible and acceptable besides being possible to implement practically,

Potential pitfalls : A public health practitioner wishing to succeed in ensuring policy formulation must be wary of certain known pitfalls which have been mentioned earlier and take appropriate proactive actions which are reiterated for emphasis as follows :

Prevent failure to understand the intense political nature ●of the policy making. Be realistic about the possible contribution of their ●evidences. Look for rare windows of opportunities for the uptake ●of evidence into policy which may occur when policy maker’s interest and the social climate coincide to support public health evidence in policy making. These need to be recognized early and successfully exploited. Be in possession of appropriate advocacy and ●communication skills. Build relationships with civil servants and policy makers. ●Engaging with media. ●

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SummaryA Policy is a deliberate plan of action to guide decisions & achieve rational outcomes, which can be applied to Govt. , private sector organizations & groups, & individuals. Polices are therefore political, management, financial & administrative mechanisms arranged to reach explicit goals. It differs from rules or law in that law can compel or prohibit behaviors while policy merely guides actions.

Public policy-making is accepted to be political & seldom driven by public health evidence. To achieve healthy public policy, timing & relevance of evidence are crucial. Good policy is designed for successful implementation & one approach to focus attention on progress of policy implementation is to set targets followed by local action. Framing of issues in the media is critical to how they are dealt with, influencing policy & politicians. Actions at the local level are essential, although, international developments are increasingly gaining importance. Globally, public opinion & the media can be critical in getting public health issues onto the policy agenda.

Policies are generally instituted to avoid some negative effect noticed in the organization, or to seek some positive benefit. Policies frequently have unintended consequences or counter-intuitive results. The Policy formulation process typically includes an attempt to assess as many areas of potential policy impact as possible.

Policy cycle is a tool used for analyzing the development of a policy item, having the following stages :

Agenda setting (Problem identification) ●Policy formulation ●Decision making – Regarding Implementation & Policy ●contentPolicy implementation (Requires Interpretation, ●Organisation & Application)

Policy analysis & evaluation (to continue or terminate) ●Successful public health policy requires appraisal of ●aspects that are scientifically plausible & acceptable, being possible to implement practically, besides being wary of certain potential pitfalls & take appropriate proactive actions.

Study ExercisesMCQs and Exercises1. A deliberate plan of action to guide decisions & achieve

rational outcomes, which can be applied to govt. , private sector organizations & groups, & individuals is referred to as _________.

2. Policies are political, management, financial & administrative mechanisms arranged to reach explicit goals : True/False

3. Policies are same as rules or law : True/False4. Public policy-making is accepted to be political & is always

driven by public health evidence : True/False5. The tool used in Political Science for analyzing the

development of a policy item is referred to as _________. 6. The steps in implementation of a Policy are : (a)

Interpretation (b) Organization (c) Application (d) All of the above

7. The entire process of interpreting policy & designing the organization to implement it is referred to as _________.

Answers : (1) Policy; (2) True; (3) False; (4) False; (5) Policy cycle; (6) d; (7) Strategic Planning.

Further Suggested ReadingDeveloping healthy public policy. Don Nutbeam in Oxford Handbook of 1. Public Health Practice. 2nd ed, 2007. 312-320Public health Policy at a Europen level. Martin Mckee in Oxford Handbook of 2. Public Health Practice. 2nd ed, 2007. 354-363Policy development. Helen H Schauffler in Maxcy-Rosenau-Last. Public 3. Health & Preventive Medicine. Appleton & Lange. 14th ed, 1998. 1069-1080. 14th ed, 1998. 1159-1161

73 Strategic Planning in Health Care

Amitava Datta

What is “Strategy”? Strategies are plans or methods that are relatively broad in scope, are usually long term in nature and often involve a significant expenditure of resources. Strategy is about where we want to be in say 5 years from now. It can be considered to be a process as well as a product which enunciates the methodological framework for achieving a vision. The changes or steps which are necessary to be undertaken to enable achievement of this vision should be part of the strategy.

Planning without consideration of strategy is unlikely to be successful. Roughly speaking, strategies are likely to be used in attaining goals, whereas tactics are likely to be used in attaining objectives. Strategies can also be considered to be like other tools used in management for the purpose of helping us achieve the designated task better. Strategies provide us the framework for executing tasks needed for achieving stated goals laid down in the plan.

Health care strategy once enunciated as a statement, helps the wide range of like minded partners to understand, appreciate and address the ways of achieving health care goals by ensuring that they share common priorities which are similarly clearly elucidated. Devising strategies in public health have been recommended as public health projects involve expenditure of large amount of resources for the benefit of large population

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groups. Involvement of public health practitioners in devising health strategy also adequately addresses concerns regarding needs, equity, effectiveness, etc of the health interventions. The strategy process is dynamic and has been likened to a ‘journey’ rather than a static single point statement of intent or purpose.

The planning process is guided by strategy. Good strategies are based on the principles inherent in the relevant policy. However, the strategies proposed to be adopted to achieve the policy goals inform the policy planners of the practicability of putting the policy into action. Strategy thus provides the practical road map, based on practical considerations of opportunities and obstacles, which will be needed to make the vision of the policy achievable. Planning concerns the day-to-day details of how the key steps of strategy are achieved over months and years. The linkage between policy, strategy and planning can be understood better with an example – The Indian government while developing national highways may consider it necessary to state a policy that trauma victims of accidents on the highways must be provided care at a fully functional trauma care centre as soon as possible on occurrence of an accident to save life and limb. The state governments, who are responsible for provision of health services, will then need to develop strategy that within a period of five years trauma care centres are provided in such a manner that the maximum distance from any site of accident on the highway is not more than 30 minutes driving distance to ensure observance of the ‘golden hour’ concept in trauma management. Detailed plans will therefore need to be developed of how the trauma care centres will be developed including upgrading of existing primary health centres and even seeking assistance of private hospitals.

The factors associated in general with successful strategy development have been understood with experience. Any strategy needs to incorporate the values and vision of the people who will actually implement it. The strategy must provide an impetus for forward movement towards achieving goals and the key issues clearly identifiable by planners who will need to address these issues. The uncertainties in the initial stages need to be overcome by ensuring that all participants are focused in their thinking without any constraining lateral thinking. Involvement of dedicated and correctly selected persons, right from inception stage, who will acknowledge the policy context and the needs of planners are essential to successful strategy development. Clarity of purpose, engaging of the right people and right policy context, continued evaluation and appropriate implementation are needed to avoid floundering of strategies which may have sounded grand initially. Similarly, the strategy development needs to avoid becoming too complex by attempting to keep the strategy simple and practical as far as possible without constraining thought.

Health Care Planning Planning is the future oriented, systematic process of determining a direction, setting a goal and taking actions to reach that goal. Planning is considered a basic management function essential to the functioning of all levels of an organization. While planning can be described in terms of techniques and tools, it is also a very complicated social

process that must be mastered by the successful manager and any thriving organization. While every manager must realize the need to plan, there are few prescriptions available for effective planning. Gaps that exist between public expectations and how an institution, sector of government or the society actually functions may point to inadequate planning or lack of planning, rather than poor leadership and implementation.

Planning is as much a social and political process as a technical process. It is essential to recognize that all participatory planning takes place in the context of an organizational culture and a history of relationships between the planning parties (both organizations and individuals). Complications and conflicts often arise over disagreements on the scope of planning strategies and specific actions necessary to achieve goals. Unfortunately, policies sometimes set out grand principles and the courses of action suggested are frequently with scant details and occasionally with little apparent thought as to how they will be implemented.

In the field of public health, even in the present developed world, planning was not common until the 1920s. The increase in funds allotted to public health over the years has created a need to plan for and be accountable for the expenditure of the funds. The planning process was developed especially in countries with socialistic forms of government. India started its development program after independence and adopted the Soviet model of a command economy. The planning structure was enshrined in the Planning Commission which prepared plans for development, recommended funding mechanism through government allocation and monitored the implementation in a “top down” approach. The health sector was also included in the planning process and public health facilities were all funded through governmental sources. Since the execution of the 1st five year plan, India is now into the 11th five year plan. The funding situation till today has not seen much change as regards the public health sector is concerned.

Planning is a form of rational decision making and can be considered to be executed in a step wise manner as follows :

Step 1 : Decide on goals and objectives.

Step 2 : Determine the constraints on the planning process and the likely changes in the environment that may affect how easy the goals and objectives are to achieve.

Step 3 : Figure out what actions, policies and programs to implement.

The details of planning process are discussed in an exclusive chapter in the section on health management.

The term ‘strategic planning’ derives from military jargon. It implies a planning process of significance, usually done by high- level decision makers, that will result in setting the organization’s overall direction. It is often coupled with the term ‘long term’ or ‘long range’ to create an important sounding term ‘long range strategic planning’ which implies a systematic periodic process that sets the overall business strategy of the organization for the years ahead.

Steps in Strategic PlanningStrategic planning is planning directed at the achievement of the planned goals, which are the significant or even ultimate

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ends. As such, it is an extremely important task and falls largely on the shoulders of the leadership. The steps are :

Step 1 : “Planning for plan” stage – the reasons for choosing strategic planning, needs to be clear and communicated to potential stakeholders to lay the groundwork for a shared vision. It can however be an expensive process and funds will be needed for conducting it.

Step 2 : This involves the clarification of organizational mandates.

Step 3 : Agency leaders begin to investigate the values that will govern the agency and the agency’s community relationship. It may include conduct of a stakeholder analysis.

Step 4 : Assessment of the internal and external environments in order to identify the opportunities and the challenges arising from the change process, called the SWOT analysis. The internal assessment looks at the agency’s resources, the process of carrying out the agency activities and the performance outputs.

Step 5 : Identification of the issues to be addressed by the plan. Identify the critical issues and why they are critical and the consequences of not addressing these issues.

Step 6 : Development of strategies to address the issues delineated in step 5.

Step 7 : Stakeholders review, modify and adopt the strategic plan developed in step6.

Step 8 : Creation or revision of the organizational vision. Strategic planning may lead to changes that impact the vision and thus visioning is tied to each step.

Step 9 : Implementation of the plan.

Step10 : Monitoring the implementation and making necessary mid-course corrections.

Operational planning : This is the most common type of planning is engaged in by managers, supervisors and every member of an organization in routine yet essential, day-to-day activities. Besides being most common, it is crucial to providing the services and products in health and human service organisations. When objectives are clearly defined and resources known, operational planning is straight forward. The presently available tools like office automation, computerized scheduling systems, spread sheets, voice mail and electronic mail all provide for better planning and implementation.

Tactical planning : Its an another term having military origins, is “how to” or implementation planning. ‘Program planning’ and ‘project planning’ are other planning types that deal with implementation. Tactical planning implies a broader scope and somewhat longer time horizon than operational planning. Projects can be as massive as a new hospital or a nationwide immunization campaign or as limited as implementing a re-engineered care process or new computer software system. Numerous management tools and techniques, such as a decision support and project planning software, exist to aid in monitoring progress and optimizing project implementation. Planning process can be formal or informal. Formal planning leaves a paper trail with all critical decisions being documented. Informal planning is less organized and more guided by social interactions.

Methods and Tools for PlanningPlanning information and the scientific method : Information is at the core of all planning and a variety of collection techniques may be useful. Gathering and transforming data that is useful in making decisions is at the core of any systematic planning process. Information may come from formal or informal sources or systems.

Mathematical modelling and quality planning : In recent years, various methods / models for improving the quality of products and services have become popular in health care settings. In many situations, organisations and communities must make decisions for the future with little information. Statistical modeling is among the useful techniques in such situations. Mathematical models are often essential because we may be unable to wait for even preliminary empirical data that could aid our decisions. Integrated planning, budgeting and improvement approaches : Over the years management science, industrial engineering and organizational development specialists have developed systems designed to integrate and improve various management functions including planning. Management By Objectives (MBO) swept businesses in the 1970s with the promise of quantitatively linking the performance of every member of the organization with the organization’s goals by using a system of quantifiable objectives. Large organisations developed their own approaches including zero-based budgeting, which America tried to introduce to the public sector. Many management systems have proved to be short term fads. However, other systems and management tools have been successful and worthy of long term adoption.

Role of Public Health Practitioner in Health Care PlanningAs a public health practitioner it is likely that he will need to work with the following in the field of health planning :

Managers and clinicians in organizations who are involved ●in purchasing and providing health care services. Patients and users who will have experienced most of the ●good and bad aspects of any system. In western countries, citizens panels can be a good way to do this, but are time-consuming and expensive. In India the role of members of the ‘panchayati samiti’ or ‘rogi kalayan samitis’ serve a similar purpose. There are likely to be existing planning groups and one ●will need to work with these to be effective, but to be useful these planning groups need to be part of the power structure, with authority over budgets.

The public health practitioner may need to help develop specific options for implementing policy, including new ‘models of health care’, involving changes to inputs or processes. The role will involve presenting to health sector civil servants or politicians and other health care professionals, research evidence on the effectiveness of relevant health interventions.

They may be tasked to also provide information for planning. This includes quantifying how the new models of health care will affect health services - patterns of provision, activity, budgets and outcomes. Based on the output from the above mentioned three tasks, usually an implementation plan for a

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strategy or project proposal is developed using an agreed work plan.

The public health practitioner will also be called upon for dissemination and supporting decision-making. It is necessary to analyze thoroughly the implications of the policy options produced in earlier tasks. The planning cycle then begins again with the monitoring and evaluation tasks, to determine what effect the implemented changes are having on the existing health system.

Potential Pitfalls and Fallacies in Health Planning Completing the implementation of planning decisions may usually take several years. Often there will be inadequate time but based on the suggested framework, it should be possible to reap the most benefit in the time available for health planning.

It must be appreciated that Planning rarely goes ‘according to plan’ as circumstances and personnel change. The intended objectives in planning are usually only partially attained and there are often unintended consequences. Therefore, monitoring the effects of planning and making adjustment are crucial. The public health practitioner should therefore be ready to accept only partial implementation of the planned intervention on the basis of changed circumstances, be ready with the evaluation process to assess the needs for changes in the plan which can be then presented to the decision makers and not become emotionally attached with the original plan.

Success in the planning process is usually not absolute. Although there should be specific objectives and measurement of their attainment, however, success, like the planning process, usually comes little by-little. That implies that monitoring and evaluation are essential to successful planning. Similarly, discussions with colleagues and formal evaluations, including workshops, are important.

It is clear that the terms policy, strategy and planning are linked and seen as being part of hierarchy of time-scale, but definitely not a hierarchy of challenge or importance in achieving aims. It is therefore important for public health practitioners to possess a clear understanding of the procedures involved in devising health care strategy and health care planning to meet the stipulated goals in public health.

Summary Strategies are plans or methods that are relatively broad in scope, long term & often involve a significant expenditure of resources. It is a process as well as a product. Strategies are likely to be used in attaining goals, whereas tactics are likely to be used in attaining objectives. Devising strategies in Public health have been recommended. Planning without strategy is unlikely to be successful.

Planning needs to be compared to the process of strategy development as both the processes have distinct entities although they are linked. Good strategies are based on the principles inherent in the relevant policy. Strategy thus provides the practical road map, based on practical considerations of opportunities & obstacles, which will be needed to make the vision of the policy achievable. It must provide an impetus for forward movement towards achieving goals & the key issues

clearly identifiable by planners who need to address them.

Planning is the future oriented, systematic process of determining a direction, setting a goal and taking actions to reach that goal. It is as much a social & political process as a technical process. This process was developed especially in countries with socialistic form of government.

Planning is a form of rational decision making & can be considered to be executed in a stepwise manner as follows :

Decide on goals & objectives. ●Determine the constraints on the planning process. ●Figure out what actions, policies & programs to ●implement.

Roher describes three planning models that are typically used in public health - Rational planning model, Community development model and Activist model. The ‘Strategic planning model’ applies to both organizational reform & community health planning & Bryson developed a ten step procedure for it. ‘Operational Planning’ is the most common type & is crucial to providing services & products in health. ‘Tactical Planning’, ‘Program Planning’ & ‘Project Planning’ are other planning types that deal with implementation.

The methods & tools for planning include the following : Planning information & the scientific method. ●Mathematical modeling & quality planning. ●Integrated planning, budgeting & improvement ●approaches.Funding of plan. ●

A Public health worker needs to work with managers, clinicians, patients, users & existing planning groups to be effective. Besides he is also required to help develop specific options for implementing policy, provide information for planning & disseminate & support decision making.

Planning rarely goes ‘according to plan’, as circumstances & personnel change. Therefore monitoring the effects of planning & making adjustments are crucial. It is a continuous process & evolves as it unravels. Success in the process is usually not absolute. Policy, strategy & planning are linked & seen as being part of hierarchy of time-scale, but definitely not a hierarchy of challenge in achieving aims.

Study ExercisesMCQS & Exercises1. Plans or methods that are relatively broad in scope, long

term & often involve a significant expenditure of resources are referred to as _______________.

2. _________ are likely to be used in attaining goals, whereas __________ are likely to be used in attaining objectives.

3. The planning process is guided by strategy : True/False.4. Strategy development ensures progression in small

incremental but predictable steps : True/False.5. Health care priorities need not be examined & debated, but

can be hidden or accidental : True/False.6. India adopted the ____________ model of a command

economy after starting its development program. 7. The planning which is empowerment oriented & promotes

local citizen partnership in planning activities is : (a) Rational planning model (b) Community development model (c) Activist model (d) Strategic planning model.

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74 Bringing about Equality in Health Care

Amitava Datta

Concepts of EquityThe concept of equity dates back to early human civilization and is linked to disadvantaged, impoverished, deprived human beings. Equity has been discussed by politicians and statesmen from ancient times when comparing the ‘haves’ with the ‘have nots’. The central dogma of the socialist pattern of politics is “To each as per his need” and “from each as per his ability”. Equity includes the concepts of fairness, justice and equality which have been the central theme of modern day democracies. In the health sector, it is assessed by comparing levels of health of individuals or a community, or the ability of individuals and communities to obtain health care.

There are two forms of health equity. “Horizontal” equity refers to equal treatment for equal needs, for example, the devotion of equal resources to patients with similar conditions, or equal access to care for people with equal needs. The components of horizontal equity in health are described as providing equal resources for people with equal needs, providing equal access to health care for people with equal needs, providing equal utilization of health care by those with equal need and providing equal health aimed at reducing inequalities in health status between populations.

“Vertical equity” refers to unequal treatment for unequal needs; that is treating individuals who are unequal in society in different ways in order to overcome the effects of differences in their social or clinical situation. Vertical equity can be achieved by ensuring that individuals with more need should have more treatment to bring them upto the same level as others with less need. This might include devoting more resources to patients with serious conditions than to those with trivial conditions or financing health care according to the ability to pay. The alternative perspective points out that equal use for equal need does not necessarily always result in unequal use

of unequal need. If mildly diabetic persons are treated in the same way regardless of gender, age or ethnicity, but severely diabetic men are more likely to receive treatment than severely diabetic women, then equal use for equal need (- the concept of horizontal equity) occurs for mild diabetes but not for severe diabetes (where there is vertical inequity). The central theme of “need” therefore determines equity.

It must be recognized that differences in health care use are not biased if they are due to differences in need. Such differences demonstrate equal but fair care. The fair distribution of health care should be considered from two related perspectives. The first is that people with equal needs should be treated the same (equal use for equal needs). This is referred to as the achievement of horizontal equity. For example, if we consider differences in clinical need, such as differences in disease severity or presence of co-morbidity, then patients with similar levels of disease severity should be equally likely to receive an effective intervention regardless. The alternative perspective is that people with greater clinical needs should have more treatment than those with lesser needs (unequal use for unequal need). This is referred to as the achievement of vertical equity. Thus, patients with severe disease should be more likely to receive an effective intervention compared with patients with a milder form of the same disease, regardless of age or gender.

Theories of EquityAlthough defining equity is relatively easy, however it becomes difficult to decide what is fair or just. Most of the health and health care issues related to equity come under the broad category of “distributive justice” – that is, how benefits, resources and burdens of society are distributed to each individual. The manner in which members of the society cooperate and the value system in the society determine its theory of equity. Theories of distributive justice differ in different political systems and societies. Some of these known theories of distributive justice can be broadly divided into libertarian, liberal and collectivist.

Libertarian theory : The ‘Libertarians’ believe in the protection of individual freedom, namely, political liberty, freedom of speech

8. The model that has the advantage that it applies to both organizational reform & community health planning is the: (a) Rational planning model (b) Community development model (c) Activist model (d) Strategic planning model.

9. The ten step procedure for strategic planning was given by _______________.

10. The form of planning which is a type of implementation planning is : (a) Tactical Planning (b) Program Planning (c) Project Planning (d) All of the above.

Answers : (1) Strategies; (2) Strategies, tactics; (3) True; (4) False; (5) False; (6) Soviet; (7) b; (8) d; (9) Bryson; (10) d.

Further Suggested ReadingsAn introduction to health care strategy. David Puncheon in Oxford Handbook 1. of Public Health Practice. 2nd ed, 2007. 376-381Strategies for health services. Martin Mckee and Josep Figueras in Maxcy-2. Rosenau-Last. Public Health & Preventive Medicine. Appleton & Lange. 14th ed, 1998. 1069-1080. 14th ed, 1998. 1889-1910Structures and Strategies for public health intervention. Don Nutbeam and 3. Marilyn Wise in Maxcy-Rosenau-Last. Public Health & Preventive Medicine. Appleton & Lange. 14th ed, 1998. 1069-1080. 14th ed, 1998. 1873-1888

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and economic freedom. People are considered to be entitled to what they have, provided it was acquired justly. It has been propagated that for the state to raise taxes from individuals in order to provide services for the least advantaged class is a form of theft by the state against the private citizen. One obvious limitation to libertarian theory is that biological and genetic influences mean that the distribution of health cannot be described as fair. This has implications for the allocation of health care under a libertarian system.

Liberal theory : It also emphasizes individual liberty, but also includes the concept of “need” in its definition. Liberal theory also relies on the free market to allocate resources, but also recognizes the unequal distribution of assets among individuals. State intervention is therefore deemed appropriate when the market fails to safeguard the needs of all the members of society. Public health interventions such as universal immunization for measles or polio are based on utilitarianism principles.

Collectivist theory : This theory is based on 3 main rules- equality, freedom and fraternity, though the dominant concern is equality. Collectivist theories are therefore egalitarian and are in favour of positive, equalizing measures to re-distribute rights and wealth.

The Concern for Removal of Health InequalitiesIn the recent years, interest in equality, equity and health of the poor has begun to assume a more important place in international agenda. The 1970s ended in the declaration for “Health for All” movement. The Alma-Ata conference in 1978, lead to a strong focus on community orientation with governments supporting or encouraging the development of free health care services. The ‘primary health care’ approach was advocated by WHO to achieve provision by all countries of basic health care services to all their citizens.

Pragmatic examination of the various facets of primary health care approach created doubts whether this approach was capable of providing the dramatic improvements ascribed to it. “Health sector reform” became the new buzzword. The focus shifted to sustainability and efficiency rather than only concern for the health of the poor people living in developing countries. Importance was also given to health, nutrition and population by WHO during the late 1990s. The focus still remained on the poor – World Health Report for 1999 laid stress on reducing the burden of excess of mortality and morbidity of the poor. Overall, the situation in the recent times has become encouraging for those concerned with health equity and the health of the poor. However, it is uncertain whether it will be enough to guarantee significant improvements in health equity in a sustainable manner. The dispute ridden areas in Africa and Asia, which are taking their toll in terms of worsening human misery, are a major source of health inequity today in the world.

The Problem of Poverty and HealthPoverty and ill-health are interlinked. It is known that poor countries tend to have worse health outcomes than better-off countries. Within individual countries, poor people have worse health outcomes than better off people. The association between poverty and ill-health reflects causality running in both directions. Illness or excessively high fertility may have a

substantial impact on household income and may even make the difference between being above and being below the poverty line. Furthermore, ill-health is often associated with substantial health care costs. But poverty and low income also cause ill-health. Poor countries and poor people within countries, suffer from a multiplicity of deprivations that translate into high levels of ill-health. Poor people are thus caught in a vicious circle- poverty breeds ill health, ill-health maintains poverty.

Latin America appears to have higher inequalities in child health between poor and non-poor than other parts of the developing world, whatever health indicator is used. By contrast, inequalities in child mortality and malnutrition are less pronounced in sub-Saharan Africa than in North Africa, Asia and the Near East, but the opposite is true of inequalities concerning diarrhoea and acute respiratory infections. Socioeconomic inequalities in health seem to be widening rather than narrowing. This is true of both the developing and developed world. Three points are worth highlighting.

First, the world today knows a good deal about the extent of health inequalities between poor and non-poor in developing countries and a reasonable amount about inequalities in health determinants. Most striking in this connection is the failure of publicly financed health care to reach the poor in almost all developing countries.

Second, too little is known about the relative importance of inequalities in the determinants of health and health service utilization. Present knowledge suggests that inequalities in health and most probably in service utilization, largely reflect inequalities in variables at the individual and household levels, such as education, income, location and housing characteristics. Policies aimed at combating health sector inequalities should therefore aim to reduce both inequalities in the quality and availability of health services and inequalities in income, knowledge (especially health-specific knowledge), accessibility of health services, availability of safe drinking-water and sanitation, etc.

Third, too little is known about the impact of programmes and policies on health sector inequalities. There is undoubtedly a large gap in our knowledge on how best to reach the poor in the health sector. In order to fill this gap, more work is needed along the lines of the above studies related to health sector inequalities and public policy.

Action to Overcome Health InequityHaving accepted that poverty is linked to almost all health inequity, it is necessary to attempt to overcome health inequity. The different approaches which may be considered are measures to improve the health of the poor, reducing poor-rich health inequalities or redressing health inequities. The approaches may be individually different. Those who approach health from a poverty viewpoint are typically concerned with improving the health of the poor alone rather than with reducing the poor-rich health differences. To improve the poverty status, the concept of ‘poverty line’ is used. While the concern for lessening poverty and improving the health of the poor is widespread, it is not necessarily the most preferred way. Many focus on inequalities in general and with respect to health in particular. Health inequalities have played a more central role than the

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health of the poor alone in European concern. There appears to be different views on the most appropriate strategies for the reduction of inequalities. The aspects which must be borne in mind while considering the strategies are – how is the inequality to be measured, what aspects of inequality are most important and whether the focus should be local or global.

The concern for attaining of health equity is no longer the domain of health professionals only. It has been well appreciated that reduction in health inequity can be attained by the world through comprehensive multi-disciplinary action involving diverse resources. The adoption of the Millennium Development Goals by World Assembly in 2000, is the latest international initiative to attempt at equity including health equity. This aspect has been discussed in detail in an earlier chapter on health for all, primary health care and MDGs and the readers are advised to refer to the same. It is considered necessary to clearly highlight the appreciation by the world community of the prevalent causes of inequity and health inequity not only between countries but also within countries and the proposed means to reduce this inequity. The salient features of MDGs in relation to health equity are as follows :

Goal 1 - Eradicate extreme poverty and hunger : The fundamental problem affecting equity among mankind being poverty and its related fact, hunger, it is extremely apt that this fact has been stressed by United Nations in stating it as the first goal of all nations. It has been proposed to reduce by the year 2015, the number of people who earn less than $ 1 per day by 50% in low and middle income countries and also reduce by 50% the persons who suffer from hunger.

Goal 2 - Achieve universal primary education : Illiteracy has rightly been considered as a major impediment to attainment of equity by all people. Hence the stress to at least attain primary education by all children of the world. To reach the education goal, countries must first enroll all school-age children. Then they must keep them in school. Although not officially included as one of the MDG indicators, primary completion rate is increasingly used as a core indicator of an education system’s performance.

Goal 3 - Promote gender equality and empower women : Women have an enormous impact on the well-being of their families and societies – yet their potential is not realized because of discriminatory social norms, incentives and legal institutions. And while their status has improved in recent decades, gender inequalities remain pervasive. Gender inequality starts early and keeps women at a disadvantage throughout their lives. Educating women and giving them equal rights is important for many reasons- It increases their productivity, raising output and reducing poverty; it promotes gender equality, within households and removes constraints on women’s decision making thus reducing fertility rates and improving maternal health; and educated women do a better job caring for children, increasing children’s chances of surviving to become healthier and better educated.

Goal 4 - Reduce child mortality : The target is to reduce by two-thirds the under- 5 years mortality rate by 2015. Immunization is an essential component of activities to reduce child mortality. Child mortality is also closely linked to poverty. In 2002, the average under-five mortality rate was 121 deaths

per 1,000 live births in low-income countries, 40 in lower-middle-income countries and 7 in high-income countries.

Goal 5 - Improve maternal health : The target is reduce by three-quarters the maternal mortality ratio. Women in high-fertility countries in Sub-Saharan Africa have a 1-in-16 lifetime risk of dying from maternal causes, compared with women in low-fertility countries in Europe, who have a 1-in-2, 000 risk and in North America, who have a 1-in-3, 500 risk of dying. Greater access to family planning, providing rapid access to emergency obstetrical care, including treatment of hemorrhages, infections, hypertension and obstructed labor and supported by the right environment are suggested interventions.

Goal 6 - Combat HIV/AIDS, malaria and other diseases : The economic burden of epidemics such as tuberculosis, malaria and HIV/AIDS on families and communities is enormous. Estimates suggest that tuberculosis costs the average patient three or four months of lost earnings, which can represent up to 30 percent of annual household income; Malaria slows economic growth in Africa by about 1.3 percent a year; and when the prevalence of HIV/AIDS reaches 8 percent the cost in growth is estimated at about 1 percent a year. The targets are that by 2015, halt and start reversing the spread of HIV/AIDS and the incidence of malaria and other diseases.

Goal 7 - Ensure environmental sustainability : Improved water and sanitation reduce child mortality and better drainage reduces malaria. It also reduces the risk of disaster from floods. Managing and protecting the environment thus contributes to reaching the other Millennium Development Goals. Fortunately, good policies and economic growth, which work to improve people’s lives, can also work to improve the environment. The targets are to halve by 2015 the proportion of people without sustainable access to safe drinking water and basic sanitation, besides achieving by 2020 a significant improvement in the lives of at least 100 million slum dwellers. The interventions suggested include reversing the denudation of forests, reduce the existing pressures on biodiversity by declaring protected areas and species, change in use of energy sources away from fossil fuels and reducing carbon dioxide emission by use of better technology

Goal 8 - Build a global partnership for development : It is advocated to have an open, rule-based trading and financial system, more generous aid to countries committed to poverty reduction and relief for the debt problems of developing countries. It draws attention to the problems of the least developed countries, which have greater difficulty competing in the global economy. It also calls for cooperation with the private sector to address youth unemployment, ensure access to affordable, essential drugs and make available the benefits of new technologies. In March 2002 leaders from developing and high-income countries came together in Monterrey, Mexico, to discuss new strategies for attacking global poverty. Rich countries made new commitments that would increase official development assistance in real terms by about $16 billion a year by 2006.

Health inequity has come to the forefront of international concern in recent years. With globalization, boom in information technology and communication, besides relative affluence and overall development in many parts of the

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world, there is greater awareness of the existing disparity in health equity in different parts of the word. This awareness exists at the individual, governmental and institutional levels. Philanthropic institutions and professional bodies are investing their own resources in developing and implementing strategies to overcome many of the identified inequities. It can be reasonably anticipated that the pace of reduction of health inequities will proceed in a sustained manner as planned by the international agencies like United Nations with the full participation of national governments and assisted by like minded donor agencies.

Summary Equity includes the concepts of fairness, justice & equality, which in the health sector is assessed by comparing levels of health of individuals or a community or their ability to obtain health care. The two forms of health equity are ‘Horizontal equity’ which refers to equal treatment for equal needs & ‘Vertical equity’ which refers to unequal treatment for unequal needs. The central theme of “need” therefore determines equity.

Differences in health care use are not biased if they are due to differences in need. Such differences demonstrate equal but fair care. It is essential to take account of different levels of clinical need in order to measure the fair use of health care.

Most of the health & health care issues related to equity come under the broad category of “distributive justice”. Theories of “distributive justice” can broadly be divided into : Libertarian theory, Liberal theory and Collectivist theory

Poverty has long been associated with health inequities. Also poverty & ill-health are interlinked. The international community has an increasing concern over health inequities in recent times. The different approaches which may be considered to overcome this are to improve the health of the poor, reducing poor-rich health inequities or redressing them. The priority need at present is to begin applying what is already known to obtain political commitment & develop effective intervention strategies, besides redefining health goals.

The adoption of Millennium Development Goals by World Assembly in 2000, is the latest international initiative to attempt at equity including health equity. It may be expected that the pace of reduction of health inequities will proceed in a sustained manner as by the international agencies with participation of national Govts. & assistance by like minded donor agencies.

Study ExercisesMCQs and Exercises1. The equity which refers to equal treatment for equal needs

is referred to as _________________2. ‘Vertical equity’ refers to equal treatment for unequal needs

: True/False3. The central theme of “need” determines equity. True/False 4. The theory of equity which emphasizes individual liberty

with the concept of need is : (a) Libertarian (b) Freedom (c) Liberal (d) Collectivist

5. The theory of equity which is based on 3 main rules of equality, freedom & fraternity is : (a) Libertarian (b) Freedom (c) Liberal (d) Collectivist

6. The adoption of Millennium Development Goals by World Assembly took place in the year : (a) 1999 (b) 2000 (c) 2001 (d) 2002

7. As per the MDGs, the target of Goal 4 is to reduce under - 5 mortality by _________ by the year __________.

8. As per the MDGs, the target of Goal 5 is to reduce maternal mortality ratio by one-fourth : True/False

Answers : (1) Horizontal equity; (2) False; (3) True; (4) c; (5) d; (6) b; (7) Two-thirds, 2015; (8) False.

Further Suggested ReadingsMeasuring and monitoring health inequalities and auditing inequity. Julian 1. Flowers in Oxford Handbook of Public Health Practice. 2nd ed, 2007. 170-183Improving equity in health care. Anna Donald in Oxford Handbook of Public 2. Health Practice. 2nd ed, 2007. 412-419Reducing health inequalities in developing countries. Davidson R Gwatkin 3. in Oxford Textbook of Public Health. 4th ed, 2002. 1791-1810.

75 Health Care Quality

Amitava Datta

The word “quality” can convey different meanings. It can convey a high degree of excellence, e.g. “a quality product”, or a degree of excellence or the lack of it e.g. “work of average quality”, or a property of something, e.g. “the addictive quality of alcohol”. Usually however the word is used in the world of business where it is subjective term for which each person has

his or her own definition. In technical usage, quality can have two meanings – first, the characteristics of a product or service that bear on its ability to satisfy stated or implied needs and second, a product or service free of deficiencies. It has been opined that “Quality in a product or service is not what the supplier puts in. It is what the customer gets out and is willing to pay for. ” Quality thus has no specific meaning unless related to a specific function and/or object. Quality is a perceptual, conditional and somewhat subjective attribute.

Health care Quality also has many facets which are needed to be understood as the health care manager, usually a public

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health specialist is expected to assess the quality of health care in given community. According to the United States Institute of Medicine, ‘Quality of health care’ is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. This definition explicitly acknowledges that ‘Quality’ is measured as a scale or degree, encompasses all aspects of care and can be observed from an individual as well as a population perspective. The quality ‘outcomes’ do not specify for whom, thus allowing differing perspectives on which aspects of quality are most important (professional, patient, public, political, etc). There is rarely a causal link between the quality of care and outcome. The phrase ‘consistency with current professional knowledge’ indicates that the quality of care can only be judged relative to what is known at that moment in time.

Defining and Measuring the Quality of Health CareAlthough it is apparent that quality often being perceived as difficult to define, however the quality of a service is the degree to which it conforms to certain preset standards of good care. An important dimension of measuring quality is to make the standards against which one is assessing quality absolutely explicit and preset. It has been expounded that there are six dimensions of quality which can be considered while measuring the quality of a product or practice – effectiveness, efficiency, acceptability, access, equity and relevance which are explained as follows :

Effectiveness : measures the desired effect.

Efficiency : measures the cost of the input as compared with the cost elsewhere for the same requirement (treatment) /service.

Acceptability : measures how humanely and considerately the treatment/service is delivered. What does the patient think of it? What does an observant third party like his attendant think? To what extent does the treatment /service conform to patient/public expectations and how much are they utilizing it.

Access : measures whether people get this treatment/service when they need it. Identifiable barriers like large distances to travel, inability to pay and waiting times also influence the access.

Equity : measures whether all groups of patients are being fairly treated compared to others or is there discrimination in who gets the service / treatment.

Relevance : compares the treatment / service with the best that could be achieved, taking account the needs and wants of the population.

Measurement of ‘Quality’The quality of health care can be assessed by measuring the structure, process, or outcomes. “Structure” (often also referred to as “inputs” in certain managerial parlances) refers to the components of the health-care system like number of health centres, the number of beds in the health centre, the ratio of the number of nurses and doctors to the number of beds in a centre, the presence of laboratory, x-ray machine, etc.

Although the absence of adequate health structure has strong negative influence on health, however, mere presence of health care structure cannot necessarily improve the health of the population.

The “processes” of health care are those things which are delivered to individual patients in specific clinical circumstances, such as prescription of certain medications, conduct of diagnostic tests and therapeutic procedures, etc.

“Outcomes” refer to health states such as recovery, death, disability, improvements in functional status, etc. Measuring outcomes appears logically to be the best measure of the quality of health care but there are serious limitations because of the following reasons :

Many determinants of outcome are poorly understood or not under the control of the health-care system. For example the recovery of a patient treated with angioplasty after a heart attack cannot be clearly measured. His functional state may not be an indication of the competence of the cardiologist or the hospital as various other factors like the severity of the disease process, socio-economic support system of the patient and his age, occupation, etc may play a major role on his complete physical, social, mental and economic rehabilitation

For many chronic conditions, the time between the key processes of care and the outcomes may be very long. For example, untreated diabetes may be asymptomatic for years before leading to retinal damage or kidney failure.

Therefore, use of outcome measures of quality is usually restricted to areas where the above problems are not present, for example in measuring mortality following major surgical procedures in a hospital.

By assessing the health processes as indicators of health care quality, we measure what is delivered to patients under specific circumstances and they must be strongly linked to subsequent outcomes, preferably by good evidence from epidemiological studies like randomized clinical trials, or professional consensus. A good example to study the effect of a “process” is an immunization campaign as a means of reducing morbidity and mortality due to an infectious disease like measles.

For all of these reasons, measures of health-care quality are dominated by “process” measures rather than “outcome” measures.

Measuring Quality of CareIn order to assess and improve the quality of health care provided to a community, it first must be measured. For example, let us examine an operational statement about a specific health-care process – “if a patient has diabetes and is over the age of 55 and is at increased risk for cardiovascular disease then he should be offered treatment with an ACE inhibitor”. To be a quality measure it will need to be applied to a specific population and data sources and spell out precisely how patients with diabetes are to be identified, what factors (and how they are measured) are considered to be evidence of increased cardiovascular risk and what efforts count in terms of offering ACE inhibitor therapy.

Criticisms of the use of quality indicators or measures include that the selected items aren’t necessarily related to improved

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Comparative Quality StandardsIn contrast to the ‘appropriateness method’ for specific patients and interventions a variety of standards have been set by comparing performance of different clinicians or services. Take the example of normal delivery by gynecologists. It may be that after an uneventful period of recovery in hospital and discharge in the case of 100 such primi-gravida cases, there are unplanned readmission rate for post delivery reproductive tract infection which varies from 1% to 5% in different hospitals. What rate of unplanned readmission should we adopt as an indicator of high-quality care? If we adopt the lowest, we may be ignoring avoidable problems even in the best units. On the other hand, we may be setting impossible targets that cannot be achieved.

The different levels of standards usually used are Excellent standards- these are typically standards achieved ●by the ‘best’ services, such standards can identify what’s possible and challenging excuses. Minimal acceptable standards- are those below which no ●service should fall; this may arbitrarily be what 90% of hospitals are achieving.

In practice, the standards must be such that it is clear what individuals need to do to achieve them and they must be attainable. i.e. a balance needs to be struck between standards of excellence and achievable standards. These standards must be agreed to, implemented and achieved preferably locally. Standards developed in one country may not necessarily be applied in another. Most standards applied in medicine are based on achievements in western countries like USA. However adaptation for local conditions may be needed before its acceptance. The standards may also vary. For example, exacting standard of sterility will be required in a cardiology OT or orthopedic OT. However it may not be necessary or cost effective to insist on same standards in a general surgery OT. Not only do different people value different dimensions differently but the same individual may value different dimensions over time or depending on the condition that needs attention.

Perspectives on Improving Quality Assessing quality through mechanisms such as monitoring, audit and evaluation is essential. However, there are different philosophical and practical approaches to how a system’s quality is maintained and improved. Comparison in medical care giving will invariably identify bad doctors or bad procedures. It is difficult to identify the other end of the spectrum – good doctors or good procedures which can be the standard which is aimed to be achieved. After assessment, If a ‘punitive’ attitude is taken, it need not necessarily lead to improvement in standards. In the ‘system improvement’ approach, emphasis is laid on learning from mistakes but some mistakes will have to be permitted although all efforts made to lessen their chance of occurrence.

Highlights of Measurement of Health QualityThe issues which must be considered when measuring quality of health care are :

The need to measure quality ●Definition of the aspects which have been planned to be ●measured

health outcomes and that focusing attention on certain measures will lead to decreasing attention on other aspects of health care, which may be as much or more important. Therefore, development of measures should aim to be as rigorous as possible and cover a broad array of aspects of health care, to better represent care and minimize the ability to distort or game the measurement system.

The Appropriateness of Clinical InterventionsThe ‘appropriateness’ of health-care interventions have been defined as the degree to which benefit of care exceeds the expected negative consequences. Through this concept it is possible to establish a set of rules or standards of care based on identifying appropriate interventions which should be used (or not used) in a specific clinical situation.

The ‘appropriateness method’ was developed as a pragmatic solution to the problem of trying to assess for which patients certain surgical and medical procedures are ‘appropriate’. For example, it may be stated that in the case of middle aged male patients detected to have single or double vessel blockage on coronary angiography, they be offered angioplasty. However for triple vessel blockage in similar age group of patients, coronary bypass graft surgery be offered. Attempts are made to determine ‘appropriateness’ with a thorough literature review, but this may prove insufficient for developing comprehensive, clinically detailed measures of appropriateness in some cases. Several fundamental concepts assist in developing the ‘appropriateness’. Some of these are :

Clinical judgment is required to supplement findings ●published in medical literature which on its own is insufficient. All relevant clinical disciplines must be involved ●Indicators must be specific and described in sufficient ●clinical details specially with respect to risks and benefits of the procedure. The definitions of appropriate care should be comprehensive ●and applicable to a very large number of the possible clinical situations relevant to the procedure. Applying the method must be feasible in terms of ●resources.

The key elements of the appropriateness method are somewhat arbitrary and hence the method has been criticized because there is potential for variability in the process due to the composition of the panel or the actual panel members themselves as well as the role of the moderator. There is a possibility of misclassification bias of individual scenarios and the process lacks specificity about what outcomes are being considered for individual scenarios. The ratings may reflect nothing more than codifying existing clinical dogma. A substantial amount of methodological research has been done to try and assess these criticisms which have determined that clinicians who perform the procedure are more enthusiastic about its use. Favourable predictive validity for appropriateness ratings have been reported for several procedures, including coronary angiography and coronary revascularization. The sensitivity and specificity of the method for identifying inappropriate over use has been estimated at varying between 68% and 99% and under use 94% and 97% respectively.

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Choice of investigators involved in the assessment process. ●Care to consult all those with a stake in the issue and their perspective on quality understood. Aspect of quality planned to be assessed may need to ●have been analysed before deciding on which ones will be measured. Perspective of quality which will be considered needs to ●be decided based on rational understanding of advantages and limitations of each. Aspects of Population appropriateness and Individual ●appropriateness Approach planned to be used ●Dimension planned to be assessed - structure, process or ●outcome

Taking Action to Improve QualityAfter conducting an assessment of quality of health care, the logical sequalae must be to improve the quality of health care. By definition, a quality improvement project is a clearly articulated plan to improve the quality of health care. Commonly, the quality improvement will be attempted to incorporate one or more aspects and include Safety, Timeliness, Effectiveness, Efficiency, Equity and Patient-centeredness.

To implement a successful improvement project it is necessary to develop ‘will’ (that is support of senior leaders and clinicians), have good ideas and have a carefully thought out strategy for execution. The ‘ideas’, or ‘change package’, may be a strategy for implementing clinical practice guidelines that has already been tested and is ready for local adoption and adaptation, or may require innovation if no one has achieved quality improvement in a similar setting before.

Obtaining the Support of Senior Leaders and CliniciansSenior leaders and clinicians may not be directly involved in the day-to-day work of improvement, but their support is crucial to success. ‘Not all change is improvement, but all improvement is change’ and organizations tend to resist change. By getting the leaders to agree to the changes will help remove obstacles to change. This can be achieved by use data to demonstrate the opportunities for improvement, build a business case for improvement, periodically get reports on safety and quality for consideration of leaders and if available use stories of real patients to reinforce the suggested change.

The Business Case for ImprovementTo project a business case for improvement it will be necessary to use data to show how the projected changes will improve results either directly or indirectly besides reduction of wastage in the system or other business parameters which either increase efficiency or reduce losses.

Forming Quality Improvement TeamThe team should to implement the quality improvement must include representatives from all disciplines and departments involved in the improvement work, who are preferably enthusiastic about the changes which have been demonstrated to them. The important stakeholders must be incorporated and not necessarily all senior persons. The team must be encouraged to study the existing process and help identify opportunities

for improvement. They must collaborate and share ideas with institutions with similar problems or where similar problems have been solved to arrive at an appropriate improvement strategy. While implementing the improvement project, it is necessary to set clear measurable goals, like, ‘to reduce hospital acquired infections among newborn by 50 percent over a six months period of time’. The measures of the outcome must be specified so that the improvement can be measured, documented and communicated in the form of graphs, charts, etc. The team must be motivated and prepared for hard work and provided required commitment and support from the leadership in order to be able to succeed in implementing the desired changes.

SummaryThe term ‘quality’ refers to perceptual, conditional and a subjective attribute of a product or service, to satisfy stated or implied needs. According to United States Institute of Medicine, ‘ Quality of health care’ is the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge. In order to assess, improve and compare the quality of health care provided to the community, it must first be measured against defined standards, to assess the quality. There are six dimensions to measure the quality of health care services viz- effectiveness, efficiency, acceptability, access, equity and relevance. The quality of health care can be assessed by measuring the structure, process or outcomes. The appropriateness method of health care interventions is the degree to which benefits of care exceed the expected negative consequences. This method has been criticized because of potential for variability, besides lacking specificity. Comparative method utilizes comparing performance of different clinicians and services either by using established excellent standards or minimal acceptable standards. Assessing quality through mechanisms such as monitoring, audit and evaluation is the heart of system improvement approach. Quality improvement has to incorporate aspects of safety, timeliness, effectiveness, efficiency, equity and patient centeredness.

Study ExercisesMCQs1. Which dimension of Health Care Quality measure, assesses

the cost of input compared with cost elsewhere for the same reqmt : (a) Effectiveness (b) Efficiency (c) Relevance (d) Acceptability.

2. The quality of health care can be assessed by measuring : (a) Structure (b) Process (c) Outcome (d) All.

3. Measures of health care quality are dominated by “process” measures rather than “outcome” measures : True/False

Answers : 1. (b); 2. (d); 3. True.

Further Suggested ReadingUnderstanding health care quality. Paul Shekelle, David Pencheon and David 1. Melzer in in Oxford Handbook of Public Health Practice. 2nd ed, 2007. 430-441Taking action to improve quality. Charlie Tomson and Rashid Massoud in in 2. Oxford Handbook of Public Health Practice. 2nd ed, 2007. 442-451Quality assurance and quality improvement. Richard S Kurz in Maxcy-3. Rosenau-Last. Public Health & Preventive Mediicne. Appleton & Lange. 14th ed, 1998. 1069-1080. 14th ed, 1998. 1162-1164

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76 Social Marketing

Anuj Bhatnagar

Social marketing can be described as the process of motivating people (through application of marketing techniques) to voluntarily adopt behaviour which is beneficial to them, over other ‘potentially’ harmful behaviour. It can be defined as ‘the design, implementation and control of programs seeking to increase acceptability of a beneficial social idea or practice in target group(s) (Philip Kotler 1975). Social marketing is a means to assist in gaining acceptance and willingness on the part of the concerned individuals to adopt a particular behaviour. For example, for a new vaccine to be successful, it should first be developed and produced, then social marketing should be used to create acceptance of need for the vaccine among physicians and public, so that it is used by the target groups. The term ‘Social Marketing’ gained popularity when the Journal of Marketing brought out an issue on the topic in July 1971 (Kolter 1971). Around the same time, it was being increasingly felt that health professionals should assume more responsibility for health education in community.

The objective of social marketing is to promote public health with the overall aim of improving health for all. It therefore relies heavily on preventive medicine. Moreover, social marketing should not be confused with marketing of new commercial health & hospital establishments since these promote curative services for profit of shares holders and the resultant benefits may not always be beneficial to public health. Social Marketing offers a unique opportunity for public health specialists to bridge the gap between the health care delivery systems and those who are unaware or unwilling to use it.

Principles & Techniques of Social MarketingAs a health planner, one must be aware that like commercial marketing, Social Marketing also consists of four marketing elements (marketing mix) of Product, Place, Price and Promotion.

The Product : In health care setting, the product may be a tangible material (such as a therapeutic drug of an educational pamphlet) or an intangible/non-standardised service (such as a training course on HIV counselling or nursing care in ICU). Social marketing of health products also involves issues like product/service branding, packaging, positioning, form, life cycle and product development. For example, if the packaging and quality of a condom is poor, there is bound to be poor response and low acceptability of such condoms. Thus, pretesting and obtaining feedback from users can reduce some obstacles in social marketing.

The Place : It is important for success of social marketing that the product/service should be located where users are most likely to find them without any stigma. Marketing of STD clinics as a separate entity has largely been a failure because of stigma attached to such clinics, hence poor utilisation of such services. On the other hand, some countries have very successfully increased utilisation of condoms by making them

available in areas where the potential users can find them easily, such as in ‘red light’ areas, on bus stands, on highways etc. Similarly, a public health specialist should realise that the best place to undertake social marketing of immunisation and breast feeding would perhaps be an antenatal clinic of a hospital which is visited by expecting mothers.

The Price : In ordinary curative or promotive health care scenario, the demand for health care is dependent on the price and personal income, in comparison with life threatening situations, where an individual seeks the required surgical/ medical care at whatever cost it is available, irrespective of his personal income. For promotive/preventive health care, demand is more if the price is low and personal income is high. In addition, the ‘perceived value’ of the health service/behaviour also determines the demand. For example, use of helmets among two-wheeler users would be higher if cost of good quality helmets is affordable and also if driver perceives the benefit of using a helmet, which may be as a safety measure or even as a fashion statement.

In addition, a public health specialist should realise that social marketing is also associated with ‘convenience costs’ (cost of loss of work, pay or travel if the individual has to visit a clinic) and ‘response costs” (embarrassment in case of purchase of condoms in market place or exposure of a particular personal problem in case of visit to a STD clinic in the neighbourhood). Such costs are often intangible since they are personal to the individual and thus are difficult to accurately quantify.

Promotion (Visibility & Timing) : High visibility constantly reminds the user of the existence of a product/service. Timing, on the other hand, pertains to presenting the reminder when the user is most likely to accept the idea, product or the service. People at different times vary in their readiness to receive information and accept new ideas. A new message should thus be promoted to people when they are most likely to accept it and it should be in a form and from a source most acceptable. For example, social marketing of Oral Rehydration Solution (ORS) is best undertaken by doctors in a paediatric OPD or by Village Health Guides during home visits, especially when a child is suffering from diarrhoea. Educating a woman about ORS when she is about to go into labour would be of no consequence since the felt-need is not present at that time and the woman is thus not receptive to the idea.

Designing the message : A message for any social marketing endeavour depends on local sensitivities rather than on any strict rules. Social marketing messages should be able to educate the target group about the existence of the health problem and its understanding, empower the group to undertake action/ behaviour recommended and explain to the target group about benefits of a particular recommended behaviour. The social message must also overcome any cultural, social and traditional practices, which resist change. Repeated message for Pulse Polio Immunisation on mass media by leading film stars in India is an excellent example of an effectively designed and presented social message. A social message needs to be short, correct and delivered to target audience at most opportune moment when they are most likely to accept and adopt new behaviour, by overcoming existing resistance.

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A Step-Wise Approach to Social MarketingStep 1 - Identification of health problem & establishing methods for social marketing : Effective social marketing needs an in-depth identification of the health problem. In addition, rigid customs and opinions of community have to be considered. Consensus building among public (to minimise conflicting opinions) through operational and political cooperation with community is essential. The decision makers in government and community should be identified at the earliest since their cooperation is essential for success of social marketing. In addition, social marketing for healthy behaviour will require identification of traditional health measures, demographic & population studies including mortality/ morbidity patterns and economic impact etc. The causes of the problem have to be established clearly and the required & available resources like mass media, marketing & design expertise should also be identified. Step 2 - Identification of priorities and implementation of affordable efforts : Organising priorities saves time, energy and money for a social marketer. The health problem and desired objectives should be assessed from the viewpoint of the consumer and should ideally be quantified. Cost estimates for media, material & delivery, personnel and other resources should be assessed in advance. It is essential to project realistic and achievable goals & objectives and prepare realistic budgets. Step 3 - Analysis of marketing activities, including social message : The strategy of social marketing needs to be evaluated regularly. There may be a need to adopt different messages and message styles for effectively communicating the message for a particular target group. For example, messages and their style of delivery for HIV prevention would be different for college students, commercial sex workers, MSM groups, truck drivers and housewives. Step 4 - Identification of target audience for each marketing component : ‘Market segmentation’ involves accurate identification of the group or individual who is not doing what they should be doing, in terms of health related behaviour (for example, identification of clients of CSWs who are not using condoms when they should be using). Accurate market segmentation will result in better and effective social marketing & better message delivery since a health message needs to be designed and delivered differently for different socio-economic and demographic groups. Step 5 - Analysing each marketing strategy to determine attitudes and potential resistance among target groups : A public health specialist should identify all possible cultural, social and religious resistance points, which will differ in strength within each target group. Attitude testing techniques are used to isolate beliefs and values which offer resistance to healthy behaviour. Instead of countering such beliefs head-on (which will result in rejection of the social message), it is more appropriate to build consensus and strategy to overcome the resistance.

Step 6 - Identification of objectives for each target group : The proposed behaviour change in each target group should be accurately identified and preferably quantified. For example, we may define our objective as “raising condom use among

clients of CSWs in a geographical area from 40% to 90% in next one year” or “increasing household use of iodised salt in a given district from 60% to 95% in next 2 years”. All necessary and relevant information should be provided according to understanding abilities of the target group and effect of each message should be evaluated periodically to assess if it has been understood properly or not.

Step7 - Designing and testing the social message : The social message should be pretested on samples of target audience for acceptability, comprehension, believability and conviction. Even the best designed social message is of no utility if it is not understood or believed by the target audience. After pre testing, messages should be revised and retested as necessary.

Step 8 - Selection of marketing/distribution system : Media and distribution system for the message should be in a manner which ensures maximum coverage among target audience. Introduction of statutory warnings on tobacco products is one such way to ensure that the anti-smoking message reaches all target audience.

Step 9 - Evaluate the impact of social messages : Quantifiable variables should be identified which indicate impact of the social messages over a certain period of time. These should be assessed periodically to evaluate the impact of social marketing and mid-term corrections should be made wherever required. For example, incidence of sexually transmitted diseases as ascertained from a busy STD clinic or hospital in a district is a good indicator of the impact of social marketing for condoms in that district.

Limitations of Social MarketingA public health specialist should realise that social marketing techniques are only appropriate in certain circumstances and have certain limitations. It is most often focussed on change in individual behaviour whereas other health education techniques aim intervention at families, villages and communities. Social marketing may lead people to believe that a particular marketed behaviour is better than other health promoting behaviours, which are not being marketed intensively. For example, use of condoms for multi partner sex may be perceived by some as better than abstinence and avoidance of multi partner sex due to intensive social marketing for promoting condom use. Social marketing often proves ineffective where major barriers (such as poverty, lack of health facilities, social discrimination and lack of political will) resist change in individual behaviour. It is also ineffective where individual efforts are inadequate to achieve the desired behaviour. Social marketing must ideally involve the consumer in decision making as there are often ethical and social difficulties in determining who must make the decisions or what behaviour must be promoted. For example, the decision to promote condoms in India still faces resistance from some sections, who favour promotion of single-partner sex and avoidance of sex outside marriage. Social marketing is often a labour and time intensive activity and obtaining adequate funds may be a problem. Actual social marketing programs are very few due to high demand of manpower & resources. Since the target population of social marketing is traditionally devoid of cash, the process of behaviour change is culturally, socially and psychologically different from commercial marketing. As a result, progress is slow and results are difficult to achieve,

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making social marketing efforts low priority activities even within government channels. Mass media too is mostly aimed at an audience capable of paying, thus social marketing efforts by mass media are often poor in quality & ineffective. In addition, social marketing faces greater challenges as compared to commercial marketing as highlighted under :

(a) Accurate market analysis is most often not possible. Primary data collection, besides being expensive and time consuming, is also inaccurate due to incorrect or socially desirable responses of subjects. Secondary data is inaccurate, simplistic and not easily available, since social behaviour is complex and can not be objectively measured.

(b) Market segmentation, which is essential for targeting efforts towards the target audience, may itself be detrimental to efforts because of discrimination & stigma attached to such segmented behaviour. For example, clients of commercial sex workers for targeted intervention for promoting condoms or patients of sexually transmitted diseases (STDs) when they visit designated & and well advertised STD clinics may be discriminated against due to their high visibility & stigma. Such kind of stigma and discrimination is contrary to audience response in conventional commercial marketing scenario.

(c) Product strategy in the form of developing complex behaviour which is acceptable to target audience and which meets their felt needs is difficult in social marketing.

(d) Pricing strategy in social marketing is also a challenge since a social marketer aims to reduce monetary barriers which prevent consumers from adopting healthy behaviour, rather than maximising the tangible financial gains for the consumer. Social marketing often has no control over (and cannot address) issues of intangible consumer costs such as cost of personal embarrassment (as in case of examination by a male doctor for cervical cancer) or fear (as in voluntary testing for HIV).

(e) Strategy for selecting channels for dissemination of social messages is a challenge since incentives & financial returns for the medium of distribution (such as a doctor or a hospital) are minimal, intangible and often non- financial. In addition, indirect dissemination of social message is often associated with misinformation.

(f) Communication options in social marketing are limited because paid advertising is often not possible and large amount of information needs to be conveyed to target audience before behaviour can be changed.

(g) Social marketing programs often face failure due to limited knowledge of marketing principles among health planners. Such programs also often face opposition from competing groups (such as tobacco companies in anti-smoking campaigns and baby food manufactures in breast feeding campaigns).

(h) Evaluation of impact is especially difficult in case of social marketing because change in social & individual behaviour & attitude is complex and intangible with very few objective variables.

SummarySocial marketing involves the research, product design, distribution, information, communication & often introduction of a new product / concept /service, with the aim of changing

behaviour. The basic differences between commercial and social marketing are summarised as under :

Commercial marketing : (1) Meets identified needs & wants of target market segment. (2) Aims to make a profit by serving the interests of target market. (3) Marketing of products/services mostly through ideas.

Social marketing : (1) Aims to change attitudes & behaviour to a healthier behaviour. (2) Serves interests of target market without personal profit. (3) Mostly marketing of ideas and concepts rather than tangible products.

A social marketer primarily acts in the benefit of targets group. Social marketing aims to broadly bring about social changes as under :

(a) Cognitive changes : are relatively easy to market where groups which need information are identified through market research, their media habits are identified and messages are carried to the target audience through appropriate channels.

(b) Action changes : involves that the target audience should understand the social message and take specific action based on it. Action change may be hampered by factors such as distance & non-availability of product/service hence the social marketer has to often facilitate action for target group by making the products/services easily available, accessible & acceptable.

(c) Behaviour change : is still more difficult than action change as it requires careful segmentation of target audience and specifically tailored ‘solutions’ for each segment; to enable them to alter their behaviour consistently.

(d) Value change : attempts to alter the deeply held beliefs of an individual & thus is most difficult. A prolonged and intense indoctrination program is required to change an individual from one basic value - orientation to another.

Social marketing uses scientific evidence on health and creates education and action programs for healthier habits & behaviour through methods of marketing. Social marketing can be used to help combat many major fatal diseases, especially in children in developing countries, that can be prevented by vaccination, nutrition or hygiene. Even in developed societies, social marketing finds place in diet education programs to lower cholesterol levels or anti-smoking campaigns.

Study ExercisesLong Questions : (1) You are posted as a Medical Officer in a PHC. Plan a step-wise approach for “Social marketing of new Oral Rehydration Solution (ORS)” in a particular Village. (2) What is Social Marketing? What are the principles, techniques and Limitations of Social Marketing?

Short Notes : (1) Differentiate Social marketing from Commercial marketing. (2) Principles of Social marketing (3) Enumerate Steps for Social marketing (4) Limitations of Social Marketing.

MCQs1. Which of the following is true about Social marketing?

(a) Meets identified needs & wants of target market segment. (b) Aims to make a profit by serving the interests of target market. (c) Marketing of products/services mostly through ideas. (d) Marketing of ideas and concepts rather than tangible products.

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2. Social marketing aims to broadly bring about the following changes except (a) Cognitive Changes among people (b) Behaviour changes among people (c) Price value changes of that particular product (d) changes in false beliefs of an individual.

3. All of the following are the elements of commercial marketing which are also used in social Marketing except (a) Product (b) Place (c) Price (d) None of the above.

4. The accurate identification of the group or individual who is not doing what they should be doing, in terms of health

related behaviour is known as (a) Marketing Analysis (b) Market segmentation (c) Commercial marketing (d) None of the above.

5. Social Marketing can be used for (a) Health education (b) Behaviour change (c) Combating many major fatal diseases, especially in children, that can be prevented by vaccination and nutrition (d) All of the above.

Answers : (1) d; (2) c; (3) d; (4) b; (5) d.

77 Public Health Aspects of Disaster Management

Ashok K. Jindal & Puja Dudeja

It is the people who matter most and without the people we have no disasters.

Disasters have existed ever since the existence of mankind and no community is immune to the emergence caused by natural and man-made disasters. Worldwide, natural disasters have been known to be one of the major problems in terms of mortality, number of people adversely affected and economic losses. The spectrum of occurrence of disasters indicates that the Asian region is one of the most disaster prone regions as 60% of the major natural disasters reported in the world occur in this region. India is amongst the most disaster prone countries in the world due to high vulnerability to natural disasters like floods, earthquakes, cyclones and droughts. In India, flood affects over 9 million hectares area annually, 56% of landmass is vulnerable to seismic activity of varying degree and 5700 kms long coastline is prone to severe cyclones with very severe loss of life and economic damage. Besides the natural disasters, India is also vulnerable to man-made disasters like transportation accidents, chemical and technological disasters and other such events.

It is evident from the spectrum of occurrence that adequate procedures to deal with disaster situations are necessary. Disaster management requires well-coordinated public policy for disaster prevention, mitigation, preparedness, emergency response and reconstruction. Health care in disaster is one of the critical elements (1). The issue becomes even more relevant since proper foresight and planning is of considerable importance for disaster management. Often, in disaster situations, a lot of resources have been wasted due to improper planning and impulsive actions (2).

Definition Commonly disasters are defined as an ‘overwhelming ecological disruption which exceeds the capacity of a community to adjust

and consequently requires assistance from outside’. W Nick Carter defined it as ‘an event, natural or man-made, sudden or progressive, which impacts with such severity that the affected community has to respond by taking exceptional measures’(3). As per the Disaster Management Act 2005, ‘Disaster means a catastrophe, mishap, calamity or grave occurrence in any area, arising from natural or man-made causes, or by accident or negligence which in substantial loss of life of human suffering or damage to and destruction of property, or damage to, or degradation of environment and is such a nature or magnitude as to be beyond the coping capacity of the community of the affected area (4).

Classification of Disasters(i) Natural Disasters

(a) Meteorological Disasters : Storms, cyclones, hailstorms, hurricanes, tornados, typhoons, snow storms, cold spells, heat waves and droughts.

(b) Topological Disasters : Earthquake, avalanches, landslides and floods

(c) Biological Disasters : Epidemics of communicable diseases and insect swarms (e.g. locust swarms)(ii) Man-made Disasters

(a) Accidents : Transportation accidents (Land, air and sea), collapse of buildings, dams and other structures, mine disasters and technological failures such as mishap at a nuclear power station or leak at a chemical plant causing pollution of atmosphere (5).

(b) Civil disturbances : Riots and demonstrations.

(c) Warfare : Conventional warfare (Bombardment, blockage or siege); Non - conventional warfare (Nuclear, Biological and Chemical warfare, guerrilla warfare including terrorism).

(d) Refugees : Forced movements of large number of people usually across the frontiers.

Elements of Disaster ManagementThe spectrum of disaster management involves disaster prevention, mitigation, preparedness, response and recovery (Fig. - 1).

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situation has been conceptualized as a process with differing phases. In each different phase, the information needed, the action required, the problem encountered and people involved may be quite different.

Principles of Disaster PlanningDisaster Management means a planned and systematic approach towards understanding and solving problems in the wake of disasters. Disaster planning cannot prevent disasters but its effect could be minimized by appropriate plans and preparedness. The key issues in disaster management are communication, coordination and control. Important issues in pre-disaster management are prediction, prevention, planning and preparedness. The critical issues when disaster event occurs are the immediate response, rescue, relief and rehabilitation. Fig. 1 shows elements in the management of a disaster.

Effects of DisasterThese are summarised in Table - 1.

Health Problems Common to all Disasters(a) Social reactions : These could be grouped as follows : (i) Spontaneous behavioral reactions e.g. generalized panic or

stunned waiting. (ii) Widespread looting

(a) Disaster Prevention : It covers those measures, which are aimed at impeding the occurrence of a disaster event and/or preventing such an occurrence having harmful effects on communities. It is concerned with the formulations and implementation of long-range policies and programs.

(b) Disaster Mitigation : Measures aimed at reducing the impact of a natural or man-made disaster on a nation or community.

(c) Disaster Preparedness : Measures, which enable governments, organizations, communities and individuals to respond rapidly and effectively to disaster situations. Preparedness measures include the formulation of viable disaster plans, the maintenance of resources and the training of personnel. Organizing, planning coordinating, resources planning and training are its major concerns.

(d) Disaster Response : Response measures are those, which are taken immediately, prior to and following disasters. Such measures are directed towards saving life and protecting property and dealing with the immediate damage caused by the disaster. Its success depends vitally on good preparedness.

(e) Disaster Recovery : Recovery is the process by which communities and the nations are assisted in returning to their proper level of functioning following a disaster. Disaster

Fig. - 1 : Elements in the disaster management

Disaster Management

Disaster Mitigation

Risk Assessment Prevention Preparedness

Hazard

Assessment

Voluntary

Assessment

Structural

Measures

NonStructural

Measures

Contingency

Planning

Warning&

Evacuation

Disaster Response

Relief Rehabilitation Reconstruction

- Search & Rescue- Security- Food & Water- Shelter

- Sanitation- Clothes- Health care

DISASTER

Table - 1 : Effects of Disaster

Effects Type of Disaster

Earth-quakesHigh Winds

(Without Flooding)Tidal waves

(Flash Floods)Floods

Death Many Few Many Few

Severe injuries requires extensive care Overwhelming Moderate Few Few

Increased communicable disease loadPotential risk following all major disaster (Probably rising

with overcrowding and declining sanitary conditions)

Food scarcity Rare Rare Common Common

Population displacements and movements

Rare Rare Common Common

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(iii) Rumors regarding spread of epidemic(iv) Population displacements leading to excessive burden on

relatives and friends, parks city squares, vacant lots and government buildings in urban areas where public services can’t cope resulting in increased morbidity and mortality.

(b) Exposure to elements : The need to provide emergency shelter varies greatly with local conditions.

(c) Food and Nutrition : Food shortages in the immediate aftermath may arise in two ways. Food stock destruction within the disaster area may reduce the absolute amount of food available, or disruption of distribution system may curtail access to food even if there is no absolute shortage.

(d) Communicable Diseases : The transmission of communicable diseases after natural disasters may be influenced by following factors :

(i) Pre existing Diseases in the Population : The risk of epidemic after a disaster is related to the endemic levels of diseases in the population. Where a disease agent did not exist in a population before a disaster, there is generally no risk of an outbreak occurring. These include diarrhea and dysentery, cholera, measles, whooping cough, meningococcal meningitis, tuberculosis, malaria, intestinal parasites, scabies and other skin diseases, louse borne typhus and relapsing fever.

(ii) Ecological Changes resulting from Natural Disasters : Natural disasters may alter the potential for disease transmission by altering the ecological conditions. In this context, the most important diseases are those transmitted by mosquito vectors and by water. The breakdown in living conditions following disasters may increase the hazard of transmission of plague, louse borne typhus and relapsing fever. The incidence of dog bite and risk of rabies may increase as neglected strays come in close contact with persons living in temporary shelters.

(iii) Population Movements : Population movements may influence the transmission of diseases by increasing population density causing burden on the water supply and other services in the receiving areas and/or introducing susceptible population to a new disease or disease vector. The important diseases to occur in temporary settlements are diarrheal diseases and dysentery, viral hepatitis, measles, whooping cough, malaria, tuberculosis, scabies and other skin infections.

(iv) Damage to public Utilities : Damage to water supplies and sewage disposal systems may increase water borne and excremental diseases.

(v) Interruption in Public Health Services : The important services interrupted in this context are vector control programme, which might lead to resurgence of malaria and other vector borne diseases, routing immunization programme against measles, whooping cough, poliomyelitis, tuberculosis and diphtheria.

(vi) Altered Individual Resistance to diseases : Protein Energy Malnutrition, which affects children in poorer population of most of the developing countries, increases susceptibility to many communicable diseases including malaria and tuberculosis.

Medical Care for Disaster The principles of mass casualty management are universal and can be applied in any mass casualty situation, natural

or man-made. The importance of triage, first aid, life saving measures, transport and evacuation for definitive care to hospital has been recognized the world over. The mass casualty management demands standard simple therapeutic procedures and standardized drugs & medical supplies. On site care demands establishment of a command post triage team, first aid team, mobile hospital (if required), evacuation team, transport and communication.

Disaster PreparednessDisaster plan should be realistic, adaptable and harmonized at all levels. It must be clearly written and periodically tested. It should include (a) Resources plans for health care. (b) Role and responsibility of resources organization. (c) Logistics, equipment and supplies required. (d) Arrangement for communication, transportation and

evacuation. (e) Coordination and control.(f) Disaster drills.

Disaster Management Plan for Natural DisastersAll disasters are unique in that they affect areas with different social, medical and economic backgrounds. The peculiar problems associated with disasters are essentially due to increased load of communicable diseases, food scarcity and mass population displacements and movements. Disaster management includes certain interventions namely good site planning, provision of basic clinical services, shelter, clean water, good sanitation, vaccination and control of disease vectors. The diseases prevented by these interventions are given in Table - 2.

Table - 2 : Preventive measures in a disaster

Preventive measures Impact on spread of

Site planning Diarrhoeal diseases, acute respiratory infections

Clean water Diarrhoeal diseases, typhoid fever, hepatitis A and E

Good Sanitation Diarrhoeal diseases, vector-borne diseases, scabies

Adequate nutrition Tuberculosis, measles, acute respiratory infections

Vaccination Measles, meningitis, Japanese encephalitis, diphtheria

Vector control Malaria, plague, dengue, Japanese encephalitis, other viral haemaorrhagic fevers

Personal protection (insecticide –treated nets, clothing, shoes)

Malaria, leishmaniasis, leptospirosis

Personal hygiene Louse-borne diseases, typhus

Health education Diarrhoeal diseases

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Organisation of Medical Setup The State Chief Secretary should be overall incharge of Disaster Management in the State. The medical aspects will be coordinated by the State DGHS. He will ensure that adequate manpower reserves are rushed from non affected areas in the State to those which are worst affected so that medical manpower is properly augmented.

At the District Level, the District Collector will be the Chief Executive of the Disaster management cell. He will be in a position to coordinate all relief efforts with various departments including ensuring NGO participation. The medical team will be headed by the Chief Medical Officer (CMO) of the district. The various programme officers under him like the District Malaria Officer, the District Immunisation Officer, etc will ensure availability of equipment, stores and manpower required for disaster activities. The District hospital will be responsible for providing referral services for curative care as well as outreach teams to be deployed at short notice in affected remote areas. These teams should have medical officers, surgeon, anesthetists and adequate paramedical staff. The nodal peripheral unit for providing medical relief will be the PHC of the area and the MO i/c PHC will coordinate all efforts and seek assistance of the CMO as and when required. The sub-centre staff will support him in all the activities.

Public Health AspectsThe important aspects include provisioning of appropriate shelter for displaced population, potable water supply, food and nutrition and sanitation.

Excreta Disposal : Improper excreta disposal contaminates soil and water sources. It also often serves as a breeding ground for certain species of flies and mosquitoes, giving them the opportunity to lay their eggs and multiply or to feed and transmit the infection. It also attracts domestic animals and rodents which carry fecal matter on them and with it, potential diseases. Furthermore, this situation usually creates unsightly areas and disagreeable odors. The goal of sanitary excreta disposal is to isolate excrement so the infectious agents in it cannot reach a new host. The method selected for a given area or region will depend on many factors, including local geology and hydrogeology, the communities’ culture and preferences, the materials available locally and the cost.

The aim is to develop physical barriers against the transmissions of diseases, in order to protect the health of the disaster affected population. These barriers include both engineering measures and personal hygiene measures. The provision of latrine and the development of methods of waste disposal are essential elements of the programme. These measures are only fully effective, when complemented by a sanitation education programme. The efficient and safe disposal of human excreta is as important as the provision of water in its positive effect on the health of the emergency affected population. Human excreta are more likely to transmit diseases than animal waste. It contributes to the transmission of numerous diseases (particularly when combined with low levels of nutrition) and can also be a breeding ground for flies and other insects. In the acute phase of an emergency, any form of excreta disposal is better than none. The simplest and quickest methods should be

adopted; these can later be improved on and changed initially speedy action is important in averting human catastrophe.

What to do :a. If there are no sanitation services, latrines must be built

(individual, collective, portable).b. Before installing a latrine, the soil at the site must be

evaluated along with topographical conditions, user access and the presence of surface and ground water in the surrounding area.

c. If the land is not appropriate for latrine construction (rocky soil or high water table) aboveground latrines with removable tanks must be built. The excreta must be transported to a pit located on appropriate ground, for immediate burial.

d. Estimate the number of latrines to be installed, based on the number of persons in the shelter (1 waterless toilet/25 women and 1 waterless toilet and 1 urinal/35 men).

e. Provide information and instructions to the population on throwing used toilet paper into the latrine. Using the sanitation services only for defecating or ●urinating (do not store tools or other items in the latrine) Washing their hands with soap and water after urinating ●or defecating. Keeping the floor, walls and area surrounding the latrine ●clean.

Not defecating or urinating outdoors in the area around the sanitation services or near bodies of water, since this encourages the proliferation of flies and larvae and water contamination through water runoff.

What not to do :a. Install excreta disposal systems without first assessing

the situation (existence of sanitation services, number of users and characteristics of the site, among others)

b. Select the location of the sanitation services without taking into account the characteristics of the site (soil type, topography, accessibility, presence of bodies of water, etc. )

c. Try to implement sophisticated excreta disposal technologies without having facilities to operate / maintain.

Accommodation : In natural disaster, the displaced population must be sheltered in temporary settlements or camps. The selections of sites must be well planned to avoid risk factors for communicable diseases transmission, such as overcrowding, poor hygiene and inadequate water supply, insanitary disposal of excreta vector, inadequate sites and lack of adequate shelter. Such conditions favour the transmission of diseases such as measles, meningitis and cholera. Critical factors to consider when planning a site are : water availability, means of transport, access to fuel and access to fertile soil. The guidelines are given in Table - 3. The surrounding environment may also pose a threat to health in the form of vectors not encountered in the population’s previous place of residence. In order to reduce such risks it is essential that site selections, planning and organization be undertaken as soon as possible.

Water supply : Water and sanitation are vital elements in the transmission of communicable diseases and in the spread of diseases prone to cause epidemic. Diarrheal diseases are

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a major cause of morbidity and mortality among affected populations, most being caused by a lack of safe water, inadequate excreta disposal facilities and poor hygiene. The goal of proper water and sanitation facilities is to minimize risks to the health of a population, particularly one caught up in the difficult circumstances of an emergency with its attendant displacement and dangers. Such a programme is an integral part of preventive heath activities. The main focus of such a programme is on the following :(a) The provision of a safe and sufficient water supply(b) Provision for excreta disposal and the establishment of

other waster control and hygiene measures(c) A programme of public education of the affected population

on the issue of hygiene and water use. In a natural disaster, the affected population need immediate access to a water supply in order to maintain health and to reduce the risk of epidemics. If the emergency affected populations have to be sheltered in temporary settlements or camps, water supply is an essential consideration in choosing the site location. An adequate amount of safe drinking water must be provided for the entire displaced population. The first objective is to provide sufficient water; quality can be addressed later, sufficient water of low quality is better than very little water of high quality. During the rapid assessment of a proposed site it is essential to protect existing water sources from possible contamination. If the population has already moved into the area in question, then immediate measures should be taken to isolate and protect the water sources, if it is on or near the site. Table - 4 gives the recommended doses of Chlorine tablets that can be distributed to the affected population to prevent diarrheal diseases. Location, design and number of water distribution points are given in Table - 5.

Solid Waste : Solid waste may be refuse, manure ]or animal cadavers. There is a correlation between improper solid waste disposal and the incidence of vector-borne diseases. As a result, arrangements must be made to collect, store and dispose of solid waste.

What to doa. Assess the situation, considering the number of people in

the shelter, existing services, collection service, topographic conditions, accessibility and soil type (if the waste must be disposed of on site).

b. Estimate the quantity, type and capacity of the water storage containers, based on the number of persons and existing services. For a short time, empty food containers, plastic or water-resistant paper bags and disposable packaging can be used. The capacity of the containers should be 50-100 liters and should not exceed 20-25 kg when full.

c. Provide three or four containers per 100 persons and distribute them so that every family has access to a container (or plastic bag).

d. The containers should not touch the ground, for example they should be on a wooden platform. They must be emptied and washed daily.

e. If there is regular waste collection and final disposal service : Coordinate with the responsible entity to cover refuse ●collection from the shelter or camp. Check the accessibility of the regular collection service and ●take the appropriate steps for the shelter or camp. If the regular service does not have access to the shelter ●or camp, place waste pick-up sites in the surrounding area and locate storage bins or containers away from water sources.

f. If there is no regular waste collection and final disposal service : Organize collection, transport and final waste disposal ●service, involving the persons living in the shelter or camp. For final disposal, bury the waste by building pits 1.5 ●meters wide, 1.5 meters long and 2 meters deep. At the end of each day, cover the refuse with 15 cm of dirt and pack it down. This pit will last 10 days for a population of 200. For larger populations, increase pit size proportionately, up to a maximum of 3 meters x 3 meters. Before the pit is full, cover it with a layer of packed dirt 40 cm thick, so that it is level with the ground. Then dig a new pit.

g. Dead animals and excrement from domestic animals must be buried immediately, since they can be a source of contamination.

h. Provide information and training to the population on sanitary refuse handling.

What not to doa. Request tools, containers, bins, plastic containers or other

devices without first assessing the situation.

Table - 3 : Guidelines to provide accommodation for displaced

Area per person for collective activities 30 m2

Shelter space per persons 3.4 m2 (4.5 -5.5 m2 in cold climates)

Distance between shelters 2m minimum

Area for support services 7.5 m2/persons

Number of people per water point 250

Number of people per latrine 20

Distance to water point 150 m maximum

Distance to latrine 30m

Distance between water point and latrine 100m

Firebreaks 75m every 300m

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b. Mix common waste with medical waste, thus endangering the population.

c. Accept or request sophisticated technology for treating medical waste without having the facilities or trained personnel to operate it.

Vector control : The purpose of a vector control programme is to reduce disease transmission by rendering the environment unfavourable for the development and survival of the vector. Prevention is better than cure and when the planning and construction of camps is undertaken, preventing the development of vector problems should be taken into account. The vector population and its life expectancy should be kept to a minimum. Community adhesion and participation in a vector control programme is essential for its success. Early diagnosis and treatment are needed to prevent severe forms of the disease (especially for malaria) when transmission control is needed to reduce incidence. Both are complementary and

two essential components of any effective vector borne disease control programme.

Types of vectors : The major biological vectors are mosquitoes, sand flies, ticks, fleas, lice, mites. Important carrier reservoirs or intermediary hosts are synanthropic flies and rodents.

Diseases spread : The diseases most commonly spread by vectors are malaria, filariasis, dengue fever, leishmaniasis, typhus and plague. Major diseases transmitted by intermediate hosts or carriers are schistosomiasis, diarrhoeal diseases and trachoma.

Prevention : The main methods of control in emergency situations can be classified into the following groups :

Residual spraying, ●Personal protection, ●Environmental control, ●Camp site and shelter design and layout, ●Community awareness. ●

Table - 4 : Recommended dosage of chlorine

Type of water source

Clear piped water

Protected tube wells, ring wells, clear rain water

Unprotected wells and cloudy water (filtered

before purifying)

Water known to have faecal contamination

(filtered before purifying)

Tablet SizeChlorine per tablet (mg)

Volume of water treated per tablet (Litres)

8.5mg 5 5 2.5 1 0.5

17mg 10 10 5 2 1

67 mg 39.41 39.41 19.7 7.77 3.94

340mg 200 200 10 40 20

500mg 294 294 147 58.5 29.4

Free available chlorine content after treatment (Residual)

1mg/Litre 2mg/Litre 5mg/Litre 10mg/Litre

Table - 5 : Location, design and number of water distribution points

Location Water distribution point must be set up in suitable places around the camp. A good location is an elevated spot in the centre of a living area. If the water points are from ground sources, no sanitation facilities should be within 50 meters and definitely not closer than 30 meters. If the water point is too far away, people will not collect.

Design When designing water points consider the following :

- Traditional water carrying methods

- The containers used : for example, a raised area is suitable for people who carry the bucket on their heads

- Persons collecting and carrying the water (it is usually the women and children)

- The availability of spare parts.

- There should be enough space on the concrete slab around the water point for laundry and bathing areas. If sanitation is compromised, it may be felt necessary to locate bathing and washing areas away from collection points. However, traditional practices and habits need to be accommodated as much as possible. Animals must certainly be kept away. If they are mobile herds, watering facilities should be established some distance away and a fence erected around the eater point.

Number One tap per 200-250 people is the ration recommended by the United Nations High Commissioner for Refugees (UNHCR). The more the people per tap, the more would be wear and tear. Nobody should have to wait longer than a few minutes : if collection takes a long time, people will return to old, contaminated but quicker sources.

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Indoor Residual Spraying : This is a recommended technique for controlling mosquitoes and sandflies. It is the most common method in the post-emergency phase when the displaced population is living in more permanent dwellings such as huts or houses. IRS is very effective in almost all epidemiological settings and recommended as the first line intervention to control epidemics. Ground space spraying, either Ultra-Low-Volume (ULV) cold mist or thermal fogging, is not the preferred intervention for malaria vector control in emergency situations. In the context of camps, especially in crowded areas, ground space spraying can be resorted to if residual spraying is delayed or cannot be implemented. Pyrethrins or pyrethroids are the best choice for such application but organophosphate insecticides are also suitable.

Personal protection : Personal protection against the spread of disease includes a variety of methods : insecticide-treated nets, treated sheets and blankets, personal hygiene, insect repellents and clothing and dusting powder. Insecticide-Treated Nets (ITNs) are primarily used to protect against mosquito. Daily bathing, washing of hands after using the latrine, regular washing of clothes and good food and water storage practices can prevent the spread of fly-borne diseases. Biting by mosquitoes, flies and ticks can be reduced by wearing long-sleeved shirts and long trousers and by using insect repellents. Appropriate dusting powders can be used in the treatment of flea and louse infestations.

Environmental control : Environmental control strategies aim to minimize the spread of disease by reducing the number of vector breeding sites. Some of the most important measures, namely the provision of clean water, the provision and maintenance of sanitary latrines and the efficient and safe disposal of waste water are other important aspects to be looked into. Larvicides may be applied via hand-carried, vehicle-mounted or aerial equipment. The larvicide is added to water at sites that are recognized breeding grounds, such as ponds or water jars, in areas where the breeding sites are limited in number. Long-term measures, such as land drainage or filling, should be planned and implemented to avoid future spraying.

Community awareness and health education : Community participation in a vector control programme is essential for its success. It allows the implementing agency to develop an awareness of community practices that prevent or encourage the spread of disease. Both the community and the vector control team can develop strategies that can be implemented with some degree of success. Information on the spread of disease can be disseminated in a culturally sensitive manner.

Food and nutrition : Food shortages and malnutrition are common features of emergency situations. Ensuring that the food and nutritional needs of an emergency-affected population are met is often the principal component of the humanitarian response to an emergency. When the nutritional needs of a population are not met, this may result in protein–energy malnutrition and micronutrient deficiencies such as iron-deficiency anaemia, pellagra, scurvy and vitamin A deficiency. There is also a marked increase in the incidence of communicable diseases, especially among vulnerable groups such as infants and young children and these contribute further

to the deterioration of their nutritional status.

The mean daily per capita energy requirements for some population groups vary depending on the weight, age, gender and physical activity of the individual. Energy requirements increase during certain specific situations, such as the second and third trimesters of pregnancy, lactation, infection (e.g. tuberculosis) and recovery from illness (for every 1°C rise in body temperature there is a 10% increase in energy requirements), cold temperatures (an increase of 100 kcal per person for every 5 °C below 20 °C), moderate or heavy labour. The mean energy requirement is 2100Kcal per person per day, out of which 17-20% of energy should be in the form of fats or oils and 10-12% from proteins.

Food is an important source of pathogens and there is a risk of diarrhoeal disease epidemics when basic food safety principles are not followed. It is estimated that 70% of diarrhoeal episodes in children under the age of 5 years are due to the consumption of contaminated food. There are a number of routine practices that should be adhered to when preparing food, in both the household and in health facilities. To overcome this menace following actions are recommended :

Ensure an adequate water supply. ●When preparing food or washing utensils, use a chlorinated ●water supply. Store food in sealed containers. ●Ensure that food is covered during cooking and prior to ●serving. Ensure that cooked food is consumed once prepared. ●Cover food when served, if left unattended. ●Place hand-washing facilities outside latrines, living areas ●and kitchens. Ensure that people use them. ●Ensure an adequate number of sanitary latrines and that ●they are maintained and used. All areas in a feeding centre must be cleaned daily using ●chlorine as a disinfectant. Cover water containers at all times. ●Ensure that water is taken either from a tap or from a clean ●container. Disposal of garbage safely. ●

Prevention & control of communicable diseases: The prevention and control measures of communicable diseases should be on the following broad principles.

(a) Setting up a Surveillance System : It is established to collect, collate and interpret the data, It will need the services of an epidemiologist/public health specialist, paramedical and health personal and clerical staff.

(b) Disease Surveillance : The objective of disease surveillance after disaster is to identify disease outbreak, in order to investigate them and to instigate appropriate disease control measures. The diseases considered for surveillance include those known to be endemic to the area, those, which represent a serious health hazard and those, which are amenable to control. A more focused, system based surveillance system should be instituted. This system complex, which might be important, include fever, fever and diarrhea, fever and cough, trauma, burns, measles etc. This data should be analyzed, interpreted and presented to the higher authorities (6, 7).

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(c) Laboratory Services : Lab for basic diagnostic tests of stool and blood may be established by field reporting units but for specific bacteriological and virological tests, the referral labs in nearby cities or areas will have to be marked (7, 8, 9).

(d) Vaccinations and Vaccination Programs : Mass vaccination campaigns against Tetanus and Measles will be helpful, as well as some other vaccines for specific diseases, depending on the threat perception (7, 8, 9). However mass vaccination campaign against typhoid and cholera should be avoided because of the following reasons : (i) Offer low and little individual protection. (ii) Complete coverage of population is probably impossible(iii) Require large number of workers who could be better

employed elsewhere. (iv) Could lead to reuse of inadequately sterilized needles that

may transmit Hepatitis B/HIV. (v) May lead to false sense of security about the risk of

diseases and to neglect effective control measures. Surveillance system : The objectives of a surveillance system in a disaster are to : (a) Identify public health priorities.(b) Monitor the severity of an emergency by collecting and

analyzing mortality and morbidity data.(c) Detect outbreaks and monitor response.(d) Monitor trends in incidence and case-fatality from major

diseases.(e) Monitor the impact of specific health interventions

(e.g. a reduction in malaria incidence rates after the implementation of vector control programmes).

(f) Provide information to the Ministry of Health, agency headquarters and donors to assists in health programme planning, implementation and adaptation and resources mobilization.

Experience from many disaster situations has shown that certain diseases/syndromes must always be considered as priorities and monitored systematically. In the acute phase of an emergency, the major diseases/syndromes that should be reported are : Bloody diarrhoea; Acute watery diarrhea; Suspected cholera; Lower respiratory tract infections; Measles; and Meningitis. After the second/third week the following diseases should be added on : Malaria; Dengue/DHF; JE; Leptospirosis; and Septic dermatological complications. Lab for basic diagnostic tests of stool and blood may be established by field reporting units but for specific bacteriological and virological tests, the referral labs in nearby cities or areas will have to be marked.

Burial / Disposal of the Dead : Bodies are unlikely to cause outbreaks of diseases such as typhoid fever, cholera, if death resulted from trauma. However, they may transmit gastroenteritis or food poisoning syndrome to survivors if they contaminate water sources. Despite the negligible risk, dead bodies represent a delicate social problem. The normal local method of burial or cremation should be used although mass cremation requires large amounts of fuel. Before disposal, bodies must be identified and the identifications recorded.

Suggested Logistics Planning The suggested (approximate) requirements of drugs, vaccines and insecticides / hygiene chemicals for a displaced population

for a period of 30 days are laid down in Table 6a, b & c. Readers may please note that these are only suggestions for logistic planning and the actual requirement should be worked out after actual on-ground assessment of the displaced population.

Table - 6a : Requirements of Vaccines & related items

Vaccine Doses

Typhoid oral 600

Cholera 400

Measles 250

Japanese Encephalitis 250

Tetanus Toxoid 300

Tetanus immunoglobulin 300

Meningococcal vaccine 300

Vaccine Carrier 15

Cold boxes 10

Table - 6b : Requirements of Insecticides, hygiene chemicals & equipment

Thermal fogger 01

Knapsack sprayer(16L) 02

Compression sprayer(12L) 03

ULV fogger 01

Malathion EC 50% DDP WP 300 l/Kg

Temephos/Baytex EC 10L

Aquatabs (17 mg) 1,00,000

DMP oil 25L

Impregnated bed nets* 600

Bleaching powder (33# Available Chlorine) 30 Kg

Cresoli Black 150L* alternatively, 6 ltrs of 2.5% deltamethrin solution will be required to impregnate 600 bed nets

Table - 6c : Requirements of Drugs and expendables

Nomenclature Quantity

Inj Lignocaine 02

Inj Atropine 02

Tab Common Cold 2, 000

Inj Morphine 50

Inj Ranitidine 10

Inj Fortwin 50

Inj Adrenaline 30

Tab Cetrizine 800

Tab Periactin 100

Tab Dexamethasone 200

Inj Dexamethasone 10

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Table - 6c (Contd.)

Nomenclature Quantity

Inj Hydro Cortisone 20

Inj Avil 20

Tab Avil 400

Inj Phenargan 20

Inj Diazepam 20

Tablets Anti Inflammatory 1000

Cap Antibiotics 5000

Tab Antipyretic 1000

Tab Anti malarials 2000

Syp Antitussives 10L

Tab Antispasmodics 300

ORS 1500

Hydrogen Peroxide 5.000L

Liq Antiseptic 1.000L

Eye Drops 15

IV Fluids Normal Saline 576 Bott

IV Fluids DNS 576 Bott

IV Fluids Ringer Lactate 2, 256 Bott

Haemaccel 900 Bott

IV Set 576

IV Catheter 576

Cotton Absorbent 10 Kg

SummaryWorldwide, natural disasters have been known to be one of the major problems. India is amongst the most disaster prone countries in the world. Adequate procedures to deal with disaster situations are necessary. Disaster management requires well-coordinated public policy for disaster prevention, mitigation, preparedness, emergency response and reconstruction. Health care in disaster is one of the critical elements. Disasters are defined as an ‘overwhelming ecological disruption which exceeds the capacity of a community to adjust and consequently requires assistance from outside. Disasters can be classified into natural disasters (which would include Meteorological, Topological & Biological disasters) and Manmade disasters (that would include Accidents, Civil disturbances & Warfare). The spectrum of disaster management involves disaster prevention, mitigation, preparedness, response and recovery. Disaster Management means a planned and systematic approach towards understanding and solving problems in the wake of disasters. The key issues in disaster management are communication, coordination and control. Important issue in pre-disaster management is prediction, prevention, planning and preparedness.

There are some health problems which are common to all types of disasters. These include Social reactions (such as looting,

rumor spreading etc.), Exposure to elements - depending on local conditions and issues of Food and Nutrition. Also prominent among the health problems would be risk of spread of communicable diseases, the occurrence of which would depend on factors such as pre- existing Diseases in the Population, Ecological Changes Resulting from Natural Disasters, Population Movements, Damage to public Utilities, Interruption in Public Health Services and Altered Individual Resistance to diseases. The principles of mass casualty management during disaster include the vital elements of triage, first aid, life saving measures, transport and evacuation for definitive care to hospital has been recognized the world over. Disaster plan for preparedness should be unambiguous, well-rehearsed and must specify Resources plans for health care and Coordination and control, among other essentials. Disaster management plan should include good site planning, provision of basic clinical services, shelter, clean water, good sanitation, vaccination, healthy food and nutrition and control of disease vectors. In organization of medical set-up, the nodal point(s)/ personnel in-charge of co-ordination and execution of activities would be : State Chief Secretary & District Collector at respective levels for overall administration, State DGHS, Chief Medical Officer (CMO) of the district and MO i/c PHC at respective levels for the medical aspects. The aim of hygienic excreta disposal is to develop physical barriers against the transmissions of diseases, in order to protect the health of the disaster affected population. These barriers include both engineering measures and personal hygiene measures. The simplest and most effective measure in this context would be construction of appropriate latrines (catering to aspects such as topography, numbers) and also educating the public on relevant aspects. Temporary settlements or camps would form the best possible mode of accommodation in disaster scenario. The selection of sites must be well planned to avoid risk factors for communicable diseases transmission and keeping in mind water availability means of transport, access to fuel and access to fertile soil. The goal of proper water and sanitation facilities is to minimize risks of water-borne diseases such as diarrheal diseases to the population. In a disaster, the affected populations need immediate access to a water supply in order to maintain health and to reduce the risk of epidemics. The first objective is to provide sufficient water; quality can be addressed later. Appropriate chlorination, proper location of water distribution points and health education are inevitable steps in this regard. Necessary arrangements must be made for collection, storage and disposal of solid waste. The vital steps would be assessment of the situation, tailor-making the supplies- quantity and quality-wise; according to the need (a thumb-rule could be 03 or 04 containers per 100 persons) and proper disposal, depending on whether regular waste collection and final disposal service are available or not. Preventing the development of vector problems should be taken into account, when the planning and construction of camps is undertaken. Community adhesion and participation in a vector control programme is essential for its success The main methods of vector control in emergency situations would include residual spraying (preferably Indoor Residual spraying with pyrethrin or pyrethroids), personal protective measures [using Insecticide-Treated Nets (ITNs) and/or dusting powders], environmental

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control (measures such as provision of clean water, provision and maintenance of sanitary latrines for short –term purposes and land drainage or filling for long –term), campsite and shelter design and layout and creation of community awareness. Ensuring that the food and nutritional needs of an emergency-affected population are met is often the principal component of the humanitarian response to an emergency, since protein–energy malnutrition, micronutrient deficiencies and a marked increase in the incidence of communicable diseases, especially among vulnerable groups will result if due care is not accorded to provision of adequate healthy food. The mean daily per capita energy requirements for some population groups vary depending on the weight, age, gender and physical activity of the individual. There are a number of routine practices that should be adhered to when preparing food, in both the household and in health facilities. Some useful measures in this regard would include, among other points, ensuring an adequate and safe water supply, placing hand-washing facilities outside latrines, living areas and kitchens and so on. The prevention and control measures of communicable diseases during disasters should be on the broad principles of Setting up a Surveillance System, Disease Surveillance, establishment of Lab facilities for basic diagnostic tests of stool and blood, mass vaccinations and Vaccination Programs (definitely targeting Tetanus and Measles, but never against Typhoid or Cholera). The normal local method of burial or cremation should be used, after proper identification and recording. Requirements of drugs, vaccines and insecticides / hygiene chemicals should be worked out after actual on-ground assessment of the displaced population.

Study Exercises MCQs and Exercises1. All of the following are examples of natural disasters except

(a) Meteorological Disasters (b) Topological Disasters (c) Accidents (d) Biological Disasters.

2. All of the following are Elements of Disaster Management, except : (a) Disaster Treatment (b) Disaster Preparedness (c) Disaster Response (d) Disaster Recovery .

3. Measures aimed at reducing the impact of a natural or man-made disaster on a nation or community, is collectively known by the term (a) Disaster Response (b) Disaster Mitigation (c) Disaster Recovery (d) Disaster Prevention.

4. Relief, Rehabilitation and reconstruction are essential components of (a) Disaster Mitigation (b) Disaster Response (c) Both of the above (d) None of the above.

5. Overwhelming number of Severe injuries which require extensive care, when compare to other disasters, take place in (a) Flooding (b) Tidal waves (c) High winds (d) Earthquakes.

6. All of the following factors influence the transmission of communicable diseases after natural disasters, except (a) Damage to public Utilities (b) Population Movements (c) Interruption in Public Health Services (d) Social reactions.

7. The nodal peripheral unit for providing medical relief in times of disasters, will be (a) Sub-centre (b) Anganwadi (c) Primary Health Centre (d) District hospital.

8. At the District Level, the CMO (Chief Medical Officer) will

be the Chief Executive of the Disaster management cell. Yes/ No.

9. Among the following choices, the most appropriate one while constructing toilets in disaster scenario, will be (a) 1 waterless toilet/25 women (b) 1 waterless toilet/25 men (c) 1 waterless toilet/35 women (d) 1 waterless toilet/45 men.

10. While considering factors for proper accommodation of homeless persons in disaster situation, the distance from the site to the water point should be not more than (a) 50 meters (b) 100 meters (c) 150 meters (d) 250 meters.

11. Sufficient water of low quality is better than very little water of high quality, in disaster scenarios. Yes /No.

12. While locating water points during times of disasters, if the water points are from ground sources, no sanitation facilities should be definitely not closer than a distance of (a) 50 meters (b) 100 meters (c) 10 meters (d) 30 meters.

13. The ratio of taps to persons as recommended by the United Nations High Commissioner for Refugees (UNHCR), especially in setting of disasters, is (a) One tap per 100-150 people (b) One tap per 200-250 people (c) One tap per 250-300 people (d) One tap per 50-100 people.

14. The maximum permissible weight of solid waste that can be collected in a single container, (i. e weight of a single container, when full), is (a) 20-25 kg (b) 30-35 kg (c) 40-45 kg (d) 50-55 kg.

15. The Insecticidal method of choice for controlling mosquitoes and sandflies during disaster situations is (a) Space spraying (b) Knockdown spraying (c) Indoor residual spraying (d) Ground spraying.

16. The mean energy requirement per person per day, that has to be catered for by provision of appropriate food, at times of disasters, is (a) 2500 Kcal (b) 2000 Kcal (c) 2100 Kcal (d) 2300 Kcal.

17. Mass vaccination campaigns against one of the following diseases would be imperative and helpful in times of disasters (a) Typhoid (b) Cholera (c) Scrub Typhus (d) Measles.

18. Match the following features in column A with that in Column B.

Column A Column B

Type of water at source Recommended Free available chlorine content after treatment (Residual)

(a) Clear rain water (i) 5mg/Litre

(b) Unprotected wells (ii) 1mg/Litre

(c) Water known to have faecal contamination

(iii) 2mg/Litre

(d) Clear piped water (iv) 10mg/Litre

Answers : (1) c; (2) a; (3) b; (4) b; (5) d; (6) d; (7) c; (8) No; (9) a; (10) c; (11) Yes; (12) d; (13) b; (14) a; (15) Yes; (16) c ;(17) d; (18) (a) iii; (b) i; (c) iv; (d) ii.

ReferencesPan American Health Organization, Emergency Health Management after 1. disasters PAHO/WHO Scientific Publication No 407, Washington, DC, 1981.

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Rennie D. After the earthquake. Lancet 1970 : 2 : 704-72. Carter W Nick. Disaster Management A. Disaster Management Hand Book. 3. Asian Development Bank, Manilla. 1991. The Disaster Management Act 2005. The Gazette of India N. ODL 4. (1V)04/0007/2003-04. Ministry of Law and justice : 2005Disasters & Emergencies Definitions Training Package WHO/EHA Pan African 5. Emergency Training Centre, Addis Ababa Updated March 2002 by EHAPan American Health Organization Epidemiological surveillance after natural 6. disaster PAHO/WHO scientific publication No 420. Washington DC, 1982. Bres P. Public Health Actions in Emergencies Caused by Epidemic. WHO 7. publications, Geneva 1986. World Health Organization, Guidelines for the collection of Clinic Specimens 8. during Field Investigations of Outbreak. WHO Dept of Communicable Disease, Surveillance and Response. WHO Geneva 2000.

World Health Organization – Manual for Basic Technique for a Health 9. Laboratory. WHO Geneva, 1980Pan American Health Organization, Environment Health Management after 10. Natural Disaster. PAHO/WHO Scientific Publication No 430. Washington DC 1982. The United Nations. Disaster Prevention and Mitigation Volume-9, Sanitation 11. Aspects. United Nations New Work 1982. Franceys R, Pickford J, Reed R. A Guide to the Development of on site 12. Sanitation WHO, Geneva 1992. Assar M Guide to Sanitation in Natural Disaster, WHO Geneva 1971. 13. Pan American Health Organization. Emergency Vector Control after Natural 14. Disasters. PAHO/WHO scientific publication No 419. Washington DC 1982.

78 Principles & Practice of Hospital Management

Anuj Bhatnagar

World Health Organisation (WHO) has defined a ‘hospital’ as ‘an integral part of a social and medical organization, the functions of which are to provide to the population, complete health care, both curative and preventive including out-patient services which reach out to the family in its own environment and also carry out training of health workers/functionaries and undertake bio-social research’. Besides this comprehensive WHO definition, a hospital has also been described as an institution which is operated for medical, surgical and/or obstetrical care of in-patients and which is deemed to be a hospital by the government or local licensing bodies (Directory of Hospitals in India, 1988)

Hospitals are generally considered as institutions where the sick and injured are treated as indoor patients, in comparison to dispensaries where primarily out-door patients are treated and medicines are distributed. Thus, a hospital can be described as an organisation which provides health care services (preventive, promotive and curative) by pooling in the various skills & services of health professionals, supportive staff and ancillary staff, with the overall objective to provide health care to patients.

Role of a HospitalThe role of a hospital in a community can be summarized graphically as shown in Fig. - 1.

Peculiarities of a Hospital as an OrganisationAs a health manager, one should be acutely aware that a hospital differs greatly from any other organisation. It is a highly complex institution which brings together highly qualified and highly technical professionals for common cause of providing comprehensive health care and medical care to patients, in the most cost-effective manner, within the limited available resources. The peculiarity of a hospital as an organisation is enhanced since the ‘ product ’ in a hospital is ‘ medical care ’,

Fig. - 1 : Role of a Hospital

Providecurative andrestorative healthcare (Diagnosis,Treatment, Rehabilitationand Emergency MedicalCare)

Disease Surveillance(generate mortality &

morbidity data)

Medical & SocialResearch

Medical education &Training

Support to PrimaryHealth Care

establishments

Promotionof Health and

Disease Prevention(MCH, immunization,

health education,screening for disease)

Hospital

which is highly personalized, professional and technical in nature and hence can not be assessed in quality by a lay person.

This ‘service’ provided by a hospital can not be quantified in any economic/financial terms and can not be evaluated on any objective criteria for quality and standard. Hospital care and service differs for every patient depending on his/her condition & requirements and thus standardization of such medical care is not possible. Pre- planning at micro level is not possible in a hospital and most often, hospital management is management by crisis wherein each patient is unique requiring highly professional and personalized medical care, provided by the entire team rather than any one individual. A hospital also employs a wide variety of people, from highly trained professionals to unskilled individuals. It is thus a challenge for any hospital manager to manage people of such wide ranging skills as a team and to make them work together. In addition, staff in a hospital is always under dual control, with professional control vested with heads of respective departments and

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administrative control vested with the hospital administrators, which often leads to conflict of interest among the various members of the team.

Work Areas of a HospitalA hospital can be broadly divided into :

(a) Clinical Areas : A&E Dept, OPD, Operation Theatre, ICU & inpatient services

(b) Diagnostic Areas : Laboratory, radiological services, blood transfusion & pharmacy services

(c) Support Services : CSSD, medical records dept, laundry services & dietary services

(d) Auxiliary Services : Basic and allied engineering services.

Clinical Areas of a HospitalA hospital comprises of certain key clinical areas which are engaged in the primary task of providing medical care to the patients. These clinical areas are vital areas in hospitals where the actual objective of the hospital (of treating the sick and injured) is achieved through various categories of health care providers. A description of these areas is as follows :

Accident and Emergency Services (A & E Services)The term “Accident and Emergency Department” was suggested to be used in all hospitals by Platt Committee in UK in 1960s and in India, the Central Council of Health, as early as 1963, recommended the setting up of ‘emergency medical services’ in all States. Emergency Medical Services (EMS) can be described as medical services undertaken with the aim to transport the right patient to the right hospital at the right time so that right treatment can be given, thereby preventing death & disability among such patients. The essential components of EMS are described as in Fig. - 2.

Fig. - 2 : Essential components of EMS

Efficientcommunication

Pre hospitalexpert care

Timelytransportation to

A&E

Departmentof a hospital

Hospital basedcare

Planning considerations for A&E facilities of a hospital

(i) Patient load (ii) Morbidity pattern (iii) Time of maximum patient load (iv) Location of main roads (v) Communication facilities (vi) Similar facilities for population (vii) Architecture of hospital (viii) Industries / infrastructure in the area.

Role of A&E Services in a Hospital1. Provisioning of prompt life/limb saving medical care

(including surgeries) to patients in need, at all times. 2. Liaise with police and assist the courts in medico-legal

cases, but without compromising on the primary duty of providing life saving medical care.

3. To provide ambulance services equipped with trained

manpower and adequate life saving equipment for transport of patient to & from the hospitals.

4. To function as an information centre about seriously injured patient, especially in case of large scale disasters.

5. To sensitively and maturely cater to the emotional needs of relatives of seriously ill/ injured patients brought to the hospital.

6. Continuous training of medical staff in trauma care and emergency medical care.

Planning of an A&E Dept : The basic principle while planning an A&E Dept in a hospital must be remembered that ‘design should follow function’ that means that various areas should be planned and designed according to their intended function, as under :

(a) Location : The A&E Dept should be separated from the main hospital but with access to dependent areas like ICU, OT, laboratories and mortuary etc. It should be situated on ground floor with direct access from main road and a porch for patients to alight from ambulances. There should be adequate facility for parking of ambulances and other patient vehicles. Adequate sign posting (both at day & night) should exist.

(b) Space requirements : The A&E Dept should have an average space of 10 square meters per patient visiting the Dept, with an additional 50% of space to avoid overcrowding. For example, if the A&E Dept of a hospital is visited every day by an average of 50 patients, the required space would be 500 square meters + 250 square meters = 750 sq m. There should be facility for expansion of A&E Dept without affecting functioning or form of any other department. Approximately 10% of all patients coming to the hospital visit A&E Dept during any given time; hence there should be 6 parking spaces for every 10, 000 annual visits. All A& E Depts should have a Trolley/Wheel chair bay (1 wheelchair & trolley per 1000 annual visits).

(c) Planning of facilities : The A&E Dept of a hospital should be planned to ensure availability of Reception, Registration and Waiting areas. There should also be a police and mass media room. The Dept should have a separate entrance 1.6 meter wide with two-way doors with glass panel at eye height. Triage area, separate examination and treatment areas, resuscitation cubicles, observation beds, plaster room (1 per 15, 000 annual visits), burns room, radiography unit, ECG room, isolation room and an emergency laboratory should also be catered for.

(d) Architectural design : While planning the architectural design of an A&E Dept, the following aspects should be kept in mind. (i) Entrance should be separate for ambulatory and stretcher-

borne patients with two-way swinging doors 1.6 meters wide with glass at eye level. There should be no steps, only ramps with side railings should be provided at the entrance.

(ii) Waiting area should be in form of a large lobby, including the waiting area which may also be used for triage of patients. Toilets should be located near the main entrance and every specialist cubicle or special investigation should have its own sub-waiting area.

(iii) Reception, Registration & Records should have an office adjacent to main entrance which should be manned

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24 hours. This office should be used for admissions, discharges, billing, record keeping and safe keeping of patients’ valuables. There should also be an adjacent Nurses Station and work room.

(iv) Examination & Treatment area should be in form of cubicles (7mx13.4m) with temporary partitions which can be removed to expand the area. There should be examination beds which permit access to patients from all sides. Loose hanging wires or clutter of unwanted equipment should be avoided.

(v) Resuscitation Room should ideally have an area of 30 square meters with all resuscitative equipment & standby emergency electricity supply system. All shelves, drawers & cabinets should be properly labeled.

(vi) X Ray facility in A&E Dept is desirable if more than 1000 patients undergo radiological investigations in A&E Dept per month. It should have an area of 180 square feet.

Suggested flow of patients in A & E department : It is described in Fig. - 3

Fig. - 3 : Suggested flow of patients in A & E department

Reception. waitingarea and triage

Entrance forambulatory

patients

Entrance fornon-

ambulatorypatients

Resuscitation Examination,diagnosis &treatment

Further treatment inplaster room. burnsunit, OT, ICU, ward

Shift to OPD, otherreferral hospitals,

discharge

Out - Patient Department An out-patient department (OPD) can be defined as that part of the hospital with allotted physical and medical facilities and staff in adequate numbers, with regularly scheduled hours, to provide care for patients who are not registered as indoor patients. The present magnitude and importance can be gauged from the fact that a hospital OPD load is around 500 patients per bed per year against an inpatient load of 25 patients per bed per year.

Out patients Departments are also called the ‘show windows’ of hospitals. They are the first point of contact between the patients/their relatives and the hospital staff and the facilities and the care provided in OPDs often are the true reflection and determine the image of the hospital. The important functions of an OPD in a hospital are summarized as under : (a) To provide day care investigative, diagnostic and treatment

specialist procedures to the community. (b) To undertake day care surgical procedures (e.g. vasectomy)

for ambulatory patients.

(c) To conserve hospital beds (and inpatient resources) by acting as an admission filter and admitting only those patients who are actually in need of admission.

(d) Undertake health education and thus promote health. (e) To carry out medical follow up and rehabilitation of patient

after discharge from the hospital. (f) To undertake various promotive and preventive measures

such as antenatal care, vaccination, well baby clinics etc. Broadly, the OPD Services can be classified into two types. Firstly, the decentralized type in which the specialist services are located in the respective departments (speciality clinics). All specialist services are usually located in a compact area, including all diagnostic and therapeutic facilities (polyclinic).

Planning Considerations and Principles for OPD : The planning of an OPD facility in a hospital would be determined by many key factors. The range of services to be offered (investigative and therapeutic services offered) would determine the space requirement and the capacity of the OPD being planned. Other important considerations for planning an OPD are the number of medical and paramedical personnel available to the hospital for OPD, the service time for patients, type of patients expected, rate of arrival of patients, holding capacity expected & the number of admissions to the hospital. The following principles should be observed for planning an OPD :

(a) Location : The OPD of a hospital should be located near the main road and near the main entrance of the hospital with adequate space for parking of vehicles including ambulances. The OPD should ideally be separate from in-patient wards but connected to them, especially vital investigative centers like pathology laboratory and radiological services.

(b) Patient flow : It should be only in one logical direction with minimal cross traffic. This can be ensured by planning the various facilities in a logical sequence of possible utilization by the patients.

(c) Interdepartmental Resource Sharing : All OPDs should be so located that they are all able to share common and interdepartmental resources of the hospital such as pharmacy, radiological services, pathology services, hospital records, billing etc.

(d) Facility for expansion : All OPDs should be planned and laid so that they can be expanded in future without disrupting the routine functioning.

(e) Physical facilities

(i) Space provisions : The Bureau of Indian Standards (BIS) has laid down the space specifications of 2 square meters per bed for entrance zone, 10 square meters per bed for ambulatory area, 6 square meter per bed for diagnostic zone for OPD area out of a total OPD space specification of 60 square meter per bed for the entire hospital area.

(ii) Public areas in OPD : An OPD should have a wide entrance with double swinging doors with glass at eye level, ramps and steps. Reception and information desk should be located near the entrance in the public area. There should be registration counters (01 desk per 20 patients per hour) with a counter for storing files etc. The waiting area should be at the scale of 0.1 square meter per patient (minimum of 4 square meter) adjacent to Reception/Registration. Sub-waiting areas should

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also be provided for specialist consulting rooms & special investigations. Public toilets should be provided separately for males and females at the rate of one toilet each for 200 patients/ visitors. Snack bar should be conveniently located in the waiting area in for large OPD.

(iii) Clinical areas of OPD : These include various specialist consulting areas such as surgical OPD, Ophthalmic OPD, Medical OPD, Dental OPD, Pediatric OPD etc. and may also include certain super specialty OPDs such as cardiology, neurology etc. These specialist and super specialist OPDs should have separate sub-waiting areas and at any given time should not have more than one thirds of the total patients of OPD in each sub-waiting area. The consultation room should have a space of 14-28 square meter, should accommodate all furniture and equipment necessary for examination of patients and each consultation room should be able to cater for examination of 100 cases per day.

(iv) Additional clinical areas : These include Injection room with 12-40 square meter area and waiting ●area for 10-20 patients, depending on the patient load. Dressing and Treatment Room with an area of 12-16 ●square meter.Pharmacy is generally the last point to be visited by OPD ●patients, by which time they are tired, hence it should have multiple dispensing windows & adequate staff to reduce waiting time, in addition to comfortable seating arrangements for the patients.

(v) Auxiliary facilities for OPD : These should be able to provide care both to inpatients and outpatients and thus should be easily approachable from OPD and various wards. The important auxiliary facilities in any hospital are :

Pathology laboratory with separate male and female toilets ●(15 square meters) and bleeding room (20 sq mt). Radiology Services. ●Blood Bank with adequate waiting area, reception, bleeding ●room, laboratory, recovery room and storage facility for blood and blood components. Health Education Facility with adequate audiovisual aids. ●Medico–Social Service Facility with adequate number of ●counselors, located in OPD. Screening Clinic should be located near the reception ●with adequate equipment for examining patients where all patients would be initially screened and referred to the appropriate specialist OPD. This reduces the load on specialist OPDs, guides the patients correctly and improves the quality of OPD services. Preventive & Promotive Health Care facility with an ●area of at least 15 square meter, would be the centre for advice on preventive and promotive health aspects such as immunization, nutrition, family welfare & counseling, sanitation etc.

(vi) Administrative Areas of an OPD : These areas should consist of an administrator’s office, a business office for personnel section, record keeping, requisitions etc, a janitor’s closet for house keeping and adequate storage facility for general stores, drugs (including dangerous and controlled drugs) and linen etc.

(vii) Circulation Areas : These include corridors, lifts and stairs and would occupy almost 30% of the total area of an OPD complex. These areas, esp corridors and doors should be at least 1.8 mt wide to allow the passage of a stretcher with a person on either side. Adequate communication facilities, lighting, public address system and fire fighting facilities should also be provided.

Common problems faced in OPDs :(a) Overcrowding at screening OPDs, specialist OPDs and

special investigation centres. (b) Timings of OPDs and auxiliary/ supportive services may

not be same. (c) Jumping of queue by influential patients/ staff members. (d) Long waiting time. (e) Investigation results not available centrally and on time. (f) Lack of communication (absence of PA system and patient

call system).

Operation TheatreAn Operation Theatre (OT) is defined as a specialized facility of the hospital where life saving / life improving procedures are carried under strict aseptic conditions in a controlled environment by specially trained personnel, to promote healing and cure with maximum safety, comfort and economy. Surgical operations have been classified broadly as emergency surgeries (which must be carried out as soon as the diagnosis has been made and patient prepared for surgery in a proper manner) and elective surgeries (undertaken some time after the diagnosis has been made and when best suited to the patient & hospital). An OT in a hospital should be planned with the following objectives in mind : (a) Ensure complete asepsis during surgeries. (b) Ensure maximum safety for patients and medical personnel

from bio-medical, engineering, electrical and radiological hazards in the OT environment.

(c) Optimal utilization of trained manpower and other resources in OT.

(d) To optimize working condition for OT staff. (e) Allow for flexibility. (f) Minimize maintenance and regulate flow of traffic through

OT. The Concept of ‘Zoning’ in an OT : The OT has to be divided into four distinct zones based on bacteriological cleanliness, in order to attain maximum asepsis for surgeries. Bacteriological contamination progressively diminishes from outer zone to the core zone (100% sterile) where all surgeries are performed. The following zones are identified in an OT (Fig. 4): (a) Disposal zone with facilities like patient closet, disposal

corridor for solid linen and surgical waste and dirty wash up room.

(b) Protective zone includes areas in OT like Reception, waiting room, stores, trolley bay, autoclave, TSSU, control area of electricity, changing rooms for staff with toilets and pre- anesthesia room.

(c) Clean Zone includes areas in OT such as theatre work room, plaster room, recovery room, surgeons’/ nurses’ staff rooms, anesthesia stores, X Ray facility, blood stores, pre and post operative rooms.

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(d) Sterile Zone (innermost) consists of facilities like operating room, scrub room for staff, anesthesia induction room and instruments/trolley area.

Intensive Care UnitThe intensive care unit (ICU) of a hospital is one of the most important places in a hospital. It can be defined as a specific area in a hospital where sophisticated monitoring, titrated life support, specific therapy and specialized nursing are provided for potentially salvageable, critically ill patients with life threatening illness or injuries. ICU is a place where seriously sick patients, highly skilled medical and nursing staff with knowledge and experience & sophisticated medical equipment are brought together for better health care at an optimum cost. One of the major objectives of ICU is to identify patients who require intensive medical care and close monitoring round the clock. Broadly, such patients are classified as : (a) Patients expected to survive.(b) Potentially recoverable patients. (c) Patients with uncertain prognosis. (d) Patients not likely to survive irrespective of whatever is

done. (e) Patients for whom death is imminent. Classification of ICU : (based on organizational structure)(i) Open unit is available for admission to all patients by any

attending physician but the triage decision and allotment

of a bed is the decision of the medical officer in charge of the intensive care unit. (ii) Semi closed unit is where the medical team in charge of the intensive care unit must review and approve all admissions into ICU. Concerned specialists recommend ICU admissions but all final decisions rest with administrators. (iii) Closed unit is one where Heads of Departments and treating physicians are responsible for all admissions and discharges but after admission, the ICU team along with the treating physicians is responsible for providing health care. Staffing requirements in ICU : Since ICU is one of the most sensitive places in a hospital, it is necessary to be staffed accordingly by medical and nursing personnel. Ideally, ICU should have a medical officer in charge who should provide continuity and direction to ICU services. The ICU should also be staffed by one Resident round the clock in addition to a junior resident who is pursuing post graduate studies. ICU has extensive nursing and paramedical requirements. The acceptable staff : patient ratio are as under :

Nurse : patient ratio - 1 : 1 during day & 1 : 2 during night

Staff : Patient ratio - 2 : 1 for a 6-8 bedded ICU

Any ICU for constant patient care requires a nurse : bed ratio of 4 : 2 allowing for leave

and other absences of nursing staff. Physical facilities and design of ICU

(a) Location : ICU should be ideally located near operation theatre and should have access from other departments. The movement areas in ICU should be spacious and corridors should be at least 2.4 m wide.

(b) Space requirement : The should have a space of 50 sq m per bed. There should be facility for removing shoes and wearing masks /gowns and entrance should have air curtains to prevent dust from entering. Every patient should have at least 15 sq ft of clear space (with minimum head wall width of 1-2 ft / bed) excluding service areas like toilets. ICU should have a nursing station equipped with patient monitoring equipment (including an alarm system and telephone to call for assistance from outside). At least one hand washing facility should also be provided for every three beds in ICU.

(c) Patient services : ICU should have piped oxygen supply and suction facility. Adequate electric sockets should be available for every bed. Each bed in ICU should be isolated by mobile partition to form a small cubicle for each bed.

(d) Nursing station in ICU : It should have adequate storage space for documents and should have adequate counter space. Since all patients in ICU need to be monitored round the clock, nursing station in ICU should be so oriented so that every

Fig. - 4 : Zoning in OT

ScrubRoom

Disposal corridor

Pre anaesthesia area Reception / Staff toilets

Theatre work room Theatre work room

Operatingroom

Inductionroom

Trolley &instruments

DirtyWash uproom Staff

Changingroom

Waitingroom

Pre / PostOp. room

BloodStores

X-ray facility Plaster room

Autoclave Stores

Anesthesiastores

Staffroom

Electricitycontrolarea

Trolleybay

Dirtyutility

Janitor’s closet

Disposal Zone Protective Area Clean Area Sterile Zone

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patient can be directly observed from central nursing station without being able to see other patients in ICU.

(e) Miscellaneous : ICU should be well illuminated without reflective or bright lights. It should stock all necessary routine and emergency medicines, should have refrigerator for storing medicines which require to be stored at low temperature. In addition, every ICU should have a clean supply room, clean linen store, soiled linen holding room, X-Ray viewing facility and equipment storage space. Laboratory, radiological and pharmacy services should be available to ICU round the clock.

In-Patient ServicesThe inpatient services of a hospital provide clinical care to non-critical patients who need to be admitted to the hospital for investigations, diagnosis and treatment. The hospital wards (which accommodate the inpatients) and their ancillary areas & services thus are the most vital areas of any hospital, occupying as much as 50% of the entire hospital area. The inpatient areas consist of various wards (including the nursing station) the patient beds and the entire necessary support services and areas. Since inpatients are required to be monitored and are mostly dependent on nursing staff, these areas also witness non-stop patient related activities. A ‘ward’ in a hospital can be defined as a section of a hospital, including a nursing station, bed and necessary storage service, work and public areas, where nursing care is provided to in patients.

Various types of wards : The main factor to be kept in mind while designing a ward is that nursing staff should be able to hear & see all patients and should be able to react accordingly with maximum efficiency and least stress and strain.

(a) Open ward (pavilion type) : It was first constructed in 1770 by a Frenchman and later modified by Florence Nightingale in 1850’s. Such wards have patients’ beds in two rows at right angles to the longitudinal walls. Bathrooms and toilets are located at one end while the nursing station and doctor’s room is located at the other end. The usual length of such open ward was 96 feet, where 30-35 patients were admitted (Fig. - 5).

Fig. 5 : Open ward

NursingStation

Sun glare in tropical countries was prevented by constructing covered verandas on either side of wards. After 1925, the nursing station was shifted to center of the ward to reduce nurse fatigue. Similarly, service areas were also shifted to a central annexe to reduce the distance traveled by each patient.

Open wards offer the advantages that all patients are directly visible to nurses on duty, adequate ventilation and natural light is available to all patients and it is economical to construct and maintain. It however suffers from certain disadvantages like lack of privacy, danger of cross infection and constant glare for all patients. Moreover, seriously ill patients requiring constant attention have to be placed in the center close to the nursing station which is also the area for maximum movement in the ward.

(b) Rig’s ward : In Denmark, Rig’s Hospital first adopted a design where patient beds were arranged in small cubicles along the longitudinal walls of the wards. This has the advantages that patients have privacy, cross infection can be contained to some extent, infectious patients can be partially isolated in cubicles and patients of both sexes can be accommodated in the same ward since privacy is offered by cubicles. However Rig’s pattern of ward suffers the disadvantages that patients are not under direct supervision of nurse, there is difficulty in communication between patients and nurse, additional nurses are required since wards became larger and it is costly to construct and maintain (Fig. - 6).

Fig. - 6 : Rig’s Ward

Nursing Station

The Committee On Plan Projects (Buildings Projects Team) of the Planning Commission (COPP) has recommended 20-30 beds per ward with 2-3 single-bed rooms for patients requiring special nursing care. In addition there may be 2-3 additional beds for patients on payment. The rest of the ward should be divided into cubicles with 6-8 hospital beds each. Outer verandas are no longer recommended. Recent studies have indicated that Nightingale pattern is more acceptable and appropriate for inpatients in India since it was easier to observe all patients at all types. The nurse fatigue is less and hence job satisfaction is higher among nurses. Open type wards offer a subtle form of group therapy for admitted patients and ambulatory patients are less likely to feel bored.

The primary area in a ward consists of patient space, with generally 7 square meter space per bed. The size of the bed is 1 meter X 2 meter and the minimum distance between centre of adjacent beds should be 2.5 meters. The distance from centre of the aisle to the foot end of bed should be 0.9 meter and distance from wall to head end of the bed should be 0.25 meter.

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Ward Management : The objective of Ward Management is to provide the best possible medical & nursing care to patients by using the abilities of every member of the staff to fullest extent possible & by providing close supervision of both patient care & of the individuals who provide the health care. The common problems in ward management are summarised in Table - 1.

Table - 1 : Common problems in Ward Management

Over crowding ●Inadequate staff ●Untrained staff ●Excessive use of student nurses ●Lack of equipment /supplies/ stores ●Multiplicity of units ●Pilferage of stores & medicines ●Undue paper work/ inventory ●Lack of discipline in staff ●Lack of supervision ●Lack of incentives for staff ●Lack of coordination ●

Ward management would consist of the following :

(a) Patient Management Admission & orientation of the patient ●Realistic assessment of patients’ needs ●Observation and recording ●Monitoring the progress & reporting ●Assignment of patient care ●Planning of work schedule ●Ward rounds ●Disposal & rehabilitation of patient ●

(b) Management of Supplies & EquipmentIndent, receipt & issue of supply ●Accounting of drugs & med stores ●Requisition of diets & its distribution ●Provision of linen & its exchange ●Maintenance of equipment ●

(c) Management of EnvironmentAdequate lighting, ventilation, prevention of noise, dust ●control, regulation of temp & humidity, adequate privacy, control of visitors & control of infection

(d) Management of personnelJunior Doctors & interns, Nurses, paramedicals and ●ancillary staff

Diagnostic ServicesThe diagnostic and supportive services in any hospital broadly consist of the laboratory services, radio-diagnostic and imaging services, blood transfusion services and pharmacy services, which are described in detail subsequently.

Laboratory ServicesThe functions of a laboratory can be described as :

Provision of comprehensive & accurate analytical test ●resultsCollective consultation with clinicians regarding most ●useful application of scientific procedures for patient careTraining of professional & technical staff ●

Research (e.g. types of diseases, social, genetic, nutritional, ●environmental etc. )Adaptation of Laboratory Medicine to useful advances in ●basic sciencePreventive (through examination of food handlers, ●personnel, materials for delivery rooms, nursery, OT, examination of food, water & milk)

Major considerations while planning a hospital laboratory

(a) Space : The total area of a hospital laboratory should be 10.3 to 14.4 square feet per bed depending on the load and the type of hospital. A hospital laboratory broadly consists of three areas. Primary space is the area occupied by technical & professional staff and should be ideally 3.5 Laboratory Space Unit (LSU) (1 LSU = 200 square feet). Secondary space (1.4 LSU) is the area for non-professional activities of those personnel who occupy the primary space. Circulation space (0.4 LSU) is the area for movement of personnel and goods.

(b) Staffing : The suggested staffing pattern is as summarised in Table - 2.

The average number of tests which can be performed by a technician, depending on the automation of the laboratory is as under :

Semi automated laboratory : 1800 tests per year ●Partial automated laboratory : 25,000 tests per year ●Totally automated laboratory : 2,85,000 tests per year ●

Table - 2 : Staffing pattern in a laboratory

Beds Pathologist Technicians Steno

<50 1 (part time) 2-3 As needed

50-100 1 (part time) 3-5 Part time

100-200 1 5-8 Part Time

200-300 1 or more 8-10 1

300-500 3 20-30 2-3

Blood Transfusion ServicesA blood bank is defined as a organisation for carrying out all or any of the operations pertaining to collection, aphaeresis, storage, processing & distribution of blood drawn from a donor &/or preparation, storage & distribution of blood components, with the aim to provide adequate quantity of safe blood & blood products or components for patients in a cost effective & coordinated manner. The role and functions of a blood bank can be summarized as under :

Selection of donors & maintenance of donor records ●Collection of blood in an aseptic manner ●Screening for HIV, Hepatitis B & C, Malaria & Syphilis ●Component preparation ●Optimum storage of blood and blood components ●Carry out emergency matching, cross matching ●Record all Blood Bank procedures ●Training of medical & paramedical staff ●Conduct camps in community for voluntary donation of ●blood

Blood banks can be broadly classified into three categories based on consumption of blood :

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(a) Category I : Hosp consuming 3-7 units of blood/yr/bed (100-400 beds) (100 sq m space)

(b) Category II : Hosp consuming 8-15 units of blood/yr/bed (400-1000 beds) (300 sq m space)

(c) Category III : Hosp consuming >16 units of blood/yr/bed (>1000 beds) (895 sq m space)

Planning considerations for establishing blood transfusion services :

The location should be preferably on ground floor and easily accessible from Operation Theatre & A&E Dept. There should be proper signage and parking facilities for donors and ambulances. The public access areas should consist of donor reception office, counseling room, medical examination room, bleeding room and refreshment / rest room (including toilet & pantry). The laboratory areas (accessible only by professional staff consists of a transfusion lab, a component lab and facilities for disposal of biomedical waste. The storage & issue areas consist of storage facilities for blood and blood components and issue counter, which should be prominently marked and located near A&E Dept/OT. Administrative areas in a transfusion facility would include offices for medical officer & paramedical staff, rest rooms for technicians, conference room & library etc. Equipment required for blood transfusion services are described in Table - 3.

Table - 3: Equipment required for blood transfusion services

For Routine Work For Blood Component work

Refrigerators ●Centrifuges ●Dielectric tube ●sealersPlasma separators ●Hot air oven ●Microscope ●Tube stripper / ●cutter/ sealerBlood Bags ●

Refrigerated Centrifuge ●(5000Xg)Deep freezers with power ●back up Water bathsIncubators ●Platelet agitators ●Cryo precipitate ●thawing bathLaminar flow ●Weighing scales ●

Supportive ServicesCentral Sterile Supply Department (CSSD)The Central Sterile Supply Department is responsible for collecting & receiving used patient care items with the view to decontaminate, process, sterilize, store and dispose these items to all other parts of the hospital (Mayhall). Thus the Central Sterile Supply Department (CSSD) comprises of the services within the hospital which receives, stores, processes, sterilizes, distributes and controls professional supplies and equipments, both sterile and non sterile, to all departments of the hospital for the care and safety of patients. The CSSD is a central agency in a hospital which ensures quality control of sterilized material, economy of scale (since it dispenses optimum requirements of various wards) and better utilization of trained nursing manpower. CSSD is set up in hospital with the aim of providing sterilized materials from a central department where sterilizing practices is conducted under conditions which can be properly controlled (thereby reducing incidence of hospital infections)

and to take some of the work off the nursing staff so that they can devote more time to patient care. The objectives of a CSSD are thus,

To provide sterile supplies centrally ●To provide assistance to purchasing dept in selection and ●pretesting of goodsAdvisory role to Hosp Infection Control Committee ●(HICCOM)Ensure quality control measures in sterilization of various ●itemsImpart training to hospital personnel ●

CSSD caters for sterilization of items such as needles & glass syringes, rubber goods, including catheters & tubings, treatment & diagnostic sets (such as lumbar puncture sets), dressings, intravenous sets and infusion fluid for renal dialysis. Normally, CSSD does NOT include sterilization of surgical instruments used in OT, bed pans & urinals, bedding of patients, diets, medicines including blood & crystalloids and laundry.

Planning considerations : CSSD must be located close to and be easily accessible to areas which it serves most frequently such as Operation Theatre, ICU, acute wards & labour room. The space requirements recommended for CSSD (based on number of beds) are as shown in Table - 4 :

Table - 4 : Space requirement recommendation for CSSD

Up to 100 beds 10 square feet per bed

101 - 200 beds 9-10 square feet per bed.

201 - 300 beds 8-9 square feet per bed

301 beds and above 7-8 square feet per bed

The functional layout of CSSD should be so planned so that sterile and contaminated items do not come in contact and are not handled in the same area. Functional areas are thus divided into Receiving area, Cleaning and washing area, Unsterile area for inspection and maintenance, Work area for assembly and packing, Work area for sterilization, Sterile storage area, Gloves and rubber goods processing area and Issue area. Broad layout of a CSSD is as shown in Fig. - 7:

Fig. - 7 : Layout of CSSD

ReceivingArea

Preparation &Packaging Area

Cleaning &Decontaminating

Area

SterilisationArea

Sterils StorageArea

IssueArea

The concept of ‘Zoning’ in CSSD : Zoning is essential to ensure that contaminated items do not mix with sterile items in CSSD. Broadly the CSSD is divided into (i) Dirty Zone (receiving area, cleaning area and repair place); (ii) Clean Zone (Assembly and packing place) and (iii) Sterile Zone (Sterilisation, storage and issue areas). Accordingly the flow of items inside CSSD should be in such a manner that dirty items and sterile items do not mix.

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Distribution System : CSSDs in various hospitals may follow any one of the distribution systems in vogue, as under : (a) Clean for Dirty Exchange system in which one used item

is exchanged for sterile one on an exchange basis. This method of distribution is mostly used in cases where the demand for sterile items is less, such as in chronic wards.

(b) Topping system where stocks of each ward, OT, ICU etc. are topped up daily to a predetermined level by making rounds and topping up the stocks. It is recommended that 50% extra items (more than the average daily consumption) should be added when one daily round is made and 25% extra items should be added when two daily rounds are made.

(c) Requisition system where the requirements of each ward, ICU, OT etc are intimated to CSSD in advance and sterile items from CSSD are supplied based on the demand from each ward.

(d) Exchange Trolley system wherein entire trolley is exchanged which has a fixed number of items. Such a system is followed where demand is substantial, such as a busy OT, ICU or acute surgical wards.

Medical Records DepartmentA medical record is defined as a clinical, scientific, administrative and legal document related to patient care in which is recorded sufficient data in sequence of events to justify the diagnosis, warrant the treatment given to the patient and results (McGibony 1969). Medical records are thus clear, concise & accurate history of patient’s life & illness, written from medical point of view (Mac Eachern 1957). They are the sequentially recorded findings, observations and prescriptions of all medical & paramedical health care providers who attend to a patient during his / her interaction with health care facility. Types of Medical Records (a) Directly related to patient care such as admission

forms, medical history sheets, medical record forms, nurses’ bedside records like TPR charts, consultations, investigations ordered & their results, OT notes and discharge summaries etc.

(b) Indirectly related to patient care such as budget, accounts and financial transactions during patient’s stay in hospital.

Importance of medical recordsFor the patient, medical records help in continuity ●of medical care, prevent omission / duplication of investigations, support or refute medico-legal issues, provide reliable information for health insurance and disability entitlements for the patients. For the treating physician, accurate medical records provide ●a quality check regarding the adequacy and continuity of medical care, helps in evaluation of medical care provided and protects from legal suits of medical malpractice or medical negligence. For the hospital, medical records serve as evidence ●for evaluation of medical & nursing care, helps the management in planning & allocation of resources for the future and protects in case of legal suits. For medical research, accurate medical records assist in ●deriving conclusions or investigating them, aids informal

education, forms basis for clinical research and provides reliable source for advancement of medicine. For public health, medical records provide reliable info ●regarding mortality & morbidity profile of population, assists in planning preventive & social measures and provides early warning of incidence of communicable diseases.

Some commonly used terms in medical records

(a) Hospital Death : Death of a patient admitted as an inpatient in the hospital is considered as a hospital death. Death of a patient in casualty, OPD, ambulance or anywhere in the hospital before actual admission is not termed as hospital death. Gross Hospital Deaths are hospital deaths irrespective of duration of admission, whereas Net Hospital Deaths are deaths of inpatients after 48 hours of admission.

Net Death Rate of a hospital serves as an accurate indicator of quality of medical care provided by that hospital. It is natural that net death rate (hospital deaths after 48 hours of admission) will be low where quality of medical care is good. Excessive net death rates indicate poor quality of hospital care and should be investigated.

(b) Patient Day : It is defined as the duration of medical care rendered to an inpatient between the census taking hours of two successive days. While counting the patient days, the day of admission is always counted (irrespective of the time of admission) and the day of discharge is always excluded (irrespective of the time of discharge). Patient day is a useful unit of time for assessing various hospital related activities such as patient days of health care provided, cost incurred on ICU bed per patient day, cost of hospital food per patient day etc.

(c) Average Daily Census : It is the average number of patients in the hospital at any given time of the day and is expressed as:

(d) Occupancy Rate : It is the ratio of actual patient days expressed as a percentage of the maximum possible patient days (based on bed complement) in a hospital during any given period. It is :

Total number of hospital deathsduring the given period

Total discharges (Including deathsduring the same period)

=Gross deathrate X 100

Total number of deathsof inpatients after 48 hours

of admission during a given periodTotal discharges (including deaths)

during the same period

=Net deathrate X 100

Sum of daily census for a given periodNumber of calender days in the period

Number of patient days (based ondischarges) during a given period

Bed complement x days duringthe same period

X 100

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(e) Average length of stay : It is the average number of days of medical care rendered to each discharged patient during a given period of time and can be compiled from the discharge summary of patients. It is expressed as :

(f) Turnover Interval (T interval) : It is the average number of days that bed remains vacant between a discharge and subsequent admission. It is expressed as :

A negative value of T interval indicates a scarcity of hospital beds whereas a prolonged positive T interval indicates under-utilization of hospital beds (vacant beds) due to inadequate admissions or poor quality of medical care offered by the hospital. T interval is a sensitive index of hospital bed utilization and a short positive T interval indicates optimum utilization of beds.

Legal aspects of Medical Records : Medical Records, besides recording the complete diagnosis, treatment and outcome of a patient in a hospital, is also an important legal document and hence must be complete (must contain adequate data to identify the patient, justify diagnosis & treatment and outcome and must contain all bedside recordings of various medical & nursing procedures), adequate (must contain all necessary clinical information), accurate (information recorded should be quantifiable and assessable for correctness and legible (records must be legible and names of all medical professionals endorsing the records should be recorded clearly). The medical records are property of the hospital and not of the patient or the treating doctor. Since a medical record pertaining to an individual is a personal document, the contents ordinarily should not be divulged to anyone without consent of the patient. However, details may be divulged to the patient concerned in form of brief summary and findings of investigations. Relevant details may be released to press under exceptional circumstances only by the administrator of the hospital. Details of hospitalization can be released to LIC even without consent of patient to dispose claims arising from insurance policies and to police in case of medico-legal cases, injury reports etc. Police should ordinarily not be allowed to record a patient’s statement without prior certification by MO (compos mentis). According to Indian Evidence Act, hospital documents including medical records are admissible as evidence. Courts can subpoena any document or medical record and can summon any doctor for evidence under law of torts. Medical documents can also be used for education, research & public health when used as impersonal details. At times, some personal information has to be divulged in public interest for communication & notification of certain diseases.

Safety & retention of medical documents : It is the responsibility of hospital administration to safely store medical records pertaining to patients. Medico-legal documents should be especially kept safely as these are required in courts of law subsequently. The general guideline for retention of hospital

Total patient days during a given periodTotal discharges (including deaths)

during the same period

Maximum possible patient days -- Actual patient days(bed complement x days) during a given period

Number of discharges (including deaths) during that period

documents is that OPD records should be stored for 5 years, indoor records for upto 10 years and medico-legal documents should be stored permanently.

Linen & Laundry ServicesLinen & laundry services are one of the important support services of a hospital, which not only contributes to patient satisfaction, but also assists in healing by reducing cross infection among patients. Hospital linen can be defined as all clothing made of cotton, linen, wool or synthetic fabrics which are used by the patient or used for him while in hospital. Importance of laundry services for a hospital

(a) Prevention of cross infection among patients : Frequent change & adequate cleaning of patient linen reduces the chances of cross infection among patients, thereby assisting in faster healing of wounds.

(b) Comfort & patient satisfaction : Clean and appropriate clothing for patients invariably leads higher levels of comfort and satisfaction among patients.

(c) Aesthetic aspect : Clean linen in hospital wards provide a neat and cheerful look to the wards, which makes the patients stay more comfortable. In addition, clean linen in hospital also improves the job satisfaction of nursing and paramedical staff in the hospital, by providing a clean working environment.

(d) Public Relations : A clean ward serves as an important public relation factor wherein all visitors and patients carry a favorable impression of the services and medical care rendered at the hospital. Types of Laundry Services (a) In-plant System is a hospital owned laundry and is best

suited for large teaching or referral hospitals with large number of beds and adequate patient turnover. It is costly to maintain but better control over quality can be exercised by the administration.

(b) Rental System is where a hospital hires linen from a contractor who is also responsible for replacement and laundering of the linen. Though less costly for the hospital, quality control has to be monitored closely as it is dependent on the contractor.

(c) Contract System is where the hospital owned linen is laundered by a contractor because the hospital does not have facilities for laundry.

(d) Cooperative System is one of the most cost-effective methods for smaller hospitals where a single laundry is shared by more than one hospital.

Classification of linen : Laundry linen is classified as under based on the cleaning process required for the linen. (a) Soiled linen that has been used by patients and has to

cleaned by routine procedures of washing, conditioning and ironing.

(b) Infected linen which has been contaminated by infective material such as blood or Pus. Such linen is collected in polythene bags, is handled least and has to be first disinfected before routine washing.

(c) Foul linen is linen which is contaminated with faeces, excreta or blood and has to be passed through sluicing before washing.

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(d) Radio-active linen is linen contaminated with radioactive substances and has to be suitably decontaminated & monitored before washing and re-using for patients.

Life of hospital linen is a major concern for administrators since it involves a recurring expenditure. Generally, 15-20% of linen becomes unusable after 35 washes (or after 3 months) and has to be replaced. The overall life of hospital linen would depend on availability of linen in adequate quantity type of laundry system (in-plant system will lead to longer life) and type of detergents used etc.

Types of Linen Distribution System : One out of the following systems of linen distribution is followed in all hospitals.

(a) Centralized linen services(i) ‘Clean for Dirty’ exchange system where laundered linen is

issued whenever used/soiled linen is deposited in laundry by user departments.

(ii) Topping up system where a pre-decided laundry stock (calculated on the basis of one day’s requirement) is replenished every morning by laundry staff in each user department.

(iii) Exchange Trolley system where daily stock of linen is supplied to each ward in a trolley and replaced the next day. This reduces handling of clean laundry by too many people in the hospital.

(iv) Pack system where complete requirement of linen patient-wise is prepared in laundry itself in form of packs and supplied to user departments.

(b) Decentralized linen services : Linen is issued to wards on their inventory and used linen is sent to a central laundry by the ward nursing staff. Every linen is marked to identify the user department and laundered linen is issued to user wards out of the stock maintained for each department.

(c) Mixed linen services : These are followed where some key areas like Operation Theatre, ICU etc. are issued with their own linen as in decentralized system but rest of the hospital follows the centralized system of laundry.

Hospital Dietary ServicesDietary services of a hospital is one of the main supportive services, which contributes to recovery of health through scientifically prepared diets, dietary counseling of patients and training of health care providers in dietary requirement & planning. Hospital dietary services can be described as supportive services which cater to the needs of outpatients regarding diet counseling and provision of appropriate diets to the inpatients, as per their requirements.

Conventional dietary system in most hospitals consists of menu items prepared in a kitchen on the premises where meals are prepared and held for a short time and maintained either hot or cold until serving time. This system is more adaptable to regional, ethnic & individual preferences and ensures quality control. However, because of differences in menu, this system is more stressful for workers. In addition, skilled workers may be assigned tasks that could be done by non-skilled workers and the system needs two shifts of employees.

In the Commissary (large central kitchen) system, there is centralized food purchasing & delivery of prepared food to

satellite units located in different hospital areas for final preparation and service to patients. This system is economical because of bulk cooking & quality control is better because there is only one unit to supervise. However, poor food safety during distribution may result is contamination. In the ready prepared (Cook & Chill) system, foods are prepared in advance & stored under refrigeration. There is thus no peak period pressure & no delay in preparation. But the system needs cold storage and freezers for chilling the food items immediately after they are prepared.

SummaryA hospital can be described as an organisation which provides health care services (preventive, promotive and curative) by pooling in the various skills & services of health professionals, supportive staff and ancillary staff, with the overall objective to provide health care to patients. It is a highly complex institution which brings together highly qualified and highly technical professionals for common cause of providing comprehensive health care and medical care to patients, in the most cost-effective manner, within the limited available resources. A hospital can be broadly divided into Clinical Areas, Diagnostic Areas, Auxiliary Services and Support Services. Emergency Medical Services (EMS) can be described as medical services undertaken with the aim to transport the right patient to the right hospital at the right time so that right treatment can be given. Role of A&E services in a hospital includes such functions as to function as an information centre about seriously injured patient, to provide ambulance services and so on.

Location, Space requirements, Planning of facilities and Architectural design (such as considerations on Entrance, Waiting area, Reception, Registration & Records, Examination & Treatment area) are the vital considerations while planning an A& E Dept. An Out-Patient Department (OPD) can be defined as that part of the hospital with allotted physical and medical facilities and staff in adequate numbers, with regularly scheduled hours, to provide care for patients who are not registered as indoor patients. They are the first point of contact between the patients/their relatives and the hospital staff. Functions of OPD include provision of day care investigative, diagnostic and treatment specialist procedures, health education and health promotion and so on. Location, Patient flow, Interdepartmental Resource Sharing, Physical facilities, Space provisions, Clinical areas, Pathology laboratory & Auxiliary facilities are some of the factors that have to considered while planning an OPD. Overcrowding and long waiting time are some of the problems faced in OPDs.

An Operation Theatre (OT) is a specialized facility of the hospital where life saving / life improving procedures are carried under strict aseptic conditions. Surgical operations have been classified broadly as emergency surgeries and elective surgeries. Objectives to remember while planning an OT include flexibility, complete asepsis and maximum safety. In order to attain maximum asepsis, an OT should ideally include Disposal zone, Protective zone, Clean Zone, Sterile Zone. The intensive care unit (ICU) is a place where seriously sick patients, highly skilled medical and nursing staff with knowledge and experience & sophisticated medical

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equipment are brought together for better health care at an optimum cost. Based on organizational structure, ICUs can be classified into Open unit, closed unit and Semi- Closed unit. ICU should have a medical officer, one Resident round the clock and a junior resident, apart from nursing staff. Physical facilities and design of ICU should factor in the appropriate location, space requirement, patient services and facilities for nursing station in ICU. Illumination, ventilation etc. are the other considerations in designing an ICU. A ‘ward’ in a hospital can be defined as a section of a hospital, including a nursing station, bed and necessary storage service, work and public areas, where nursing care is provided to in patients. The main factor to be kept in mind while designing a ward is that nursing staff should be able to hear & see all patients and should be able to react accordingly with maximum efficiency and least stress and strain. Open ward (pavilion type) and Rig’s ward are some of the types of wards. 20-30 beds per ward with 2-3 single-bed rooms for patients requiring special nursing care has been prescribed as a norm. The objective of Ward Management is to provide the best possible medical & nursing care to patients by using the abilities of every member of the staff to fullest extent possible. Ward management comprises of Patient Management (including assignment of patient care, planning of work schedule) and management of Supplies, Equipment, Environment and personnel. Common problems in Ward Management include inadequate staff, untrained staff, lack of supervision and the like. The diagnostic and supportive services in any hospital broadly consist of the laboratory services, radio-diagnostic and imaging services, blood transfusion services and pharmacy services. The functions of a laboratory would include training of professional & technical staff and provision of comprehensive & accurate analytical test results, among others. Major considerations while planning a hospital laboratory would include Space, Staffing etc.. A blood bank is an organisation for carrying out all or any of the operations pertaining to storage processing & distribution of blood drawn from a donor &/or preparation, storage & distribution of blood components. Component preparation, collection of blood in an aseptic manner and screening are the main functions of a blood bank. Blood banks can be broadly classified into three categories based on consumption of blood. Planning considerations for establishing blood transfusion services should cater for proper public access areas, laboratory areas, storage & issue areas and administrative areas. The Central Sterile Supply Department is responsible for collecting & receiving used patient care items with the view to decontaminate, process, sterilize, store and dispose these items to all other parts of the hospital comprises of the services within the hospital which receives, stores, processes, sterilizes, distributes and controls professional supplies and equipments, both sterile and non sterile, to all departments of the hospital for the care and safety of patients. The objectives of a CSSD includes provision of sterile supplies centrally, Advisory role to Hosp Infection Control Committee (HICCOM) and the like. CSSD must be located close to and be easily accessible to areas which it serves. The functional layout of CSSD should be so planned so that sterile and contaminated items do not come in contact and are not handled in the same area. CSSD is divided into Dirty Zone, Clean Zone and Sterile Zone. CSSDs in various hospitals may follow any one of the

distribution systems like Clean for Dirty Exchange system, Topping system, Requisition system or Exchange Trolley system. A medical record is defined as a clinical, scientific, administrative and legal document related to patient care in which is recorded sufficient data in sequence of events to justify the diagnosis, warrant the treatment given to the patient and results. The various types of Medical Records are those that are Directly or indirectly related to patient care. The Importance of medical records is manifold, like for the patient, for public health and so on. Death of a patient admitted as an inpatient in the hospital is considered as a hospital death. Patient Day is defined as the duration of medical care rendered to an inpatient between the census taking hours of two successive days. Average Daily Census is the average number of patients in the hospital at any given time of the day and Occupancy Rate is the ratio of actual patient days expressed as a percentage of the maximum possible patient days. Average length of stay is the average number of days of medical care rendered to each discharged patient during a given period of time. Turnover Interval (T interval) is the average number of days that bed remains vacant between a discharge and subsequent admission is also an important legal document. Medical Records should be complete, accurate, legible and adequate. It is the responsibility of hospital administration to safely store medical records pertaining to patients. Hospital linen can be defined as all clothing made of cotton, linen, wool or synthetic fabrics which are used by the patient or used for him while in hospital. The Importance of laundry services for a hospital includes mainly aesthetic aspect, public relations and the like. Types of Laundry Services include In-plant System, Rental System, Contract System and Cooperative System. Soiled linen, infected linen, foul linen and radio-active linen are the various types of Linen. Distribution System for linen includes Centralized linen services & Decentralized linen services. Dietary services of a hospital is one of the main supportive services, which contributes to recovery of health through scientifically prepared diets, dietary counseling of patients and training of health care providers in dietary requirement & planning. Conventional dietary system and Commissary (large central kitchen) system are the main types of hospital dietary services.

Study ExercisesMCQs and Exercises1. The word ‘product’ in a hospital setting would actually

mean (a) number of patients (b) income generated (c) medical care (d) variety of specialists.

2. All of the following are types of Support Services in a hospital except : (a) laundry services (b) medical records dept (c) dietary services (d) pharmacy services.

3. Average recommended space per patient visiting the A&E (Accident & Emergency) Dept in a hospital is (a) 10 square meters (b) 20 square meters (c) 30 square meters (d)40 square meters.

4. Against an inpatient load of 25 patients per bed per year, a hospital OPD load on an average, is around (a) 400 patients per bed per year (b) 500 patients per bed per year (c) 600 patients per bed per year (d) 800 patients per bed per year.

5. Public toilets should be provided in hospitals separately

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for males and females at the rate of one toilet each for (a) 200 patients/ visitors (b) 100 patients/ visitors (c) 300 patients/ visitors (d) 400 patients/ visitors.

6. The following are the zones are identified in an Operation Theatre, except (a) Disposal zone (b) Protective zone (c) Clean Zone (d) Fertile zone.

7. The type of Intensive Care Unit (ICU) where the medical team in charge of the intensive care unit must review and approve all admissions into ICU, is known as (a) Open unit (b) Semi-closed unit (c) closed unit (d) Quasi- open unit.

8. The open type of ward is also known as the Rig’s ward. Yes/ No.

9. The minimum distance between centre of adjacent beds in a ward should be at least (a) 2.4 metres (b) 1.0 metres (c) 0.4 metres (d) 1.4 metres.

10. A hospital laboratory broadly consists of all of the following areas, except (a) Primary space (b) Secondary space (c) Tertiary space (d) Circulation space.

11. The space requirements recommended for CSSD (Central Sterile Supply Department) in a hospital with 201 - 300 beds is (a) 10 square feet per bed (b)08-09 square feet per bed (c) 07-08 square feet per bed (d) 06-07 square feet per bed.

12. The duration of medical care rendered to an inpatient between the census taking hours of two successive days, is known as (a) Patient Day (b) Hospital Day (c) Average length of stay (d) Bed occupancy duration.

13. Where a single laundry is shared by more than one hospital, the type of laundry service system is known as (a) In-plant System (b) Rental System (c) Contract System (d) Co-operative System.

14. Large central kitchen system in hospital dietary system, is also known as (a) Commissary system (b) Conventional dietary system (c) Ready Prepared system (d) Cook & Chill system.

Answers : (1) c; (2) d; (3) a; (4) b; (5) a; (6) d; (7) d; (8) No; (9) a; (10) c; (11) c; (12) a; (13) d; (14) a.

79 Advanced Diagnostic Technologies in Public Health

Rohit Tewari

A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease. It may be used to diagnose diseases or measure the progress or recovery from disease or confirm that a person is free from disease.

Some medical tests are parts of a simple physical examination which require only simple tools in the hands of a skilled practitioner and can be performed in an office environment. Some other tests require elaborate equipment used by medical technologists or the use of a sterile operating theatre environment. Some tests require samples of tissue or body fluids to be sent off to a pathology lab for further analysis. Some simple chemical tests such as urine pH, can be measured directly in the physicians office. However, with advancements in health care, a large array of diagnostic tests have become available. The aim of this chapter is to provide an introductory overview of the various modern (and often, expensive) diagnostic modalities which are often discussed routinely in contemporary medical world.

According to IPHS standards stated as a part of NRHM, the laboratory facilities which should be available at various levels are (Table-1) :

Table - 1 : IPHS Standards for Availability of laboratory Services at various levels of care (31-50 Bedded Hospital)

Speciality Diagnostic Services / Tests

Haematology

Haemoglobin estimation, Total Leucocyte count, Differential Leucocyte count, Absolute Eosinophil count, Reticulocyte count, Total RBC count, E. S. R. , Bleeding time, Clotting time, Peripheral Blood Smear, Malaria/Filaria Parasite, Platelet count, Packed Cell volume, Blood grouping, Rh typing, Blood Cross matching

Urine Analysis

Urine for Albumin, Sugar, Deposits, Bile salts, Bile pigments, Acetone, Specific gravity, Reaction (pH)

Stool Analysis

Stool for Ova cyst (Eh), Hanging drop for V. Cholera, Occult blood

Sputum Sputum cytology

MicrobiologySmear for AFB, KLB (Diphtheria), Grams Stain for Throat swab, sputum etc. KOH study for fungus

SerologyRPR Card test for Syphilis, Pregnancy test (Urine gravindex), WIDAL test, Rapid Test for HIV, HBs Ag, HCV

BiochemistryBlood Sugar, Urea, Serum Bilirubin, Liver function tests, Kidney function tests, Blood Cholesterol, Blood Uric acid

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For 51-100 Bedded (All as in 31-50 bedded with the following additional facilities) (Table - 2)

Table - 2 : For 51-100 Bedded

Speciality Diagnostic Services / Tests

HaematologyProthrombin time, ELISA for HIV, HBsAg and HCV

Semen Analysis

For count, morphology and motility

CSF Analysis Cell count cytology

Aspirated fluids

Cell count cytology

Others

Stocking of rapid H2S based test for bacteriological examination of water, Stocking of OT test for residual chlorine in water

For 201-300 Bedded (All as in 51-100 bedded with the following additional facilities) (Table - 3)

Table - 3 : For 201-300 Bedded

Speciality Diagnostic Services / Tests

Haematology Prothrombin time

Semen Analysis

For count, morphology and motility

CSF Analysis Cell count cytology

Aspirated fluids

Cell count cytology

Others

Stocking of rapid H2S based test for bacteriological examination of water, Stocking of OT test for residual chlorine in water.

Microbiology

Culture and sensitivity for blood, sputum, pus, urine etc., Stool culture for Entero pathogen, Supply of different Specimen collection and transportation media for peripheral Laboratories, KOH Study for Fungus

Biochemistry

Lipid Profile, Serum calcium, sodium, potassium, Serum Phosphorous, Serum Magnesium, Blood gas analysis, Thyroid T3 T4 TSH, CPK, Chloride

The various modern diagnostic technologies that shall be discussed in this chapter can be classified under the following groups :

Immunopathology ●Molecular Biology ●Clinical Chemistry ●Haematology ●Cytopathology ●Histopathology ●Radiology ●Electrophysiology ●

Diagnostic Technologies in ImmunopathologyAntigens can be defined as any substance that can represent antigenic sites (epitopes) to produce corresponding antibodies, from small molecules such as haptens and hormones to macromolecules such as proteins and glycoproteins. Antibodies are produced in response to antigenic stimulation. Immunoassays (antigen antibody reactions) can be used for detection of either antigens or antibodies. For detecting antigens, the corresponding specific antibody should be used as one of the reagents and vice versa.

The technologies available are –

Precipitation immunoassays : It is based on the occurrence of precipitation when large complexes of antigens and antibodies combine to form an insoluble lattice. These techniques suffer from poor sensitivity. The lower limit of sensitivity remains in the range of 0.1-0.4 mg/dl. Typical examples of precipitation immunoassay are the Widal test and the Weil-Felix test.

Particle immunoassay : Here specific antigens are coated onto a particle and on reaction with antibody under test, the agglutination is made more visible. Reverse agglutination where the antibody is coated onto the particle is also performed. The particle used may be RBC, latex or gelatin. The sensitivity of hemagglutination tests is upto 50 ng/ml for antigen detection.

Applications in public health : Hemagglutination test using RBC as the particle is widely used for Treponema pallidum called as the TPHA (Treponema pallidum Hemagglutination). Hemagglutination tests for hepatitis B and hepatitis C are also widely used. (for detection of antibody). Reverse passive hemagglutination (RPHA) has extensive application in detection of hepatitis B surface antigen (HBsAg). Latex agglutination is widely used in measurement of hCG for qualitative pregnancy tests.

Radioimmunoassay : Radioimmunoassay (RIA) is a scientific method used to test antigens (for example, hormone levels in the blood). Although the RIA technique is extremely sensitive and extremely specific, it requires a sophisticated apparatus and is costly. It also requires special precautions, since radioactive substances are used. Therefore, today it has been largely supplanted by the ELISA method, where the antigen-antibody reaction is measured using colorometric signals instead of a radioactive signal. To perform a radioimmunoassay, a known quantity of an antigen is made radioactive, frequently by labeling it with gamma-radioactive isotopes of iodine attached to tyrosine. This radiolabeled antigen is then mixed with a known amount of antibody for that antigen and as a result, the two chemically bind to one another. Then, a sample of serum from a patient containing an unknown quantity of that same antigen is added. This causes the unlabeled (or “cold”) antigen from the serum to compete with the radiolabeled antigen for antibody binding sites.

Applications in public health : These are limited to hormonal assays for example thyroid hormone levels in goiter endemic areas.

Enzyme Linked Immunosorbent Assay (ELISA) : This is a technique used mainly in immunology to detect the presence of an antibody or an antigen in a sample. In simple terms, in ELISA an unknown amount of antigen is affixed to a surface

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SDS-PAGE gel, or on the basis of size and their electric charge by using what is known as a 2D gel electrophoresis.

Hybridisation assays : When the hybridization reaction is used to analyse the nucleic acid content of an unknown sample, the process is known as a hybridization assay. The property of complimentary base pairing allows fragments of known composition (the probes) to interrogate an unknown for the presence of matching (complimentary) sequences. The detection of the hybrids can be done a variety of technologies including radioisotope labels, fluorochrome based detection and enzyme based systems.

Liquid phase hybridization : When both sample and probe are in solution.

Solid support hybridization : In these assays, hybridization occurs in a biphasic environment, a solid phase (usually sample) and a liquid phase (usually probe).

Southern and Northern hybridization assays : These combine electrophoretic separation of test nucleic acids with transfer to a solid support and subsequent hybridization. Hence these assays give information of hybridization as well as the molecular weight of the hybridizing species. The original procedure was described by EM Southern and the test nucleic acid was DNA [11]. When RNA is the nucleic acid under test, the technique is called northern blotting by analogy. A further extension to the analogy is western blotting where proteins are subjected to the same procedure.

In situ hybridization : This is the detection of specific genetic information within a morphological context (intact tissue, cells or chromosomes affixed to glass slides).

Amplification technology : All the target amplification systems are enzyme based processes in which a single enzyme or multiple enzymes synthesize copies of target nucleic acid. All result in production of billions of copies of the amplified product in a few hours. These techniques are subject to contamination from product molecules of previous amplifications and hence false positivity is high. However, special lab design, practices and workflow have helped to reduce false positives to an acceptable range.

Polymerase Chain Reaction (PCR) : It is a simple in vitro chemical reaction that permits synthesis of large quantities of nucleic acid. This is brought about by heating the reaction mixture to separate the strands of the DNA, then cooled to permit the primers to anneal to the target DNA in a sequence specific manner. The DNA polymerase then initiates extension from 3’ end. Thus the whole process is carried out in a programmable thermocycler which controls the temperatures at which various steps occur.

Reverse transcriptase PCR (RT-PCR) : PCR was initially described to amplify DNA. RT-PCR was developed to amplify RNA targets

Nested PCR : This variation increases the sensitivity and specificity of PCR. The products of the first round of amplification are subject to second round of amplification with a second set of primers.

Real time PCR : Here the target amplification and detection occur simultaneously. The computer software supporting the

and then a specific antibody is washed over the surface so that it can bind to the antigen. This antibody is linked to an enzyme and in the final step a substance is added that the enzyme can convert to some detectable signal.

Applications in public health : ELISA can be performed to evaluate either the presence of antigen or the presence of antibody in a sample, hence it is a useful tool both for determining serum antibody concentrations (such as with the HIV test or West Nile Virus) and also for detecting the presence of antigen. ELISA can also be used in toxicology as a rapid presumptive screen for certain classes of drugs. ELISA can be used for detecting tumour markers for certain cancers, e.g. Prostate Specific Antigen (PSA) in carcinoma prostate.

Fluorescent immunoassay : When fluorescent molecules are irradiated with light at appropriate wavelengths, an electron in the ground state is transited into the excited state. As the electron returns to the ground state, physical energy is released in the form of a photon which is detectable.

Applications in public health : Immunofluorescence assays have been extensively used for detecting antigens in tissue sections, e.g. kidney biopsies. Use of Auramine rhodamine stain in detection of tubercle bacilli in smears is well documented and shown to have better sensitivity than the conventional ZN stain. They have also been developed to detect the concentration of drugs, hormones and proteins and polypeptides.

Chemiluminescent immunoassay : These assays use chemiluminescence generating molecules as labels, such as luminol derivatives.

Applications : Assays of hormones and tumour markers can be performed. The detection limit has been reported as 0.2 to 0.4 ng/ml for Carcino-Embryonic Antigen (CEA) and 0.4 ng/ml for Alfa Feto Protein (AFP).

Diagnostic Technologies in Molecular BiologyMolecular biology is the study of biology at a molecular level. Molecular biology chiefly concerns itself with understanding the interactions between the various systems of a cell, including the interactions between DNA, RNA and protein biosynthesis and learning how these interactions are regulated. The tools of molecular biology have proven readily adaptable for use in the clinical diagnostic laboratory and promise to be extremely useful in diagnosis, therapy, epidemiologic investigations and infection control [8, 9]. Although technical issues such as ease of performance, reproducibility, sensitivity and specificity of molecular tests are important, cost and potential contribution to patient care are also of concern [10]. Molecular methods may be an improvement over conventional microbiologic testing in many ways. Currently, their most practical and useful application is in detecting and identifying infectious agents for which routine growth-based culture and microscopy methods may not be adequate

Gel electrophoresis : Gel electrophoresis is one of the principal tools of molecular biology. The basic principle is that DNA, RNA and proteins can all be separated by means of an electric field. In agarose gel electrophoresis, DNA and RNA can be separated on the basis of size by running the DNA through an agarose gel. Proteins can be separated on the basis of size by using an

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thermocycler monitors the data throughout the PCR at every cycle and generates a plot. Restriction Fragment Length Polymorphism (RFLP) based assays : Assays that utilize the sequence recognition property of restriction enzymes to demonstrate variations or polymorphisms in the DNA sequence of two samples are known as RFLP assays.

Arrays : A DNA array is a collection of spots attached to a solid support such as a microscope slide where each spot contains one or more single-stranded DNA oligonucleotide fragment. Arrays make it possible to put down a large quantity of very small (100 micrometre diameter) spots on a single slide. Each spot has a DNA fragment molecule that is complementary to a single DNA sequence (similar to Southern blotting). A variation of this technique allows the gene expression of an organism at a particular stage in development to be qualified (expression profiling). Since multiple arrays can be made with the exact same position of fragments they are particularly useful for comparing the gene expression of two different tissues, such as a healthy and cancerous tissue. Arrays can also be made with molecules other than DNA. For example, an antibody array can be used to determine what proteins or bacteria are present in a blood sample.

Applications of molecular biology in Public Health

Pathogen detection by hybridisation : The DNA of the infectious agent is detected directly in the clinical specimens by DNA probes. The disadvantage is that at least 104 or more copies are required for detection. In infectious diseases hybridization assays are unlikely to be a significant tool for diagnosis in the future due to low sensitivity. These formats are more applicable to batch processing of large numbers of specimens as in research labs.

DNA probes for culture identification : Probes are available for various organisms like Mycobacterium tuberculosis, Chlamydia trachomatis, Neisseria gonorrhoeae, Human papilloma virus, Hepatitis C virus, Cytomegalovirus and Herpes simplex virus.

This is especially important for slow growing organisms like Mycobacteria, fungi etc. Identification of cultured Mycobacteria by conventional methods is slow and time consuming. The use of probes for this purpose permits identification from cultures within one working day and sensitivity (95.4%) and specificity (99%) are excellent [12].

DNA amplification for diagnosis : Hepatitis C Virus- Detection of the virus by reverse transcriptase PCR confirms current infection and has a role in diagnosis and monitoring response to therapy [13]. Development of Quantitative PCR allows quantification of HCV which is important in prognosis and monitoring of therapy.

HIV : Molecular diagnosis is required in cases where serological testing results are indeterminate and neonates where serological detection of antibodies may be positive due to transplacental transfer of maternal antibodies and a prolonged follow up period (18 mths) may be needed to confirm infection by serologic methods. Quantitation of HIV virus is widely used for prognosis and for evaluation of response to antiretroviral therapy [14].

Mycobacterium tuberculosis : In general the sensitivity of these assays for specimens for which the smear for acid fast bacilli (AFB) is positive is excellent (95-100%). It is lower for specimens that are AFB smear negative (50-80%) [15]. Currently, the amplification processes cannot replace the AFB smear because the latter is used to determine the level of infectivity of patients and in gauging the initial response to therapy. At present the role of amplification assays remains complimentary to microscopy and culture.

Sexually Transmitted Diseases : Amplification assays have been developed for Neisseria gonorrhoeae and Chlamydia trachomatis.

Fungi : PCR assays for diagnosis of invasive Candidiasis and Aspergillosis have been developed.

Detection of antimicrobial resistance : Resistance of microbes to antimicrobials is one of the major public health problems of this decade. Molecular methods have contributed towards understanding of the genetics of antimicrobial resistance and the spread of resistance determinants. e.g. Molecular detection of the Mec-A gene is now considered a reference method for assessing Methicillin resistance in Staphylococci [16]. PCR amplification of DNA sequences from the rpoB (rifampicin resistance) and the kat G, inh A and ahp C genes (isoniazid resistance) followed by detection of mutations associated with resistance has a high sensitivity for detection of resistance to rifampicin (>96%) and isoniazid (87%) [17].

Molecular Epidemiology : The techniques of molecular typing are useful not only in research settings but also in real life clinical and public health problems. e.g. prediction of response to interferon therapy is important in patients with Hepatitis C virus infection. HCV genotypes 1b and 1a appear less likely to respond to interferons [18]. If molecular evidence of identity of multiple isolates of Staphylococcus epidermidis isolated from a single patient at different times can be shown, it indicates that the isolate is clinically significant.

Diagnostic Technologies in Clinical ChemistryColorimetry : This is performed in a device that measures the absorbance of particular wavelengths of light by a specific solution. This device, invented by Jan Szczepanik, is most commonly used to determine the concentration of a known solute in a given solution by the application of the Beer-Lambert law, which states that the concentration of a solute is proportional to the absorbance. Changeable optic filters are used in the colorimeter to select the wavelength of light which the solute absorbs the most, in order to maximize accuracy. The usual wavelength range is from 400 to 700 nanometres (nm). In modern colorimeters the filament lamp and filters may be replaced by several light-emitting diodes of different colors.

Applications in public health : These are far reaching and extensive since colorimetry forms the basis of assessing almost all parameters in clinical chemistry (including routine analytes like urea, creatinine, glucose, uric acid etc) and also hemoglobin in hematology. The technology involved is simple and made available at almost all levels of health care. Levels in blood of routine analytes forms the basis of the diagnosis of diabetes, hyperlipidemia, metabolic syndrome etc.

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Nephelometry : This is a method for measuring the concentration of a solution that contains particles that are too large for colorimetry/ absorption spectroscopy. When a collimated light beam strikes a particle in suspension, portions of the light are absorbed, reflected, scattered and transmitted. Nephelometry is the measurement of the light scattered by a particulate solution.

Applications in public health : This is useful in measurement of antigen antibody complexes formed in immunoassays.

Electrophoresis : Electrophoresis is the separation of charged compounds based on there electrical charge. Common support media for electrophoresis in clinical work include cellulose acetate, agarose and polyacrylamide gel. Once separation has occurred, the support medium is treated with dyes to stain and identify the separated fractions. To obtain a quantitative profile of the separated fractions, densitometry is performed on the stained support medium.

Applications in public health :

Separation of serum proteins : Patterns of hypoproteinemia in malnutrition or gross loss of protein show decreases in all fractions with dramatic reduction in albumin. Cirrhosis of the liver shows a specific pattern with severe reduction of albumin and increased immunoglobulins. The pattern in monoclonal gammopathies (multiple myeloma) is very characteristic and shows an M band due to high levels of paraprotein secreted by a monoclonal proliferation of plasma cells.

Separation of hemoglobins : This is important in the diagnosis of various abnormal hemoglobins like thalassemia, sickle cell anemia etc.

Chromatography : Chromatography is a separation method based on the different interaction methods of the specimen compounds with the mobile phase and with the stationary phase, as the compounds travel through a support medium. The compounds interacting more strongly with the stationary phase are retained longer in the medium than those that favor the mobile phase.

Gas chromatography : It is a procedure used for compounds which are naturally volatile or those which can be easily converted to a volatile form.

Liquid chromatography : It is used for compounds that are too unstable or insufficiently volatile for gas chromatography.

Applications in public health : Routinely, chromatography is used for determination of drugs and chemicals in body fluids (toxicology). Detection of additives / chemicals in food is possible through High performance liquid chromatography. Environmental and water pollutants can be detected with accuracy through the use of various chromatographic procedures.

Automation in clinical chemistry : Automated analyzers allow labs to process a large volume of tests quickly. This is possible through the increased speed of testing. The increase test throughput is possible by automating many steps involved. Most automated chemistry analyzers, photometric methods of analysis such as colorimetry, spectrophotometry or nephelometry etc. calculations, calibration curves and quality control are performed by the computers, thus reducing errors

and providing more accurate results. The testing pathway in an analyser may be a) Sequential testing- Multiple tests analysed one after

another on a single specimen. b) Batch testing- All samples are loaded at the same time and

a single test is conducted on each sample. c) Parallel testing- More than one test is analysed concurrently

on a given clinical specimen. d) Random access testing- Any test can be performed on any

sample in any sequence.

Diagnostic Technologies in HematologyAutomated Instruments : These instruments have many different components to analyze different elements in the blood. The cell counting components count the numbers and types of different cells within the blood. The results are printed out or sent to a computer for review. Blood counting machines aspirate a very small amount of the specimen through narrow tubing. Within this tubing, there are sensors that count the number of cells going through it and can identify the type of cell; this is flow cytometry. The two main sensors used are light detectors and electrical impedance. One way the instrument can tell what type of blood cell is present is by size. Other instruments measure different characteristics of the cells to categorize them. Because an automated cell counter samples and counts so many cells, the results are very precise. However, certain abnormal cells in the blood may be identified incorrectly and require manual review of the instrument’s results and identify any abnormal cells the instrument could not categorize. In addition to counting, measuring and analyzing red blood cells, white blood cells and platelets, automated hematology analyzers also measure the amount of hemoglobin in the blood and within each red blood cell.

Diagnostic Technologies in CytopathologyExfoliative cytology : The microscopic examination of cells that have been shed from a lesion or have been recovered from a tissue for the diagnosis of disease.

Applications in public health

Cervical cytology : Exfoliative cytology from the uterine cervix is valuable in picking up premalignant lesions of the cervix and goes a long way in early detection of cervical cancer. Cervical cytology has been perhaps the most successful cancer screening technique of the 20th century. Technology used may be conventional i.e. where the smear is taken on a glass slide directly by the sampling device which may be an Ayres spatula or an endocervical brush or it may be Liquid based where the cells are suspended in a liquid fixative and subsequently spread onto a glass slide by a centrifugation process. In general, it has an overall sensitivity of 80% and a specificity of 99.4% for cytologic screening for cervical cancer. The sensitivity was slightly lower for mild and moderate dysplasia (78.1%) and slightly higher for carcinoma in situ and severe dysplasia (81.4%) and invasive carcinoma (82.3%) [19].

Fine Needle Aspiration Cytology : Fine Needle Aspiration Cytology (FNAC) is a technique where a fine needle is introduced into a lesion and with aspiration from a syringe, cellular material is obtained which can be spread on to glass slide, stained and evaluated cytologically. It is a technique

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which is applicable not only to superficial accessible lesions but also to deep seated lesions under imaging guidance. A needle aspiration biopsy is safer and less traumatic than an open surgical biopsy and significant complications are usually rare, depending on the body site. Common complications include bruising and soreness. There is a risk, because the biopsy is very small (only a few cells), that the problematic cells will be missed, resulting in a false negative result. There is also a risk that the cells taken do not enable a definitive diagnosis. The technique is suitable to evaluation of lesions/ nodules arising from breast, lymph nodes, thyroid, liver, kidney and soft tissue. The sensitivity and specificity varies according to the organ involved and also depends on the aspiration of a representativeness of the sample.

Diagnostic Technologies in HistopathologyHistopathology from the Greek histos (tissue) and pathos (suffering) refers to the microscopic examination of tissue in order to study the manifestations of disease. Specifically, in clinical medicine, histopathology refers to the examination of a biopsy or surgical specimen by a pathologist, after the specimen has been processed and histological sections have been placed onto glass slides. This is the most important tool of the anatomical pathologist in routine clinical diagnosis of cancer and other diseases. Histopathological examination of tissues starts with surgery, biopsy or autopsy. The tissue is removed from the body and then placed in a fixative which stabilizes the tissues to prevent autolysis. The samples are transferred to a cassette, a container designed to allow reagents to freely act on the tissue inside. This process is known as tissue processing. The processed tissue is then taken out of the cassette and set in a mold. Through this process of embedding, additional paraffin is added to create a paraffin block. The process of embedding then allows the sectioning of tissues into very thin (2 - 7 micrometer) sections using a microtome. The microtome slices the tissue ready for microscopic examination. The slices are thinner than the average cell and are layered on a glass slide for staining. To see the tissue under a microscope, the sections are stained with one or more pigments. The most commonly used stain in histopathology is a combination of hematoxylin and eosin.

Applications in public health : Histopathology is the gold standard of diagnosis in clinical medicine. It is eminently suited to diagnosis of diseases and conditions like malignancies and also some non neoplastic conditions like tuberculosis and other infections.

Immunohistochemistry : Immunohistochemistry or IHC refers to the process of localizing proteins in cells of a tissue section exploiting the principle of antibodies binding specifically to antigens in biological tissues. Immunohistochemical staining is widely used in the diagnosis of abnormal cells such as those found in cancerous tumors. IHC is also widely used in basic research to understand the distribution and localization of biomarkers and differentially expressed proteins in different parts of a biological tissue.

Applications in public health : Diagnosis of tumours/ non neoplastic conditions by histopathology occasionally is hampered by similar morphological appearances and hence

recognition of specific molecular markers by IHC like S100, Cytokeratin etc. helps in identifying the origin and hence the diagnosis of various tumours and conditions.

Radiological TechniquesX-ray : X-radiation (composed of X-rays) is a form of electromagnetic radiation, used primarily used for diagnostic radiography and crystallography. As a result, the term “X-ray” is metonymically used to refer to a radiographic image produced using this method, in addition to the method itself. X rays are produced by accelerating electrons which collide with a metal target (Tungsten/Molybdenum). These short X-ray pulses are shot through a body with radiographic film behind. The bones absorb the most photons by the photoelectric process, because they are more electron-dense. The X-rays that do not get absorbed turn the photographic film from white to black, leaving a white shadow of bones on the film. This technique is useful not only in the detection of pathology of the skeletal system, but also for detecting some disease processes in soft tissue. Some notable examples are the very common chest X-ray, which can be used to identify lung diseases such as pneumonia, lung cancer or pulmonary edema and the abdominal X-ray, which can detect ileus (blockage of the intestine), free air (from visceral perforations) and free fluid (in ascites). However they have a very little use in the imaging of soft tissues such as the brain or muscle.

Applications in public health : Chest x ray was the backbone of National Tuberculosis Control Programme in 1962 and had been an important component of battle against Tuberculosis in our country. But unfortunately it did not meet the criteria of being “Appropriate Technology” being expensive, requiring infrastructure and trained professionals for reporting and was left out in formulating the components of DOTS. However it is included in the diagnostic algorithm of RNTCP where one sputum sample is positive/ three negative smears in a symptomatic patient. In occupational health the ILO criterion for diagnosis of pneumoconiosis uses findings of x ray chest only.

DEXASCAN : DEXA Scan stands for Dual Energy X-Ray Absorptiometry. Two different types of X- ray scan the body and the images are subtracted by the computer giving a very accurate estimation of bone density/body fat. It is used to detect the presence of osteoporosis in men and women with particular risk factors, screen for osteoporosis, particularly in women making decisions about hormone replacement therapy at menopause, predict future fracture risk and monitor bone density in those with low normal levels and in those with osteoporosis. Dual energy X-ray absorptiometry or DXA (formerly DEXA), is a good method for estimating body fat percentage.

Angiography : It is the study of blood vessels with a contrast medium. It has a great role in study of coronaries to detect the status of these vessels and decide the treatment modality for the patient. With the epidemic of coronary artery disease in the country this investigation will go a long way in the final management of the patients.

Digital Subtraction Angiography (DSA) : In traditional angiography, we acquire images of blood vessels on films by

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exposing the area of interest with time-controlled x-ray energy while injecting contrast medium into the blood vessels. The images thus obtained would also record other structure besides blood vessels as the x-ray beam passes through the body. In order to remove these distracting structures to see the vessels better, we need to acquire a mask images for subtraction. The mask image is simply an image of the same area without contrast administration. So, using manual darkroom technique, clear pictures of blood vessels are obtained by taking away the overlying background. In DSA, the images are acquired through digital format in computer. With the help of computer the images are subtracted automatically. As a result a near instantaneous film show of the blood vessel can be obtained.

Mammography : Mammography is the process of using low-dose X-rays, high contrast, high-resolution film and an X-ray system designed specifically for imaging the breasts to examine the human breast. The goal of mammography is the early detection of breast cancer, typically through detection of characteristic masses and/or micro calcifications. Mammography has been shown to reduce mortality from breast cancer.

Ultrasound : Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons and many internal organs, their size, structure and any pathological lesions. It is also used to visualize a fetus during routine and emergency prenatal care. Other uses include cardiac scan (echocardiography), renal, liver and gallbladder scans. It is also used for musculo-skeletal imaging of muscles, ligaments and tendons, ophthalmic ultrasound (eye) scans and superficial structures such as testicle, thyroid, salivary glands and lymph nodes. Because of the real time nature of ultrasound, it is often used to guide interventional procedures such as fine needle aspiration FNA or biopsy of masses for cytology or histology testing in the breast, thyroid, liver, kidney, lymph nodes, muscles and joints. Modifications of ultrasound include 3-D and 4-D ultrasonography for better visualization of the anatomy.

Applications in Public Health : This technique in antenatal cases is practiced to date the pregnancy (gestational age), confirm fetal viability, determine location of fetus, intrauterine vs ectopic, check the location of the placenta in relation to the cervix, check for the number of fetuses (multiple pregnancy), check for major physical abnormalities, assess fetal growth (for evidence of intrauterine growth restriction (IUGR), check for fetal movement and heartbeat and determine the sex of the baby. However it has been wrongly used extensively to find the sex of unborn child. This malpractice has altered the child sex ratio (0-6 yrs) of the nation to an abnormally low level of 819 in 2001 and 849 in 2008 and inhuman killing of unborn girl child. Ultrasound is also increasingly being used in trauma and first aid cases, with emergency ultrasound becoming a stable of most emergency response teams.

CT scan : CT scan works on the principle that cross sectional slices of the body are produced using X rays, followed by processing by the computers to study detailed anatomy of the specific location or slice. The modification of conventional CT is spiral where the X-ray tube/ detector combination rotates continuously around the patient creating a spiral and helps in generating high quality images.

Magnetic Resonance Imaging : Charged spinning particles such a protons behave like tiny bar magnets and are used to produce image of biological tissue in black and white depending upon the type of tissue and the specific imaging technique used. It does not use ionizing radiation hence is safe with no known biological hazards. It provides excellent tissue contrast with good spatial resolution. Images can be obtained in any plane (Multiplanar Imaging) and does not produce artifacts due to bone and is an ideal imaging modality for spine, posterior fossa and musculoskeletal system.

Applications of CT Scan and MRI in public health and clinical practice are shown in Tables - 4 and 5.

Radionuclide scan : A radionuclide scan is a way of imaging bones, organs and other parts of the body by using a small dose of a radioactive chemical. There are different types of radionuclide chemicals. The one used depends on which organ or part of the body is to be scanned. Radionuclide is put into the body, usually by a injection into a vein. Sometimes it is breathed in, or swallowed, depending on the test. Cells which are most ‘active’ in the target tissue or organ will take up more of the radionuclide. So, active parts of the tissue will emit more gamma rays than less active or inactive parts. The gamma rays which are emitted from inside the body are detected by the gamma camera, are converted into an electrical signal and sent to a computer. The computer builds a picture by converting the differing intensities of radioactivity emitted into different colours or shades of grey.

Public Health Importance

Bone scan : Used to detect areas of bone where there is cancer, infection or damage.

Kidney scan : Used to detect scars on the kidney and how well urine drains from the kidney to the bladder.

Lung Perfusion Scan (‘VQ scan’) : Detects pulmonary embolus.

IPHS Standards for Provision of Radiological Techniques: According to IPHS standards in NRHM radiological facilities which should be available at various levels are given in Table - 6.

Electrophysical TechnologiesDespite existence of modern diagnostic imaging, biochemical and other techniques that enable detection of morphological and chemical changes within the body, there are also various functional disturbances sometimes detectable only via analysis of electric potentials produced by some organs (tissues) as a manifestation of their function (ECG, EEG, EMG, ERG, EOG and others). These methods can also be preferable in some cases because of their non-invasive character and economical efficiency.

Evaluation of these signals is performed either in the “time domain” (detection of particular specific peaks and wave complexes - “grapho-elements” - and description of their time and amplitude characteristics) or in the “frequency domain” (frequency spectrum characteristics). At present this is done almost exclusively with the use of computers. Since electrical activity analysis serves mainly for recognition of functional changes, pathophysiology deals with some of these signals

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(mainly with ECG, EEG) and instructs basic interpretation of some pathological findings.

Electroencephalography : This is the neurophysiologic measurement of the electrical activity of the brain by recording from electrodes placed on the scalp or in special cases, subdurally or in the cerebral cortex. The resulting traces are

known as an electroencephalogram (EEG) and represent an electrical signal (postsynaptic potentials) from a large number of neurons. In conventional scalp EEG, the recording is obtained by placing electrodes on the scalp, usually after preparing the scalp area by light abrasion and application of a conductive gel to reduce impedance. Each electrode is connected to an input of a differential amplifier, which amplifies the voltage between

Table - 4 : CT scan, its modifications and their use in public health

Modality Remarks Public health field

CT AngiographyArteries and veins of any part of the body are visualized by giving a contrast medium.

Coronary Artery Disease Venous Thrombosis in smokers Diabetics

CT of Musculo-skeletal System

Musculoskeletal system is visualized and is used in detecting congenital anomalies and in trauma cases.

Trauma cases

CT ColonographyThin CT sections of the abdomen are taken and is a useful tool over direct colonoscopy in detecting lesions specially in geriatric cases.

Geriatric field

CT Bronchoscopy CT sections of the tracheobronchial tree are taken. Smokers with lung cancer

Cardiac CT Used as a marker of atherosclerosis and risk indicator for coronary event and coronary artery disease.

Coronary Artery DiseaseCoronary Calcium scoring

Can be used to follow progression of Coronary atherosclerosis.

CT Coronary angiography

Contrast medium is used to visualize the Coronary Artery Disease (CAD) to detect and study blockage.

CT Perfusion of Brain

IV contrast is used to study Cerebral Blood Flow, Cerebral Blood Volume and Mean Transit time which can indicate presence of acute cerebral ischemia. It helps in early diagnosis of ischemic stroke.

Stroke

Table - 5 : MRI : Clinical uses

Technique Remarks

MR Angiography Used for display of vascular anatomy

MR Spectroscopy Used in diagnosis of disorders of central nervous system

Diffusion Weighted MR imaging

Used for diagnosing ischaemic injury

Perfusion weighted MR imaging

Evaluation of viable but ischaemic brain tissue in stroke, assessment of cerebral blood volume and in patients with brain tumors Alzheimer’s disease

BOLD Imaging Useful in seizure evaluation

Cardiac MRIIts applications include evaluation of congenital heart diseases, acquired heart diseases like pericardial effusion, pericarditis and pericardial masses. Cardiac MRI can be used to evaluate the myocardium cardiomyopathy and to assess myocardial viability in coronary artery disease.

Table - 6 : IPHS Standards : Suggested Availability of radiological techniques

Level of hospital (No of beds) Facilities available

31-50 X-ray, Ultrasonography

51-100 X-ray, Ultrasonography, Colour Doppler, CT

101-200 X-ray, Ultrasonography, Colour Doppler, CT

201-300 X ray, OPG, HSG Ultrasonography Colour Doppler, Spiral CT scan, MRI 0.4 TESSLA

301-500X-ray, Barium swallow, Barium meal, Barium enema, IVP, HSG, Dental X-ray, Ultrasonography, CT scan

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them (typically 1,000-100,000 times). The resulting voltage signal is filtered which is shown on paper (in older systems), or displayed on a computer screen. It is widely used as a tool for monitoring and diagnosis in certain clinical situations :

Epilepsy and syncope ●Sleep disorders ●Coma and brain death ●

Electrocardiography : An electrocardiogram (ECG or EKG, abbreviated from the German Elektrokardiogramm is a noninvasive transthoracic graphic produced by an electrocardiograph, which records the electrical activity of the heart over time. Electrodes on different sides of the heart measure the activity of different parts of the heart muscle. An ECG displays the voltage between pairs of these electrodes and the muscle activity that they measure, from different directions, also understood as vectors. This display indicates the overall rhythm of the heart and weaknesses in different parts of the heart muscle.

Applications in public health : It is the best way to measure and diagnose abnormal rhythms of the heart, particularly abnormal rhythms caused by damage to the conductive tissue that carries electrical signals, or abnormal rhythms caused by levels of dissolved salts (electrolytes), such as potassium, that are too high or low. In myocardial infarction (MI), the ECG can identify damaged heart muscle.

Electromyography : Electromyography (EMG) is a technique for evaluating and recording the activation signal of muscles. EMG is performed using an instrument called an electromyograph, to produce a record called an electromyogram. An electromyograph detects the electrical potential generated by muscle cells when these cells contract and also when the cells are at rest. EMG is used to diagnose two general categories of disease : neuropathies and myopathies.

SummaryIPHS prescribed various standards for the availability of laboratory facilities as per the bed status of Health care setting and are stated as a part of NRHM. The various modern diagnostic technologies can be classified into various categories like Immunopathology, Molecular Biology, Clinical Chemistry, Haematology, Cytopathology, Histopathology, Radiology and Electrophysiology.

The available Diagnostic Technologies in Immunopathology are Precipitation immunoassays (Widal test and the Weil-Felix test), Particle immunoassay (hemagglutination tests), Radioimmunoassay (ELISA) and Immunofluorescence assays.

Hemagglutination tests are used for diagnosis of Syphilis, hepatitis B and hepatitis C and Latex agglutination is widely used in measurement of hCG for qualitative pregnancy tests. ELISA can be used for diagnosing HIV and detecting tumour markers for certain cancers, e.g. Prostate specific antigen (PSA) in carcinoma prostate. Immunofluorescence assays have been extensively used for ZN staining in TB and in detecting antigens in tissue sections, e.g. kidney biopsies.

The available Diagnostic Technologies in Molecular Biology are Gel electrophoresis, Hybridisation assays, Amplification technology, PCR (Polymerase chain reaction) and Restriction

Fragment Length Polymorphism (RFLP) based assays. DNA Probes are available for various organisms like Mycobacterium tuberculosis, Chlamydia trachomatis, Neisseria gonorrhoeae, Human papilloma virus, Hepatitis C virus, Cytomegalovirus and Herpes simplex virus. This is especially important for slow growing organisms like Mycobacteria, fungi etc. DNA amplification is used for diagnosis of Hepatitis C Virus, HIV, TB, STDs and for Detection of antimicrobial resistance.

The available Diagnostic Technologies in Clinical Chemistry are Colorimetry, Nephelometry, Electrophoresis, Chromatography and Automation in clinical chemistry.

Colorimetry forms the basis of assessing almost all parameters in clinical chemistry Nephelometry is useful in measurement of antigen antibody complexes formed in immunoassays. Electrophoresis is used for Separation of serum proteins and Separation of hemoglobins, which is important in the diagnosis of various abnormal hemoglobins like thalassemia, sickle cell anemia etc. Chromatography is used for determination of drugs and chemicals in body fluids (toxicology). Detection of additives / chemicals in food is possible through High performance liquid chromatography. Environmental and water pollutants can be detected with accuracy through the use of various chromatographic procedures.

The available Diagnostic Technologies in Hematology are Automated Instruments like the cell counting components, Blood counting machines, flow cytometry etc. In addition to counting, measuring and analyzing red blood cells, white blood cells and platelets, automated hematology analyzers also measure the amount of hemoglobin in the blood and within each red blood cell. The available Diagnostic Technologies in Cytopathology are Exfoliative cytology (used for cytologic screening for cervical cancer), Fine Needle Aspiration Cytology (used for evaluation of lesions/ nodules arising from breast, lymph nodes, thyroid, liver, kidney and soft tissue). The available Diagnostic technologies in Histopathology are Histopathological staining and Immunohistochemistry. Histopathology (the most commonly used stain in histopathology is a combination of hematoxylin and eosin) is used as gold standard of diagnosis in clinical medicine and it is eminently suited to diagnosis of diseases and conditions like malignancies and also some non neoplastic conditions like tuberculosis and other infections. Immunohistochemistry is used for diagnosis of tumours/ non neoplastic conditions by specific molecular markers like S100, Cytokeratin.

The available Radiological techniques are X-ray (e.g. for diagnosis of Chronic infections like TB), DEXA Scan (used for screening of osteoporosis, particularly in women), Angiography and Digital Subtraction Angiography(DSA) (mainly used for Cardiovascular diseases), Mammography (screening of Breast Ca), Ultrasound (e.g. Antenatal care), Radionuclide scan (used for Bone scan, Kidney scan, Lung Perfusion scan), CT scan and Magnetic Resonance Imaging (mainly used for Cardiovascular diseases).

The available Electrophysical Technologies are Electro-encephalography, Electrocardiography and Electromyography. EEG is widely used as a tool for monitoring and diagnosis Epilepsy and syncope, Sleep disorders, Coma and brain death.

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ECG is widely used for diagnosis of Arrhythmias and CAD. EMG is used to diagnose neuropathies and myopathies.

Study ExercisesShort Notes : (1) Applications of Radiological techniques in Public Health (2) Applications of Immunopathology techniques in Public Health (3) Applications of Hematological techniques in Public Health (4) Applications of Electrophysical techniques in Public Health.

MCQs1. Which of the following is not a electrophysiological

diagnostic technique : (a) EEG (b) EMG (c) DEXA SCAN (d) a &b.

2. Which of the following is usually used as gold standard of diagnosis in clinical medicine (a) Histopathology (b) Electrophysiology (c) X-ray (d) Clinical Chemistry.

Answers : (1) c; (2) a.

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buffy coat blood parasite detection system in diagnosis of malaria. Indian J Med Microbiol 2001;19 : 219-21. Wilson M, Schantz P, Pieniazek N. Diagnosis of parasitic infections : 6. Immunologic and molecular methods. In Murray PR, Baron EJ, Pfaller MA, et al (eds) : Manual of clinical microbiology 6 ed. Washington DC. Asm Press 1995, p1159. Anthony Moody. Rapid Diagnostic Tests for Malaria Parasites. Clinical 7. Microbiology Reviews 2002;15(1) : 66-78Cormican MG, Pfaller MA. Molecular pathology of infectious diseases. In : 8. Henry JB, editor. Clinical diagnosis and management by laboratory methods. 19th ed. Philadelphia : W. B. Saunders Company; 1996 : 1390-9. Pfaller MA. Diagnosis and management of infectious diseases : Molecular 9. methods for the new millennium. Clinical Laboratory News 2000; 26 : 10-13. Kant JA. Molecular diagnostics : Reimbursement and other selected financial 10. issues. Diagn Mol Pathol 1995;4 : 79-81. Southern EM. Detection of specific sequences among DNA fragments 11. separated by gel electrophoresis. J Mol Biol 1975; 98 : 503-517. Richter R, Niemann S, Gerdes R. Identification of Mycobacterium kansassi 12. by using a DNA probe (Accuprobe) and molecular techniques. J Clin Microbiol 1999;37 : 964-970. Poljak M, Seme K, Koren S. Evaluation of the COBAS AMPLICOR hepatitis C 13. virus PCR system. J Clin Microbiol 1997; 35 : 2983-84. Ledergerber B, Egger M, Opravil M. Clinical progression and virological failure 14. on highly active antiretroviral therapy in HIV 1 patients : A prospective cohort study. Lancet 1999; 353 : 863-68. Tortoli E, Tronci M, Tosi CP. Multicenter evaluation of two commercial 15. amplification kits (Amplicor Roche and LCx abbott) for direct detection of M tuberculosis in pulmonary and extrapulmonary specimens. Diagn Microbiol Infect Dis 1999; 33 : 173-179. Kolbert CP, Arruda J, Varga- Delmore P. Branched DNA assay for detection of 16. the MecA gene in oxacillin resistant and oxacillin sensitive Staphylococci. J Clin Microbiol 1998; 36 : 2640-2644.

80 Accreditation of Health Care Facilities

Udai Bhaskar Misra

External assessment of healthcare has attained an ever increasing dimension globally. There are various models of External Assessment like ISO certification, business excellence, peer review, statutory inspection and accreditation. Accreditation can be regarded as one of the most attractive form of tool for External Quality Assessment of healthcare organizations. The concept was started in USA and at present many countries world over are practising this model of External Quality assessment (1).

Evolution of Accreditation The inception of the process began with the development of Minimum Standards for Hospitals by American College of Surgeons in 1917. In 1951, the American College of Physicians, the American Hospital Association, the American Medical

Association and the Canadian Medical Association joined with the American College of Surgeons to create the Joint Commission on Accreditation of Hospitals (JCAH). The Canadian Medical association withdrew from the JCAH in 1959. In 1971, the JCAH established the Accreditation Council for Long-Term Care and subsequently Accreditation for ambulatory care began in 1975. In 1987, since the scope was further expanded, the name of the organization was changed to the Joint Commission on Accreditation of Healthcare Organizations (2). Accreditation for healthcare networks began in 1994 and JCAHO and Quality Healthcare Resources formed the Joint Commission International with the goal of serving hospitals in other countries. Joint Commission Resources now provides consultation worldwide on healthcare issues and Joint Commission International is the largest Accreditation organisation, concerned with global accreditation. Gradually, accreditation has become a national yardstick for healthcare organisations in many countries including Australia, UK and European Countries. In developing countries, though, some beginning has been made but it is still in infancy.

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Definition Accreditation may be defined as a formal process by which a recognized body, usually a non-governmental organization (NGO), assesses and recognizes that a healthcare organization meets pre-determined standards. It can also be defined as a system of external peer review of an organization for determining compliance against predetermined standards, usually as a voluntary process.

Accreditation standards are usually regarded as optimal and achievable and are designed to encourage continuous improvement in delivery of healthcare within accredited organizations. An accreditation decision about a specific healthcare organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. It is usually a voluntary process in which organizations choose to participate, rather than one required by law and regulation. Accreditation has following principal components : (a) It is based on written and published standards. (b) Reviews are conducted by professional peers. (c) The accreditation process is administered by an independent

body. (d) The aim of accreditation is to encourage organisational

development. (e) It is usually a voluntary process. The effectiveness of accreditation is dependent on its voluntary nature, non-threatening process and interaction with external reviewers as a means of attaining desired quality improvements. Accreditation programmes, if undertaken with careful planning, strong government support and organizational commitment have the potential to improve the quality of care available in hospitals and medical laboratories in many developing countries.

PurposePurpose of Accreditation is to : (a) Improve the quality of healthcare by establishing optimal

achievement goals in meeting standards for healthcare organizations.

(b) Stimulate and improve the integration and management of health services.

(c) Establish a comparative database of healthcare organizations able to meet selected structure, process and outcome standards or criteria.

(d) Reduce healthcare costs by focusing on increased efficiency and effectiveness of services.

(e) Provide education and consultation to healthcare organizations, managers and health professionals on quality improvement strategies and “best practices” in healthcare.

(f) Strengthen the public’s confidence in the quality of healthcare and reduce risks associated with injury and infections for patients and staff.

(g) Accountability to professional bodies. Accreditation ProcedureThere are many recognized bodies providing Accreditation to Healthcare Institutions. These have diverse policies and procedures (3, 4). However, the common elements in a typical

Accreditation procedure are as under :

(a) Setting and publication of standards and elements of performance by a recognized body :

(i) Standard : A Standard is a Statement that defines the performance expectations and /or structure or processes that must be in place in order for an organization to provide safe, high quality care, treatment and services.

(ii) Elements of performance : The specific performance expectations and /or structures or processes that must be in place in order for an organization to provide safe, high-quality care, treatment and services.

(iii) Rationale : Some of the accrediting bodies have also included rationale for having standards in their document. Rationale is a statement that provides background, justification or additional information about a standard. (b) Application for registration by the healthcare institution. (c) Payment of fees. (d) Pre-survey activities. (e) Survey by the multidisciplinary team of Accreditation

Body. (f) Resurvey, if the Institution is found deficient in certain

areas of delivery of care. (g) Accreditation report and award of Accreditation.(h) Resurvey after a fixed period. Health care accrediting bodies use a variety of evaluation approaches during the on-site survey in order to determine the healthcare organization’s performance with predetermined standards. These methods include any combination of the following (5) : (a) Interviews of the top level Administrators or the Managers

of the organization(b) Clinical and support staff interviews. (c) Patient and family interviews. (d) Observation of patient care and services provided. (e) Tour of the building facilities, observation of patient care

areas, equipment management and diagnostic testing services.

(f) Review of written documents such as policies and procedures, training documents, financial documents and quality assurance plans.

(g) Evaluation of the organization’s achievement of specific outcome measures (e.g. Immunization rates, hospital-acquired infection rates, patient satisfaction).

(h) Evaluation of patients’ medical records.

Advantages of AccreditationAlthough this area requires more research but many studies have indicated the advantages of Accreditation to the hospitals, staff and the patients. It forms an essential basis for Quality Assurance Programme in a healthcare organization (6, 7). The advantages of accreditation can be grouped as under : Benefits to the Hospital(a) It Improves delivery of medical care and enhances the image

of the hospital. Thus, for private healthcare organizations it also results in more business.

(b) It stimulates a process of continuous improvement in delivery of medical care.

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(b) Organisational functions : Standards pertaining to following aspects are included in this section : (i) Improving organization performance (ii) Leadership(iii) Management of the environment of care (iv) Management of human resources (v) Management of Information(c) Structures with functions : This section includes standards on following aspects : (i) Medical Staff(ii) Nursing In 1997 Joint Commission initiated first step in establishing a link between accreditation and the outcomes of patient care, treatment and service issues using an ORYX tool. In order to apply this tool, initial core measure focus conditions for patient in a given location are identified in consultation with various professional bodies and field assessment. Subsequently, accredited hospitals choose 3 core measures out of the list earlier decided for example Acute Myocardial Infarction, Pneumonia and Heart failure.

During on site survey, the Joint Commission team assesses performance improvement in conditions related to selected core measures with the help of data from the hospital. ORYX Plus is a voluntary option, the requirements of which far exceeds those of ORYX. It is used by organizations that intend to contribute to a national database. The JCAHO expects home health agencies to establish their own performance measures, which gives these organizations the freedom to develop their own quality assurance programs and outcome measures (9).

Accreditation system in Australia (10, 11) : The Australian Council on Healthcare Standards (ACHS) is an institutional accreditation body established in 1974. At present Ninety percent of the country’s healthcare organisations are its members. ACHS conducts a voluntary program of health facility accreditation modeled along the lines of the Joint Commission. To increase clinician involvement in the accreditation process, also in quality assurance programs and to enable some assessment of the outcome of care in a facility at the time of survey, the ACHS, together with the medical colleges, is developing objective measures of care (clinical indicators).

Ten medical colleges were incorporated in developing the clinical indicators. The first set of measures, the Hospital-Wide Medical Indicators (HWMIs) developed in conjunction with the Royal Australian College of Medical Administrators, was formally introduced into the accreditation process in January 1993. These indicators were developed by a combined working party of the Care Evaluation Program and the Royal Australian College of Medical Administrators. The HWMIs address the areas of trauma, postoperative pulmonary embolism, readmissions to hospital, returns to the operating room, hospital-acquired infection, medication errors, etc. Development of objective measures of care (clinical indicators) will facilitate the accreditation process. It will also enable Australian physicians to compare patient care throughout the healthcare system. Accreditation system in UK (12) : The royal commission on the NHS recommended in 1979 that a special health authority be set up to develop and institutionalise standards for healthcare

Benefits for the employees(a) It helps in education, training and development of

professional staff.(b) Provides leadership for quality improvement within

medical profession and nursing. (c) Increases satisfaction of employees with working

conditions and leadership.(d) It aims for improved employee safety and security.(e) It promotes team work.Benefits for Patients(a) Provides access to organizations providing quality medical

care. (b) Patient’s rights are respected and protected. (c) It increases patient’s Involvement in medical care

decisions. (d) Focuses on patient safety.

Review of Accreditation Systems in selected countriesThe discussion on accreditation will not be completed without a review of status in selected countries, the same is appended below :

Accreditation System in USA : There are a number of organizations in US performing the function of accreditation of healthcare institutions as given below (8) : (a) The Joint Commission on Accreditation of Healthcare

Organizations (JCAHO). (b) The National Committee for Quality Assurance (NCQA). (c) The American Medical Accreditation Program (AMAP). (d) The American Accreditation Health Care Commission /

Utilization Review Accreditation Commission (AAHC/URAC).

(e) Accreditation Association for Ambulatory Health Care (AAAHC).

JCAHO is the largest and oldest accrediting body of USA. It is an independent, non government and not-for-profit organization. It has provided accreditation to more than 20,000 healthcare organizations both in US and outside. It has a board of Commissioners including 28 members. The constitution of the board includes : (a) Administrators, Physicians, Medical directors and Nurses(b) Consumers (c) Providers of care (d) Employers, Human Resource and quality expert(e) Health Insurance expert and expert in Ethics(f) Corporate and Public Members.The Corporate members include American College of Surgeons, the American College of Physicians, the American Dental Association, the American Hospital Association and the American Medical Association. JCAHO hospital standards can be grouped as under :

(a) Patient focused functions : These include standards on following : (i) Ethics, Rights and Responsibilities (ii) Provision of care, treatment and services (iii) Medication management(iv) Surveillance, Prevention and Control of Infection

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organizations. In the early 1980s several monitoring agencies were suggested but, despite favourable response from national professional bodies, no such national agency featured in the government’s white paper of 1989 “Working for Patients”. In the absence of any governmental lead, several small and large peer review accreditation programmes emerged as external voluntary mechanisms for organisational development. There are now more than 35 such programmes equipped with standards and trained assessors. However, integration and consistency between these programmes are lacking.

NHS institutions also have their visits from clinical training programmes, inspectors (such as for fire regulations, environmental health, etc). In addition the NHS Information Authority and Information Management Centre for data quality, Controls Assurance for risk management. The Clinical Standard Board for Scotland, the National Institute for Clinical Excellence (NICE) and Commission for Health Improvement (CHI) for England and Wales have been established to improve standards in the NHS. At present the requirement is to provide public access to the valid standards, reliable assessment and fair judgment. The NHS system also suffers from duplication and inconsistency.

Accreditation System in IndiaAccreditation Boards under Quality Council of India (QCI) : QCI is an autonomous body set up jointly by Government of India and Industry to establish and operate accreditation structure in the country. Initially it started with product certification and inspection under ISO 9001 series. Subsequently QCI developed standards for accreditation of laboratories and the Hospital as different boards. The same are discussed below. National Accreditation Board for Testing and Calibration Laboratories (NABL) : National Accreditation Board for Testing and Calibration Laboratories (NABL) is an autonomous body under the aegis of Department of Science & Technology, Government of India and is registered under the Societies Act. Government of India has authorised NABL as the sole accreditation body for Testing and Calibration laboratories.

NABL provides laboratory accreditation services to laboratories that are performing tests / calibrations in accordance with ISO/ IEC 17025 : 1999 General Requirements for the Competence of Testing and Calibration Laboratories. These services are offered in a non-discriminatory manner and are accessible to all testing and calibration laboratories in India and abroad, regardless of their ownership, legal status, size and degree of independence.

Scope and duration : NABL Accreditation is currently given for Testing Laboratories like Electronics, Calibration Laboratories like Optical and Radiological, Clinical Laboratories and Forensic Laboratories. The accreditation granted to a laboratory is valid for a period of 3 years subject to satisfactory annual surveillance. National Accreditation Board for Hospitals and Healthcare providers (NABH) : NABH is a constituent board of QCI set up with cooperation of the Ministry of Health and Family Welfare, Government of India and the health Industry. However, the Board has complete autonomy in its operation. NABH is a member of International Society for Quality in healthcare

(ISQua). The Technical Committee of NABH had formulated first edition of standards for hospitals in 2005 which have been revised and in November 2007 second edition of standards have been published.

Standards of NABH : There are 10 chapters in NABH document including 100 standards. The standards can be classified as :

(a) Patient Centered standards : These include : (i) Access, Assessment and Continuity of Care (ii) Care of patients(iii) Management of medication(iv) Patient Rights and Education (v) Hospital Infection Control(b) Organisation Centered Standards : These include : (i) Continuous Quality Improvement(ii) Responsibilities of Management(iii) Facility Management and Safety(iv) Human Resource Management(v) Information management System Each standard is further divided into variable number of objective elements. There are 515 objective elements for accomplishment of 100 standards. Objective elements frame the guidelines for achieving a particular standard.

Indian Confederation for Healthcare Accreditation (ICHA): ICHA is a body of national associations / institutions in healthcare sector. The basic objective of ICHA is to establish a mechanism of comprehensive healthcare accreditation system. It is an autonomous not-for-profit but self sustaining organisation driven by healthcare professionals. In August 2002 ICHA was constituted with the members from major healthcare associations of the country like the National Associations of Physicians (API), Surgeons (ASI), Anaesthetists (ISA), Ophthalmologists (AIOS), Pharmacists (IPA), Hospital administrators (AHA) and Hospital Pharmacists (IHPA). At present there are about 25 National Associations as members, 4 affiliate associations, 12 Individual organisational affiliates and 179 individual affiliates. The basic methodology of ICHA in granting accreditation is similar to NABH, however, the system is not as comprehensive and popular as NABH. .

Future ChallengesCompetitive rivalry amongst the healthcare organizations: Accreditation is an important method for Healthcare Organizations to distinguish themselves amongst their competitors in India. This will promote competitive rivalry amongst Healthcare Organisations, to obtain Accreditation. It is intimated that about 20 Hospitals have already applied for Accreditation to NABH and 40 more are preparing for it in India (16). After obtaining Accreditation, our Healthcare Organisations will become tough competitors to International Hospitals as they will be delivering quality care at much lower cost compared to other countries.

However, considering the giant size of healthcare sector in our country, it is suggested that the development of infrastructure of Accreditation Agencies like NABH should keep pace with the number of Healthcare Organizations applying for accreditation; otherwise the process may continue more than a decade before the healthcare organizations are accredited. This will require

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meticulous planning for trained assessors to undertake the survey.

Technological Boom : There will be increasing acquisition of high cost and advanced technology to over ensure the implementation of accreditation standards and to satisfy competitive rivalry amongst healthcare organisations. This will result into technological boom and haphazard mushrooming of equipment Industries. Such trends may lead to a requirement of accreditation of equipment agencies / OEM providing medical technology. Accreditation agencies like JCAHO are not only concerned with the proper technology but also whether the use information with regards to the equipment has been transferred to the ultimate users. Thus it is imperative on our part to work out some regulatory mechanism so that quality equipment is provided to users with assured after sale maintenance. Accreditation of equipment agencies will discourage mushrooming of substandard technology and facilitate the implementation of technology related standards of Accreditation for healthcare organizations.

Promotion of medical tourism : Many countries are already suffering with sky rocketing cost of care and long waiting line for definitive care. India has about 20 million individuals living abroad as NRIs or otherwise. They function as best of marketing ambassadors of medical care for brand India when they return to the Nation they are settled, after spending their leave back home. This is one of the major factors which have led to the promotion of Medical Tourism. The phenomenon can be further supported if our hospitals are accredited by a comprehensive Accreditation System and regulation of Tourism Industry. In some countries Medical Tourism is having an economic impact and similar predictions are made for our country in McKinsey Report submitted by the commission engaged for Study on Health care under the aegis of Confederation of Indian industry. Countries like USA are in an advantageous position for health tourism as about Ninety six percent of the hospital beds are in accredited hospitals. However, the cost of treatment in US is inhibitory for patients which is a definite advantage with Indian hospitals. Accreditation of miscellaneous healthcare organisations other than hospitals and part-facilities : It is evident that the “first takers” for the Accreditation will be the Corporate Hospitals for the obvious reasons. Subsequently, other facilities like Ambulatory Care Centers, Nursing Homes and Clinics may come forward for obtaining Accreditation. Thus in the subsequent phase the Accreditation body should be ready with standards which are applicable to variety of healthcare organizations. However, Indian Accrediting bodies are not ready with the standards for various healthcare organizations. A workable solution could be to evolve the standards in the form of modules which are applicable to different organizations with addition / deletion of certain items.

Accreditation of disease specific care : Once the process of Accreditation is established in India, the Disease Specific Accreditation may be developed. The common diseases like Diabetes, Hypertension, Tuberculosis, COPD and IHD may be identified which cover about 80 to 90% population. The willing organisations which may not afford for Comprehensive

Accreditation may be considered for Disease Specific Accreditation Programme. JCAHO has already started with Disease Specific Accreditation in 2002. However, it may have both positive and negative aspects. For example the organisations may obtain Accreditation for limited number of diseases but this transparency may not be maintained during marketing campaigns. Thus it needs further deliberation and formulation of policies accordingly (4).

Accreditation of Clinical Care : Once the Accreditation process is well firmed up in India, a possible ramification of the process to introduce the Clinical Accreditation programme may be initiated in collaboration with apex Medical Institutions / experts. Initially, particular aspect of care for example Acute Care may be chosen for programme and gradually it may be extended. Australian Council of Healthcare Standards has already started an Accreditation Programme for Acute Care by identifying about 200 Indicators which are utilised to monitor the clinical services. The growth of this programme has been overwhelming and many nations have joined this programme. Such programmes can be beneficial in improving the clinical processes and the outcome aspect of care. Accreditation of healthcare organisations providing alternative care : A large amount of Indian population is seeking healthcare from healthcare providers dealing in alternative medicine. With increasing awareness of clients, these healthcare organizations may also like to apply for Accreditation. This may involve further efforts at the part of Accreditation Providing Agencies in the form of formulation of policies, designing different set of Standards and other resources. In developed countries there are many agencies providing accreditation for alternative systems of medicine for example Royal College of Alternative Medicine UK, British Medical Acupuncture Society, The American Alternative Medicine Association and so on.

Accreditation of Public sector healthcare organization : It is contemplated that the Public Sector Healthcare organizations may be the last one to seek the Accreditation. However, with increasing awareness of clientele about the Accreditation of Healthcare organizations in Corporate Sector, the client pressure will compel the Public Sector Organisations to seek the accreditation. It is suggested that our ultimate goal should be to ensure reasonable standard of care at the grass root level by accreditation of Primary Health Care Centers through involvement of Central and State Governments. Increasing empanelment of accredited organisations by Insurance agencies : It is evident that there will be rising trend for Insurance agencies to empanel the hospitals which are accredited. Insurance companies may use accreditation as a tool to decide which healthcare organisations to reimburse.

Cost Escalation : There may be miscellaneous reasons for escalation of the cost for healthcare during the process of accreditation. It is documented that the cost of accreditation by NABH is about one tenth of Joint Commission International (JCI). The cost of Accreditation process for a 500 bedded hospital is about 7 lakh. However, additional cost will be incurred in implementing the structure, process and outcome in accordance with NABH standards and then maintaining it. The question is

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who will bear this cost ? Most likely this cost may be shifted to the patients. Secondly, the increase in paying capacity can also lead to rise in cost. The influx of foreign patients has already resulted in cost escalation in some of the areas of our country.

Care of unaffordable class : Accreditation of healthcare organisations does not provide an answer for the medical care of unaffordable class. If the accreditation process is not monitored / regulated in a disciplined way it may result in escalation of cost of care which will further hurt the poor class. There is a need for Government intervention in this regard to formulate adequate policies. The feasibility for cross subsidisation of the medical care of the poor class from the revenue earned by accredited hospitals through Medical Tourism should be worked out.

Medical trade : With growing recognition of Indian Hospitals having an accreditation tag and influx of foreign nationals for healthcare, doors of miscellaneous trade ventures will be opened. Sooner or later there will be involvement of third party between the patient and the hospital. Such agencies may offer different types of packages, starting from identification of a hospital to provision of transport and other administrative and logistics aspects including the hospice services if required at any point of time. It will be very essential to regulate such trade so that the image of our healthcare sector is not tarnished in the eyes of the other Nations.

To conclude, Accreditation is an International phenomenon. It is catching up in India in the right time as many countries are looking for alternative destinations to their healthcare organisations either due to cost escalation or due to a long waiting line for the procedures. However, it should be designed, regulated and monitored properly.

It is suggested that design of standards should be such so as to provide high inter assessor reliability and validity. Standards which are low on inter-assessor reliability should be revised or discarded. Similarly, assessing which factors contribute to inter-rater reliability and understanding how attitudes and behaviours of surveyors contribute to an effective system will influence the choice and training of surveyors.

While many claims are made about the benefits of accreditation processes, empirical evidence to sustain many such claims is currently lacking. Researching the impact of accreditation on individual and organisational performance is an important undertaking. The question arises as to how best to research the validity, impact and value of accreditation processes in healthcare. In countries where most healthcare organisations participate in some sort of accreditation process it may not be possible to study its merits using a randomised controlled strategy.

However, In India it is the right time for such research. As the sample will be available for a randomized controlled trials from the hospitals which are accredited and those without accreditation. Thus, research studies are necessarily required in India to discover the overall impact of Accreditation.

SummaryAccreditation can be regarded as one of the most attractive form of tool for External Quality Assessment of healthcare

organizations. Accreditation for healthcare networks began in 1994 and JCAHO and Quality Healthcare Resources formed the Joint Commission International with the goal of serving hospitals in other countries. Joint Commission Resources now provides consultation by Joint Commission worldwide on healthcare issues and Joint Commission International is the largest Accreditation body, concerned with global accreditation. One of the chief purposes of Accreditation is to Improve the quality of healthcare by establishing optimal achievement goals in meeting standards for healthcare organizations. Health care accrediting bodies use a variety of evaluation approaches during the on-site survey in order to determine the healthcare organization’s performance with predetermined standards.

The advantages of accreditation can be grouped as benefits to the Hospital, which include improvement of delivery of medical care, benefits for the employees in providing education, training and development of professional staff and benefits for Patients which include provision of access to organizations providing quality medical care. There are a number of organizations in US performing the function of accreditation of healthcare institutions. JCAHO is the largest and oldest accrediting body of USA. It has provided accreditation to more than 20,000 healthcare organizations both in US and outside. It has a board of Commissioners including 28 members. JCAHO hospital standards can be grouped as Patient- focused functions and Organisational functions. The Australian Council on Healthcare Standards (ACHS) is an institutional accreditation body established in 1974. At present Ninety percent of the country’s healthcare organisations are its members. The first set of measures, the Hospital-Wide Medical Indicators (HWMIs) developed in conjunction with the Royal Australian College of Medical Administrators, was formally introduced into the accreditation process in January 1993.

The royal commission on the NHS recommended in 1979 that a special health authority be set up to develop and institutionalize standards for healthcare organizations. There are now more than 35 such programmes equipped with standards and trained assessors. The Clinical Standard Board for Scotland, the National Institute for Clinical Excellence (NICE) and Commission for Health Improvement (CHI) for England and Wales have been established to improve standards in the NHS.

QCI is an autonomous body set up jointly by Government of India and Industry to establish and operate accreditation structure in the country. National Accreditation Board for Testing and Calibration Laboratories (NABL) provides laboratory accreditation services to laboratories that are performing tests/ calibrations in accordance with ISO/ IEC 17025. Indian Confederation for Healthcare Accreditation (ICHA) : ICHA is a body of national associations / institutions in healthcare sector. The basic methodology of ICHA in granting accreditation is similar to NABH. It is imperative on our part to work out some regulatory mechanism so that quality equipment is provided to users with assured after sale maintenance. In some countries Medical Tourism is having an economic impact and similar predictions are made for our country. A workable solution could be to evolve the standards in the form of modules which are applicable to different organizations with addition / deletion of certain items.

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Once the Accreditation process is well firmed up in India, a possible ramification of the process to introduce the Clinical Accreditation programme may be initiated in collaboration with apex Medical Institutions / experts. With increasing awareness of clients, alternative medicine healthcare organizations may also like to apply for Accreditation. It is contemplated that the Public Sector Healthcare organizations may be the last one to seek the Accreditation.

There are miscellaneous reasons for escalation of the cost for healthcare during the process of accreditation. The feasibility for cross subsidisation of the medical care of the poor class from the revenue earned by accredited hospitals through Medical Tourism should be worked out.

With growing recognition of Indian Hospitals having an accreditation tag and influx of foreign nationals for healthcare, doors of miscellaneous trade ventures will be opened.

Accreditation is an International phenomenon. It is catching up in India in the right time as many countries are looking for alternative destinations to their healthcare organisations either due to cost escalation or due to a long waiting line for the procedures. However, it should be designed, regulated and monitored properly.

Study ExercisesMCQs1. The concept of accreditation was started in which country?

(a) USA (b) UK (c) Germany (d) France.2. A Statement that defines the performance expectations

and /or structure or processes that must be in place in order for an organization to provide safe, high quality care, treatment and services, is known as (a) Rationale (b) Element of performance (c) Vision (d) Standard.

3. The largest and oldest accrediting body of USA is (a) Accreditation Association for Ambulatory HealthCare (AAAHC) (b) American Medical Accreditation Program (AMAP) (c) National Committee for Quality Assurance (NCQA) (d) Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

4. The autonomous body set up jointly by Government of India and Industry to establish and operate accreditation structure in the country is (a) Bureau of Indian Standards (BIS) (b) Quality Council of India (QCI) (c) National Accreditation Authority (NAA) (d) Indian Confederation for Healthcare Accreditation (ICHA).

5. The cost of Accreditation process for a 500 bedded hospital is about (a) Rs. 10 Lakhs (b) Rs. 05 Lakhs (c) Rs. 07 Lakhs (d) Rs. 01 Lakh.

Answers : (1) a; (2) d; (3) d: (4) b; (5) c.

References Luce JM, Bindman AB, Lee PR : A brief history of health care quality 1. assessment and improvement in the United States. West J Med 1994; 160 : 263-268. Shaw C D, Collins C D. Health service accreditation : report of a pilot 2. programme for community hospitals. BMJ 1995;310 : 781-784. Frolich A, Christensen M. Accreditation of Hospitals a review of International 3. Experiences. Ugeskr Laeger (Danish Article), 2002 Sep 6;164 (38) : 4412-6. JCAHO. Comprehensive Accreditation Manual for Hospitals : The Official 4. Handbook. 2005 : Department of Publications, Joint Commission Resources, Illinois USA. APP 1-15. Rooney AL, van Ostenberg. Quality Assurance Methodology Refinement 5. Series : Licensure, Accreditation and Certification to Health Services Quality 1999 : USAID Quality Assurance Project Bethesda, USA, 22 – 26. Pickering E, Evaluating the benefits and limitations of an accreditation 6. system, World Hosp and health Services 1995 : 31 (1) : 31-5. Hadley TR, Mcgurrin MC, Accreditation, Certification and the Quality of Care 7. in State Hospitals. Hosp Community Psychiatry July 1988 : 39 : 739-742. Viswanathan HN, Salmon JW, Accrediting Organizations and Quality 8. Improvement, Am J Manag Care 2000;6 : 1117-1130. Robinson ML. JCAHO emphasizes patient outcomes. Hospitals 1989;63 : 9. 21. Collopy BT, Balding C. The Australian Development of National Quality 10. Indicators in Healthcare. Jt Comm J Qual Improv. 1993 Nov;19 (11) : 510-6. Faunce T A and Bolsin SNC. Three Australian Whistle blowing sagas : lessons 11. for internal and external regulation. MJA 2004; 181 : 44–47. Shaw C, External Assessment of healthcare Programmes in Britain, BMJ 12. 2001;322;851-854.

Further Suggested Reading National Accreditation Board for Hospitals and healthcare Providers. 1. Standards for Hospitals November 2007. NABH New Delhi. Zende V, Dynamics Of Accreditation Of Private Hospitals, Healthcare 2. Management, November 2006. Healthcare Management, ICHA Is An Accreditation System That India Can 3. Identify With’, January 2006

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81 Health Care Financing

Sunil Nandraj, N Devadasan, Alaka Singh

Every health system has the responsibility not just to improve the health of the population, but also to protect them against the financial cost of illness and to treat them with dignity. The way a health system is financed is a key determinant of population health and well-being. In many of the poorest countries, the level of spending is still insufficient to ensure equitable access to basic and essential health services and interventions and therefore a major policy issue is how to ensure adequate and equitable resource mobilization for health. There is no single answer to the question of how to finance health systems. Not only do the specific challenges faced by countries differ, each country already has a system of health financing that has developed over a period of time.

Health policy and financing policy are inseparable because financing policy determines who has access to basic health care, how much is available, who controls the funds and how they are used; the technical, allocative and distributive efficiency of resource in use, social protection, what financial incentives are given to patients and providers and whether health care cost inflation can be controlled. Fig. -1 shows conceptual framework of Health System.

Fig. - 1: Health System conceptual framework

Social Determinants of HealthSystem Building Blocks Goals of Health System

Info

rmat

ion

Supp

ort

Leadership &governance

Healthworkforce

Financing

Healthtechnology

Providerperformance

Quality &Safety

Efficiency

Responsiveness

Health

Serv

ice

Deliv

ery

Coverage

Equity

Financialprotection

Spending on health has been increasing world-wide. While cost-effective responses to preventable and communicable morbidity and mortality, there is a growing challenge from high-cost non-communicable and ‘new’ diseases. Advances in medical technology, higher population and providers’ expectations, income growth, health system development are some determinants. Increased inequalities in health spending between and within countries. Health care financing is at the center of most health policy reforms. New medicines and other technological developments, rising expectations and aging populations fuel increased demand and hence put upward pressure on system costs. Concurrently, macroeconomic, demographic and fiscal constraints limit the extent to which governments can simply allocate more public revenues for health. The combination of upward pressure on costs and

limitations on the ability of governments to increase spending forces countries to consider reforms to the way that their health systems are financed.

Financing of Health Care in IndiaThe current scenario in the health sector is plagued by high maternal and child mortality, dual burden of communicable & non-communicable diseases, poor health of majority, especially the poor. Inability of a large section of the population, especially from lower income to access good health care with spiraling health costs. Hospitalization for major illness is a cause of indebtedness for all income groups, especially those from the lower income. There is an increasing demand for health care services. The government is functioning under a resource crunch coupled with states facing financial crisis and unable to meet recurring expenditure of the health sector.

Like all countries in the world, India too faces difficult challenges and choices in financing its health systems. India has a mixed form of financing health care. The government is supposed to provide ‘free’ health care for all the citizens by raising funds from taxes. Unfortunately, the government’s revenue is low, resulting in a small proportion being allocated for health care. Because of this chronic under funding, most government facilities are not able to provide health care to all its citizens. So, many patients go to the private sector institutions and pay for their health care which accounts for 72 percent from households (Chart 1). Thus, the Indian health service is financed by both tax based revenues and by out of pocket payments (OOP). Health insurance plays a very small part in financing health services in India. The total health expenditure in India for the year 2001-02 was Rs 1,057,341 million, which accounted for 4.6 percent of its GDP. Of the total expenditure, 20.3 percent was public / government expenditure, 77.4 percent was private expenditure and remaining 2.3 percent external support. (Table1) Over all, the per capita health expenditure for the year was Rs 1021 (about US$ 25). Compare, this with amounts spent by high income countries (US$ 3000 – 5,000).

Chart - 1 : Health Expenditure by Financing Sources (2001-02)

Households 72%

External Aid (2%)

Central Government (6%)

State Government (13%)

Local Government (2%)

Firms (5%)

Source : National Health Accounts 2001 – 02. Ministry of Health and Family Welfare, Government of India. 2006.

Health Care Functions and Mechanisms A health system has many actors and many functions. One of this is to finance health care. There are three basic functions of a health financing system :

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Revenue collection : Financial contributions to the health system have to be collected equitably and efficiently;

Pooling : Contributions are pooled so that the costs of health care are shared by all and not borne by individuals at the time they fall ill. This requires a certain level of solidarity in the society.

Purchasing : The contributions are used to buy or provide appropriate and effective health interventions.

Table - 1 : Health Care Expenditure in India (2001-02)

Source of FundsExp. in Rs 000s

% Distri-bution

(a) Public funds

Central Government 67,198,262 6.3

State Government 132,709,065 12.5

Urban Local Bodies & PRI # 18,042,955 1.7

Total (a) 217,950,282 20.5

(b) Private funds

Households 764,840,500 71.9

Firms $ 55,460,000 5.2

NGOs and Indian Funding Agencies

NA

Total (b) 820,300,500 77.2

(c) External Aid

Aid to Central Government (MOHFW Budget)

16,483,158 1.6

Material Aid to Central Government (MOHFW Budget)

825,937 0.1

Aid to State Government (State Budgets)

2,389,555 0.2

To NGOs 5,161,353 0.5

Total (c) 24,860,003 2.3

Total funds 1,063,110,785 100# from National Commission on Macroeconomics and Health (2005); NA : not available

Source : National Health Accounts 2001 – 02. Ministry of Health and Family Welfare, Government of India. 2006.

Ideally a financing system should be able to generate revenue, pool the funds so that there is cross-subsidy between the rich and the poor and also between the healthy and the sick. Finally, the financing system should be able to purchase appropriate and efficient health care services from the provider on behalf of the patient. A health care financing is assessed on feasibility, equity, efficiency and sustainability.

Broadly, there are various options and mechanisms for financing the health care services :

Out of Pocket Payment ●General Tax Revenue ●Insurance : Social Health Insurance; Private Health ●Insurance; Community Based Health Insurance External Finance ●

Provider Payment ●Out of Pocket Payments (OOP) This is the simplest form of health care financing i.e. a patient goes to a provider and pays for the services received. In India, this is commonly followed when a patient visits a private practitioner. User fees paid in government hospitals are an example of “out of pocket payments”. In India, this is the most common form of financing health care. While the revenue collection function may be good, the pooling and purchasing mechanism is negligible. Individual patients have very little negotiation power and information to purchase effective and appropriate care.

The main financer of health services in India is the individual household. They meet 72% of the total health care costs by paying out of pocket at the time of service. Thus patients go to dispensaries, clinics and hospitals and receive health care. In turn they pay money for this health care from their own funds. Indian households have one of the least protection in terms of OOP payments. In most high income countries, only about 5-10% of households have to pay OOP payments and these are usually in the form of pre/co-payments to contributory financial protection schemes e.g. social health insurance. In middle income and low income countries, the proportion increases to about 25-50% of households. OOP have two adverse consequences, they lower access to health care by creating financing barriers. Some people hesitate to go to hospitals or dispensaries as they may not be able to afford the fees. NSSO studies have shown that 18% of households do not access even OP care, mainly because of financial barriers. Secondly, they impoverish the households because of high medical costs. Studies have shown that at least 40% of Indian households have had to borrow or to sell their assets to pay hospital bills. A quarter of hospitalised patients in India have been impoverished because of high medical costs. (NSSO 60th Round : Morbidity, Health care and condition of the aged). Further, it is seen from Chart - 2 that there are wide variations of ratio of public to private expenditure across the major states in India.

General Tax Revenue Governments collect revenue through taxes, both direct and indirect. This revenue is allocated to various sectors including the health sector. Equity and efficiency of government revenue-financed health systems ultimately depends on the overall tax collection structure. Financing health services through government is to raise sufficient and sustainable revenues in an efficient and equitable manner to provide individuals with both a basic package of essential services and financial protection against unpredictable catastrophic financial losses caused by illness and injury. The key issues in revenue collection are level of income, tax-base and fiscal space, tax incidence, transaction cost and size of informal sector. General revenues are considered to be the most equitable means for health financing. They may be considered a mechanism for sustainable risk pooling that allows financial protection based on political and societal choices – this may be subsidized primary care, public health interventions and / or services for targeted population groups. General revenues allow a broader

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range of taxes for financing health while earmarked taxes could potentially safeguards funds for health – from competing demands on general revenues from other sectors as well as for flexibility in use. Earmarked taxes are the ‘boundary’ between tax-based health financing and social insurance.

Chart - 2

Ratio of Public & Private Exp. on Health in Major States(2001-02)

UttarPradesh

Andhra

Assam

Bihar

Gujarat

Haryana HP

J&K

Karnataka

Kerala

MP

Maharashtra

Orissa

Punjab

Rajasthan

TamilNadu

WestBengal

% Private % Public

Government health services are usually financed by general revenue sources e.g. in India, most of the government health services are financed from this budgetary allocation. This is the second most important mechanism of financing health care in India. Here the collection and pooling functions are the best, but purchasing function may be limited. This is seen very obviously in our country where the government financing is low. As seen from Table 1, out of the total expenditure, 20.3 percent was public / government expenditure. The break up of the public expenditure shows that one third of the government spending was from the central government, the rest two thirds was from state and local governments. Thus the state governments are the main funding of public health services.

Given this scenario, the Government in India in its National Health Policy 2002 had suggested that the allocation to health be raised to 2-3%. In the recent past, the National Rural Health Mission (NRHM) has been formed with a view to increasing the expenditure in the health sector from a current 0.9% of GDP to 2% over the next five years and to focus on Primary Health Care. The Mission has been made operational from Apri1, 2005. The NRHM financing for the period 2005-2012 would be around Rs. 300, 000 million for non recurring expenditure and recurring expenditure of more than Rs. 400, 000 million. This financing is to be shared between the Centre and the states (increase the share of central and state from 20-80 to 40-60 sharing in the long run).

InsuranceThis is the most complex mechanism of financing health care. The revenue is generated either by individuals paying a premium or by employers contributing towards their employees

or even the government paying on behalf of the poor. This revenue (called premium) is pooled into an autonomous fund that is used specifically to finance health care. In this way, this mechanism is different from the tax based government funding as the taxes collected is not dedicated only to health care. The insurance fund subsequently purchases health services on behalf of the insured from providers – be it government of private. The objective is to manage the revenues to equitably and efficiently pool health risks allowing for subsidies from healthy to unhealthy, rich to poor and productive workers to dependents. Health insurance has a limited effectiveness in collecting revenue; it depends on the workforce in the formal sector and also the size of the better off population. However, it has the potential to pool the funds effectively, especially if funds are collected from both low income and high income individuals. And finally because it is autonomous, it has an enhanced ability to purchase health services.

Health insurance could be an alternative health financing mechanisms; however, factors on both demand side and supply side coupled with high administrative costs limit the smooth functioning of the market for insurance in health. Further, action to counter market failure requires mature financial systems and institutional capacity to enforce corrective measures.

Demand side limitations : Protection from the real cost of ill-health may make individuals less risk averse, causing them to neglect precautionary/ preventative measures. Or, being covered, an individual may consume excessive amounts of health care. This change in health behaviour due to insurance is moral hazard. Further, given uncertainty and incomplete/asymmetric information regarding ill-health, each member of an insurance pool may have different individual expected losses from ill-health and where this is lower than that reflected in premium charged, members may drop out of the group, leaving only an ‘adverse selection’ of high expected losses in the pool.

Supply side limitations : With insurance, excess demand can be supplier - induced as well -- the provider has fuller information on health status than the patient and could have used this asymmetry in information to over-prescribe services covered under the insurance plan. Adverse selection on the supply side occurs when insurers ‘cream skim’ through risk selection by including only healthier individuals in the plan; or, conversely, skimp or exclude certain high cost disease or pre-existing conditions.

There are various types of health insurance namely, Indemnity insurance wherein the person spends first and gets it reimbursed from the insurer afterwards. Health Maintenance Organizations (HMO’s), which is broadly managed care, a health plan providing a full range of health services against a fixed monthly premium.

Broadly there are three major types of health insurance: Social Health Insurance (SHI) ●Private Health Insurance ●Community Health Insurance ●

Social Health InsuranceSHI is usually publicly mandated for specific groups, financed through payroll taxes, semi-autonomous administration, the care provided is through its own, public, or private facilities.

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The law mandates employers to deduct a percentage of each employees monthly wage for health to be paid to a “social insurance fund”. This fund could be managed publicly or privately; they can be monopolies or competitive. The employer/employee deductions are earmarked for health and cannot be used for any other purpose. Usually, it is applicable largely to formal sector employers and employees. The main strengths of SHI are that they area additional health revenue source, generally provides covered population with access to a broad package of services, can effectively redistribute between high and low risk and high and low income groups in covered population and often serves as the basis for the expansion to universal coverage. The major weaknesses are that the poor are often excluded unless subsidized by government, potential negative impact on employment, administrative cost can be high, can lead to cost escalation unless effective contracting mechanisms are in place, poor coverage for preventive services and often needs to be subsidized from general revenues. In India, there two major SHI schemes namely the Employees State Insurance Scheme (ESIS) and the Central Government Health Services (CGHS).

Employees State Insurance Scheme (ESIS) : The ESIS is a social security system which provides both cash and medical benefits. The Employees State Insurance Corporation (ESIC) manages the scheme and is a corporate semi-government body headed by the Union Minister of Labour as Chairman and a Director General as the chief executive. The Act compulsorily covers : (a) all power using non-seasonal factories employing 10 or more persons; (b) all non-power using factories employing 20 or more employees and (c) service establishments like shops, hotels restaurants, cinema, road transport and news papers are covered. Contributions are paid through a payroll tax levied on the employer and a contribution levied on the employee and contribution by state governments. The benefits are comprehensive cover, including OP, IP and rehabilitation. All workers and their dependent relatives are eligible for the benefits. These include comprehensive health care at ESIS facilities, cash compensation for illness, maternity benefits, disability benefits, survivorship and funeral expenses in the event of death of the worker. ESIS has its own dispensaries, hospitals and medical staff. It also empanels select private practitioners to provide medical care. Presently the scheme is spread over 677 centres in 25 states and Union territories across India covering 7.8 million employees and more than 25 million beneficiaries (17). In 1992, of a total expenditure of Rs 3.8 billion, Rs 2.2 billion was spent on health care. In 2001, the ESIC had surplus funds of Rs 67 billion, invested mostly in government securities.

While the ESIS has managed to cover the low paid workers in many organizations and provided them with a degree of comprehensive health security, various studies have been critical for the following reasons : Less than half the enrollees use the ESIS facilities because of the low quality of care. This is further compounded by the shortage of staff, inadequate drug and supplies and non-functional equipment. Many of the staff are not aware of the benefits. The employers also do not disseminate the information to their staff. Also, because of the salary limits on eligibility, some staff keep shifting in and

out of the ESIS and they may not be aware of their eligibility status. There is very little penetration in rural areas.

Central Government Health Scheme (CGHS) : The CGHS was introduced in 1954 as a contributory health scheme to provide comprehensive medical care to the central government employees and their families. The list of beneficiaries includes all categories of current as well as former central government employees, members of Parliament, Supreme Court and High Court Judges. In 1997, there were approximately 4.2 million beneficiaries. The staff contributes a nominal amount (ranging from Rs 15 to Rs 150 per month) from their salaries. The benefit package includes both outpatient care and hospitalisation. OP care is provided through its own dispensaries, 320 in 2002 in 17 major cities. It also uses the facilities of the Government and approved private hospitals to provide inpatient care and reimburses the expenses to the patient. The entire scheme is funded by the government of India and is administered by a separate directorate. Various evaluations have noted that while it has been effective in providing health security for more than 4 million people, there are certain problems in the scheme that needs to be addressed. In terms of demand side, moral hazard – it is noted that 83% of the hospitalised patients are self referred. It appears that most patients prefer to bypass the dispensaries and directly avail of specialist services. The number of annual visits per beneficiary was 3.5 (1994-95). Poor quality care – there are regular complaints about long waiting periods, inadequate supply of medicines and equipment and unhygienic conditions.

Private Health InsurancePrivate health insurance emerges from voluntary actions in a market where buyers are willing to pay premium to insurance companies that; pools people with similar risks and insure them for health expenses. Commercially run for-profit private insurance companies usually base contributions on risk-rating i.e. adjusted according to the anticipated cost of use of services, care reimbursed in private and public facilities who provide treatment for members. Private health insurance is generally motivated by the prospect of earning a profit and companies compete for clients on the basis of “price” and quality. The major strengths are that as a prepayment and risk pooling mechanism it is generally preferable to out of pocket expenditure. It may increase financial protection and access to health services for those able to pay. When there is “strategic purchasing” function is present it may also encourage better quality and cost-efficiency of health care providers. The main weaknesses are : it is associated with high administrative costs and profit, it is generally inequitable. Applicability in LICs and MICs requires well developed financial markets and strong regulatory capacity.

Private health insurance in India is usually associated with the “Mediclaim” policy. Introduced in 1986, it is a voluntary health insurance scheme offered by private insurance companies. While initially only “non-life insurance companies” were allowed to market health insurance products, the Insurance Regulatory & Development Authority (IRDA) has recently permitted even life insurance companies to introduce health insurance products. Currently there are 14 general insurance companies and three life insurance companies providing health insurance products.

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With the introduction of Third Party Administrators (TPAs), the reimbursement policy has changed into a ‘cashless’ policy, where the TPA reimburses the hospitals and the entire treatment is cashless for the patient. While initially only hospitalisation expenses were covered, today health insurance products cover a variety of risks, ranging from hospitalisation to outpatient care to ambulance expenses and also pre & post hospitalisation expenses. While earlier, there were only individual or group insurance products, recently family floater products have slowly gained popularity. While earlier a family of four had to pay the individual premiums (e.g. Rs 2000 X 4 = Rs 8000) and get a cover of Rs 2 lakhs each, today under a family floater product, the family needs to pay a much lower premium (e.g. Rs 5, 000) and get a family cover of Rs 5 lakhs. This means that anybody who is sick in the family can avail of hospitalisation expenses upto Rs 5 lakhs. This is a much more attractive product to cover families. Today many of the products also provide a daily cash benefit for each day of hospitalisation. This is to take care of non-medical expenses like transport, food, attendant expenses etc. Yet another innovation has been the introduction of ‘critical illness’ cover. Under this, an individual is insured for a particular period. During that period, if the individual contracts one of the listed critical ailments like stroke or cancer or myocardial infarction (MI) or end stage renal failure (CRF), then the patient is paid a lumpsum amount and the policy is terminated. The patient is free to use this lumpsum for whatever need required. There is no need to submit any bills and receipts, just a proof of diagnosis of the critical ailment. Initially the senior citizens had very little opportunity to insure themselves, but today many companies have developed products tailor made to the needs of senior citizens. Similarly, more and more products are reducing the list of exclusions and providing a more comprehensive cover. While earlier pre-existing diseases were not insurable in the Indian market, today many of the companies include them in the cover after a fixed claim free period (usually two years). Today there are many different products catering to people.

Community Health Insurance Community health insurance is mostly not-for-profit prepayment plans for health care, with community control and voluntary or compulsory membership, care is generally provided through NGO or private facilities. Members pre pay a set amount periodically for specified services. It is managed by community members and accountable back to members. Community based health insurance schemes have had some success in providing financial protection to the poor in the informal sector. These initiatives are based on the social insurance principle of solidarity, de-linking contributions from use and thus supporting equitable access to care. It promotes pre-payment and mobilizing additional resources, providing access and financial protection in LICs. Experience indicates that community health financing has been most successful where this has been associated with income generation activities. The major weakness are Community health initiative tends to be limited in scope by their capacity for financial risk pooling – while based on the principles of social insurance, they cannot establish similarly large pools. Also, such schemes rely on the existing network of public and private providers (rather their

own facilities). This has implications for the benefit package offered as well as long term sustainability. CHI can be a helpful complement but is not a substitute for SHI systems. CHI movement is slowly picking up momentum in India. Currently there are about 100+ CHIs in the country, many of which have begun operations in the past two to four years.

Unfortunately, in India, there is very little penetration of health insurance in the country. Estimates range from 3 to 8% (10, 11). This for a country of 1 billion is negligible. Most of those insured are in the formal sector and have security in terms of insurance policies as well as steady incomes. On the other hand, the rural populations are left at the mercy of ailments; and usually have to borrow and sell assets to meet even a small hospitalisation episode.

External Finance There are two main forms of external contributions for development : loans and grants. Loan, administered largely through the Bretton Woods Institution, are non-commercial long-term loans at substantially low rates of interest. Eligibility for such ‘soft’ loans is based on country economic status/progress. Usually negotiated between the loan agency and the concerned ministries for a specific programme and with funds flowing through the national budget (albeit earmarked for programme activities), such external assistance does, in theory, allow country ‘ownership’. Donor assistance in the form of grants traditionally took the form earmarked project funding, restricted to specific activities and implemented by the donor alone or in collaboration with the government, depending on national procedures. More recently, two new options are being used by donors to promote aid harmonisation and alignment in support of the overall national health strategies. Basket funding is a joint funding mechanism that pools donor contributions and provides un-earmarked funds for implementing planned national health strategies (usually developed in consultation with donors). Through general budget support, donor funds for health are released to ministries of finance and allow them the ultimate decision vis-à-vis actual allocation. For health, this means such funding in not necessarily secure for health activities. For national budget and macroeconomic planning, given experiences with volatility in donor contributions particularly during global economic downturns, this brings in elements of unpredictability and instability. Overall, external assistance may be effective for filling short/medium term funding gaps. For sustainable financing for health, this must in the long run depend primarily on domestic resources.

Development assistance, including loans and grants, contribute a small percentage of India’s expenditure on the health sector and has never been more than 1–3% of the total public health expenditure. The overall foreign assistance to India in 1999 was 0.4% of GDP and per capita Overseas Development Assistance (ODA) was US$1.6 in 1998 as against an average of US$ 9 for developing countries. Of this, the share of health in the total assistance was 6.7%. In India, at present, assistance from only a few countries is accepted to be channeled through the Government. Other donors are requested to direct their contributions through UN agencies and non-governmental organizations.

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Recent years have also seen the emergence of funding agencies that are not governments or part of the UN system. Important among these are the Global Alliance for Vaccine Initiative (GAVI), Global Fund for AIDS, TB and Malaria (GFATM) and the Bill and Melinda Gates Foundation, among others. These agencies could be expected to further influence the development assistance scenario in the medium term.

Provider PaymentsThe objectives in purchasing are to assure the purchase of health services is strategic and both allocatively and technically efficient (for whom to buy, what services to buy, from who to buy and how to pay). Provider payments may be made to individuals or at facility level and, these may be prospective or retrospective The key issues are that purchasing is performance-based payments to promote quality and efficiency, equity and social protection, allocative efficiency. Provider payments mechanisms are the channels through which payments are transferred from the purchaser of care to the service provider. For health financing, they are an important part of the overall strategy to impact equity and efficiency. They have been used very successfully in Cambodia to increase access to hospital care for the poor (1). In India provider payment mechanism has been used under the Chiranjeevi scheme in Gujarat. For more details http://gujhealth. gov. in/Chiranjeevi%20Yojana/M_index. htm.

Mapping Resource Flows in National Health Systems through National Health Accounts (NHA)Major financing reforms in the health sector concern securing sustainable financing for health care. Regular updates of NHA provide useful insights to governments as to what their further options are, or as to the level of public and private expenditure, as well as to modifying the allocation of these expenditures.

NHA provides a systematic, consistent, comprehensive information for any given year all the resources that flow through the country’s health system over time and across countries both in absolute and relative terms. Time series information permits the use of NHA as a standard management tool for situation analysis, planning, monitoring and evaluation purposes. NHA are designed to capture the full range of information contained in these resource flows and to reflect the main functions of health care financing : resource mobilisation and allocation, pooling and insurance, purchasing of care and the distribution of benefits. NHA enable stakeholders to identify policy concerns and to simulate the impact of solutions to the problems monitored. NHA address four basic sets of questions : where do resources come from, where do they go, what kinds of services and goods do they purchase and whom do they benefit ? In doing so, NHA captures total national health expenditure from all sources, public and private. NHA are a standard set of tables showing and describing the financial flows of health system. They are presented in two-way tables (matrix format) and the tables are interconnected. The tables provide key indicators to policymakers as well as researchers to diagnose the financial health of the health system. It shows the flow of financing from a source of funding to a particular use, to a user of that expenditure or to beneficiaries following a standard classification of health expenditure. Six dimensions

are considered :

Financing sources : Defined as resources for health goods and services, whether from tax-based, social security, other private entities such as firms, NGOs, households or other entities.

Financing agents : Defined as institutions receiving and managing funds from financing sources to pay for or purchase health goods and services, including social security schemes, ministries of health, medical private insurance, NGOs and firms.

Providers : Defined as entities that receive financial resources and use those resources to produce health goods and services, include public and private hospitals, clinics, nursing homes, community health centres, private practitioners etc.

Functions : Defined as the categories of goods and services consumed, include inpatient services, ambulatory services, public health interventions, etc. Health related functions, part of the total, refer to investment, training and R&D.Cost of Factors of Production (often referred to as “line items”) : Defined as the type of resources allocated to health care. It includes variables such as labour, drugs and pharmaceuticals, medical equipment etc.

Beneficiaries : Defined through distributional tables in which the value of goods and services produced are classified according to : geographic boundaries, demographic characteristics, economic strata and disease categories/interventions.

For more details a good reference is ‘Guide to Producing National Health Accounts : With special applications to low and middle income countries, WB, WHO and USAID, 2003. Link- http : //www. who. int/nha/docs/English_PG. pdf.

In India the work on National Health Accounts is underway, The MOHFW, GOI in collaboration with WHO India Country office has brought out the NHA for 2001-02 which is available at link- http : //mohfw. nic. in/NHA%202001-02. pdf.

Health Financing Issues in IndiaAs seen from above public health financing is very low as a ratio to GDP, total health expenditure and per capita expenditure. Seventy percent of public spending is by the states where a major part of it is on salary and administration. Eighty percent of all health spending is from out-of-pocket at the point of service use. More than forty percent of the people hospitalized borrow money / sell assets to cover expenses. A quarter of those hospitalized fall below the poverty line because of high costs. Only around four to six percent of people in India have some form of health insurance coverage. Health financing policy questions broadly would be : Are we investing enough in health? Is there a minimum efficient level of spending? What would be “optimum” investment by public funding? Do external funds help? What amount and how to use? What are the opportunity costs of investing more for health? Is the financial risk protection feasible? If so, how? Can user charges play a useful role? Is there a role for community-based financing?

SummaryThe way a health system is financed is a key determinant of population health and well-being. There is no single answer to the question of how to finance health systems. Health policy

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and financing policy are inseparable because financing policy determines who has access to basic health care, how much is available, who controls the funds and how they are used. While cost-effective responses to preventable and communicable morbidity and mortality, there is a growing challenge from high-cost non-communicable and ‘new’ diseases. The combination of upward pressure on costs and limitations on the ability of governments to increase spending forces countries to consider reforms to the way that their health systems are financed. Like all countries in the world, India too faces difficult challenges and choices in financing its health systems. India has a mixed form of financing health care. The total health expenditure in India for the year 2001-02 was Rs 1,057,341 million, which accounted for 4.6 percent of its GDP. Of the total expenditure, 20.3 percent was public / government expenditure, 77.4 percent was private expenditure and remaining 2.3 percent external support. There are three basic functions of a health financing system; Revenue collection, Pooling and Purchasing. Broadly, there are various options and mechanisms for financing the health care services. Out of Pocket Payments is the simplest form of health care financing. In India, this is the most common form of financing health care. The main financer of health services in India is the individual household. They meet 72% of the total health care costs by paying out of pocket at the time of service. In most high income countries, only about 5 – 10% of households have to pay OOP payments and these are usually in the form of pre/co-payments to contributory financial protection schemes e.g. social health insurance. In middle income and low income countries, the proportion increases to about 25 - 50% of households. Governments collect General Taxes, both direct and indirect, which is allocated to various sectors including the health sector. General revenues are considered to be the most equitable means for health financing. Government health services are usually financed general revenue sources e.g. in India, most of the government health services are financed from this budgetary allocation. The Government in India in its National Health Policy 2002 had suggested that the allocation to health be raised to 2-3%. Insurance is the most complex mechanism of financing health care. The revenue is generated either by individuals paying a premium or by employers contributing towards their employees or even the government paying on behalf of the poor. Health insurance could be an alternative health financing mechanisms, however, factors on both demand side and supply side coupled with high administrative costs limit the smooth functioning of the market for insurance in health. Protection from the real cost of ill-health may make individuals less risk averse, causing them to neglect precautionary/ preventative measures. With insurance, excess demand can be supplier- induced as well -- the provider has fuller information on health status than the patient and could used this asymmetry in information to over-prescribe services covered under the insurance plan. There are various types of health insurance namely, Indemnity insurance, Social Health Insurance (SHI), Private Health Insurance and Community Health Insurance. The Employees State Insurance Scheme (ESIS) is a social security system which provides both cash and medical benefits. All workers and their dependent relatives are eligible for the benefits. Central Government Health Scheme (CGHS) was introduced in 1954 as a contributory health scheme

to provide comprehensive medical care to the central government employees and their families. The benefit package includes both outpatient care and hospitalisation. Private health insurance emerges from voluntary actions in a market where buyers are willing to pay premium to insurance companies that; pools people with similar risks and insure them for health expenses. Private health insurance in India is usually associated with the “Mediclaim” policy. With the introduction of Third Party Administrators (TPAs), the reimbursement policy has changed into a ‘cashless’ policy, where the TPA reimburses the hospitals and the entire treatment is cashless for the patient. Community health insurance is mostly not-for-profit prepayment plans for health care, with community control and voluntary or compulsory membership, care is generally provided through NGO or private facilities. Experience indicates that community health financing has been most successful where this has been associated with income generation activities. In India, there is very little penetration of health insurance in the country. Most of those insured are in the formal sector and have security in terms of insurance policies as well as steady incomes. There are two main forms of external contributions for development: loans and grants. Loan, administered largely through the Bretton Woods Institution, are non-commercial long-term loans at substantially low rates of interest. Development assistance, including loans and grants, contribute a small percentage of India’s expenditure on the health sector and has never been more than 1–3% of the total public health expenditure. Recent years have also seen the emergence of funding agencies that are not governments or part of the UN system. Regular updates of National Health Accounts (NHA) provide useful insights to governments as to what their further options are, or as to the level of public and private expenditure, as well as to modifying the allocation of these expenditures. NHA address four basic sets of questions : where do resources come from, where do they go, what kinds of services and goods do they purchase and whom do they benefit? The flow of financing from a source of funding to a particular use, to a user of that expenditure or to beneficiaries following a standard classification of health expenditure. Six dimensions are considered : Financing sources, Financing agents, Providers, Functions, Cost of Factors of Production and Beneficiaries. Health financing policy questions broadly would be like Are we investing enough in health and Is there a minimum efficient level of spending.

Study ExercisesMCQs1. The most common form of financing health care in India

is (a) Provider Payment (b) General Tax Revenue (c) Out of Pocket Payment (d) External Finance.

2. What percentage of hospitalised patients in India have been impoverished because of high medical costs (a) 25% (b) 10% (c) 50% (d) 35%.

3. The National Rural Health Mission (NRHM) has been formed with a view to increasing the expenditure in the health sector from a current 0.9% of’ GDP to ____over the next five years (a)1% (b) 2% (c) 3%(d) 4%.

4. The most complex mechanism of financing health care is (a) Provider Payment (b) General Tax Revenue (c) External Finance (d) Insurance.

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5. Central Government Health Scheme was introduced in the year (a) 1952 (b) 1954 (c) 1955 (d) 1957.

6. Penetration of health insurance in India is in the range of (a) 3-8% (b) 9-15% (c) 16-20% (d) 25-40%.

Answers : (1) c; (2) a (3) b; (4) d; (5) b; (6) a.

Further Suggested Reading http : //www. who. int/health_financing/mechanisms/en/1. Achieving universal health coverage : developing the health financing 2. system [pdf 337kb, link-http : //www. ho. int/health_financing/documents/pb_e_05_1-universal_coverage. pdf

Health Financing Revisted : Gottret, Schieber George, The World Bank, 2006 3. Link-http : //siteresources. worldbank. org/INTHSD/Resources/topics/Health-Financing/HFRFull. pdf Better Health Systems for India’s Poor, Preker, Alexander S. ; Peters, David 4. H.; Yazbeck, Abdo S. ; Sharma, Rashmi R. ; Ramana, G. N. V. ; Pritchett, Lant H.; Wagstaff, Adam Report of the National Commission on Macroeconomics and Health, NCMH, 5. MOHFW, 2005 link-http : //mohfw. nic. in/reports_on_ncmh. htm Bulletin of the World Health Organization, Special Theme : Health Financing, 6. Volume, 86, Number, 11, November, 817-908 http : //www. who. int/bulletin/volumes/86/11/en/index. html

82 Trade and Public Health Kumar K M Gopa, Syam Nirmalya

In the recent times the impact of trade on public health has come under sharp attention of governments, policy makers, academia and civil society. A few explanations can be given for this growing interest in trade and public health. During the last part of 20th century most countries shifted their development strategy from self-sufficiency to export oriented growth strategy. This was then complemented with the establishment of world Trade Organization (WTO) and a web of Free Trade Agreements (FTA) with developed countries. The underline rationale of this shift towards export oriented growth strategy was that growing trade would help countries to achieve over all development including alleviation of poverty. As a result most of the countries made a series of policy change to facilitate gains from international trade. However, these policy shifts were not accepted without criticism because much of these policy changes were aiming at increasing competing capacity of the manufacturers within a country. As a result, policy changes were introduced to many countries to liberalize labour markets and environmental regulations. These changes constituted vast changes in the public health scenario of many countries especially developing countries.

However, the most important issue with regard to trade and public health is the loss of policy space of developing country government related to public health. This erosion of policy space is the result of a set of international trade agreements regulating international trade and trade related subject matters.

International Trade Regime International trade regime is regulated through various institutions and international agreements. However, the most important institution and agreement relevant the discussion here is WTO and the agreement establishing WTO. Another set of relevant international trade agreements are FTA entered

between developed and developing countries. The first attempt to establish an international trade agreement was in 1948 to establish and international trade organization. However, the organization did not get establish mainly due to the internal resistance from the USA. However, an ad hoc arrangement known as General Agreement on Trade Tariff (GATT) was established and it continued to function till 1994. In 1995 GATT was replaced by WTO. The agreement establishing WTO contains a set of international agreements regulating specific aspects of trade. Two of these agreements deal with intellectual property protection and trade in services. These agreements reduces the policy space of countries with regard to access to medicines and access to health services. Since these agreements are part of the agreement establishing WTO, member countries cannot be members of WTO without accepting these agreements. Similarly, member countries are not allowed to make any reservation in the provisions of these agreements. As a result, all WTO members are to accept these agreements in its entirety. However, these agreements provide certain transition periods for developing countries and least developing countries to full comply with this agreements.

However, free trade agreements between developed and developing countries forces developing countries to undertake more commitments than WTO agreements in areas of intellectual property and trade in services. As a result, developing countries are on the verge of loosing the existing policy space in those areas. As mentioned earlier, the trade itself has the potential to impact the people life negatively as well as positively. However, the following paragraphs discuss the impact of intellectual property provisions and services on public health.

Intellectual Property RightsThe term intellectual property rights generally refer to a set of exclusive rights granted to the owner of intellectual property. Generally speaking, intellectual property refers to the extension, of property rights to intangible assets including the intellectual efforts like invention. There are nearly seven types of intellectual property rights viz. patents, trademark, copyrights, industrial designs, plant varieties protection, trade secrets and geographical indications. International intellectual

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protection, recognise importation as part of exclusive rights of the patent holder, reversal of burden of proof in the case of process patent infringement proceedings, certain procedural regulation on the granting of compulsory license and exclusive marketing rights during the transitional period. However, TRIPS provides a ten-year transitional period (1-1-1995-31-12-2004) for developing countries like India to fully comply with TRIPS patent regime. Further, TRIPS permits a three-stage time frame (1995, 2000 and 2005) for compliance. Patents especially product patents create monopoly and eradicate competition. Patent monopoly often abused by the patent holder and fixes a higher price for the patented medicines. Hence, patents on drugs compromise the accessibility and availability of medicines, two important components of right to health. Today, there is ample evidence to show how patents adversely affect the accessibility and availability of medicines. The main task before lawmakers during the implementation of TRIPS patent regime is to provide strong public interest provisions to curb the abuse of patent monopoly. Hence, the approach to the implementation of TRIPS is to place provisions to ensure accessibility of medicines and not to strengthen patent protection. In other words, the task is how can WTO member country implement TRIPS agreement without compromising the policy objective ensuring access to affordable medicines.

Question often asked is whether TRIPS permits use of public interest provisions to safeguard accessibility and availability of medicines in the product patent era. The answer is that TRIPS does recognise such approach. Even, though product patent per se creates barriers to access to affordable medicines the damage can be minimise to certain extent by incorporating the flexibility available within the TRIPS in the domestic legislation. The domestic legislation should incorporate the flexibilities to the maximum extent. The following paragraphs explain the nature of TRIPS obligation and the flexibility available within the TRIPS.

The Preamble of TRIPS states that measures and procedures to enforce intellectual property rights should not themselves become barriers to legitimate trade. Further, the Preamble recognises the underlying public policy objectives of national systems for the protection of intellectual property, including developmental and technological objectives. Hence, the implementation of TRIPS should not undermine the developmental and technological objectives including public health goals of the implementing country. In other words, it states that under TRIPS protection of intellectual property is not a an end itself but a means to achieve developmental goals.

According to Article 1 of TRIPS, members “shall not be obliged to, implement in their domestic law more extensive protection than required by this Agreement”. Thus, there is no obligation under TRIPS to provide extra protection to any intellectual property rights other than what is mentioned in the TRIPS Agreement. Further, TRIPS permits states to “determine the appropriate method” to implement the provisions of the TRIPS Agreement within their legal system. As a result, it is up to each state to decide the manner in which it should implement TRIPS Obligations. India along with other developing countries stated in their submission to TRIPS Council on 29 June 2001 (IP/C/W/296) states : “ … more extensive protection in national

property regime is governed through a series of international agreements regulating various procedural and substantial aspects of intellectual property rights. Till the conclusion of Agreement on trade related aspects of Intellectual Property Rights (TRIPS), these international agreements did not put minimum level of protection. In other words, these IP agreements gave member countries sufficient policy space to determine the level of intellectual property protection.

TRIPS is one of the most controversial agreements administered under the World Trade Organisation’s (WTO) frame work because it took away the freedom of member countries to determine the level of intellectual property protection. It prescribes a universal minimum standard of protection to all types of intellectual properties irrespective of member countries developmental needs. This universal minimum standard put an end to hitherto freedom of determining the level of intellectual property protection in member countries. In other words, every member country is to offer a minimum level of all types of intellectual property. The most controversial provisions TRIPS are related to the patent protection. TRIPS patent regime resulted in the denial of access to medicine to the people in developing and least developing countries.

Often monopoly results in abuse of monopoly position and extracts high prices from the consumer. Patents especially product patents create a statutory monopoly for a limited number of years and increases the chance of abuse of patents. This statutory monopoly will have undesired consequence on vital sectors especially in the health sector because pharmaceutical industry relay heavily on the patents to market their product using the monopoly rights provided by the patents. For instance, till 2000 anti-retro viral (ARV) drugs for the treatment of HIV/AIDS were not affordable to people due it the exorbitant price charged by the multinational pharmaceutical companies. The price of first line ARV drugs used to be USD 10,000-12, 000 per patient per year (PPY). In 2001, the Indian pharmaceutical companies using the advantage of absence of product patent protection in India at that time introduced the cheap generic version of first line ARV drugs to USD 350 PPY. This generated competition in the market and reduced the price of first line ARV drugs especially price of first line ARV drugs for bulk procurement. Currently various governments and international agencies are procuring first line ARV drugs at USD 132 PPY. After the introduction of product patent protection, Indian pharmaceutical companies cannot produce the generic version of new drugs because most of the new drugs are patent protected. Therefore, the product patent protection eliminates the possibility of availability of affordable generic drugs in the market. Hence, countries need to take utmost care while framing their patent laws to address the bad effects of patents especially to facilitate access to medicines.

Nature of TRIPS ObligationAs mentioned above, TRIPS prescribes a universal minimum standard to different forms of intellectual property viz. Trademarks, designs, Copyrights, Geographical Indications, Topography of Integrated circuits, patents, plant varieties, trade secrets etc. Regarding patents it obligates member countries to provide the following : compulsory product patents for pharmaceuticals and agro-chemicals, 20 years duration of

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legislation than is required by the TRIPS Agreement may result in limitations for the implementation of health policies. We consider that Members should be free to implement the TRIPS Agreement in ways that best accommodate the protection of health policies in national legislation” Hence, there is no need for India country to implement provisions which goes beyond TRIPS patent regime.

The objective of TRIPS mentioned in Article 7 states that “the protection and enforcement of intellectual property rights should contribute… to the mutual advantage of producers and users of technological knowledge and in a manner conducive to social and economic welfare…”. On objectives, India’s submission states : “ …patent rights should be exercised coherently with the objectives of mutual advantage of patent holders and the users of patented medicines, in a manner conducive to social and economic welfare and to balance of rights and obligations. Where confronted with specific situations where the patent rights over medicines are not exercised in a way that meets the objectives of Article 7, Members may take measurers to ensure that they will be achieved…”. Thus, the submission put the question of access above the patent rights and assert the right to take measures to achieve the objectives of Article 7.

Further, principles of implementation under Article 8 states “members may, in formulating or amending their national laws and regulations, adopt measures necessary to protect public health and nutrition and to promote the public interest in sectors of vital importance to their socio-economic and technological development…”. According to the submission “any interpretation of the provisions of the Agreement should take into account the principles set forth in Article 8. The reading of such provision should confirm that nothing in the TRIPS Agreements will prevent Members from adopting measures to protect public health, as well as from pursuing the over-arching policies defined in Article 8”. Thus, the domestic legislation should strike a balance between public and private rights and the rights of patentee should not be at the cost of public health concerns.

In 2001, WTO Ministerial Conference in Doha endorsed the same approach for the implementation of TRIPS patent provisions at the domestic level by adopting the Doha Declaration Public Health and the TRIPS Agreement (Doha Declaration). According to Doha Declaration “…TRIPS Agreement does not and should not prevent members from taking measures to protect public health. Accordingly, while reiterating our commitment to the TRIPS Agreement, we affirm that the Agreement can and should be interpreted and implemented in a manner supportive of WTO Member’s right to protect public health and, in particular, to promote the access to medicines for all”. Further, the Declaration reaffirms “the right of WTO Members to use, to the full, the provisions in the TRIPS Agreement, which provide flexibility for this purpose”. Hence, India has a legal right to interpret and implement the TRIPS Agreement to promote access to drugs.

Further, Doha Declaration explicitly recognises the following flexibilities viz. using the customary rules of interpretations of public international law and the interpretation of TRIPS provisions in the light of objectives and principles, right to grant compulsory license and freedom to determine the grounds

of granting compulsory license, right to determine what circumstances constitute a national emergency, freedom to adopt suitable exhaustion regime. Further, there is a flexibility to determine the scope of patentablity by providing suitable definitions three basic criteria viz. novelty, inventive step and industrial applications. Furthermore, flexibility also exists to define the subject matter of patents. For instance in the absence of a definition to microorganisms in TRIPS through a definition certain microorganisms can be excluded from patentability.

The general understanding on TRIPS is that obligations under TRIPS do not create any hierarchy of international obligations and therefore does not override obligations under other treaties. Therefore, TRIPS implementation should not compromise any of the rights guaranteed by any previous international treaty. India as a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), it cannot compromise the right to health (Article 12, ICESCR) and the right to enjoy the benefits of scientific progress and its applications (Article 15, ICESCR) while implementing TRIPS patent regime. The right to health also falls within Article 21 of the Indian Constitution (Vincent Panikurlangara v Union of India 1987 (2) SCC 165). The Supreme Court has recognised that Article 21 has to be interpreted in consonance with international treaties. Hence, the implementation of any provision in TRIPS should not result in the denial of any of the rights guaranteed under the ICESCR and the Constitution of India. In the absence of a contrary statute enforceability of ICESCR and the International Covenant on Civil and Political Rights (ICCPR) in India has been upheld by the Supreme Court through a number of judgements (Vishaka v State of Rajsthan (1997) 6 SCC 241).

Even though TRIPS per se is objectionable and need to be reviewed in the coming days to ensure accessibility and availability of drugs the flexibility within TRIPS provides some manoeuvring space to Members States to address the issue of access to drugs. According to Commission on Intellectual Property Rights (CIPR) “developing countries should adopt a pro-competitive strategy that, as one observer suggests, is tilted towards second comers rather than distant patentees. This is especially important in those areas of technology such as pharmaceuticals and agriculture where, as we have already considered, the cost of providing strong protection is likely to be greatest”.

Thus, the flexibilities available within the TRIPS offer some policy options for the developing countries to mitigate the adverse affects of product patent protection on the availability of affordable medicines. However, the intellectual property rights provisions within the FTAs between developed and developing countries eliminate the possibilities of TRIPS flexibilities. Most of the FTAs entered between USA with developing countries obligates developing countries to limit the scope of TRIPS flexibilities. For instance, US FTAs insists that patent protection should be extended to the new use of known substance. Further these FTAs limits the circumstances under which a country can use the compulsory licence or a government use of patented invention. These FTAs also insists for extension of patents beyond 20 years prescribed under TRIPS. Hence, IP provisions of FTAs goes beyond TRIPS patent regime and considerably restrict the policy space of developing countries.

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India and TRIPS ImplementationIndia, as a member of the WTO has an obligation under TRIPS to comply with its patent provisions. A TRIP provides three time frames for developing countries like India for its absolute compliance, with the patent regime in particular. The first dead line was in 1995 to introduce mail box protection and exclusive marketing rights (EMR). The second was in 2000 to comply with TRIPS provisions on duration of patent protection, compulsory license, extension of patent protection to micro organism etc. India amended its Patents Act in 1999 and 2002 (well beyond the dead line) to comply with these obligations. The third deadline was to introduce product patent protection for pharmaceuticals and agrochemicals by 1 January 2005. To meet the deadline, Government of India issued an Ordinance on 26 December, to amend Patents Act 1970. The Ordinance carried out 77 amendments to the Act. Later, the ordinance was replaced through an amendment Act passed by he parliament in March 2005.

Thus, countries like India gave importance to the question access to affordable medicines and survival of its generic industry over the protection of intellectual property while implementing the TRIPS Agreement. India has incorporated restricted approach to the scope of patentability. As a result, a known substance is not eligible for patent protection in India unless there is a significant improvement in India. Similarly, substance obtained from by a mere admixture resulting in the aggregation of properties is excluded from patent protection. Further, the Indian Patents Act provides strong provisions against abuse of patented invention. The Act contains compulsory license and government use provisions. For instance, a compulsory license can be granted if patented article is not available at an affordable price. Compulsory license allows a third party to use the patented without the authorisation of the patent holder. However, a compulsory license is issued by the patent office after examining the application for compulsory license. However, the critiques point out that compulsory licence provisions under the Patents Act, procedure wise, is cumbersome and therefore little use to curb the abuse of patents. Government use provisions allow government or its authorised agent to use the patent without the permission of patent holder. Patent Act also allows parallel importation, which allows third parties to import the patented article from any where in the world without the permission of the patent holder provided the product is introduced legally in that market. Patent Act contains the early working of patents in order to obtain the regulatory clearance. Hence, the generic companies can produce the patented drug during the life of the patent to obtain marketing approval. As a result, the generic companies can introduce the generic version immediately after the expiry of patent. Even though India implemented most of the TRIPS flexibilities in the Patents Act, it needs lot of fine tuning to use it as an effective tool to ensure access to affordable medicine under the product patent regime.

Trade in ServiceTraditionally, health services in most countries have been largely provided by the State. Healthcare services were seen as essentially public welfare services and were not regarded as commercial in nature. However, in many developing

countries, the public health system could not meet the demand for healthcare services. In this context, it was felt that private participation in health services might be the solution for meeting the demand for adequate healthcare services. The underlying assumption was that facilitating trade in healthcare services by liberalising healthcare services will not only increase the supply of healthcare services but will also provide a boost to the economic growth of the State, which in turn will lead to better standards of health in the country by enabling people to spend more on healthcare. A culmination of this logic was the push for liberalising health services. As a result, many developing countries started liberalising health services. Initially liberalisation of health services took place in two ways viz. autonomous liberalisation and liberalisation due to structural adjustment programmes under the instruction of the World Bank and the International Monetary Fund (IMF). Of late, countries entered into legally binding agreements to maintain the level of liberalisation through General Agreement in Trade and Service (GATS) and FTAs.

GATS attempts to establish a framework within the WTO for regulating international trade in services and it envisages the progressive liberalisation of all trade in services. To that end it locks in the level of liberalisation to which a State commits a particular service sector under the GATS. The current approach to GATS, negotiations involves a two-stage process wherein each Member makes specific requests on every sector to every other Member and every Member makes their offers on each sector. The GATS can be applied to all services including health services. In respect of liberalisation of health services under GATS, the WTO regards the current level of liberalisation as inadequate (1). Hence, liberalisation of health services within the framework of the GATS is a thrust area of current GATS negotiations.

However, there is a concern expressed by health policy analysts and the civil society as to the adverse implications of GATS disciplines on health services. The concern is that it may reduce the space available to governments to devise policies and regulations for the health sector, particularly with regard to access and affordability of health services (2). This is based on the belief that many public health measures may be deemed to be unnecessarily restrictive of trade in health services under GATS. This concern assumes significance in the light of the fact that the right to health is a human right.

Trade in Health ServicesHealth services have not been considered traditionally as a commercially tradable service. However, the traditional notion of health as non-commercial services has undergone a paradigm change. The growing potential for trade in health services is driven by various factors such as

Decline in public sector expenditure on health services and ●the rise of private sector participation in healthcare;Liberalisation of related sectors like insurance and ●telecommunications services;Increasing mobility of consumers and health service ●providers;Technological developments enabling cross-border delivery ●of health services (3).

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While the ultimate delivery of a health service necessarily involves physical contact between the health professionals like doctors and nurses with the patient, owing to technological developments the extent to which physical contact is required can be reduced significantly. For instance, a team of doctors in one country may seek the opinion of some specialist in another country through electronic exchange of medical data in real time without having the patient to visit that specialist in a foreign country. Such services are called telemedicine services. Similarly, a hospital can reduce its expenses of maintaining medical records by outsourcing the same to firms in other countries where the records can be maintained at lesser costs while their transcripts can be communicated back in real time to the concerned hospital whenever needed. The health sector comprises various kinds of health services including medical and dental service, hospital services, diagnostic services, nursing and midwifery services, medical education services, veterinary services and medical data processing services. Hospital services comprises not only services that include treatment of patients, these also include services like hospital management services that facilitate the treatment of patients.

However, while health services comprise a host of health related services, countries do not follow a uniform system of classification of such services. Services are usually classified in the GATS in accordance with the Services Sectoral Classification List of the WTO, which closely follows the UN Central Products Classification system (UNCPC), which provides a more detailed breakdown of the services that fall within each service sector. In scheduling their GATS commitments, Members are free to follow either the Services Sectoral Classification List or the UNCPC or their own system of classification. Hence, every Member’s commitment on a particular service sector has to be seen in the context of the system of classification that it follows. In terms of classification of services under GATS, nursing services and services of doctors are classified as professional services and not health services. Hence, many health related services do not fall within the health services. For instance, medical education services would be classified as education services and medical transcription services as data processing services under GATS.

Trade in health services involves 4 modes of services delivery.

For example, services like telemedicine and telediagnosis can be delivered through cross-border supply, health tourism can be facilitated through movement of patients, hospitals of one country may set up commercial presence in another and medical and paramedical professionals may move abroad to offer their services. Table - 1 illustrates the kinds of health and health related services that can be delivered in each mode.

It is necessary to examine the impact of trade in health services in each of the four modes on access of all to health services. A joint study by WHO and UNCTAD has examined this issue. The WHO has identified three policy objectives in terms of which the impact of liberalisation of health services may be measured viz. equitable access to health services, quality of health services and efficient allocation of resources for health services (4). Hence, the liberalisation of health services should not compromise any of the three policy objectives.

Issues of Concern In India the public sector provides health services through the central governments, state governments, municipal corporations and other local bodies. The private sector includes health services provided by charitable institutions, missions, trusts, non-governmental organisations (NGOs), etc. as well as clinics, nursing homes and hospitals providing such services for profit. The private sector has comprised the largest constituent of the country’s healthcare delivery system ever since India’s independence and has expanded rapidly since the 1980s even before the creation of the GATS. In 1990, 57.95 per cent of hospitals and 29.12 per cent hospital beds in India were in the private sector (5). According to the National Health Accounts India (2001-02), 77.4 per cent of the total health expenditure in India was private expenditure while only 20.3 per cent was government expenditure, while the total health expenditure accounted for only 4.6 per cent of the GDP. However, there is a strong concentration of bed occupancy in the public health sector at a ratio of about 62 per cent(6). While developed countries like USA, Germany, France, Canada and UK spent from about 7 to 14 per cent of their GDP on health, their government’s share of this expenditure was in the range of 44 to 84 per cent (7). This clearly shows that even in developed countries, the government has a substantial share in the expenditure on

Table - 1

Mode of delivery of the Service Kind of service delivered

Cross-border service (mode 1)

Shipment of samples, diagnosis, clinical consultation via traditional mail channels. Electronic delivery of health services like telemedicine, telesurgery, telediagnostic services; medical back office services, medical transcription services and online medical education services.

Consumption abroad (mode 2)Medical tourism for super specialty medical services and alternative systems of healthcare.

Commercial presence (mode 3)Establishment of super specialty hospitals and clinics, diagnostic and treatment centres in collaboration between domestic and foreign health services providers, health insurance services and hospital management services.

Movement of natural persons (mode 4) Services of doctors, surgeons, nurses and midwives in foreign countries. Source : Rupa Chanda, ‘Liberalizing Trade in HealthServices : Issues and Concerns for India’, presentation made at the National Workshop on Health Services Liberalisation under WTO / GATS - Whither and How?, organised by the Ministry of Health and Family Welfare and the WHO India Office, 15 Feb 2006.

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health sector and this factor certainly helps in maintaining equity in access to healthcare in this sector. Hence, a further liberalization without addressing equity in access to healthcare would worsen the situation.

There is evidence of a strong concentration of hospitals in India in economically developed areas including a strong concentration in economically developed urban areas (8). From 1991 to May 2001 there have been 62 cases of approval of foreign investments in hospitals or diagnostic centres in India. An overwhelming majority of these investments are concentrated in urban areas with the most investments being in Chennai, Delhi and Kolkata (9).

Noting the growing presence of super-specialty private hospitals in India established with foreign collaboration and India’s emergence as a hub for medical tourism, the report of the National Commission on Macroeconomics and Health (NCMH) has observed that this ‘… will increase the overall cost of healthcare in the country and generate pressures for increased budgetary allocations for government hospitals to stay competitive. ’ On the basis of a survey of the health sector, the report draws the following conclusions :

The resources in the health sector are distributed unevenly ●with 88 per cent concentration of resources in towns;75 per cent of specialists and 85 per cent of technology is ●in the private sector;49 per cent of beds are in the private sector with an ●occupancy ratio of 44 per cent while the public sector has an occupancy ratio of 62 per cent;There is an acute shortage of human resources in the health ●sector with an average of 0.49 doctors and 0.79 nurses per 1000 people while the global norm is 2.25 per 1000 people. This shortage is further compounded in rural areas with about two-thirds concentration of health professionals in urban centres;75 per cent service delivery for dental health, mental ●health, orthopaedics, vascular and cancer diseases are provided by the private sector (10).

Thus, while there is a severe shortfall in the availability of doctors and nurses in proportion to the population, most of the human resource is concentrated in the private sector, which is primarily based in urban centres. On the other hand the understaffed public sector with less resource has a higher occupancy ratio than the private sector. Therefore, the growth of the private sector with foreign collaboration has not reduced the load on the public sector. Indeed while the economy was growing at about 8 per cent in 2005, the Infant Mortality Rate (IMR), considered, as the most important indicator of how the resources are distributed for health, in India was 60 per thousand live births (11). The NCMH report also shows that there is already a two-tier system with internal and external brain drain is exiting in India. The following discussion examines how far the existing regulatory mechanism addresses the concerns on health service liberalisation.

Trade and Health : Human Rights ImplicationsThe issue of impact of liberalisation on access to health services including access to health medicines should be seen from a human rights perspective. Multilateral trade agreements adopt

a commercial approach towards trade issues which reduces the policy making space for states. Rights based approach to trade liberalisation the promotion, protection and fulfilment of human rights as an integral and fundamental objective of trade liberalisation, which seeks to make the States primarily responsible under international human rights law for ensuring that human rights are not compromised in the process of trade liberalisation.

The human rights based approach to trade liberalisation regards certain goods and services that are essential for leading a life in dignity as entitlements, which must be accorded to all. In accordance with this approach, the international community has been examining the possible ways of ensuring the availability of these entitlements for all peoples through the process of trade liberalisation.

The UN Sub-Commission on the Promotion and Protection of Human Rights has examined the relationship between the liberalisation of trade in services and the enjoyment of human rights including the right to health. The right of everyone to the enjoyment of the highest attainable standard of physical and mental health is recognised in Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR). To achieve the full realisation of this right States have the responsibility to create conditions that would ensure to everyone medical service and medical attention in the event of sickness (12).

The content of the right to health has been explained in general comment no.14 of the Committee on Economic, Social and Cultural Rights (CESCR). Accordingly, the essential elements of the right to health are :

The availability of a functioning public health system and ●health-care facilities including hospitals, clinics, trained medical professionals and essential drugs. Universal access to health services in both physical as ●well as economic terms. Thus, there should not be an over-promotion of investments in expensive curative health services instead of primary and preventive healthcare services which benefits a larger section of the population. The State must ensure the quality of health services (13). ●

Besides the UN, the right to health as a fundamental human right has also been recognised by the Alma-Ata Declaration of the International Conference on Primary Health Care. The Declaration had set the attainment by all people of the world a level of health suitable for leading a socially and economically productive life by the year 2000, as a main social target for governments, international organisations and the world community (14). Though it is evident that the timeline set by the Alma-Ata Declaration has been missed, the objectives set therein still remain valid and they should be observed in the process of liberalisation of health services.

Thus, in spite of TRIPS and GATS commitments on patent rights and liberalising health services or autonomous liberalisation of such services, all States are primarily responsible for creating and sustaining conditions that promote, protect and fulfill the access of all peoples to a functioning, affordable, accessible and high quality health service. This primary responsibility of States under international human rights law extends to the

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trade liberalising commitments that they negotiate in the WTO and other regional trading arrangements.

SummaryDuring the last part of 20th century most countries shifted their development strategy from self-sufficiency to export oriented growth strategy. Most important issue with regard to trade and public health is the loss of policy space of developing country government related to public health. The most important institution and agreement relevant the discussion here is WTO and the Agreement establishing WTO. The agreement establishing WTO contains a set of international agreements regulating specific aspects of trade. It reduces the policy space of countries with regard to access to medicines and access to health services. Developing countries are on the verge of loosing the existing policy space in those areas. The term intellectual property rights generally refer to a set of exclusive rights granted to the owner of intellectual property.

TRIPS is one of the most controversial agreements administered under the World Trade Organisation’s (WTO) frame work because it took away the freedom of member countries to determine the level of intellectual property protection. Patents especially product patents create a statutory monopoly for a limited number of years and increases the chance of abuse of patents. As mentioned above, TRIPS prescribes a universal minimum standard to different forms of intellectual property. Patent monopoly often abused by the patent holder and fixes a higher price for the patented medicines. Hence, patents on drugs compromise the accessibility and availability of medicines, two important components of right to health. The domestic legislation should incorporate the flexibilities to the maximum extent. The Preamble of TRIPS states that measures and procedures to enforce intellectual property rights should not themselves become barriers to legitimate trade. The domestic legislation should strike a balance between public and private rights and the rights of patentee should not be at the cost of public health concerns. India has a legal right to interpret and implement the TRIPS Agreement to promote access to drugs. TRIPS implementation should not compromise any of the rights guaranteed by any previous international treaty. Even though TRIPS per se is objectionable and need to be reviewed in the coming days to ensure accessibility and availability of drugs, the flexibility within TRIPS provides some manoeuvring space to Members States to address the issue of access to drugs. The flexibilities available within the TRIPS offer some policy options for the developing countries to mitigate the adverse affects of product patent protection on the availability of affordable medicines.

India, as a member of the WTO has an obligation under TRIPS to comply with its patent provisions. Countries like India gave importance to the question access to affordable medicines and survival of its generic industry over the protection of intellectual property while implementing the TRIPS Agreement. The generic companies can introduce the generic version immediately after the expiry of patent. In many developing countries, the public health system could not meet the demand for healthcare services. General Agreement in Trade and Service (GATS) attempts to establish a framework within

the WTO for regulating international trade in services and it envisages the progressive liberalisation of all trade in services. However, there is a concern expressed by health policy analysts and the civil society as to the adverse implications of GATS disciplines on health services. The traditional notion of health as non-commercial services has undergone a paradigm change. While the ultimate delivery of a health service necessarily involves physical contact between the health professionals like doctors and nurses with the patient, owing to technological developments the extent to which physical contact is required can be reduced significantly. Trade in health services involves 4 modes of services delivery. In India the public sector provides health services through the central governments, state governments, municipal corporations and other local bodies. Even in developed countries, the government has a substantial share in the expenditure on health sector. While there is a severe shortfall in the availability of doctors and nurses in proportion to the population, most of the human resource is concentrated in the private sector, which is primarily based in urban centres. The NCMH report also shows that there is already a two-tier system with internal and external brain drain is exiting in India. The following discussion examines how far the existing regulatory mechanism addresses the concerns on health service liberalisation. Multilateral trade agreements adopt a commercial approach towards trade issues which reduces the policy making space for states. The human rights based approach to trade liberalisation regards certain goods and services that are essential for leading a life in dignity as entitlements, which must be accorded to all. The content of the right to health has been explained in the Committee on Economic, Social and Cultural Rights (CESCR). In spite of TRIPS and GATS commitments on patent rights and liberalising health services or autonomous liberalisation of such services, all States are primarily responsible for creating and sustaining conditions that promote, protect and fulfill the access of all peoples to a functioning, affordable, accessible and high quality health service.

Study ExercisesMCQs1. The most important institution and agreement regulating

International trade regime at present is (a) Free Trade Agreements (FTA) (b) Doha Declaration (c) UN Central Products Classification system (UNCPC) (d) World Trade Organization (WTO)

2. The most controversial provisions TRIPS are related to (a) Patent protection (b) Trademark (c) Copyrights (d) Industrial designs

3. Members “shall not be obliged to, implement in their domestic law more extensive protection than required by this Agreement”. This is enshrined in which article of TRIPS ? (a) 1 (b) 2 (c) 3 (d) 4.

4. In 2001, WTO Ministerial Conference endorsed the same approach for the implementation of TRIPS patent provisions at the domestic level in (a) Johannesburg (b) New Delhi (c) Doha (d) New York

Answers : (1) d; (2) a; (3) a; (4) c.

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ReferencesWTO, Health and Social Services: Background Note by the Secretariat, 18 1. Sept 1998, paragraph 4, http://www.wto.org/english/tratop_e/serv_e/health_social_e/health_social_e.htm (visited 17 Aug 2006).Nick Drager and David P. Fidler, GATS and Health Related Services: Managing 2. Liberalization of Trade in Service from a Health Policy Perspective, (WHO, 2004).Rupa Chanda, ‘Trade in Health Services’, ICRIER Working Paper No.70, 3. November 2001.Orvill Adams and Colette Kinnon, ‘A Public Health Perspective’, in UNCTAD-4. WHO Joint Publication, International Trade in Health Services: A Development Perspective, UNCTAD/ITCD/TSB/5 – WHO/TFHE/98.1, Geneva, 1998, at 36.Sunil Nandraj and Ravi Duggal, Physical Standards in the Private Health 5. Sector, http://www.cehat.org/publications/pb10a53.htm (visited 22 July 2006).Government of India, Report of the National Commission on Macroeconomics 6. and Health, 2006, Ministry of Health and Family Welfare.

Government of India, National Health Accounts: India, 2001-02, (New Delhi: 7. Ministry of Health and Family Welfare, 2005)Sunil Nandraj and Ravi Duggal, Physical Standards in the Private Health 8. Sector, http://www.cehat.org/publications/pb10a53.htm(visited 22 July 06).Communication received from Mr. Ujjwal Kumar, WHO India office, 25 May 9. 2006, on file with authors.Government of India, Report of the National Commission on Macroeconomics 10. and Health, 2006, Ministry of Health and Family Welfare.Samir K. Mondal and Vineeta Kanwal, Addressing Key issues in the Light 11. of Structural Adjustment Programme (SAP) in Health and Family Welfare Sector in India, Working Paper, National Council of Applied Economic Research, March 2006UN Sub-Commission on the Promotion and Protection of Human Rights, 12. Liberalization of Trade in Services and Human Rights: Report of the High Commissioner, E/CN.4/Sub.2/2002/9, 25 June 2002, paragraph 29.International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 13. Sept 1978, Declaration of Alma-Ata.

83 International Health

Rajesh Kunwar

The fact that the world is but a global village and health and disease can not be limited by the boundaries of the nations, was recognized long ago. Way back in 1377, the first recorded quarantine legislation was promulgated for prevention of transshipment of rodents to Venice from foreign ports. The International Sanitary Conference, convened in Paris in 1851, was the first step towards seeking international cooperation in prevention of communicable diseases with epidemic potentials. This conference, in spite of not succeeding in framing the uniform code for quarantine, gave rise to many such conferences in quick succession which in turn led to the establishment of Office International d’ Hygiene Publique (OIHP) in 1907 – a precursor of League of Nations and World Health Organization (WHO).

The term “International Health” first appeared sometime in early twentieth century and became well known following the establishment of International Health Commission in 1913 in United States. The commission played a vital role in the opening of first school of public health in 1917 in the United States at John Hopkins University but it was only in 1960 that the international health division was established in the school. Since then the activities in the field of international health has increased by leaps and bounds and has involved many governmental, inter-governmental and non- governmental organizations.

Definition of International HealthSimply said international health means public health with an international dimension. The predominant notion refers to the interactions taking place in the field of health at international level. This not only includes the risks and hazards to health

faced by individuals and populations owing to the mobility of health hazards and people but also includes various measures taken for the promotion, protection, prevention and restoration of health. It uses tools of public health, takes into account the information received from other disciplines and addresses questions that transcend the frontiers of a country. The term ‘international health’ has been defined as a field of research and intervention embracing the international dimensions of health, disease process and care systems.

While research refers to the analysis of health determinants and the health states of the individuals and populations, the intervention refers to the actions taken at economic, political and administrative levels. Broadly speaking, international health is a systematic comparison of the factors that affect the health of all human populations.

However, international health means differently to different people e.g. for a public health worker it means protection of population from illness, for an epidemiologist it means a study of distribution and control of diseases, for a clinician it means practice of medicine in a remote area, for an administrator it means organization and operation of health services, for an economist it means a study of health resource allocation and financing and for a politician it means controlling spheres of influences. The popular view, as shaped by media and perceived by masses, is that the international health deals with situations like tsunami, SARS or pandemic influenza, giving little importance to inequity in health sector globally or even the hard core issues of public health.

Contents of International HealthInternational health is seen as a conglomeration of various aspects of public health, as follows :

It uses principles of epidemiology while appreciating the ●root causes of ill health in the world in general and in defined populations in particular, with an aim of alleviating the global burden of diseases.

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It deals with psychosocial aspects while understanding the ●psychosocial effects of diseases or health related events on individuals, families and communities. Demographic aspects are important for understanding the ●composition of population segments in individual countries and of populations in different countries. Economic aspects come into play when it deals with ●public health expenditure and out of pocket expenditure on health, resource allocations and the cost of illness to individuals, families, communities and countries. It also dwells upon health system and governance while ●discussing the health systems of the countries, their health infrastructure and their governance and also of the health ministries and their interactions with other ministries which have a direct impact on the health. It also includes certain miscellaneous aspects like ●ethical issues, utilization of alternative medicine by various population segments, humanitarian response to disasters and emergencies and the participation of various governmental, non-governmental and private agencies.

Organizations Involved in International HealthA number of governmental, inter-governmental and non-governmental organizations are actively involved in International health. They can be classified as government sponsored international agencies and non-governmental organizations further subdivided into private voluntary organizations and philanthropic organizations. Among government sponsored international agencies are included several United Nations (UN) organizations of which World Health Organization (WHO) is the most important. A brief about some of these organizations are given in succeeding paragraphs.

World Health Organization (WHO)Following World War II and creation of intergovernmental organizations like United Nations (UN), a need of having an international health agency was felt by many of the countries who experienced the devastating after effects and were still reeling under colonial rule. Brazilian and Chinese delegations submitted a joint declaration to United Nations for inclusion of health in the charter of UN and when diplomats met, one of the things they discussed was setting up a global health organization. As a result the landmark international health conference was held in New York in Jun – Jul 1946. At this conference, all the 61 members approved the constitution of World Health organization (WHO) on 22 Jul 1946. This constitution, after many deliberations and ratifications, came into force on 7 April 1948 – a date we now celebrate every year as World Health Day.

Thus WHO became the United Nations’ specialized agency for Health with its headquarters in Geneva, Switzerland. It inherited the mandate and all the resources of its predecessor, the League of Nations and acts as a coordinating authority on international public health.

MissionIts objective, as set out in its Constitution, is the attainment by all peoples of the highest possible level of health. The Constitution defines health as a state of complete physical,

mental and social well-being and not merely the absence of disease or infirmity.

Role in Public HealthWHO fulfils its objectives through its core functions, which are:

(a) Leadership : Providing leadership on matters critical to health and engaging in partnerships where joint action is needed

(b) Setting standards : Setting norms and standards and promoting and monitoring their implementation

(c) Policy formulation : Articulating ethical and evidence-based policy options

(d) Capacity building : Providing technical support, catalysing change and building sustainable institutional capacity;

(e) Monitoring : Monitoring the health situation and assessing health trends

(f) Research : Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge.

OrganisationThe WHO has its Headquarters comprising of the world health assembly and the executive board, at Geneva and its regional offices for six regions covering all the member states, at six different places.

The World Health Assembly is the supreme decision-making body for WHO. It deals with the administration, finances and international policies ad programmes. It also elects the Director General of the WHO who is the chief technical and administrative officer of WHO. It meets each year in May in Geneva and is attended by delegations from all 193 Member States.

The Executive Board, which is like a cabinet, is composed of 34 members technically qualified in the field of health. Members are elected for three-year terms. The main Board meeting, at which the agenda for the forthcoming Health Assembly is agreed upon and resolutions are adopted for forwarding to the Health Assembly, is held in January, with a second shorter meeting in May, immediately after the Health Assembly, for more administrative matters. The main functions of the executive board is to give effect to the decisions and policies of world Health assembly and to facilitate its work.

In the year 1998, all the existing programmes were reduced to 35 departments grouped into nine clusters which are enumerated as follows : (a) Health system and community health(b) Communicable diseases(c) Non-communicable diseases(d) Sustainable development and healthy environments(e) Evidence and information for policy(f) Health technology and pharmaceuticals(g) External relations and governing bodies(h) Social change and mental health(i) General managementEach cluster was headed by an executive director who in turn had a high profile senior management and decision making

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team called a Cabinet. These cabinets carried out and monitored the projects assigned to them.

Regions : The six different regions of WHO and their headquarters are as given in Table - 1 :

Table - 1 : Regions of WHO

Regions Headquarters

The Americas Washington D. C. (U. S. A. )

Europe Copenhagen (Denmark)

Eastern Mediterranean Alexandria (Egypt)

Western Pacific Manila (Philippines)

South East Asia New Delhi (India)

Africa Harare (Zimbabwe)

Each regional organization is headed by a regional director who is assisted by administrative officers and technical officers. Representatives of the member states form the regional committee which meets once a year to review the ongoing health projects, their continuation and further development in their respective countries.

Activity Areas in India In India, WHO provides technical assistance and collaborates with the Government of India and major stakeholders in health development efforts. It assists notably in Policy Development; Capacity Building and Advocacy. Technical assistance to the Government is provided through the following Core Programme Clusters :

(a) Health system and community health : Reproductive Health and Research; Child and Adolescent Health; Gender and Women Health; Immunization; Nursing and Midwifery; Nutrition and AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy).

(b) Communicable diseases : Leprosy; Malaria; Filariasis; Tuberculosis; HIV/AIDS and International Health Regulations.

(c) Non-communicable diseases : Cardiovascular Diseases; Tobacco Control; Health Care for the Elderly; Prevention of Deafness; Prevention of Blindness; Health Promotion; Oral Health; Cancer; Non-Communicable Disease Risk Factors Surveillance and other Non-Communicable Diseases.

(d) Sustainable development and healthy environments: Chemical Safety; Emergency & Humanitarian Action; Food Safety; Health & Environment; Healthy Cities; Environmental Epidemiology and Water Sanitation.

(e) Evidence and information for policy : National Health Accounts; Policies; Medical Ethics; Information System; Burden of Diseases; World Health Survey.

(f) Health technology and pharmaceuticals : Essential Drugs and Medicines; Development of Vaccines.

(g) Social change and mental health : Mental Health and Substance Abuse; Disability, Injury Prevention and Rehabilitation.

(h) General management : Health Finance; Trade Agreements and Reform Issues.

Special ProgrammesWHO has also facilitated some special health programmes like National Polio Surveillance Programme, Revised National Tuberculosis Control Programme, 3 by 5 for HIV / AIDS, Leprosy Elimination, Roll Back Malaria, Tobacco Free Initiative, Lymphatic Filariasis and Health networking. WHO, in the recent past, has assisted the government of India in emergency and humanitarian action in Gujarat and Rajasthan, in the aftermath of the tsunami and for epidemic outbreaks like the Japanese Encephalitis. WHO is also working with the Ministry of Health in the pandemic preparedness plans for the Avian Influenza.

United Nations Children’s Fund (UNICEF)United Nations International Children’s Emergency Fund (UNICEF) was originally created to deal with the issue of child poverty in Europe after World War II. But it could gain official permanent status in the UN only in 1953, six years after its birth as United Nations Relief and Rehabilitation Agency (UNRRA). Over a period, it dropped the terms International and Emergency from its name, but because of the difficulty in pronunciation of UNCF it kept the acronym UNICEF. In 1961, UNICEF also included the rights of children to education and proper health care under the umbrella of its activity. Four years later, it was awarded the Nobel Peace Prize “for the promotion of brotherhood among nations. ”

Objectives “UNICEF identifies young child survival and development as the first right of the child. It advocates quality basic education for all children - girls and boys - with an emphasis on gender equality and eliminating disparities of all kinds.

Its priorities include promotion of breast feeding, immunization, growth monitoring, oral rehydration, education of girl child, child spacing and nutritional supplementation.

As the mandate of the organization is to protect a child’s right to survival and to ensure that children are given the basic right to an education, needs are analyzed primarily at a local level, assisted regionally by UNICEF and ultimately funded and administrated by UNICEF international.

Structure and FundingThe administrative and organizational headquarter of UNICEF is at New York City. Eight regional offices and 125 external offices permit UNICEF to carry out its role efficiently and provide cover to almost all children of the world. It is governed by an Executive Board made up of 36 members. Each of these members is elected for a three-year term. The election system is based on rotation, so as to take all countries into account. The Executive Director of UNICEF is nominated by the Secretary General of the UN.

UNICEF is funded exclusively by voluntary contributions. This comes through contributions from corporations, civil society organizations and more than 6 million individual donors worldwide.

UNICEF in IndiaUNICEF has been working in India since 1949 and today, it has a network of 13 state offices in the country. These enable

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the organization to focus attention on the poorest and most disadvantaged communities and to ensure that each child born in this vast and complex country gets the best start in life, thrives and develops to his or her full potential. It is currently implementing a $400 million programme from 2003 to 2007.

The milestones in the history of UNICEF’s work in India are as follows :

(a) 1949 : UNICEF begins working in India.

(b) 1967 : UNICEF’s association with GOI’s rural water programme provides emergency relief to tackle severe drought. Since then, the national water programme has expanded to provide access to protected sources of drinking water to 95% of India’s villages.

(c) 1975 : UNICEF supports piloting and launch of Integrated Child Development services (ICDS).

(d) 1985-86 : UNICEF supports launch of GOI’s Universal Immunization Programme (UIP).

(e) 1986 : UNICEF works with GOI to launch Oral Rehydration Therapy Programme for treatment of diarrhoea.

(f) 1996 : UNICEF supports launch of GOI’s Reproductive and Child Health (RCH) programme.

(g) 2000 : UNICEF partners with GOI to ensure eradication of guinea worm.

(h) 2004 : UNICEF joins Government of India’s (GOI) efforts to eradicate polio.

Besides this, UNICEF, within the context of National AIDS Control Plan III, also collaborates with the Government of India and other partners in four key areas which include primary prevention among young people, prevention of Parent-To-Child Transmission (PPTCT), paediatric HIV/AIDS and protection, care and support for affected children.

United Nations Educational, Scientific and Cultural Organization (UNESCO)UNESCO - the heir of the League of Nations’ International Commission on Intellectual Cooperation - was founded on 16 November 1945. Today it has 193 Member States and 6 Associate Members. The organizational headquarter is at Paris. It has over 50 field offices and many specialized institutes and centres throughout the world. The organization aims at promotion of international co-operation among its Member States in the fields of education, science, culture and communication.

Through its strategies and activities, UNESCO is actively pursuing the Millennium Development Goals, especially those aiming to : (a) halve the proportion of people living in extreme poverty in

developing countries by 2015 (b) achieve universal primary education in all countries by

2015(c) eliminate gender disparity in primary and secondary

education by 2005(d) help countries implement a national strategy for sustainable

development by 2005 to reverse current trends in the loss of environmental resources by 2015.

MissionThe mission of UNESCO is to contribute to sustainable human development and create the conditions for dialogue, based upon respect for commonly shared values and the dignity of each civilization and culture, through programmes and projects in UNESCO’s fields of competence - education, the natural and social sciences, culture and communication and information.

StructureThe day-to-day administration, governance, policy making and activities of UNESCO are carried out by the General Conference, the Executive Board and the Secretariat.

The General Conference consists of the representatives of member states. It meets every two years and is attended by representatives of member states, observers from non- member states, intergovernmental organizations and non-governmental organizations (NGOs). Each country has one vote, irrespective of its size or the extent of its contribution to the budget. The General Conference determines the policies and programmes and elects Members of the Executive Board. The working languages of the General Conference are Arabic, Chinese, English, French, Russian and Spanish.

The Executive Board, is responsible for the overall management of UNESCO. It meets twice a year and outlines the work of the General Conference and sees that its decisions are properly carried out. The functions and responsibilities of the Executive Board are derived primarily from the Constitution and from rules or directives laid down by the General Conference.

The Secretariat consists of the Director-General and his staff and is responsible for the day-to-day running of the organization. The Director-General is elected by the General Conference for a term of four-years. The Secretariat is divided into various administrative offices and five programme sectors viz. education, natural sciences, social and human sciences, culture and communication and information. These sectors reflect the organization’s major areas of focus.

UNESCO in IndiaIndia joined UNESCO on November 4, 1946. The Cluster Office in New Delhi covers Bangladesh, Bhutan, India, Maldives, Nepal and Sri Lanka and helps them to build their human and institutional capacities in diverse fields. It, as the Organization’s contribution towards the six Millennium Development Goals, has identified six broad areas for providing assistance and directing its activities. These are : (a) Universal Primary Education (b) Promoting gender equity and equality (c) Implementation of the new commitment to science (d) Protecting world’s cultural diversity (e) Equitable access to information and knowledge to all (f) Sustainable DevelopmentEducation is a top priority in India’s cooperation with UNESCO. The fourth UNESCO Regional Conference in Support of Global Literacy was held on 29 and 30 November 2007 in New Delhi.

India also participates in a variety of UNESCO activities related to cultural heritage and to intercultural dialogue. The Maitreya Temples (Ladakh, India) received the Award of Excellence in

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the 2007 UNESCO Asia-Pacific Heritage Awards for Culture Heritage Conservation.

The UNESCO project in Sikkim has been found to be successful. The project promotes community participation in developing tourism in the Central Asia/Himalayan region, by helping to generate employment for local people.

Food and Agriculture Organization (FAO)The FAO was founded in 1945. It is an intergovernmental organization with It’s headquarter at Rome. As of now, it has 174 Member Nations plus a member organization, the European Community. It is the largest specialized agency in the United Nations system and the lead agency for agriculture, forestry and rural development.

ActivitiesIts activities comprise four main areas:

(a) Putting information within reach : FAO serves as a knowledge network. It collects, analyses, interprets and disseminates information relating to nutrition, food, agriculture, forestry and fisheries. Through newsletters, reports and books, magazines and host dozens of electronic for a, it assists governments and planners to make rational decisions on planning, investment, marketing, research or training.

(b) Sharing policy expertise : FAO lends its years of experience to member countries in devising agricultural policy, supporting planning, drafting effective legislation and creating national strategies to achieve rural development and hunger alleviation goals.

(c) Providing a meeting place for nations : FAO provides a neutral forum where all nations - rich and poor, developing and developed - can meet to build a common understanding and to discuss and formulate policy on major food and agriculture issues.

(d) Bringing knowledge to the field : FAO provides the technical know - how and funds, only to a limited extent, for thousands of field projects throughout the world.

MissionFAO aims at achieving food security for all. Its efforts are directed to make sure that all people of the world have regular access to enough high-quality food and lead an active, healthy lives. Its mandate is to raise levels of nutrition, improve agricultural productivity, better the lives of rural populations and contribute to the growth of the world economy.

StructureFAO is governed by the Conference of Member Nations, which meets every two years to review the work carried out by the Organization. The Conference elects the Director-General and a Council of 49 Member Nations to act as an interim governing body. Members serve three-year on a rotation basis.

FAO currently has five regional offices, nine sub-regional offices, five liaison offices and 74 fully-fledged country offices in different parts of the world.

FAO is composed of eight departments viz. agriculture and consumer protection; economic and social department; fisheries and aquaculture; forestry; human, financial and physical resources; knowledge and communication; natural resource

management and environment and technical cooperation.

FAO in IndiaThe FAO, with its regional office at Bangkok, provides regular support to India in the field of Food Security and Nutrition. It’s current focus is mainly on plant production activities, forestry, fisheries, nutrition and food quality & safety. A special interests lies in the field of vulnerability mapping through the establishment of a Food Insecurity and Vulnerability Information and Mapping System (FIVIMS) and the preparation of a Nutrition Country Profile for India. In addition, under its Special Programme for Food Security, FAO supports the design of a large scale maize production scheme. Under its Technical Cooperation Programme (TCP), the various projects in India are as follows : (a) Transfer of technology for vegetative propagation of

walnuts in Jammu & Kashmir (b) Development of integrated plant nutrition systems

methodology (c) Training in sea safety development programmes (d) Greenhouse technology for floriculture (e) Food quality control

International Labour Organization (ILO)The ILO was founded in 1919 to improve the living and working conditions of the working population all over the world. In 1946, it became the first specialized agency of the UN. It has it’s headquarter at Geneva, Switzerland.

With 175 Members, ILO is unique in having a tripartite character i.e. at every level in the organization, governments with the two other social partners, namely the workers and employers jointly shape policies and programmes. This helps in setting minimum standards of basic labour rights : freedom of association, the right to organize, collective bargaining, abolition of forced labour, equality of opportunity and treatment and other standards addressing conditions across the entire spectrum of work-related issues. The overall purpose is to bring decent work and livelihoods, job-related security and better living standards to the people of both poor and rich countries.

ObjectivesThe objectives of ILO are : (a) To promote and realize standards and fundamental

principles and rights at work.(b) To create greater opportunities for women and men to

secure decent employment and income.(c) To enhance the coverage and effectiveness of social

protection for all.(d) To strengthen tripartism and social dialogue.Structure The administration and functioning of ILO is carried out by its three organs : (a) International Labour Conference, which is the General

Assembly of the ILO, meets every year in the month of June.

(b) Governing Body, which is the executive council of the ILO, meets three times in a year in the months of March, June and November.

(c) International Labour Office is the permanent secretariat.

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ILO in IndiaIndia is a founder member of ILO and has a branch office in New Delhi since 1929. The Branch Office became an Area Office of ILO in 1970. It coordinates and provides technical assistance to India and Bhutan in the field of rural labour, women workers, employment generation, occupational safety and health etc.

ILO’s interest in child labour, young persons and their problems is well known. In India, within a framework of the Child Labour (Prohibition and Regulations) Act, 1986 and through the National Policy on Child Labour, ILO has funded the preparation of certain local and industry specific projects. In two Kanor projects, viz. Child Labour Action and Support Programmes (CLASP) and International Programme on Elimination of Child Labour (IPEC), the ILO is playing a vital role.

The implementation of IPEC programmes in India has created a very positive impact towards understanding the problem of child labour and in highlighting the need for elimination of child labour. A major contribution of the IPEC programme in India is that it has generated a critical consciousness among all the 3 social partners for taking corrective measures to eliminate child labour.

United Nations Development Programme (UNDP)Founded in 1965, the UNDP is an executive board within the United Nations General Assembly. Its Administrator is the third highest ranking member of the United Nations after the United Nations Secretary-General and Deputy Secretary-General. It has it’s headquarter in New York City and country offices in 166 countries where it works with governments and local communities to help find solutions to global and national development challenges.

UNDP provides expert advice, training and grant support to developing and least developing countries (a) to meet developmental challenges (b) to develop local capacity and (c) to accomplish MDGs. It focuses on developmental challenges. It encourages the protection of human rights and the empowerment of women in all of its programmes. It also publishes an annual Human Development Report which critically analyze and present the developmental progress made by the countries of the world.

FunctionsUNDP focuses primarily on five developmental challenges :

(a) Democratic governance : UNDP supports existing democratic institutions by increasing dialogue, enhancing national debate and facilitating consensus on national governance programs. It also supports the transition to democracy by providing policy advice, technical assistance, increasing awareness and capacity building.

(b) Poverty reduction : UNDP works with governments, NGOs and local leaders to provide opportunities to impoverished people and improve their predicament. It assists governments to evolve strategies to combat poverty by linking poverty alleviation programmes to major national programmes and to find ways and means for economic opportunities.

(c) Crisis prevention and recovery : During disasters and armed conflicts UNDP assists governments in early recovery.

Recovery programs include disarmament, demobilization and reintegration of ex-combatants, programs to reintegrate displaced persons and restoration of basic services for countries recovering from warfare.

(d) Environment and Energy : As the poor are disproportionately affected by environmental degradation and lack of access to clean, affordable energy services, UNDP seeks to address environmental issues in order to improve developing countries’ abilities to develop sustainably.

(e) HIV/AIDS : UNDP works to help counties prevent further spreading of HIV/ AIDS and reduce its impact.

UNDP in India UNDP has been India’s partner in development since 1951. Some of its success stories are as under : (a) In 1980s, it supported the institution building and

technology transfer to apex scientific research institutions like the Council for Scientific and Industrial Research (CSIR) and the Indian Council for Agricultural Research (ICAR).

(b) In 1990s, UNDP launched a project on social sector strategy to enhance the incomes of the poor and disadvantaged people employed in leather and jute industries. Subsequently the project was extended to other sectors like textiles, fibres and handicrafts that employed people from these groups.

(c) In response to the Orissa cyclone and the Bhuj earthquake, UNDP launched a disaster mitigation and preparedness programme. The community–based disaster preparedness approach tried out by UNDP in Orissa following the 1999 super-cyclone has now been scaled up nationally in 169 multi-hazard prone districts in 17 states through the UNDP-Government of India Disaster Risk Management Programme.

(d) The model of poverty alleviation developed and piloted under the UNDP South Asia Poverty Alleviation Programme (SAPAP) in Andhra Pradesh successfully demonstrated the value of women’s unity and mobilisation for their social, economic and political empowerment.

(e) In Maharashtra, under the Community-based Pro-poor Initiatives (CBPPI) Programme, UNDP supported the Swayam Shikshan Prayog (SSP), a local NGO, to build alliances between women’s groups and panchayats (local elected bodies) to operationalise community monitoring of development programmes, particularly for identifying and measuring the barriers that restrict women’s access to public services.

The current country programme document for India (2008 - 12) is in harmony with the eleventh five-year plan of the Government and is based on a comprehensive review of lessons from past cooperation.

The United Nations Population Fund (UNFPA) United Nations Fund for Population Activities (UNFPA) was founded under the administration of the United Nations Development Fund in 1969. In 1987, its name was changed to United Nations Population Fund but the acronym UNFPA was retained. It is the world’s largest international source of

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funding for population and reproductive health programs.

UNFPA is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes (a) to reduce poverty (b) to ensure that every pregnancy is wanted (c) to ensure that every birth is safe (d) to ensure that every young person is free of HIV/AIDS and (e) to ensure that every girl and woman is treated with dignity and respect.

The Fund works with governments and non-governmental organizations in over 140 countries with the support of the international community, supporting programs that help women, men and young people.

UNFPA is guided in its work by the Programme of Action adopted at the International Conference on Population and Development held at Cairo in 1994. At the conference, 179 countries agreed that meeting needs for education and health, including reproductive health, is a prerequisite for sustainable development over the long term. The main goals of Programme of Action, as refined in 1999, are : (a) Universal access to reproductive health services by 2015 (b) Universal primary education and closing the gender gap in

education by 2015 (c) Reducing maternal mortality by 75 per cent by 2015 (d) Reducing infant mortality (e) Increasing life expectancy (f) Reducing HIV infection rates UNFPA in IndiaUNFPA has been providing assistance to India since 1974. Following the adoption of the Programme of Action, the approach has been to empower women and to expand access to education, health services and employment opportunities.

UNFPA supported Integrated Population and Development (IPD) Projects in approximately 40 districts in 6 states in India (Maharashtra, Gujrat, Madhya Pradesh, Kerala, Rajasthan and Orissa) are aimed to address the needs of individuals and couples to achieve their personal reproductive intentions, to help in eliminating discrimination against girls and to help in providing quality reproductive health services.

UNFPA supports the Government of India in the following key areas :

Integrating population issues within a wider development ●contextImplementing the draft national policy for the empowerment ●of womenDeveloping special programmes to improve women’s status ●and address gender disparities Strengthening the logistics system for distribution of ●contraceptives and broadening the choice of available contraceptive methodsEnhancing advocacy efforts to promote the concept of ●reproductive health and gender equality

Joint United Nations Programme on HIV /AIDS (UNAIDS)Established in 1994 by a resolution of the UN Economic and Social Council and launched in January 1996, UNAIDS is

the main advocate for global action on the HIV epidemic. It brings together ten UN agencies in a common effort to fight the epidemic. Cosponsors include UN High Commission for Refugees (UNHCR), UN Children’s Fund (UNICEF), World Food Programme (WFP), UN Development Programme (UNDP), UN Population Fund (UNFPA), United Nations Office on Drugs and Crime (UNODC), International Labour Organization (ILO), UN Educational, Scientific and Cultural organization (UNESCO), World Health Organization (WHO) and the World Bank. It has its headquarter at Geneva, Switzerland. The Cosponsors and the UNAIDS Secretariat comprise the Committee of Cosponsoring Organizations, which meets annually.

MissionUNAIDS’ mission is to lead, strengthen and support an expanded response to HIV and AIDS that includes preventing transmission of HIV, providing care and support to those already living with the virus, reducing the vulnerability of individuals and communities to HIV and alleviating the impact of the epidemic.

RoleUNAIDS help mount and support an expanded response – one that engages the efforts of many sectors and partners from government and civil society. Its role can be summarized in five major components : (a) Leadership and advocacy for effective action on the

epidemic (b) Strategic information and technical support to guide efforts

against AIDS worldwide (c) Tracking, monitoring and evaluation of the epidemic and

of responses to it (d) Civil society engagement and the development of strategic

partnerships (e) Mobilization of resources to support an effective response UNAIDS – WHO HIV Vaccine InitiativeUNAIDS and WHO, taking advantage of their complementary expertise – UNAIDS contributing with its expertise in social and behavioural research, ethical issues, political mobilization and its strong link with community and WHO bringing in its experiences in vaccine development, its administration and delivery for public health prevention programmes – joined forces to give a boost to the new HIV Vaccine Initiative (HVI). It is guided by a WHO-UNAIDS Vaccine Advisory Committee (VAC), which provides to scientists from different agencies and disciplines, a unique forum for exchange of information and a common ground for collaboration.

UNAIDS in IndiaUNAIDS works closely with the Government through the National AIDS Control Organization, government and private institutions, NGOs etc. In its fight against HIV/ AIDS it shares knowledge, skills and its worldwide experience. Specifically it supports the national response to HIV/ AIDS by promoting : (a) Strengthened leadership and resource mobilization(b) Improved planning, financing, technical assistance and

coordination at all levels for a sustainable multi-sectoral response to the epidemic

(c) Strengthened evidence base of the response through greater

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availability and use of strategic information from better monitoring and evaluation, surveillance and resource tracking

(d) Enhanced human resources and robust delivery system at all levels

(e) Policies to reduce stigma and discrimination(f) Increased coverage and sustainability of programmes for

injecting drug users, men having sex with men and sex workers

(g) Increased coverage and sustainability of programmes to address the vulnerability of women and girls, young people, emergency-affected populations and uniformed personnel.

United States Agency for International Development (USAID)History of creation of USAID dates back to 1947 Marshall Plan – European Recovery Programme following World War II – and Foreign Assistance Act. But it was only in 1961 when USAID was created by an executive order for administering economic assistance programmes. It has its headquarter at Washington, D. C.

USAID is an independent federal government agency that extend assistance to countries recovering from disaster, trying to escape poverty and engaging in democratic reforms. It supports long-term and equitable economic growth and advances U. S. foreign policy objectives by supporting economic growth, agriculture and trade; global health; and democracy, conflict prevention and humanitarian assistance.

The strength of USAID is its field offices around the world where it works in close partnership with governments, private voluntary organizations, indigenous organizations and international agencies. It provides assistance in five regions of the world : (a) Sub-Saharan Africa(b) Asia(c) Latin America and the Caribbean (d) Europe and Eurasia(e) The Middle EastUSAID in IndiaIn India, USAID has been providing assistance in the following areas :

(a) Economic Growth : For the sustained economic growth of the country, USAID supports agricultural reforms, links small scale farmers to newer markets, strengthens financial institutions and provides know how for generating finances for urban services.

(b) Health : USAID has made considerable contribution for prevention of HIV/ AIDS and for improving maternal and child health. It is because of its efforts that the use of contraception in Uttar Pradesh increased from 27 percent in 1992–1993 to 44 percent in 2005–2006; the HIV prevalence rate in Tamil Nadu reduced from 1.13 percent in 2001 to 0.4 percent in 2005. In Muslim communities with persistent polio, USAID works with faith-based organizations to battle misconceptions about the polio vaccine, creating community support and ensuring that children are immunized.

(c) Disaster Management : Floods, droughts, landslides, cyclones and earthquakes are regular features in India. USAID collaborates with the Indian government and local communities to improve their capacity in disaster risk reduction to save lives and minimize threats from large-scale financial, infrastructure, crop and productivity losses. USAID is also providing scientists and engineers with state-of-the-art tools for better early warning, for providing architecture to government buildings in Delhi which can withstand earthquakes; and for training of Indian disaster management professionals.

(d) Energy and Environment : USAID provides assistance to increase viability in the power sector to meet consumer needs, conserve energy and water resources. By leveraging private funds along with government resources, USAID’s urban program is promoting better city governance and improving water and sanitation services for over 18 million people by the end of 2008.

(e) Opportunity and Equity : USAID’s education program works with Indian non-governmental organizations, state governments and private corporations to reach the vulnerable groups. USAID also supports activities that keep girls in school, improve the legal rights of women, address the problem of female feticide and combat human trafficking. Partnerships with the private sector provide disadvantaged youth with the skills they need to participate in India’s growing economy.

World BankThe world bank was established as International bank for Reconstruction and Development (IBRD) in 1944 following United Nations Monetary and Financial Conference organized by the U. S. government. It was established to provide financial and technical assistance to developing countries around the world. But by mid- 1950s it became clear that many poor countries were unable to repay standard IBRD loans. This led to the establishment of International Development Association (IDA) in 1960. Today World bank is made up of two unique development institutions owned by 185 member countries - the IBRD and the IDA. The IBRD focuses on middle income and creditworthy poor countries, while IDA focuses on the poorest countries in the world. Together they provide low interest loan, interest-free credit and grants to developing countries for education, health, infrastructure, communications and many other purposes.

In addition to IBRD and IDA, three other institutions viz International Finance Corporation (IFC), Multilateral Investment Guarantee Agency (MIGA) and International Centre for Settlement of Investment Dispute (ICSID) are also closely associated with the world bank. Together these five make the World Bank Group.

MissionThe mission of the world bank is to help developing countries achieve Millennium Development goals by alleviating poverty and providing opportunities for sustained development.

OrganizationThe world bank is like a cooperative with 185 member countries. These countries are represented by Board of Governors who are the policy makers and usually meet once a year. The functioning

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of the World Bank is carried out by its 24 executive Directors. The five largest shareholders i.e. US, France, Germany, Japan and United Kingdom contribute one director each. The other 19 come from the remaining countries on rotation basis. The headquarter of the world bank is at Washington, D. C. Its president is a US national and is nominated by the United States, the bank’s largest shareholder.

World Bank in IndiaIndia is one of the oldest members of the World Bank. The bank’s New Delhi office, established in 1957, is the oldest continuously running country office. India is the bank’s largest single borrower and receives half of its loans interest-free. The World Bank is the largest financers of India’s National AIDS Control Program (NACP) with a commitment of around US$275 million in interest-free credits. Its four-year Country Strategy for 2005 - 2008 focuses on lending for infrastructure, human development and improving rural livelihoods. The Bank is increasingly focusing on providing analytical reports on the country’s major development challenges and extending practical advice to policy makers by sharing good practices and experience from within the country and abroad.

Ford FoundationThe Ford Foundation is a private foundation based in New York City. It was founded in 1936 by Henry Ford and Edsel ford in Michigan with an aim “to receive and administer funds for scientific, educational and charitable purposes, all for the public welfare”. Its grant making teams work in three broad program areas viz strengthen democratic values, reduce poverty and injustice, promote international cooperation and advance human achievement.

The foundation’s first international field office opened in new Delhi, India in 1952. In 1976, the foundation helped to launch the Grameen Bank, which offers small loans to the rural poor of Bangladesh. In the late 1980s, the foundation began making grants to fight the AIDS epidemic, which included support for the establishment of a programme to improve AIDS education and treatment in communities around the country. In 2000, the foundation launched the International Fellowships Program (IFP) to provide fellowships to students from marginalized communities outside the U. S. to pursue graduate studies at universities anywhere in the world.

For many years, the foundation topped annual lists compiled by the Foundation Center of U. S. foundations with the most assets and the highest annual giving; but with the establishment of the Bill and Melinda Gates Foundation in 2000, the Ford Foundation fell far behind the Gates Foundation in terms of assets and 4th in terms of annual grant giving.

Ford Foundation in IndiaFord foundation has helped India in following projects :

Establishment of National Institute of Health Administration ●(NIHAE) and education at Delhi for training of health administratorsEstablishment of training centres at Singur, Najafgarh ●and Poonamalle for training of medical and paramedical persons in the field of public healthResearch-cum-action projects for organization of rural ●

health services and use of hand-flushed sanitary latrines in rural areasSupporting research in reproductive biology and fellowship ●programmes in family planningCollaborating with other agencies for improving the water ●supply and drainage in the urban areas of Kolkata.

Rockefeller Foundation (RF)The Rockefeller Foundation (RF), based in New York City, is the most prominent philanthropic organization and private foundation in the field of International Health. Its central historical mission is to “promote the well-being” of humanity. The international health commission, set up within RF in 1913 and subsequently designated as International Health division (IHD) cooperated, in its early years, with 75 governments for the control of 21 separate diseases including tuberculosis, malaria, yaws, hookworm and yellow fever. The most prominent achievement being the development of 17D vaccine for yellow fever and ridding the southern United States of malaria and hookworm.

Besides its role in disease control, RF has also been closely associated with medical education. RF supported medical schools in Beirut, Bangkok, Brussels and elsewhere but the most famous being Peking Union Medical college (PUMC), China which was created and operated by RF. RF also financed and supported School of public Health at John Hopkins University. An interesting initiative of RF is the establishment of International Clinical Epidemiology Network (INCLEN) which is an independent non-profit organization with it’s headquarter at Philadelphia. The network includes clinical epidemiologists, biostatisticians, health economists and social scientists who are interested in health care research leading to development of preventive and treatment strategies. INCLEN supports the young researchers, provides training opportunities and a platform for international communications.

In India, RF began its activities in 1920 with a scheme for control of hookworm disease in Madras Presidency. Since then, RF is associated with many public health programmes and medical education. The establishment of All India Institute of Hygiene and Public Health in Kolkata is largely due to the cooperation of RF. Clinical Epidemiology Network - India (IndiaCLEN), a part of regional INCLEN, has 7 Clinical Epidemiology Units across the country and has played important role in the development of Integrated Disease surveillance Project (IDSP), NACP III and evaluation of Pulse polio immunization.

International Red Cross and Red Crescent MovementHenry Dunant, a Swiss businessman, in his book “A Memory of Solferino” gave a vivid description of his experiences with the wounded soldiers of Battle of Solferino in June 1859 and advocated the formation of national voluntary relief organizations to help and nurse wounded soldiers in the case of war. In addition, he called for the development of international treaties to guarantee the protection of neutral medics and field hospitals for soldiers wounded on the battlefield. It was because of his efforts that the first Geneva Convention “for the Amelioration of the Condition of the Wounded in Armies in the Field” was adopted on August 22, 1864 and “International

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Committee of the Red Cross” (ICRC), which is still its official designation today, came into being. For his work, Henry Dunant was awarded the Nobel Prize for Peace in 1901.

The Red Crescent Movement is an international humanitarian movement with approximately 97 million volunteers worldwide. Its mission is to protect human life and health, to ensure respect for the human being and to prevent and alleviate human suffering, without any discrimination based on nationality, religious beliefs, or political opinions. The movement consists of several distinct organizations that are legally independent from each other, but are united within the Movement through common basic principles, objectives, symbols, statutes and governing organs. These include :

The International Committee of the Red Cross (ICRC) : founded in 1863 in Geneva, Switzerland it has a unique authority under international humanitarian law to protect the life and dignity of the victims of international and internal armed conflicts.

The International Federation of Red Cross and Red Crescent Societies (IFRC) : founded in 1919 and based in Geneva, Switzerland, it coordinates activities between the 186 National Red Cross and Red Crescent Societies within the Movement. On an international level, the Federation leads and organizes, in close cooperation with the National Societies, relief assistance missions responding to large-scale emergencies.

National Red Cross and Red Crescent Societies exist in nearly every country in the world. Currently 186 National Societies are recognized by the ICRC and admitted as full members of the Federation. Each entity works in its home country according to the principles of international humanitarian law and the statutes of the international Movement.

The Red Cross SymbolThe Red Cross on white background was the original protection symbol declared at the 1864 Geneva Convention. It is, in terms of its color, a reversal of the Swiss national flag, a meaning which was adopted to honor Swiss founder Henry Dunant and his home country. According to an agreement within the Red Cross and Red Crescent Movement, the shape of the cross should be a cross composed of five squares. However, regardless of the shape, any Red Cross on white background should be valid and must be recognized as a protection symbol in conflict.

Red Cross in IndiaIn India, the red cross society was established in 1920. During peace time, while working with Military hospitals, it provides news papers and periodicals, musical instruments and indoor games to the indoor patients. While working outside the military hospitals, its role is diverse like running of blood banks, organizing voluntary blood donations, providing opportunities to young boys and girls for getting associated with activities like Pulse Polio Immunization on National immunization day (NID), village upliftment, first aid in the event of an emergency and building up of international friendliness. The Red Cross Home at Bangalore for disabled ex-servicemen is one of the pioneering institutions of its kind in Asia.

Swedish International Development Agency (SIDA)Swedish International Development Agency (SIDA) has been assisting India since 1964. The broad priority areas of assistance are (a) Poverty oriented projects in the primary health sector with special emphasis on reproductive health and rights of girls and women (b) Environment and urban development with focus on water and sanitation and waste management, air and noise pollution; and (c) Mutual exchange and research cooperation in the field of knowledge and technology. After 1976, Swedish bilateral development assistance has been in the form of grants and is available for mutually agreed projects. Since 1979, SIDA has been supporting the National Tuberculosis Control Programme of India. The grants given for this purpose is utilized for procuring supplies like microscopes, x-ray units and anti-tuberculosis drugs.

Danish International Development Assistance (DANIDA)Denmark’s development co-operation with India started in 1959 and within a decade India became one of the three main recipients of bilateral Danish aid. The areas of activity included health (especially blindness control, polio, leprosy and tuberculosis), agriculture and water and sanitation mainly in the states of Tamil Nadu, Karnataka, Orissa and Madhya Pradesh.

In 1998, consequent to India’s nuclear weapons policy, the Government of Denmark officially announced its intention to phase out Danish development assistance to the country. In 2003, however, it was mutually agreed between the two governments to complete the phasing out of the Indo-Danish bilateral official development cooperation by end 2005. During the 45 years of cooperation, Denmark has channelled around 6 billion Danish Kroner (about 1.1 billion US dollars) to the support of the development process in India.

Aga Khan Foundation (AKF)Founded in 1967 by Aga Khan IV, AKF is a non-governmental development network working to promote social development in the low income countries of Asia and Africa. It has its headquarters in Geneva and is currently active in Afghanistan, Bangladesh, Canada, India, Kenya, the Kyrgyz Republic, Mozambique, Pakistan, Portugal, Switzerland, Syria, Tajikistan, Tanzania, Uganda, the United Kingdom and the United States of America. With affiliates that are important national institutions in North America and Europe and grant-making offices in Africa as well as in South and Central Asia, the Foundation has genuine roots in both the developed and developing worlds. Experience and skills flow in both directions.

The foundation supports primary health care projects in several countries, including a large scale community based system that provides tetanus toxoid to mothers and iodinated oil to prevent goiter and cretinism in children in the rugged mountains of northern Pakistan. Besides, it also supports more than 200 educational and 166 health institutions.

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Oxford Committee for Famine Relief (OXFAM)Originally founded in England in 1942 as the Oxford Committee for Famine Relief by a group of Quakers, social activists and Oxford academics; today OXFAM International is a confederation of 13 organizations working with over 3, 000 partners in more than 100 countries to find lasting solutions to poverty and injustice.

Though OXFAM’s initial concern was the provision of food to relieve famine, over the years OXFAM has developed strategies to combat the causes of famine. It has three main points of focus viz. (a) development work to lift communities out of poverty with long-term, sustainable solutions; (b) humanitarian work to assist those affected by conflict and natural disasters and (c) advocacy and popular campaigning, to affect policy decisions on the causes of conflict at local, national and international levels.

OXFAM’s areas of activities also include works on HIV/AIDS, gender equality, natural disasters, democracy and human rights and climate change.

Programme for Appropriate Technology in Health (PATH)Based in Seattle, Washington, PATH is an international, nonprofit organization that by collaborating with diverse public- and private-sector partners and with the help of innovative ideas and appropriate technologies try to find sustainable, culturally relevant solutions, for communities worldwide to break long-standing cycles of poor health. Its mission is to improve the health of people around the world by advancing technologies, strengthening systems and encouraging healthy behaviors.

ActivitiesWith country offices in more than 70 countries, collaboration is always at the core of PATH’s activities. It focuses on :

Solutions for emerging and epidemic diseases, like AIDS, ●tuberculosis and malaria. Health technologies designed for low-resource settings, by ●the people who will use them. Safer childbirth and healthy children. ●Health equity for women, among the world’s most ●vulnerable - and influential - populations.

Co-operative for Assistance and Relief Everywhere (CARE)Founded in North America following World War II, CARE, today, is a leading humanitarian organization with more than 14,500 employees worldwide, fighting global poverty. It is a non-political, private voluntary organization operating in more than 65 countries in Africa, Asia, Latin America, the Middle East and Eastern Europe. It is often one of the first to deliver emergency aid to survivors of natural disasters and war.

CARE’s mission is to serve individuals and families in the poorest communities in the world. It works hand in hand with vulnerable families, especially women and girls to help them access their rights.

In India, CARE is operational since 1950. Its main area of focus

had been to provide food support to school children and to ICDS programme. Over the years it has spread its wings and is supporting many projects run by Central Government as well as by State Governments. Notable among these are Integrated Nutrition and Health Projects, Anaemia Control Project, Adolescent Girl’s project, Improving Women’s Reproductive health and Family Spacing Project. CARE is also conducting a social audit on infant and maternal mortality in Jharkhand to identify and classify all causes of maternal and infant deaths.

International Health Regulations (IHR)International Sanitary Regulations, first approved in 1892, was revised and adopted by WHO in 1951. It focused on the control of communicable diseases mainly cholera, plague, small pox, yellow fever and enteric fever. These regulations were further modified and adopted as International Health Regulation (IHR) in 1969. It required member states to report outbreaks of certain communicable diseases to WHO. With ever changing physical, social and biological environment, with increasing urbanization and decreasing distances, with mounting threats of natural and man-made disasters and with the risk of emerging and reemerging diseases, IHR required amendments in 1973 and 1981. Subsequent epidemiological evidences demonstrated the need for regulations for broader disease coverage and measures to stop their spread across borders. Accordingly, IHR was completely revised in 2005 to provide the legal framework for international cooperation. The stated purpose of IHR is to control and prevent the spread of disease, protect against it and evoke an international response commensurate with the existing public health practices without unnecessarily affecting the trade and the traffic.

IHR (2005) : The ObjectivesThe IHR (2005) entered into force with effect from 15 June 2007 with its main objectives as follows : (a) The appropriate application of routine, preventive measures

(e.g. at ports and airports) and the use by all countries of internationally approved documents (e.g. vaccination certificates).

(b) The notification to WHO of all events that may constitute a public health emergency of international concern.

(c) The implementation of any temporary recommendations should the WHO Director General have determined that such an emergency is occurring.

Scope and NotificationIHR (2005) has radically changed the international notification requirements of States to WHO. Member states are no longer required to notify the occurrence of Cholera, plague and yellow fever. Notification is now based on the identification of an “event that may constitute a public health emergency of international concern” (PHEIC). PHEIC has been defined in the Regulations as an extraordinary public health event which constitutes a public health risk to other States through the international spread of disease and may require a coordinated international response.

This non-disease specific definition of notifiable events expands the scope of the IHR (2005) and include events (beyond communicable diseases) arising from any origin or

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source. Such events are required to be reported, using decision instrument given in Annex II of the IHR (2005) to WHO (Fig. -1). If the event is identified as notifiable, it must be notified giving detailed public health information, number of cases and deaths and available lab results, to WHO immediately i.e. within 24 hours after having carried out the initial assessment.

The four decision criteria to be used in the assessment of a

public health event are : (a) The seriousness of the event’s public health impact. (b) The unusual or unexpected nature of the event.(c) The risk of international disease spread.(d) The risk that travel or trade restrictions will be imposed by

other countries. In essence, the events which must be assessed are those that

Fig. - 1: Events that may constitute a public health emergency of international concern.

Source : IHR 2005 – Annex II

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may fulfil one or more of the four decision instrument criteria and the events which must be notified are those that meet at least any two of the criteria therein.

Mandatory notification While any urgent event can be assessed for notification, the decision instrument identifies two groups of diseases which raise particular concerns :

(a) Group 1 : A single case of smallpox, poliomyelitis due to wild type poliovirus, human influenza caused by a new subtype and severe acute respiratory syndrome (SARS) must be immediately notified to WHO, irrespective of the context in which it occurs.

(b) Group 2 : Events involving epidemic-prone diseases of special national or regional concern which “have demonstrated the ability to cause serious public health impact and to spread rapidly internationally” must always be assessed using the decision instrument but only notified when fulfilling the requirements of the algorithm.

Consultation IHR (2005) also provide for a “consultation” process between a State Party and WHO. This consultation process provides States Parties with the opportunity to keep WHO informed and to have, similarly to notification, a confidential dialogue with WHO on further event assessment and any appropriate investigative or health response measures.

Other Reporting Requirements In addition to notification and consultation, States Parties are required to inform WHO within 24 hours of receipt of evidence of public health risks occurring outside their territory that may cause international disease spread. The evidence may be manifest by imported or exported human cases, or the identification of infected or contaminated vectors or contaminated goods.

Points of Entry ProvisionsPoints of entry provisions in the IHR (2005) are designed to minimize public health risks caused by the spread of diseases through international traffic. The IHR (2005) define a point of entry as “a passage for international entry or exit of travellers, baggage, cargo, containers, conveyances, goods and postal parcels, as well as agencies and areas providing services to them on entry or exit”. There are three types of points of entry: international airports, ports and ground crossings.

The two specific applications of IHR (2005) at point of entry include (a) the requirement of yellow fever vaccination of travelers as imposed by certain countries; and (b) the disinsection of aircrafts to prevent importation of disease vectors. These requirements are intended to help prevent the international spread of the diseases.

Roles for Competent Authorities and Conveyance Operators States Parties to the IHR (2005) are required to identify the competent authorities to carry out : (a) development of core capacities at designated points of

entry; (b) implementation at points of entry of appropriate levels

of hygiene and sanitation as well as ensuring effective vector, rodent and environment control measures and procedures;

(c) application of health measures at points of entry in affected areas.

Ship Sanitation Certificates Under the IHR (2005), the current Deratting and Deratting Exemption certificates have been replaced by Ship Sanitation Control and Ship Sanitation Control Exemption certificates which address a broader range of public health risks on sea going vessels.

Guidance on IHR (2005) Implementation at Points of Entry Guidance materials are being developed in the following areas: 1 Management of public health risks at points of entry 2 Provision of technical assistance in developing points of

entry capacities 3 Maintenance of accessible data for designated points of

entry, including capacity to issue Ship Sanitation Control Exemption and Ship Sanitation Control certificates

4 Inspection and WHO certification criteria for airports and ports

5 Recommended measures for affected travellers, conveyances, containers, cargo and goods

6 Ship sanitation and hygiene and sanitation in aviation 7 Application of health measures at ground crossings

Health Advice to TravellersNumber of people who are undertaking international travels, is increasing with every passing year and with that, is increasing the travel related risks to their health. These health risks are due to sudden changes in altitude, climate and physical and biological environment.

Determinants of the Health RisksDeterminants of the health risks to which travellers are exposed to are as follows :

(a) Health state before undertaking the travel : Underlying health condition of the traveller is the most important determinant of the health of traveller during the period of the travel e.g. a traveller with low immunity is more susceptible to the infectious diseases prevalent in developing countries.

(b) Place of travel : Destinations where accommodation, hygiene-sanitation, water quality and medical care are of high standard, pose little risk for the travellers.

(c) Purpose of travel : Travellers going on business trips, staying in hotels/ business centres and away from exposure to natural physical and biological environments have lesser risks compared to those who go on adventure trips or for field works and stay in resorts or temporary shelters.

(d) Duration of travel : Duration of the visit determines the nature of exposure to climatic conditions. A shorter duration of visit and inability to acclimatize to local conditions may adversely affect the health.

(e) Behaviour of traveller : Behaviour also plays an important role e.g. going out-doors in the evening in malaria endemic

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areas without taking adequate precautions poses the risk of malaria infection to the traveller.

Actions to be Taken In order to protect the health, every traveller is required to be proactive and prepared. The travel must be planned well in advance and following actions must be taken :

(a) Actions taken before the travel

(i) Learn about the destination : Collect as much information about the place of travel as possible. Find out about the health risks in the area, altitude of the place, type of available accommodation, availability of health care facility etc.

(ii) Have the medical consultation : Visit a travel clinic at least six to eight weeks prior to travel to ensure enough time to get the necessary immunizations. Even the last minute medical consultation is better than no consultation. If you have an ongoing health concern, discuss your travel plans with your doctor. Ask your doctor for a letter stating your medical history and prescribed medications. Dental, ophthalmological and - for women - gynaecological check-ups are advisable before travel to developing countries.

(iii) Health insurance : Obtain special travellers’ health insurance for destinations where health risks are significant and medical care is expensive or is not readily available.

(iv) Medical kit : Make or buy a first aid kit for common health concerns. Its contents should include :

First-aid items like adhesive tape, antiseptic wound ●cleaner, bandage, emollient eye drops, insect repellant, nasal decongestant, oral rehydration salt, sterile dressing, scissors and safety pins, thermometer, simple analgesic and antipyreticAdditional items according to destination and individual ●needs like anti-diarrhoeal medication, anti-malarial medication, condoms, anti-fungal cream, water disinfectant, medication for any pre-existing medical condition, sterile syringes and needles etc.

(b) Actions taken during the travel : The following action must be taken while travelling to the destination and during the period of stay :

(i) While Travelling to Destination : Travel can be tiring, hence get plenty of sleep before leaving. Wear loose and comfortable clothes; eat light meals, drink plenty of water and avoid alcohol and caffeine; when possible, walk around to improve circulation.

(ii) Food and Water Safety : Always wash your hands after going to the toilet and before handling food or eating. Eat fresh and well cooked food, avoid raw vegetables, salads, cut fruits or food kept in open. Do not eat undercooked or raw meat, fish or shellfish. Drink only boiled or bottled water and beverages made with boiled water. Use dairy products that are pasteurized and refrigerated. If in doubt, avoid them.

(iii) Sun Protection : To avoid skin and eye damage caused by the sun, wear clothing that covers your skin and eyes such as a hat with a wide brim and sunglasses with proper UV filter. Apply a sunscreen with a SPF 15 (sun protection factor) about 15 to 30 minutes before going out into the sun.

(iv) Safe sex : Always use a condom for sexual intercourse. Women who only use diaphragms should insist that their male partners use condoms as well.

(v) Injury Prevention : Wear closed-toe shoes to prevent cuts, wounds, insect or snake bites, or infection from parasites.

(vi) Swimming : Swim only in pools filled with clean, disinfected water. Do not swim in tropical waters, streams, canals or lakes, which may be infested with parasites. Try not to swallow water while swimming.

(vii) Road safety : Traffic accidents are the major cause of death among travellers. Whether you’re driving or walking, always check the local traffic regulations. Be very careful when driving in a foreign country and on unfamiliar roads. Use your seat belts. Do not drink alcohol and drive. Be sure to use common sense and caution.

(viii) Insect and animal bites : Use an insect repellent and keep your arms and legs covered if there’s a chance of being bitten. Animal bites can lead to serious – and even fatal – infections like rabies. Keep away from animals, even if they seem tame. If bitten, cleanse the wound with soap and clean water immediately. Consult local health authorities regarding the possible need for rabies treatment.

(c) Actions taken after the travel.

All travellers, after return, must undergo a medical examination if : (i) they spent more than three months in a developing

country(ii) they suffer from a chronic disease or the existing disease

condition has worsened(iii) they consider that they have been exposed to a serious

infection during the travel(iv) they experience illnesses like fever, persistant diarrhoea,

jaundice, skin or genital infections, in the weeks following their return

Checklist for the Traveller(a) Obtain information on local conditions (the destination)

Risks related to the area (urban or rural) ●Type of accommodation available ●Length of stay ●Altitude ●Security problems in the area ●Availability of health care facility in the area of visit ●

(b) PreventionVaccination requirement ●Malaria-risk of infection, preventive measures, ●prophylaxisFood hygiene ●Specific local diseases and the preventive measures for ●them

(c) Accidents related toTraffic (carry health card showing blood group) ●Animals (beware of snakes and rabid dog) ●Allergies – common allergens in the area and their ●preventionSun – carry sunglasses and sunscreen ●

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(d) Get the following check-upsMedical – medical kit and health card showing underlying ●health condition and prescription for medicationDental ●Ophthalmological – carry an extra pair of spectacles ●Checkup for specific conditions e.g. pregnancy ●

(e) Subscribe to a medical insurance

Responsibilities of the TravellerBy and large, travellers themselves are responsible for their health and well being while travelling. Responsibilities that they must accept as their own, are enumerated as under :

Decision to travel ●Planning for travel ●Recognition and acceptance of the risk ●Seeking medical advice in time ●Compliance with the medical advice and recommended ●vaccinationCarrying and understanding the use of medical kit ●Taking precautions before, during and after the journey ●Obtaining insurance cover ●Responsibility for the health and well being of the ●accompanying children

SummaryInternational Health has been defined as a field of research and intervention embracing the international dimensions of health disease process and care systems. While the research refers to the analysis of health determinants and the health state of the individuals and populations, the intervention refers to the actions taken at economic, political and administrative levels Broadly speaking, international health is a systematic comparison of the factors that affect the health of all human populations. International health aims at promotion, maintenance, protection and prevention of health by an interdisciplinary approach, Dealing with problems of inter-sectoral nature, International cooperation for capacity building of countries, Strengthening technical cooperation among countries, Interaction – multidirectional, not unidirectional (i.e. not from developed countries to developing countries only) – among countries, Providing an instrument for diplomacy and solidarity and not a mechanism for domination. Content of international health covers a wide area like social, economic, behavioural cultural etc factors related to health. Its organization involves governmental and non governmental organization. Main international intergovernmental organizations include the World Health Organization (WHO), the International Labour Organization (ILO), the Food and Agriculture Organization (FAO), the UN Development Programme (UNDP), the UN Children’s Fund (UNICEF), etc.

Regional office of WHO South East Asia is located in New Delhi in India. In India, WHO provides technical assistance and collaborates with the Government of India and major stakeholders in health development efforts. It assists notably in Policy Development; Capacity Building and Advocacy.

International Health Regulation was completely revised in 2005 to provide the legal framework for international cooperation in health. The purpose of IHR is to control and

prevent the spread of disease, protect against it and evoke an international response commensurate with the existing public health practices without unnecessarily affecting the trade and the traffic. Stated objective of IHR are the appropriate application of routine, preventive measures (e.g. at ports and airports) and the use by all countries of internationally approved documents (e.g. vaccination certificates), the notification to WHO of all events that may constitute a public health emergency of international concern, the implementation of any temporary recommendations should the WHO Director General have determined that such an emergency is occurring. Notification is now based on the identification of an “event that may constitute a public health emergency of international concern” (PHEIC).

“Public health emergency of international concern” means an extraordinary event which is determined, as provided in these Regulations : to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.

The four decision criteria to be used in the assessment of a public health event are : the seriousness of the event’s public health impact; the unusual or unexpected nature of the event; the risk of international disease spread; and the risk that travel or trade restrictions will be imposed by other countries.

Health Advice To Travellers : Travellers are exposed to health risks owing to sudden changes in altitude, climate and physical and biological environment. Determinants of the health risks to which travellers are exposed are health state of the traveller before undertaking the travel, place of travel and conditions prevailing therein, purpose of travel, duration of travel, behaviour of traveller.

In order to protect the health, every traveller is required to be proactive and prepared. The travel must be planned well in advance and following actions must be taken by traveller: learn about the destination not only about the ecological condition but also about the health facility, have the medical consultation, health insurance, medical kit - make or buy a first aid kit for common health concerns.

While travelling the traveller should take due precaution not to tire himself, maintain food and water hygiene, protection against physical condition prevailing in the destination, prevention of injuries and insect and animal bites, safe sex etc.

All travellers after travel must undergo medical examination if they spent more than three months in a developing country, they suffer from a chronic disease or the existing disease condition has worsened, they consider that they have been exposed to a serious infection during the travel, they experience illnesses like fever, persistent diarrhoea, jaundice, skin or genital infections, in the weeks following their return.

By and large, travellers themselves are responsible for their health and well being while travelling. Responsibilities that they must accept as their own, are decision to travel, planning for travel, recognition and acceptance of the risk, seeking medical advice in time, compliance with the medical advice and recommended vaccination, carrying and understanding the use of medical kit, taking precautions before, during and after the

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journey, obtaining insurance cover, responsibility for the health and well being of the accompanying children.

Study Exercises Short Notes : (1) IHR 2005- New regulations (2) Health advice to travellers (3) WHO Activities in India (4) UNICEF Activities in India (5) Activities of Red cross in India.

MCQs : 1. WHO came into force in (a)1942 (b)1948 (c)1952 (d)19452. World Health day is celebrated on (a)24 Oct (b) 01 Dec

(c) 07 April (d) 01 Jan.3. The administrative and organizational headquarter of

UNICEF is at (a) Geneva (b) New York (c) Rome (d) Paris.4. The administrative and organizational headquarter of

UNESCO is at (a) Geneva (b) New York (c) Rome (d) Paris.5. The FAO was founded in (a) 1945 (b) 1942 (c) 1948

(d)1950.

6. The administrative and organizational headquarter of ILO is at (a) Geneva (b) New York (c) Rome (d) Paris.

7. The organization which provides expert advice, training and grant support to accomplish MDGs is (a) UNICEF (b)UNDP (c) UNESCO (d)UNFPA.

8. The world’s largest international source of funding for population and reproductive health programs is (a) UNICEF (b) UNDP (c) UNESCO (d) UNFPA.

9. The founder of International Red Cross and Red Crescent Movement is (a) Rockfeller (b) Philip Russel (c) Henry Dunant (d) None.

10. Agency which has been supporting the National Tuberculosis Control Programme of India is (a) IRCS (b) SIDA (c) DANIDA (d) UNICEF.

11. IHR was completely revised recently in (a) 2005 (b) 2007 (c) 2009 (d) 2004.

Answers : (1) b; (2) c; (3) b; (4) d; (5) a; (6) a; (7) b; (8) d; (9) c; (10) c; (11) a.