MBAHCS

Semester 3

MH0051 – Health Administration (4 Credits)

(Book ID: B1212)

Assignment Set- 1 (Marks 60)

Note: Each question carries 10 Marks. Answer all the questions.

Q.1 Explain healthcare delivery system in India and its functions in detail. [10

Marks]

Answer:

In India Healthcare Delivery system is represented by five major sectors or agencies

that differ from each other by the health technology applied and by the source of

funds for operation.

• Public sector

• Primary Healthcare

• Primary health centers

• Sub-centers

• Hospital/health centers

• Community health centers

• Rural Hospitals

• District hospitals/health centers

• Specialist hospitals

• Teaching hospitals

• Health Insurance Scheme

• Employees state insurance

• Central government health scheme

• Other agencies

• Defence services

• Railways

Private sector

• Private hospitals, polyclinics, nursing homes, dispensaries

• General practitioners

Indigenous systems of medicine

• Ayurveda & Siddha

• Unani

• Homeopathy

• Unregistered Practitioners

Voluntary health agencies

• Jan Aakansha

• Shiksha

• Give India

• The Art of Living Foundation

• Vision Age India

• People Institute for Development and Training (PIDT)

• Child Line India Foundation

• Provision for Recognition, Education, Rejuvenation, and Awareness

Generation for Needy Anonymous (PRERANA)

• Action for Development of Human and Rural Neglected Areas (ADHARANA)

• Seva Bharti Mandal

• Voluntary Health Association of India (VHAI)

• Savera Samaj Kalyan Sansthan, etc.

National health programs

• Major Programs

• National AIDS Control Program

• National Cancer Control Program

• National Diarrheal Disease Control Program

• National Filaria Control Program*

• National Family Welfare Program

• National Iodine Deficiency Disorders Control Program

• National Leprosy Eradication Program

• National Malaria Eradication Program*

• National Program for Control of Blindness & Visual Impairment

• National Reproductive and Child Health Program

• National Program for Surveillance Program for Communicable Diseases

• National Tuberculosis Control Program

• Minor Programs

• National Mental Health Program

• National Japanese Encephalitis Control Program

• National Diabetes Control Program

• National Kala-azar Control Program

• National Water Supply and Sanitation Program

(*Programs are merged into National Vector Borne Control Program since 2003-04)

Core functions of healthcare delivery system in India are as follows:

• Monitoring health situation

• Disease surveillance

• Health promotion

• Regulations

• Partnerships

• Planning & Policies

• Human Resource Development

• Reducing impact of emergencies on health

1 Growing population and economy

One driver of growth in the healthcare sector is India’s booming population, currently

1.1 billion and increasing at a rate of 2 percent per annum. By 2030, India is

expected to surpass China as the world’s most populous nation. By 2050, the

population is projected to reach 1.6 billion. This population increase is due in part to

a decline in infant mortality, the result of improved healthcare facilities and the

government’s emphasis on eradicating diseases such as hepatitis and polio among

infants. In addition, life expectancy is rapidly approaching the levels of the western

world. By 2025, an estimated 189 million Indians will be at least 60 years of age –

triple the number in 2004, thanks to greater affluence and better hygiene.

The growing elderly population will place an enormous burden on India’s healthcare

infrastructure.

The Indian economy, estimated at roughly $1 trillion, is growing in tandem with the

population. Goldman Sachs predicts that the Indian economy will expand by at least

5 percent annually for the next 45 years, and that it will be the only emerging

economy to maintain such a robust pace of growth. Population growth and its

relation to economic growth has been a matter of debate for over a century. The

early Malthusian view was that population growth is likely to impede economic

growth because it will put pressure on the available resources, result in reduction in

per capita income and resources; this, in turn, will result in deterioration in quality of

life.

Following are the adverse effects of population growth on the Indian Economy:

• adverse effects on savings

• unproductive investment

• slow growth of Per Capita Income

• underutilization of labour

• growing pressure on land

• adverse effect on quality of population and

• adverse social impact.

2 Expanding middle class

India traditionally has been a rural, agrarian economy. Nearly three quarters of the

population still lives in rural areas, and as of 2004, an estimated 27.5 percent of

Indians were living below the national poverty line. Some 300 million people in India

live on less than a dollar a day, and more than 50 percent of all children are

malnourished.

However, India’s thriving economy is driving urbanization and creating an expanding

middle class, with more disposable income to spend on healthcare. While per capita

income was $620 in 2005, over 150 million Indians have annual incomes of more

than $1,000, and many who work in the business services sector earn as much as

$20,000 a year. While this is a fraction of the income that their US peers earn, it is

the equivalent of more than $100,000 per year when adjusted for purchasing power

parity. More women are entering the workforce as well, further boosting the

purchasing power of Indian households. Between 1991 and 2001, the percentage of

women increased from 22 percent to 26 percent of the total workforce, according to

the latest Indian government census. Many of these women are highly educated: the

ratio of women to men who have a college degree or higher level of education is

40:60.

Today at least 50 million Indians can afford to buy Western medicines – a market

only 20 percent smaller than that of the United Kingdom. If the economy continues to

grow faster than the economies of the developed world, and the literacy rate keeps

rising, much of western and southern India will be middle class by 2020.

3 Rise of diseases

Another factor driving the growth of India’s healthcare sector is a rise in both

infectious and chronic degenerative diseases. While ailments such as poliomyelitis,

leprosy, and neonatal tetanus will soon be eliminated, some communicable diseases

once thought to be under control, such as dengue fever, viral hepatitis, tuberculosis,

malaria, and pneumonia, have returned in force or have developed a stubborn

resistance to drugs. This troubling trend can be attributed in part to substandard

housing, inadequate water, sewage and waste management systems, a crumbling

public health infrastructure, and increased air travel.

In addition to battling infectious diseases, India is grappling with the emergence of

diseases such as AIDS as well as food-and water-borne illnesses. And as Indians

live more affluent lives and adopt unhealthy western diets that are high in fat and

sugar, the country is experiencing a rise in lifestyle diseases such as hypertension,

cancer, and diabetes, which is reaching epidemic proportions.

4 Deteriorating infrastructure

India’s healthcare infrastructure has not kept pace with the economy’s growth. The

physical infrastructure is woefully inadequate to meet today’s healthcare demands,

much less tomorrow’s. While India has several centers of excellence in healthcare

delivery, these facilities are limited in their ability to drive healthcare standards

because of the poor condition of the infrastructure in the vast majority of the country.

Of the 15,393 hospitals in India in 2002, roughly two-thirds were public. After years

of under-funding, most public health facilities provide only basic care.

With a few exceptions, such as the All India Institute of Medical Studies (AIIMS),

public health facilities are inefficient, inadequately managed and staffed, and have

poorly maintained medical equipment. The number of public health facilities also is

inadequate. For instance, India needs 74,150 community health centers per million

population but has less than half that number. In addition, at least 11 Indian states

do not have laboratories for testing drugs, and more than half of existing laboratories

are not properly equipped or staffed. The principal responsibility for public health

funding lies with the state governments, which provide about 80 percent of public

funding. The federal government contributes another 15 percent, mostly through

national health programs and the rest of the 5 percent comes from the individual

donations, charity funds and non-governmental organisations.

Q.2. Explain National Health Policy 2002 in detail. Also mention its aims and

objectives. [10 Marks]

Answer:

The main objective of the revised National Health Policy, 2002 is to achieve an

acceptable standard of good health among the general population of the country and

has set goals to be achieved by the year 2015. The major policy prescriptions were

as follows:

• Increase public expenditure from 0.9 percent to 2 percent by 2010.

• Increase allocation of public health investment in the order of 55 percent for the

primary health sector; 35 percent and 10 percent to secondary and tertiary sectors

respectively.

• Gradual convergence of all health programmes, except the ones (such as TB,

Malaria, HIV/AIDS, RCH), which need to be continued till moderate levels of

prevalence are reached.

• Need to levy user charges for certain secondary and tertiary public health services,

for those who can afford to pay.

• Mandatory two year rural posting before awarding the graduate medical degree.

• Decentralizing the implementation of health programmes to local self governing

bodies by 2005.

• Setting up of Medical Grants Commission for funding new Government Medical and

Dental colleges.

• Promoting public health discipline.

• Establishing two-tier urban healthcare system – Primary Health Centre for a

population of one lakh and Government General Hospital.

• Increase in Government funded health research to a level of 2 percent of the total

health spending by 2010.

• Appreciation of the role of private sector in health, and enactment of legislation by

2003 for regulating private clinical establishments.

• Formulation of procedures for accreditation of public and private health facilities.

• Co-option of NGOs in national disease control programmes.

• Promotion of tele-medicine in tertiary healthcare sector.

• Full operationalisation of National Disease Surveillance Network by

2005.

• Notification of contemporary code of medical ethics by Medical Council of India.

• Encouraging setting up of private insurance instruments to bring secondary and

tertiary sectors into its purview.

• Promotion of medical services for overseas users.

• Encouragement and promotion of Indian System of Medicine.

The National Health Policy (NHP) of 1983 was revisited by the Government of India

in 2002. The revisited policy reiterates to achieve an acceptable standard of good

health amongst the general population of the country. The precise approach of the

stated policy is to increase the access to decentralized public health system, ensure

equitable access, increase the public health investment through contribution of

central government, to enhance the contribution of NGO and private sector in health,

to regulate the services of private and public sector, to initiate user charges and

above all strengthen the delivery of primary health care in public sector. The policy

has set time bound goals for identified national problems of malaria, tuberculosis,

blindness, gastroenteritis, cholera and water vector borne diseases, leprosy,

HIV/AIDS etc. The national health policy also identifies the other public health

problems of concern such as trauma and accidents, macro and micro nutrient

deficiencies, life style diseases and problems of aged to be tackled through efforts.

Comparative differences

The first National Health Policy framed in 1983 gave a general exposition of the

policies which necessitated recommendation in the conditions then prevailing in the

country’s health sector. The notable initiatives under that policy were as follows:

1. A phased, time-bound programme for setting up a well-dispersed network of

Comprehensive Primary Health care services, associated with extension and health

education, projected in the context of the ground reality that elementary health

problems can be settled by the people themselves;

2. Intermediation through „Health volunteers having suitable knowledge, simple skills

and needed technologies;

3. Establishment of a well-worked out referral system to make certain that patient

load at the higher levels of the hierarchy is not unnecessarily burdened by those who

can be treated at the decentralized level;

4. An integrated network of evenly spread speciality and super-speciality services;

encouragement of such facilities through private investments for patients who can

pay, so that the draw on the Government’s facilities is limited to those entitled to free

use of those services.

Government initiatives in the pubic health sector have showed some remarkable

successes over time. Smallpox and Guinea Worm Disease have been eradicated

from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and

Filariasis can be expected to be eliminated in the foreseeable future. There has been

a substantial drop in the Total Fertility Rate and Infant Mortality Rate. The success of

the initiatives taken in the public health field are reflected in the progressive

improvement of many demographic/epidemiological/infrastructural indicators over

time – (Table ).

Table : Achievements through the Years 1951-2000

RGI: Registrar General of India; SRS: Sample Registration System; SC: Sub

Centers; PHC: Primary Health Center; CHC: Community Health Center; RHS: Rural

Health Statistics; CBHI: Central Bureau of Health Intelligence; MCI: Medical Council

of India; INC: Indian Nursing Council.

In India, there is no regular system for collecting data on non-communicable

diseases (NCDs)-which can be said to be of adequate coverage or quality.

Thus, most of these estimates at best may be taken as approximation only.

According to SRS-1998 estimates NCDs are responsible for 32% of all deaths in the

country. Of these, cardiovascular diseases constituted 13%, injuries 8.7% and

chronic respiratory diseases 6.7%. Cancers with 3.4% and diabetes with 0.2% were

the other contributors. Rheumatic heart disease

(RHD) is prevalent in the range of 5 to 7/1000 in the 5 to 15 years agegroup. RHD

constitutes 20% to 30% of hospital admission due to all cardiovascular diseases

(CVD) in India.

Q.3. Explain in detail the types of epidemiological studies. [10 Marks]

Answer:

Epidemiology is the study of diseases in large number of humans or other animals,

in particular how, when and where they occur. Epidemiologists endeavor to

determine what factors are related with diseases (risk factors), and what factors may

protect people or animals against disease (protective factors). The science of

epidemiology was first developed to discover and understand possible causes of

contagious diseases like smallpox, typhoid and polio among humans. It has

expanded to include the study of factors associated with non-transmissible diseases

like cancer, and of poisonings caused by environmental agents.

Types of Epidemiological Studies (Observational and Experimental)

Epidemiological studies can be divided into two basic types depending on (a)

whether the events have already happened (retrospective) or (b) whether the events

may happen in the future (prospective). The most common studies are the

retrospective studies which are also called casecontrol studies. A case-control study

may begin when an outbreak of disease is noted and the causes of the disease are

not known, or the disease is unusual within the population studied.

The first step in an epidemiological study is to strictly define exactly what

requirements must be met in order to classify someone as a "case." This seems

relatively easy, and often is in instances where the outcome is either there or not

there (a person is dead or alive).

The strength of an epidemiological study depends on the number of cases and

controls included in the study. The more individual cases that are included in the

study, the more likely it is that a significant association will be found between the

disease and a risk factor. Just as important is determining what behavioral,

environmental, and health factors will actually be studied as possible risk or

protective factors. If inappropriate factors are chosen, and the real factors are

missed, the study will not provide any useful information.

Please see the pictorial representation of the different types of epidemiological

studies in Figure.

1 Observational studies

In observational studies, the epidemiologist does not assign a treatment but rather

observes. For example, if the epidemiologist wanted to see if smoking is related to

lung cancer, she would not be able to ethically assign people to smoke and not

smoke, but rather would observe the prevalence of who (smokers vs. non) develops

cancer.

Case control studies

The "why me?" study investigates the prior exposure of individuals with a particular

health condition and those without it to infer why certain subjects, the "cases,"

become ill and others, the "controls," do not. The main advantage of the case-control

study is that it enables us to study rare health outcomes without having to follow

thousands of people, and is therefore generally quicker, cheaper and easier to

conduct than the cohort study.

Cohort studies

The "What will happen to me?" study follows a group of healthy people with different

levels of exposure and assesses what happens to their health over time. It is a

desirable design because exposure precedes the health outcome – a condition

necessary for causation – and is less subject to bias because exposure is evaluated

before the health status is known. The cohort study is also expensive, time-

consuming and the most logistically difficult of all the studies. It is most useful for

relatively common diseases.

To assess suitability, we find out the commonality of the disease we wish to study.

2 Experimental studies

In experimental studies, the epidemiologist assigns subjects treatments. This is in

contrast to the observational study, where the researcher observes subjects and, in

a sense, 'waits' for the 'treatment' or results to happen. The hallmark of the

experimental study is that the allocation or assignment of individuals is under control

of investigator and thus can be randomized. The key is that the investigator controls

the assignment of the exposure or of the treatment but otherwise symmetry of

potential unknown confounders is maintained through randomization. Properly

executed experimental studies provide the strongest empirical evidence. The

randomization also provides a better foundation for statistical procedures than do

observational studies.

One type of experimental study is the Randomized Control Trial.

Q4. Write short notes on the following:

i. Communicable disease problem in India. [5 Marks]

ii. Nutritional problem in India. [5 Marks]

Answer:

i. Communicable disease problem in India. :

A number of endemic communicable diseases present a serious public health

hazard in India. Over the years, the government has set up a variety of national

programs aimed at controlling or eradicating these diseases, including the National

Malaria Eradication Programme and the National Filaria Control Programme. Other

initiatives seek to limit the incidence of respiratory infections, cholera, diarroheal

diseases, trachoma, goiter, and sexually transmitted diseases. Smallpox, formerly a

significant source of mortality, was eradicated as part of the worldwide effort to

eliminate that disease. India was declared smallpox-free in 1975.

Malaria remains a serious health hazard; although the incidence of the disease declined sharply in the

post-independence period, India remains one of the most heavily malarial countries in the world. Only

the Himalaya region above 1,500 meters is spared. In 1965 government sources registered only

150,000 cases, a notable drop from the 75 million cases in the early post-independence years. This

success

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