The success or failure of any government in the final analysis must be measured by the well-being of its citizens. Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people.

Franklin Delano Roosevelt

An effective public health system that can assure the nation’s health requires the collaborative efforts of a complex network of people and organizations in the public and private sectors, as well as an alignment of policy and practice of governmental public health agencies at the national, state, and local levels.

Public health infrastructure provides communities, states, and the Nation the capacity to prevent disease, promote health, and prepare for and respond to both acute (emergency) threats and chronic (ongoing) challenges to health. Infrastructure is the foundation for planning, delivering, evaluating, and improving public health.

Today the health infrastructure of India is in pathetic condition, it needs radical reforms to deal with new emerging challenges. On the one hand the role of private players is continuously increasing in the healthcare sector, but simultaneously healthcare facilities are getting costly, and becoming non-accessible for the poor. The government hospitals are facing the problem of lack of resources and infrastructure; there are inadequate number of beds, rooms, and medicines.

Why Is Public Health Infrastructure Important?

All public health services depend on the presence of basic infrastructure. Every public health program—such as immunizations, infectious disease monitoring, cancer and asthma prevention, drinking water quality, injury prevention—requires health professionals who are competent in cross-cutting and technical skills, up-to-date information systems, and public health organizations with the capacity to assess and respond to community health needs. Public health infrastructure has been referred to as “the nerve center of the public health system.”

While a strong infrastructure depends on many organizations, public health agencies (health departments) are considered primary players. Health agencies rely on the presence of solid public health infrastructure at all levels to support the implementation of public health programs and policies and to respond to health threats, including those from other countries.

Background

Report on the Health Survey and Development Committee, commonly referred to as the Bhore Committee Report, 1946, has been a landmark report for India, from which the current health policy and systems have evolved.

The recommendation for three-tiered health-care system to provide preventive and curative health care in rural and urban areas placing health workers on government payrolls and limiting the need for private practitioners became the principles on which the current public health-care systems were founded. This was done to ensure that access to primary care is independent of individual socioeconomic conditions. However, lack of capacity of public health systems to provide access to quality care resulted in a simultaneous evolution of the private health-care systems with a constant and gradual expansion of private health-care services.

Although the first national population program was announced in 1951, the first National Health Policy of India (NHP) got formulated only in 1983 with its main focus on provision of primary health care to all by 2000. It prioritized setting up a network of primary health-care services using health volunteers and simple technologies establishing well-functioning referral systems and an integrated network of specialty facilities. NHP 2002 further built on NHP 1983, with an objective of provision of health services to the general public through decentralization, use of private sector and increasing public expenditure on health care overall. It also emphasized on increasing the use of non-allopathic form of medicines such as ayurveda, unani and siddha, and a need for strengthening decision-making processes at decentralized state level. Due to the India’s federalized system of government, the areas of governance and operations of health system in India have been divided between the union and the state governments. The Union Ministry of Health & Family Welfare is responsible for implementation of various programs on a national scale (National AIDS Control Program, Revised National Tuberculosis Program, to name a few) in the areas of health and family welfare, prevention and control of major communicable diseases, and promotion of traditional and indigenous systems of medicines and setting standards and guidelines, which state governments can adapt. In addition, the Ministry assists states in preventing and controlling the spread of seasonal disease outbreaks and epidemics through technical assistance. On the other hand, the areas of public health, hospitals, sanitation and so on come under the purview of the state, making health a state subject. However, areas having wider ramification at the national level, such as family welfare and population control, medical education, prevention of food adulteration, quality control in manufacture of drugs, are governed jointly by the union and the state government.

Understanding Public Health Infrastructure

Public health infrastructure can best be described by what it is and what it does. It includes three key components:

1. A capable and qualified workforce
2. Up-to-date data and information systems
3. Agencies capable of assessing and responding to public health needs

Public health infrastructure provides the necessary foundation for undertaking the basic responsibilities of public health, which have been defined as the 10 Essential Public Health Services:

1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8. Ensure competent public and personal health care workforces.
9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
10. Research for new insights and innovative solutions to health problems.

Public health-care infrastructure in India

India has a mixed health-care system, inclusive of public and private health-care service providers.6 However, most of the private health-care providers are concentrated in urban India, providing secondary and tertiary care health-care services.

Sub-centers

• A sub-center (SC) is established in a plain area with a population of 5000 people and in hilly/difficult to reach/tribal areas with a population of 3000, and it is the most peripheral and first contact point between the primary health-care system and the community.
• Each SC is required to be staffed by at least one auxiliary nurse midwife (ANM)/female health worker and one male health worker (for details see recommended staffing structure under the Indian Public Health Standards (IPHS)).
• Under National Rural Health Mission (NRHM), there is a provision for one additional ANM on a contract basis.
• SCs are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programs.
• The Ministry of Health & Family Welfare is providing 100% central assistance to all the SCs in the country since April 2002 in the form of salaries, rent and contingencies in addition to drugs and equipment.

Primary health centers

• A primary health center (PHC) is established in a plain area with a population of 30 000 people and in hilly/difficult to reach/tribal areas with a population of 20 000, and is the first contact point between the village community and the medical officer.
• PHCs were envisaged to provide integrated curative and preventive health care to the rural population with emphasis on the preventive and promotive aspects of health care.
• The PHCs are established and maintained by the State Governments under the Minimum Needs Program (MNP)/Basic Minimum Services (BMS) Program. As per minimum requirement, a PHC is to be staffed by a medical officer supported by 14 paramedical and other staff.
• Under NRHM, there is a provision for two additional staff nurses at PHCs on a contract basis. It acts as a referral unit for 5-6 SCs and has 4-6 beds for in-patients. The activities of PHCs involve health-care promotion and curative services.

Community health centers

• Community health centers (CHCs) are established and maintained by the State Government under the MNP/BMS program in an area with a population of 120 000 people and in hilly/difficult to reach/tribal areas with a population of 80 000.
• As per minimum norms, a CHC is required to be staffed by four medical specialists, that is, surgeon, physician, gynecologist/obstetrician and pediatrician supported by 21 paramedical and other staff.
• It has 30 beds with an operating theater, X-ray, labor room and laboratory facilities.
• It serves as a referral center for PHCs within the block and also provides facilities for obstetric care and specialist consultations.

First referral units

• An existing facility (district hospital, sub-divisional hospital, CHC) can be declared a fully operational first referral unit (FRU) only if it is equipped to provide round-the-clock services for emergency obstetric and newborn care, in addition to all emergencies that any hospital is required to provide.
• It should be noted that there are three critical determinants of a facility being declared as a FRU:
  • emergency obstetric care including surgical interventions such as caesarean sections;
  • care for small and sick newborns; and
  • blood storage facility on a 24-h basis.

Schematic diagram of the Indian Public Health Standard (IPHS) norms, which decides the distribution of health-care infrastructure as well the resources needed at each level of care is shown below,

On the basis of the distributional pyramid, currently there are 722 district hospitals, 4833 CHCs, 24  049 PHCs and 148 366 SCs in the country.

ISSUES

The following data obtained from National Health Profile 2010 shows condition of health infrastructure in India:

• Insufficiency of Hospital Beds: There are 12,760 hospitals having 576,793 beds in the country. Out of these 6795 hospitals are in rural areas with 149,690 beds and 3,748 hospitals are in urban areas with 399,195 beds. Average Population served per Government Hospital is 90,972 and the average population served per government hospital bed is 2,012.
• Dismal Number of Healthcare Centers: There are 1,45,894 Sub Centers, 23,391 Primary Health Centers and 4,510 Community Health Centers in India as of March 2009 (Latest). These figures are insufficient keeping in mind the model of 2005 National Commission on Macroeconomics and Health.
• Insufficient Number of Blood Banks: Total number of licensed Blood Banks in the Country as of January 2011 is 2,445. States in North East India are severely low on availability of Blood Banks except for the state of Assam; remaining six states only have 43 licensed Blood Banks.
• Urgent Need of more Medical Colleges: In terms of Medical education infrastructures the country has 314 medical colleges, 289 Colleges for BDS (Bachelor of Dental Surgery) courses and 140 colleges conduct MDS (Master of Dental Surgery) courses with total admission of 29,263 (in 256 Medical Colleges), 21,547 and 2,783 respectively during 2010-11. Population of the country during this period increased by about 1.3%.
• Concentration of Healthcare in Metro-cities: Central Government Health Scheme (CGHS) has health facilities in 24 cities having 246 Allopathic Dispensaries and Total 438 Dispensaries in the Country with 8, 47,081 registered cards/ families.

SUGGESTIONS

• The Central Government should increase the share of healthcare expenditure and the state governments should also increase their share of funds allotted for healthcare.
• It has to be remembered that education and healthcare are two sectors which must be given more and more importance by the government because of our dependence on the service sector.
• The prospect of the service sector would depend upon the human capital (professionals), and a better health among the general populace would definitely have a positive impact on the service sector.
• The government must also review its health policy at regular intervals, possibly every two years to assess the impact of different schemes and programmes which are run by it.
• The National Rural Health Mission is a wonderful programme which has brought many changes in the quality of healthcare services in the rural areas. But the mission must also include in its ambition the urban poor and especially the people who live in slums.
• Health Policy budgets should include and integrate infrastructure plans. Mere requests for infrastructure funding may face opposition because they are generic in nature and do not have the effect of directly addressing health problems which are overt in nature such as prevention of spread of infectious diseases, maternal and child health etc.

Conclusion

India has been focussing on providing comprehensive care facilities to its citizens. It has framed policies that allow the design and implementation of programs in an inclusive manner. However, looking at the pace of achievements of the targets so far and future targets, it needs to focus more on framing of the policies in terms of building capacity of existing human resources, enhancing further allocation of finances dedicated toward newborn care, identifying areas through operational research, which can enhance quantity and quality of care for newborn care in India. The path is set and we need to operationalize and move forward.