HISTORY OF PUBLIC HEALTH IIN INDIA

INTRODUCTION
Focusing on clinical services while neglecting services that reduce exposure to disease is like mopping up the floor continuously while leaving the tap running . (paraphrased from Laurie Garrett, Betrayal of Trust)

 One of the problems with public health is that it can be everything - the air, the food or water, health behavior and health sciences.
Griffiths & Hunter (1999) Perspectives in P. Health Oxford: Radcliffe Medical Press

WHAT IS PUBLIC HEALTH???

Public Health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in personal hygiene, the organization of services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.
Winslow C.E.A. (1920) The Untilled Fields of Public Health Science 51, 23

Has public health existed as long as civilisation?

Brockington noted (1960) that,

public health in some form has existed as long as civilisation. Inoculation against smallpox was practiced in India and China more than two thousand years ago. Isolation of leprosy was enforced in the Roman Empire which built leprosaria; the first isolation hospitals, and many religious abstentions concerned food and excretal pollution.
Brockington F. (1960) The Health of Community Principles (2nd Ed) London: JA Churchill

The origins of public health: historical perspectives

Classical Greek - two rival Greek medical traditions one based on disease classification and the other on emphasising the individual patient. Both based on observation, not divine causation. Hippocrates put great emphasis on the environment in relation to health and well-being

 The Romans and Chinese engineered safe water and sanitary latrines dating from 4000 years ago. The Romans also created a military medical service who focused on the holistic well being of the troops

Medieval and Renaissance Public Health

A Greek text the Salernitan Programme of Health was re-discovered in Constantinople in the eleventh century. It emphasized hygiene, diet and exercise as the basis of good living. The church dominated medieval practices, relating to ill health. Plagues were caused by divine retribution and certain illnesses were stigmatized.

The origins of the Public Health movement

The recurrence of plague in 14th and 15th Century Europe inspired concern for its control Italy set up permanent magistrates charged with overseeing moral and physical hygiene in cities These magistrates set up a system to isolate the sick and set up hospitals to do this Books of the dead were kept to record mortalities and plot the course of epidemics

 Cities swollen in size by trading activities initiated public health measures, Bruges (Belgium/Flanders) became the first city in Europe to install an integrated water and sewage network. Leprosy was very common and sufferers were stigmatised, forced into ghettos and made to comply with distinctive dress codes and sound a bell when people came near.

From the middle ages to the early Victorian period two dominant theories of disease causation

The miasmic theory, illness was due to miasma, toxic air from rotting debris, `a foul smelling vapour`. The humoral theory, the body was made up of different `humors` which needed to be kept in balance. However ultimately disease was seen as God`s punishment for the sins of humankind
Lupton D. (1997) The Imperative of Health Sage

First International Public Health Conference

In 1851 the first international public health conference was held with 12 nations debating for six months. Sardinia, Portugal and Russia supported the use of quarantine. England and France subscribed to the miasmic theory. By 1900 ten conferences had met and were most concerned with the spread of cholera.

In Europe and North America 3 phases of public health activity can be identified in the last 150 years

First Phase This movement was triggered by the appalling toll of death and disease among the working classes in the mid 19th Century following the industrial revolution. In the 1830`s half of Manchester children died before their fifth birthday, and in Liverpool a labourer had a life expectancy of 15 years.

Second Phase Public Health focuses were housing sanitation clean water The public health movement at this time resulted in Chadwick`s Public Health Act of 1848 (in Britain)

 The germ theory of disease causation and the future potential of immunization and vaccination became clear. Pressing environmental problems began to be dealt with. The therapeutic era began in the 1930/40`s in Britain with the advent of insulin and sulphonamides. Until that the therapeutic `arsenal` had proved to be of little efficacy. This period marks a weakening of the `public health` focus for health services and a shift of resources to hospital services, particularly teaching hospitals. Preventive efforts began to focus on the individual

Third Phase

Phase four
The new public health movement goes beyond the understanding of human biology and recognizes the importance of social and psychological aspects as determinants of health and well-being. The therapeutic era is being challenged; with most countries experiencing a crisis in health care costs, due to limitless demand and demographic changes.

The new public health movement

Shifts responsibility for health from the individual back to the social, and the individual and acknowledges the wider determinants of health (see next slide) Can have a mixed workforce including staff from statutory and non-statutory organizations, local residents, voluntary organizations and local pressure groups Engages with state set targets.

The wider determinants of health

Dahlgren G. & Whitehead M. (1991) in, Benzeval M. Judge K. & Whitehead M. (Eds) Tackling Inequalities in Health: An Agenda for Action London: Kings Fund Institute

Age Sex and Hereditary Factors

WHO Global Commission on the Social Determinants of Health

Closing the gap in a generation: Health equity through action on the social determinants of health (Final report of the commission Sept 2008)

History of public health in India

History of public health in india

History of Public Health in Indian can be traced back to pre medieval times. Concerns in the health development and public health dates back to the Indus Civilization. One finds evidence of well developed environmental sanitation program in the cities of that time such as underground drains, public baths etc. First concrete evidence of public health is available from the Ashoka Period when hospitals were set up for sick people

EARLY HISTORY
Excavations of Indus valley civilization showed relics of planned cities with drainage, houses and public baths built of baked bricks suggesting the practice of environmental sanitation. India was invaded by Aryans around 1,400 BC . It is during this period, the Ayurveda and the Siddha systems of medicine came into existence Ayurveda or the science of life developed a comprehensive concept of health

The MANU SAMHITA prescribed rules and regulations for personal health, dietetics and hygiene rituals at the time of birth & death. Also emphasized the unity of physical, mental, and spiritual aspects of life.

Early history-post vedic 600BC TO 600 AD

Religious teachings of Buddhism and Jainism Medical education introduced universities of Taxila and Nalanda in

Hospital system developed by King Rahula sankirtyana( Son of Buddha) for men women and animals

650 to 1850 AD Rise and fall of Moghul empire, Arabic system of medicine(UNANI MEDICINE). Changes in political system, medical education and services became static Ancient universities and hospitals disaapeared

Public Health in British India 1757 British established their rule in India 1859- royal commission appointed to investigate causes of unsatisfactory health in British army in India 1864- sanitary commissioners appointed in Bombay ,Madras and Bengal 1869- public health commissioner and statistical officer appointed with GOI

Public Health in British India

1873 to 1880birth and death registration act The vaccination act Indian factories act 1881- first all India census taken 1896- epidemic of plague, plague commission appointed

Public Health in British India

1911- The Indian Research Fund Association (now ICMR) was established for the promotion of research. 1912- Govt. Of India sanctioned the appointment of Deputy Sanitary commissioners and Health officers. 1918- The Lady Reading Health School, Delhi was established The Nutrition Research Laboratory was established at Coonoor.

Public Health in British India

1919- first step towards decentralization of health administration The MontagueChelmsford Reforms led to the transfer of Public Health, Sanitation and vital statistics to the provinces under the control of an elected minister 1930- The all India Institute of Hygiene and Public Health, Calcutta was established with aid from Rockefeller Foundation Child Marriage restraint act 1931-Maternity and Child welfare Bureau established under Indian Red Cross Society.

Public Health in British India 1937- Central Advisory Board of Health was set up. 1939- the Madras Public Health Act was passed First Rural Health Training Centre was established at Singur, near Calcutta Tuberculosis Association of India was established 1940 to 1946 Drugs act Health survey and Development Committee (Bhore committee)

 Bhore committee submitted its report in 1946 Health of nation reviewed under 1.Public health 2.Medical relief 3.Professional education 4.Medical research 5.International health

Post independence era

Bhore committees report became basis for planning and measures adopted by GOI. 1947- Ministry of Health established at centre and states, several high posts were introduced

VOLUME I, BHORE COMMITTEE REPORT

In this volume the report draws a picture of the state of the public health in the country & of the existing health organizations. Term health implies more than absence of the disease in the individual and indicates a state of harmonious functioning of body and mind in relation to his physical & social environment so as to enable him to enjoy life to the fullest possible extent and to reach his maximum productive capacity.

Post independence era

1948- India

joins WHO

Employees state insurance act and report on environmental hygiene committee was published 1949- constitution of India adopted 26 Nov.

Post independence era 1951- First Five Year Plan(1951-1955)

Rs.140 crores(5.9%) alloted for health programme. BCG Vaccination programme launched (1951) National malaria control programe.(1953) Nation wide family planning programme started(1952) Committee to draft a Model Public Health Act National water supply and sanitation programme (1954) National Leprosy Control Programme (1955)

FIRST FIVE YEAR PLAN (1951-1955)

VDRL antigen production in Calcutta Prevention of food adulteration act National Filaria Control Programme. Hindu marriage act 18 yrs for boys and 15 yrs for girls

Second five yr plan(1956-1961)

Rs.225crores were allotted for health programmes, (5%) Model public health act published Central Health Education Bureau Influenza Pandemic swept country(1957), NMCP converted to national malaria eradication programe.

Second five yr plan

National TB survey completed Mudliar committee to survey the progress made in field of health since submission of bhore committees report Central expert committee under ICMR to study problems of Cholera and Smallpox Rajasthan first state to introduce Panchayati Raj

Second five yr plan

School health committee was constituted by Union Health Ministry to assess the present standards of health & nutrition of school children and suggest ways & means to improve them National Nutrition Advisory Committee was constituted. Pilot project for eradication of smallpox was initiated. Vital statistics transferred to Registrar general of India , ministry of home affairs, from the Directorate General Health Services

Third five yr plan (1961-66)

Rs.342crores (4.3%) was allotted to National Health programmes Mudaliar committee report was published The Central Bureau of Health Intelligence was established. The Central Family Planning Institute established at Delhi National smallpox eradication programme was launched (1962). National goitre control programme was launched ( 1962).

Third five yr plan

Chaddha committee established a norm of one basic health worker for every 10,000 population (1963) Applied nutrition programme was launched (1963) Emphasis on family planning Shantilal shah committee to study the question for legalizing abortions (1963)

Third five yr plan

Director , ICMR recommended Lippes Loop as safe and effective for mass programme.(1965) MUKHERJEE committee constituted to look in to minimum additional staff required for PHC s to take over maintainence of malaria and small pox programme (1966)

Fourth five yr plan 1969 to1974

Allocation of 840 crores to health and 315 crores to Family planning Report of medical education committee was submitted ( 1969) Drug price control order,1970 was promugulated. Registration of birth and death act came into force in 1970 Family pension scheme for industrial workers came into force (1970). MTP Act came into force on April 1,1972

Fifth five yr plan 1974 to 1979

796 crores to health and 516crores to family planning 5 July 1975 India becomes free of smallpox ICDS was launched on october 2 1975 The cigarettes regulation Act 1975 was passed. Shrivastav committee submitted report on medical education and support manpower (1975) National programme for prevention of blindness

Fifth five yr plan Bill on air pollution introduced(1978) Child marriage act amendment: boys 21yrs and girls 18 yrs(1978) 1979-Declaration of Alma Ata PHC approach Regional office for health and family welfare came into existence.

Sixth five yr plan 1980 to 84

WHO and member states adopted global strategy for HFA New 20 point programme announced GOI announces its national health policy IMPACT India programme. National plan against avoidable disablement 1984- BHOPAL GAS TRAGEDY, ESI bill (amendment), the Workmens compensation act, Juvenile Justice Act 1986

Seventh five yr plan 1985 to 1990

Universal immunization programme was launched Environment protection act 1986 was launched World wide safe motherhood campaign by world bank National Diabetes control and National AIDS Control programme was initiated ( 1987) Blood safety programme was launched ( 1989) `

1991
India stages the last decadal census of the century

Eighth five yr plan 1992 to 1997 Child survival and safe motherhood prog. (1992) The infant milk substitute , feeding bottles and infant foods act 1992 came into force DOTS pilot project Return of plague after 28 yrs of silence (1994)

Eighth five yr plan

Legislation on transplantation of human organs enacted Pulse polio immunization , largest single day public health event on 9th Dec 1995 and 20th Jan 1996 RCH programme was launched

Ninth five yr plan

1998 to 2002

National family health survey-2 undertaken Signatory to UN millennium declaration 2000 2001- first census of century National policy for empowerment of women National health policy announced

Tenth five yr plan 2003 to 2007 Emergence of SARS Parliament approves prohibition, regulation of trade and commerce of cigarettes and other tobacco Vandematram scheme Mid day meal scheme National prog for prevention of vector borne diseases

Tenth five yr plan

Integrated disease surveillance project launched National guidelines for infant and young child feeding formulated in aug,2004

20051.RCH II launched 2.JSY launched 3.NRHM launched 4.Indian public health standards for CHCs formulated

2006

1. WHO releases new pediatric growth chart

2. Ban on child labor as domestic servant

3. National family health survey-3 conducted 4. Ministry of women and child carved out 5. IMNCI launched in 16 states

Eleventh five yr plan

11th five yr plan launched in 2007 NACP III launched Indian public health standards for PHC and sub centres Maintenece and welfare of parents and senior citizen bill Non communicable disease prog as pilot project launched

11th Five Year Plan Health

Reduce infant mortality rate (IMR) to 28 and maternal mortality ratio (MMR) to 1 per 1000 live births. Reduce Total Fertility Rate to 2.1.

11th Five Year Plan Health

Provide clean drinking water for all by 2009 and ensure that there are no slip - backs by the end of the 11th Plan. Reduce malnutrition among children of age group 0 - 3 to half its present level. Reduce anemia among women and girls by 50% by the end of the 11th Plan.

COMMITTEES WHOSE RECOMMENDATIONS WERE PIONEER IN HISTORY OF INDIAN PUBLIC HEALTH

HEALTH SURVEY & DEVELOPMENT COMMITTEE (BHORE COMMITTEE)

The Health survey & Development Committee was appointed by the Government of India in October 1943 to make: A broad survey of the present position in regard to the health conditions & health organizations in British India. Recommendations for future development. The committee was chaired by Sir Joseph Bhore The Committee regularly met for 2 years & submitted its famous report in three volumes in 1946

 The committee put forward, for the first time ,Comprehensive proposals for the development of National Programme of Health services for the country The Committee observed If the nations health is to be built, the health programmes should be developed on a foundation of preventive health work and that such activities should proceed side by side with those concerned with the treatment of the patients

IMPORTANT RECOMMENDATIONS OF BHORE COMMITTEE

Integration of preventive & curative services at all administrative levels. The committee visualized the development of primary health centres in two stages: As Short Term Measure: It was proposed that each primary health centre in the rural areas should cater a population of 40,000 with a secondary health centre to serve as a supervisory, coordinating and referral institution.

For each PHC: 2 Medical officers 4 Public Health Nurses 1 Nurse 4 Midwives 4 Trained dais 2 Sanitary Inspectors 2 Health assistants 1 Pharmacist 15 other class IV employees

 As Long Term programme: Setting up of Primary Health Units with 75 bedded hospitals for each 10,000 to 20,000 populations and secondary unit with 650 bedded hospitals again regionalized around district hospitals with 2500 beds Major changes in medical education which includes 3 months training in Preventive & Social medicine to prepare Social Physicians.

HEALTH SURVEY & PLANNING COMMITTEE ( MUDALIAR COMMITTEE)

In 1959, the Govt. Of India appointed a committee known as Health Survey & Planning Committee popularly known as MUDALIAR COMMITTEE (after the name of chairman Dr.A.L.Mudaliar) The purpose of the committee was to survey the progress made in the field of health since submission of the Bhore Committees report and to make recommendations for future development development and expansion of health services.

MAIN RECOMMENDATIONS OF MUDALIAR COMMITTEE

Consolidation of advances made in the first two five year plans. Strengthening of District Hospitals with specialist services to serve as central base of regional services. Regional organization in each state between the headquarters organization and the district in charge of a Regional Deputy or Assistant Directors each to supervise 2 or 3 districts medical and health officers

 Each primary health centre not to serve more than 40,000 population To improve the quality of health care provided by the primary health centres. Integration of medical & health services as recommended by Bhore Committee Constitution of All India Health Service on the pattern of Indian Administrative Services.

CHADAH COMMITTEE,1963
In 1963, a committee was appointed by the Govt. Of India under the chairmanship of DR. M.S.CHADAH, the then Director General of Health Services to study the arrangements necessary for the maintenance phase of the National Malaria Eradication programme. The committee recommended that the Vigilance operations in respect of the National Malaria eradication Programme should be the responsibility of the general health services i-e Primary Health centres at block level.

 One Basic Health Worker per 10,000 population was recommended. These workers were envisaged as multipurpose workers to look after additional duties of collection of vital statistics and family planning, in addition to malaria vigilance. The Family Planning Health Assistants were to supervise 3 or 4 of these basic workers .

MUKHERJI COMMITTEE, 1965

It was realised that the basic health workers could not function effectively as multipurpose workers. As a result the Malaria vigilance operations suffered and also the work of the family planning could not be carried out satisfactorily Therefore a committee known as MUKHERJI COMMITTEE 1965, under the chairmanship of Shri MUKHERJI, the then Secretary of health to the Govt. Of India was appointed to review the strategy of Family Planning.

 The committee recommended the separate staff for the Family Planning Programme. The Family Planning assistant to undertake only family planning duties. The basic health worker to be utilized for purposes other than family planning. The committee also recommended to delink the Malaria activities from family Planning activities.

MUKHERJI COMMITTEE, 1966

As the states were finding difficult to take over the whole burden of the maintenance phase of malaria and other mass programmes due to paucity of funds, a committee of Health Secretaries was appointed under the chairmanship of the Union Health Secretary Shri MUKHERJI. The committee worked out the details of BASIC HEALTH SERVICE which would be provided at the block level and some consequential strengthening at higher levels of administration.

JUNGALWALLA COMMITTEE,1967
The Central Council of Health at its meeting held in 1964 in Srinagar taking note of the importance and urgency of integration of health services, and elimination of private practice by government doctors, appointed a committee known as COMMITTEE ON INTEGRATION OF HEALTH SERVICES under the chairmanship of Dr. N.JUNGALWALLA, Director National Institute of Health Administration and Education New Delhi. The committee was appointed to examine various problems including those of services conditions and submit a report to the Central Government in the light of these considerations

 The committee defined integrated services as; A service with a unified approach for all problems instead of a segmented approach to different problems. Medical care of the sick and conventional public health programmes functioning under a single administrator and operating in unified manner at all levels of hierarchy with due priority for each programme obtaining at a point of time. The committee recommended the integration from highest to the lowest services, organization and personnel

MAIN RECOMMENDATIONS
Unified Cadre Common Seniority Recognition of extra qualification. Equal pay for equal work. Special pay for specialized work. No private practice Good service conditions

KARTAR SINGH COMMITTEE,1973

Also known as Committee on Multipurpose Workers. It was chaired by KARTAR SINGH, Additional Secretary, Ministry of Health & Family Planning. The terms of reference of the committee were to study and make recommendations on: The structure for integrated services at peripheral and supervisory level. The feasibility of having multi purpose, bi purpose workers in the field. The utilization of mobile unit set up under family planning programme for integrated medical, public health and family planning services operating in the field

MAIN RECOMMENDATIONS
The present auxiliary Nurse Midwives to be replaced by the newly designated Female Health Workers, and the present day Basic Health Workers, Malaria Surveillance Workers, Vaccinators, Health Education Assistants and the Family Planning Health Assistants to be replaced by Male Health Workers. The programmes for having Multipurpose Workers to be first introduced in the area where Malaria is in maintenance phase and smallpox has been controlled, and later to other areas as malaria passes into maintenance phase or smallpox controlled.

 For proper coverage there should be one Primary Health Centre for a population of 50,000 Each Primary Health Centre should be divided into 16 sub-centres, each having a population of 3000 to 3500 depending upon topography and means of communications Each sub-centre to be staffed by a team of one male and one female health worker. There should be a male health supervisor to supervise the work of 3 or 4 male health workers, and a female health supervisor to supervise the work of 4 female health workers

 The present day lady health visitor to be designated as female health supervisor. The doctor in charge of the primary health centre should have overall charge of the supervisors and health workers in his area. The recommendations of the Kartar Singh committee were accepted by govt. Of India to be implemented in a phased manner during 5th Five Year Plan.

SHRIVASTAVA COMMITEE,1975
The Govt. Of India in the Ministry of Health & Family Planning had in November 1974 set up a Group on Medical Education and Support Manpower popularly Known as SHRIVASTAVA COMMITTEE To devise a suitable curriculum for training a cadre of Health Assistants so that they can serve as a link between the qualified medical practitioners and the multipurpose workers, Thus forming an effective team to deliver health care, family welfare, and nutritional services to the people.

 To suggest the steps for improving the existing medical educational processes as to provide due emphasis on the problems particularly relevant to national requirements. To make any other suggestions to realize the above objectives and matters incidental thereto. The group submitted its report in April 1975 It recommended immediate action for:

MAIN RECCOMENDATIONS
Creation of Bands of para-professional and Semi-Professional health workers from within the community itself. Establishment of 2 cadres of Health workers, namely Multipurpose Workers & Health Assistants between the Community level workers & the doctors at the PHC. Development of Referral Services Complex by establishing proper linkages between the PHC & higher level referral and service centres ,viz.. taluka/tehsil, district, regional & Medical College Hospitals.

 Establishment of Medical & Health Education Commission for planning and implementing reforms needed in the health and medical education on the lines of University Grants commission. The Committee felt that by the end of Sixth Plan, one Male & one Female Health Worker should be available for every 5000 populations Also there should be one male and female health assistants for 2 male and 2 female health workers respectively The Health Assistants should be located at subcentre and not at the PHC.

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