2 - P - G - D - in Hospital Administration - 418 22 - Health Care System PDF

ALAGAPPA UNIVERSITY
[Accredited with ‘A+’ Grade by NAAC (CGPA:3.64) in the Third Cycle

and Graded as Category–I University by MHRD-UGC]
(A State University Established by the Government of Tamil Nadu)
KARAIKUDI – 630 003
Directorate of Distance Education
P.G. Diploma in Hospital Administration

II - Semester
418 22
HEALTH CARE SYSTEM

Authors
Dr. Puneeta Ajmera, Head and Assistant Professor, Department of Hospital Administration, Amity University, Haryana
Sheetal Yadav, Assistant Professor, Amity University, Haryana
Units (1-14)
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SYLLABI-BOOK MAPPING TABLE
Health Care System
BLOCK I: BASICS OF HEALTH CARE SYSTEM Unit 1: Health Care

UNIT 1 Health Care: Concept of health care – Levels (Pages 1-9)
UNIT 2 Health care system in India – Structure of Government Unit 2: Health Care System
Machinery in India
UNIT 3 Private, Government, Corporate Hospitals. (Pages 10-22)
Unit 3: Private, Government and
UNIT 4 Organisations for Health: Voluntary health agencies in India –
Corporate Hospitals
Indian Red cross Society (Pages 23-33)
Unit 4: Organisations for Health:
Voluntary Health Agencies in India
(Pages 34-43)
BLOCK II: PRIMARY HEALTH CARE SYSTEM Unit 5: Primary Health Care:
UNIT 5 Primary Health care – Components-Principles of primary health An Introduction
care –A new course of Action for Health-Implications of the primary (Pages 44-49)
Health care Approach – Distribution of Primary Health care centres Unit 6: Hospitals vs Primary Health
UNIT 6 Hospitals Vs Primary care : A false Antithesis, the need for Care: A False Antithesis
(Pages 50-57)
hospital Involvement –role and functions of the hospital at the first
Unit 7: Natural History of Disease
Referral level, Issues in role of Hospital in primary health care. (Pages 58-73)
UNIT 7 Natural history of disease ,Epidemiological Triad – levels of Unit 8: Occupational Health
prevention /Intervention ,Risk approach in Health care – Measurement (Pages 74-80)
UNIT 8 Occupational Health -Definition and scope of occupational
health – health problems due to Industrialization.
BLOCK III: HOLISTICAPPROACH TO HEALTH Unit 9: Occupational Hazards

UNIT 9 Occupational Hazards –Physical Hazards ,chemicalhazards, (Pages 81-97)
Biological hazards, Psycho-social Hazards, Prevention and Control Unit 10: Evolution of Health Care
Hazards. Delivery System
(Pages 98-106)
UNIT 10 Evolution of Health Care delivery system- brief history of
Unit 11: Holistic Approach
evolution-salient features of various committees – Changing trends in to Health
evolution of health care delivery system (Pages 107-139)
UNIT 11 Holistic Approach to health –Evolution of medicine- Ayurveda,
yoga, Naturopathy, Sidda Vaidya system, Unani medicine, Homeopathy,
Traditional Chinese medicine, Acupuncture, Reiki
BLOCK IV: COST BENEFIT ANALYSIS Unit 12: Education System: Medical and
UNIT 12 Education system, medical and paramedical education ,post- Paramedical Education
graduate specialization ,primary health care, secondary and tertiary (Pages 140-157)
health care, Logistics of training, Economics of Holistic medicine. Unit 13: Organizational Structure of
UNIT 13 Organisational Structure of health care system at district level, Healthcare System at District Level
functions of District health office (Pages 158-169)
Unit 14: Cost Benefit Analysis in
UNIT 14 Cost-Benefit Analysis: Cost-benefit analysis in health care
Healthcare Services
services. (Pages 170-180)
CONTENTS
BLOCK 1: BASICS OF HEALTH CARE SYSTEM
UNIT 1 HEALTH CARE 1-9
1.0 Introduction
1.1 Objectives
1.2 Concept of Health Care and Levels
1.2.1 Levels of Health Care
1.3 Primary Health Care
1.4 Answers to Check Your Progress Questions
1.5 Summary
1.6 Key Words
1.7 Self Assessment Questions and Exercises
1.8 Further Readings
UNIT 2 HEALTH CARE SYSTEM IN INDIA 10-22

2.0 Introduction
2.1 Objectives
2.2 Introduction to Healthcare System in India
2.2.1 Structure of Healthcare System in India: Government Machinery
2.2.2 Machinery (Medical Devices and Equipment) of Healthcare
2.2.3 National Health Policies and Programs
2.4 Summary
2.5 Key Words
UNIT 3 PRIVATE, GOVERNMENT AND CORPORATE HOSPITALS 23-33

3.0 Introduction
3.1 Objectives
3.2 Evolution and Development of Hospitals
3.2.1 Technological Development and Emergence of Hospitals
3.2.2 Healthcare System in India: Private, Government and Corporate
3.2.3 Classification of Hospitals
3.4 Summary
3.5 Key Words
UNIT 4 ORGANISATIONS FOR HEALTH: VOLUNTARY

HEALTH AGENCIES IN INDIA 34-43
4.0 Introduction
4.1 Objectives
4.2 Functions of Voluntary Organisations
4.3 Voluntary Health Agencies in India
4.3.1 Voluntary Health Association of India (VHAI)
4.3.2 Indian Red Cross Society (IRCS)
4.3.3 Indian Leprosy Association (Hind Kusht Nivaran Sangh)
4.3.4 Indian Council for Child Welfare (ICCW)
4.3.5 Central Social Welfare Board (CSWB)
4.3.6 The Kasturba Memorial Fund
4.3.7 Family Planning Association of India (FPAI)
4.3.8 All India Women’s Conference (AIWC)
4.3.9 All India Blind Relief Society
4.5 Summary
4.6 Key Words
BLOCK 2: PRIMARY HEALTH CARE SYSTEM

UNIT 5 PRIMARY HEALTH CARE: AN INTRODUCTION 44-49
5.0 Introduction
5.1 Objectives
5.2 Components and Principles of Primary Health Care
5.2.1 Primary Care: A New Course of Action and Implications
5.3 Distribution of Primary Health Care Centres
5.5 Summary
5.6 Key Words
UNIT 6 HOSPITALS VS PRIMARY HEALTH CARE: A FALSE ANTITHESIS 50-57

6.0 Introduction
6.1 Objectives
6.2 Hospitals and Primary Health Care
6.2.1 Administrative Functions of the Hospitals
6.2.2 Need for Hospital Involvement
6.2.3 Role and Functions of Hospitals at First Referral Level
6.3 Issues in Role of Hospitals in Primary Health Care
6.5 Summary
6.6 Key Words
UNIT 7 NATURAL HISTORY OF DISEASE 58-73

7.0 Introduction
7.1 Objectives
7.2 Meaning of Natural History of Disease
7.2.1 Four Common Stages in Natural History
7.2.2 The Disease Pattern of Population
7.3 Epidemiological Triad
7.4 Levels of Prevention/Intervention
7.5 Risk Approach in Health Care
7.5.1 Measures of Association
7.7 Summary
7.8 Key Words
UNIT 8 OCCUPATIONAL HEALTH 74-80

8.0 Introduction
8.1 Objectives
8.2 Definition and Scope
8.2.1 Effects of Industrialisation on Health and Delivery of Healthcare
8.2.2 Health Problems due to Industrialisation
8.2.3 Prevention of Occupational Disease
8.4 Summary
8.5 Key Words
BLOCK 3: HOLISTIC APPROACH TO HEALTH

UNIT 9 OCCUPATIONAL HAZARDS 81-97
9.0 Introduction
9.1 Objectives
9.2 Meaning of Occupational Hazards
9.2.1 Physical Hazards
9.2.2 Chemical Hazards
9.2.3 Biological Hazards
9.2.4 Psychosocial Hazards
9.3 Prevention and Control of Hazards
9.5 Summary
9.6 Key Words
UNIT 10 EVOLUTION OF HEALTH CARE DELIVERY SYSTEM 98-106

10.0 Introduction
10.1 Objectives
10.2 Brief History of Evolution
10.2.1 Salient Features of Various Committees
10.3 Changing Trends in the Evolution of Healthcare Delivery System
10.5 Summary
10.6 Key Words
UNIT 11 HOLISTIC APPROACH TO HEALTH 107-139

11.0 Introduction
11.1 Objectives
11.2 Holistic Health
11.3 Evolution of Different Systems of Medicine
11.3.1 AYUSH
11.3.2 Naturopathy
11.3.3 Reiki
11.4 Traditional Chinese Medicine (TCM)
11.6 Summary
11.7 Key Words
BLOCK 4: COST BENEFIT ANALYSIS
UNIT 12 EDUCATION SYSTEM: MEDICAL AND PARAMEDICAL

EDUCATION 140-157
12.0 Introduction
12.1 Objectives
12.2 Introduction to Medical and Paramedical Education
12.3 Paramedical Education System in India: Postgraduate Specialization
12.3.1 Challenges for Medical Education and Logistics of Training
12.3.2 Economics of Holistic Medicine
12.5 Summary
12.6 Key Words
UNIT 13 ORGANIZATIONAL STRUCTURE OF HEALTHCARE SYSTEM

AT DISTRICT LEVEL 158-169
13.0 Introduction
13.1 Objectives
13.2 Health Care System at District Level and Functions of District Health Office
13.4 Summary
13.5 Key Words
13.6 Self-Assessment Questions and Exercises
UNIT 14 COST BENEFIT ANALYSIS IN HEALTHCARE SERVICES 170-180

14.0 Introduction
14.1 Objectives
14.2 Economic Evaluation and Cost Benefit Analysis
14.2.1 Basic Principles of Economic Evaluation
14.2.2 Techniques of Economic Evaluation
14.4 Summary
14.5 Key Words
INTRODUCTION
Health is a state subject as per the constitution of India. It is the responsibility of

NOTES every state to make efforts for raising the health standard and standard of living of
the targeted population and the advancement of public health as its primary function.
Access to health care depends on how health care is provided. In India, the
healthcare sector shows a tremendous improvement, since last few decades. This
can be illustrated by the notable improvement in health indicators such as infant
mortality, maternal mortality, and life expectancy at birth etc. Despite these
improvements, India still faces many issues and gaps in the healthcare delivery
system.
The healthcare system faces some challenges that are, reduction in mortality
rates, improved infrastructure, availability of health personnel, etc. There is a
considerable shortage of hospitals, hospital beds, and trained medical staff such as
doctors and nurses, and so the accessibility among the public is not so good. The
rural-urban imbalance also hampers access to health care services.
This book, Health Care System is divided into 14 units which discuss the
concept, issues and challenges of the health care system in India. This book has
been designed keeping in mind the self-instructional mode or SIM format, wherein
each unit begins with an ‘Introduction’ to the topic and is followed by an outline of
the ‘Objectives’. The detailed content is then presented in a simple and structured
from, interspersed with ‘Check Your Progress’ questions to test the student’s
understanding. A ‘Summary’ of the content, along with a list of ‘Key Words’ and
a set of ‘Self-Assessment Questions and Exercises’ is provided at the end of each
unit for effective recapitulation. Relevant examples/illustrations have been included
for better understanding of the topics.
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Health Care
BLOCK - I
BASICS OF HEALTH CARE SYSTEM
NOTES
UNIT 1 HEALTH CARE
Structure
1.0 Introduction
1.1 Objectives
1.2 Concept of Health Care and Levels
1.3 Primary Health Care
1.5 Summary
1.6 Key Words
1.0 INTRODUCTION
Health is declared as a fundamental human right. Health is influenced by a number

of factors such as physical environment (air, soil, climate, water, etc.), food, living
conditions, sanitation, life style, etc. Provision of health care also embraces multitude
of services provided to individuals, families or communities by the agents of health
services or professions, for the purpose of promoting and maintaining health.
With the emergence of the concept of positive health as stated in the WHO
definition of health, health care came to be conceived as an integrated care
comprising of preventive, promotive, curative, rehabilitative and/or restorative
functions that bear long-term association with an individual extending from womb
to tomb and assessing the state of health as well as disease. It is thus clear that
health care includes medical care.
1.1 OBJECTIVES
After going through this unit, you will be able to:

 Describe the different levels of healthcare services
 Explain the concept of healthcare
 Discuss the elements and attributes of primary healthcare
 Analyse the principles of primary healthcare
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Health Care
1.2 CONCEPT OF HEALTH CARE AND LEVELS
The term medical care refers chiefly to the personal services that are directly
NOTES provided by the physicians. Until the British colonial rule, health care in India was
ill-organized and comprised of Aryurveda, Yoga, Unani, Siddha and Homeopathy
systems of medicine. After the British rule, health care predominantly became
curative, using Allopathic system of medicine. It was available chiefly to the urban
population and rich class.
As per the recommendations of Bhore Committee 1946, provision of health
care services was meant to be in an integrated manner, as a package, as explained
above. Comprehensive health is not provided by the health department alone but
in combination with health related departments such as agriculture, irrigation,
fisheries, etc.
Fig. 1.1 Levels of Health Care

Let us analyse the different levels of health care.
1. Primary Level of Health Care
Primary level of health care comprises exchange of basic, utilitarian and essential
services between the individual/family and health care providers. The health care
services are provided even to the ordinary individual of the society, i.e. at the
‘grass-root’ level. In India, this care is provided by primary health centers, and
their subcenters, supplemented by the services of the village health guides, the
anganwadi workers and trained dais. These services are also called as ‘Primary
Health Care’.
2. Secondary Level of Health Care
The health care services of the secondary level are made available for individuals
having complex issues which cannot be dealt at primary level. They are provided
by hospitals and specialized units. Therefore, remedial services are provided in
Taluka Hospitals and Community Health Centers. These centers are also served
as the First Referral Level/First Referral Units (FRU).
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3. Tertiary Level of Health Care Health Care
The healthcare services at the tertiary level are specialized services available for
individuals. The specialized services are provided by the apex or regional institutions
such as government teaching institute for eg. All India Institute of Medical Sciences, NOTES
District hospitals, and specialized high-tech hospitals. These institutions not only
provide high-tech diagnosis and highly specialized (superspecialty) care, but also
have better planning and managerial skills. They also conduct training programs
and research activities.
Private health sector is a growing industry in India, providing high amount of
economic growth to the health industry. This industry includes both Secondary
and Tertiary levels of healthcare. In order to provide good quality service to people,
it is important to use resources in a judicious and efficient manner so that health
improvement can take place. But in India, as of now more than half of the budget
is spent in providing curative care rather than preventive or primary services, which
leads to more investment but lower revenue generation.
The latest studies on health care for Schedule caste revealed that 38% of
health services are utilized from private medical facilities whereas 28% are availed
from the government health facilities. An additional study presented that the poor
population of urban areas in Calcutta avails public health facilities only for emergency
situations and prefer private facilities for regular care. Therefore, these studies
imply that access to healthcare facilities do not depend only on infrastructure and
supplies but also on the location, social and economic factors and the quality of
the services.
1.3 PRIMARY HEALTH CARE
Let us analyse the primary health care system in great detail here. This is a new
revolutionary approach to health care, identified as the ‘Key Strategy’ of achieving
the Global Social target ‘Health for all by 2000 AD’ in the International Health
Conference, held at Alma-Ata (USSR) during the year 1978. In the conference,
Primary Health Care was defined as an essential health care made universally
accessible to individuals and acceptable to them, through their full participation
and at a cost which the community and country can afford. It forms an integral part
of both the country’s health system, of which it is the nucleus and the overall social
and economic development of the community.
As India is also a developing country in the Alma Ata Declaration on primary
health care, there are various changes taking place in areas such as health indicators,
training of health personnel, health resources and equipment, incorporation of
traditional health specialties and plan to deliver optimum health in order to facilitate
proper functioning of primary health care services. This requires support from
different sectors like health, economic and social sectors. In order to meet the
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Health Care optimum health status of the country there should be proper planning and strategies
involved to reach the goal along with requirement of proper development of policies,
proper economic, social, political as well as administrative support. Most of the
health care services are accessible to urban community rather than to rural or
NOTES vulnerable groups. Therefore, training of health care personnel should be based
on keeping in view the need of the community rather than following the pattern of
other developed countries. For this cause the role of community health workers
or public health workers come into force. Both traditional and modern day practice
can work together to provide a substantially organized pattern that can attain
great heights. The strategy of promotion of health, prevention of illness and curative
aspects which involve planning of health services, providing services to needy
people and maintaining these health services should start at grass root level. A
subcenter should be well furnished with at least one male and one female staff, as
a multipurpose worker and target 5000 population each. Moreover, a subsidiary
health center is operated by a doctor with two health-assistants, and two
multipurpose-workers and targets 25,000 population each. A primary health center
is proposed to cater 50,000 people, where one in every four centers is upgraded
to a rural hospital. Furthermore, the maternal and child health is supported by the
Integrated Child Development Services (ICDS) program at the village level. The
government target by 1985, was to increase the number of ICDS programs to
cover 913 of the 5011 community blocks and 87 slum areas in urban areas.
Attributes:
 Essential health care: It means basic, utilitarian and essential services.
 Universally accessible: This means that the services are made reachable
and approachable to all sections of the population.
 Acceptable: It means that sustainable services are provided to individuals.
 Full participation: It means that provision of any service should start from
the people of the community people and must become a success.
 Affordability: It means that the services are cost-effective and economical
for individuals.
 Adaptability: It means that the services must be flexible in any given condition
and can be easily implemented.
 Availability: It refers that services should be obtainable and reachable
with 24 hours availability.
 Appropriateness: This means that the service is relevant to the requirements
and demands of the individual.
 Closeness: It refers to the vicinity between the health care providers and
the consumers, in other words, the services are readily accessible to discrete
doors.
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 Continuity: It refers that services should be uninterruptedly available from Health Care
‘Womb to tomb’.
 Comprehensiveness: It means that the services are expected to be
promotive, curative, preventive and rehabilitative/restorative for the
NOTES
community.
 Co-ordination: It means that these basic services require the cooperation
of various health related departments.
Elements of Primary Health Care (Components)
 Education concerning the prevailing health problems and methods of
identifying, preventing and controlling them.
 Promotion of food supply and proper nutrition.
 An adequate supply of safe water and basic sanitation.
 Maternal and Child health care including family-planning.
 Immunization against the major infectious diseases.
 Prevention and control of locally endemic diseases.
 Appropriate treatment of common diseases and injuries.
 Provision of essential drugs.
Principles of Primary Health Care
Primary health care consists of four principles, namely equitable distribution,
community participation, inter-sectoral coordination and appropriate technology.
1. Equitable Distribution
This means that the basic health services which are provided under primary health
care must be provided to all the people, irrespective of the caste, creed, community
and ability to pay for it (rich or poor) and thus these services must be accessible to
all. This principle is based on the fact that at present the health care services are
concentrated in towns and cities, (where only 25 per cent of population lives and
75 per cent of the budget is spent) to the rich and curative oriented. On the other
hand, the needy and vulnerable groups of population like rural and the urban slums
(where 75% population lives and only 25% budget is spent) are neglected, who
need and deserve the services the most. This social injustice must be removed and
services must be equally distributed to all people of the community. This is the
‘Key’ principle in Primary health care strategy.
2. Community Participation
This consists of active involvement by people of the community in providing primary
health care. This is based upon the fact that achieving universal coverage of primary
health care is not possible without the involvement of the local community.
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Health Care Involvement of the community in planning, implementation and maintenance of
health services is a very prominent feature. Community participation promotes
social awareness and self-reliance of the community. It increases the community
acceptance of the primary health care programs and reduces the distance between
NOTES providers and the consumers of health care. Thus health care should start with the
people. It is by the people, of the people and for the people. This is called
‘democratization’ of the health service.
Community participation is aimed at placing the health of the people in their
hands. This is a ‘new dynamism’ of health care. It contributes to their own
development and in turn community’s development. One approach that has been
successfully tried in India is training of front line health workers like anganwadi
workers, traditional birth attendants (dais) and village health guides. They are
selected locally, trained locally and provide service locally (to the area they belong)
free of cost. They get honorarium. They provide the care in ways that are acceptable
to the community by overcoming the cultural and other barriers. Thus these frontline
workers constitute the essential features of primary health care in India and
community participation has thus become a new revolutionary approach in country.
This corresponds to ‘Barefoot doctors’ scheme of China. No health program will
be successful without the participation of the public.
Advantages of community participation:
 It is a cost effective method of providing health services.
 People begin to view health more objectively. So they are more likely to
accept the care.
 There will be greater commitment of the people resulting in the success of
health care services.
 Health awareness becomes an integral part of village life.
 Health workers get greater support for their activities.
 People become more soft reliant in taking care of their health.
 Health care services become more relevant to the health needs of the people.
 There is less dependence on Government.
 Quality of the health care improves.
3. Intersectoral Co-ordination
It is also realized that primary health care cannot be provided by health sector
alone to the community. It requires the co-ordination of other health related sectors
also such as education, communication, fisheries, animal husbandry, food and
agricultural department, social-welfare, public-works, voluntary organizations, etc.
Co-ordination of all these sectors is essential. This requires a strong political action.
The co-ordination committees will make policies and implement them in a planned
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way, so as to avoid duplication of the activities. The committee also reviews the Health Care
activities periodically.
4. Appropriate Technology
This means that technology of health care service provided must be ‘appropriate’, NOTES
it must be simple, scientifically sound, practically adaptable, culturally acceptable,
economically cheaper and operationally convenient. Appropriate technologies that
have been developed and introduced in the country are Oral rehydration therapy,
immunization programs, nutritional supplementation, DOTS, distribution of
disposable delivery kits for domiciliary midwifery services, distribution of IFA tablets,
biogas plants for cooking, heating and lighting, smokeless chulhas for cooking,
family welfare services, etc.
It can be concluded that health is a fundamental human right and it is influenced
by numerous factors, so healthcare provides multiple services for each and every
individual, families and communities as a whole for prevention of illness, health
promotion and maintenance of health. According to WHO health is defined as “a
complete physical, mental and social wellbeing and not merely the absence of any
disease or infirmity”.
Health system is the system which is arranged by the people who provide
health care services to the needy population from womb to tomb and even keeping
in view both health and disease.
There are three levels of healthcare namely primary level of healthcare which
is the first level of contact where basic essential services are provided in primary
health centers. The primary health care is defined as “the essential health care
made universally accessible to individuals and acceptable to them, through their
full participation and at a cost the community and country can afford”. The other is
secondary level of health care where secondary services or the specialist services
are provided in community health centers, these are also called first referral units.
The third one is tertiary level of health care where the specialist services and the
super specialty services are provided in super specialty high tech hospitals, district
hospitals and teaching hospitals. So health is a resource and it should be preserved
and maintained in order to live a good healthy and purposeful life, in absence of
any kind of disease or infirmity but the ability to get back from illness and other
problems and live life to its fullest.
Check Your Progress

1. How was health care in India organized until the British colonial rule?
2. What are the three components of healthcare services in India?
3. What do you mean by equitable distribution of health services?
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Health Care
1.4 ANSWERS TO CHECK YOUR PROGRESS
QUESTIONS
NOTES 1. Until the British colonial rule, health care in India was ill-organized and
comprised of Aryurveda, Yoga, Unani, Siddha and Homeopathy systems
of medicine.
2. The three components of healthcare services primary, secondary and tertiary.
3. Equitable distribution of health services means that the basic health services
which are provided under primary health care must be provided to all the
people, irrespective of the caste, creed, community and ability to pay for it
(rich or poor) and thus these services must be accessible to all.
1.5 SUMMARY
 The term medical care refers chiefly to the personal services that are directly
provided by the physicians. Until the British colonial rule, health care in
India was ill-organized and comprised of Aryurveda, Yoga, Unani, Siddha
and Homeopathy systems of medicine.
 After the British rule, health care predominantly became curative, using
Allopathic system of medicine. It was available chiefly to the urban population
and rich class.
 Primary level of health care comprises exchange of basic, utilitarian and
essential services between the individual/family and health care providers.
The health care services are provided even to the ordinary individual of the
society, i.e. at the ‘grass-root’ level.
 The health care services of the secondary level are made available for
individuals having complex issues which cannot be dealt at primary level.
They are provided by hospitals and specialized units.
 The healthcare services at the tertiary level are specialized services available
for individuals. The specialized services are provided by the apex or regional
institutions such as government teaching institute for eg. All India Institute of
Medical Sciences, District hospitals, and specialized high-tech hospitals.
 Private health sector is a growing industry in India, providing high amount
of economic growth to the health industry. This industry includes both
Secondary and Tertiary levels of healthcare.
 As India is also a developing country in the Alma Ata Declaration on primary
health care, there are various changes taking place in areas such as health
indicators, training of health personnel, health resources and equipment,
incorporation of traditional health specialties and plan to deliver optimum
health in order to facilitate proper functioning of primary health care services.
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 Primary health care consists of four principles, namely equitable distribution, Health Care
community participation, inter-sectoral coordination and appropriate

technology.
NOTES
1.6 KEY WORDS
 Tertiary care: It is a specialized consultative health care, usually

for inpatients and on referral from a primary or secondary health professional,
in a facility that has personnel and facilities for advanced medical investigation
and treatment, such as a tertiary referral hospital.
 The Alma-Ata Declaration of 1978: This emerged as a major milestone
of the twentieth century in the field of public health, and it identified primary
health care as the key to the attainment of the goal of ‘Health for All’ around
the globe.
1.7 SELF ASSESSMENT QUESTIONS AND

EXERCISES
Short Answer Questions

1. Differentiate between primary and secondary level of healthcare.
2. State the attributes of primary healthcare.
3. What are the elements of primary health care?
Long Answer Questions
1. Analyse the concept of healthcare.
2. Describe the different levels of healthcare.
3. Discuss primary healthcare and describe its important principles.
1.8 FURTHER READINGS
Suryakantha, AH. 2017. Community Medicine with Recent Advancements.

4th edition. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
Das Gupta M, Chen L, Krishnan TN, ed. 1996. Health, Poverty and Development
in India. Delhi: Oxford University Press.
Websites
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121949/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588212/
https://www.ncbi.nlm.nih.gov/pubmed/6618643
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Health Care System in India
UNIT 2 HEALTH CARE SYSTEM

IN INDIA
NOTES
Structure
2.0 Introduction
2.1 Objectives
2.2 Introduction to Healthcare System in India
2.2.1 Structure of Healthcare System in India: Government Machinery
2.2.3 National Health Policies and Programs
2.4 Summary
2.5 Key Words
2.0 INTRODUCTION
Health system in India plays an important role to determine the way of living,
provision of healthcare services, their utilization and delivery, health consequences
and solutions. India has a mixed healthcare system, where public and private sectors
are working together to provide healthcare services. However, the private sectors
are majorly established in urban areas.
The healthcare system in India is governed by state governments according
to the constitution of India, instead of the central government. The responsibilities
are given to the state governments to raise the level of nutrition and individual’s
living standard. This makes it their primary duty to improve public health.
The Government of India in 1983 made the first national health policy and
updated in a sequence of 2002 and 2017. Moreover, the recent updates in 2017
were focused on decreasing the load of non-communicable diseases, to introduce
the robust healthcare industries, economic growth to enhance fiscal capacity and
on rising public health expenditure on healthcare. However, the rising expenses in
healthcare are majorly responsible by the private sectors, where the expenses are
made by the patient’s pocket and their families instead through insurance. For this
purpose, the Indian government has started many initiatives and encouraged private
sectors to expand in the partnership with public sector i.e. in public private
partnership (PPP) model. Therefore, the government has launched many healthcare
projects in 2018, out of which one of the largest projects is Ayushman Bharat,
which is funded by the central government.
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2.1 OBJECTIVES

 Describe the healthcare structure in India NOTES
 Discuss the national health policies and programmes
 Analyse the technological advancements in India in the healthcare industry
2.2 INTRODUCTION TO HEALTHCARE SYSTEM

IN INDIA
In the following section, the structure of healthcare system in India is discussed

and elaborated. The individuals in India commonly rely on private sectors more
than public sectors because the public sectors are providing poor services. The
private sectors are providing eminent facilities with advanced features. The
healthcare machinery in India is discussed and various manufacturers are introduced.
Also, the medical devices and equipment are elaborated with the major healthcare
industries.
2.2.1 Structure of Healthcare System in India: Government
Machinery
The role of private healthcare providers is increasing nowadays in providing services
to people who need assistance. The private healthcare structure is divided into
two parts: profit and non-profit organizations. On the other side, public healthcare
primarily constitutes community healthcare centers, primary health centers and
sub-centers. And these centers are extended into sub-sections based on the
provision of facilities, services and resources. Though, the secondary healthcare
system is recognized as sub-district hospitals. These hospitals are established based
on the health needs of the districts. Furthermore, the tertiary level of healthcare
includes the district hospitals and teaching hospital which are associated with medical
colleges.
India has twenty nine states and seven union territories and further divided
into districts and blocks. Since the population of India stands after China around
1.25 billion, it has been challenging to maintain the health care system and structures
fulfilling the needs of our population post-independence. Therefore, the public and
private healthcare systems needed comprehensive planning and management, and
required strong policies to implement in India.
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NOTES
Fig. 2.1 Healthcare Structure in India
1. Sub Centers
A Sub Centre is planned in rural areas to provide healthcare services. They are
fully secured and covered by the national government. At least two workers (one
male and one female) are required in mandates to assist a population of about
5000 people. The population criterion is limited to 3000 inhabitants for dangerous,
hilly or remote locations. These sub centers are working to encourage and persuade
rural people towards healthy nutrition and habits of wellbeing in a long run.
2. Primary Health Centers
The primary health care centers are established in advanced rural areas, for the
population of about 30,000 or more and it is limited to a population of about
20,000 for dangerous or hilly or remote locations. Their centers are expected to
have clinics with doctors (1 Medical officer and 1 AYUSH), 4-5 beds and a
pharmaceutical facility. The patients can be referred from sub-centers to the primary
health center to get more advanced treatment. As compared to sub centers, the
primary health centers are supported by the state government instead of the national
government.
3. Community Health Centers
The community health centers are also funded by the state government and have
better and superior facilities than primary health centers. Here, the population
covered is about 1,20,000 while it is limited to 80,000 for hilly and remote areas.
There are around 30-50 beds to treat patients needing admission. These centers
have a physician, anesthetist, surgeon, ophthalmologist, gynecologist and a
pediatrician. The patients from these centers can be referred to the general or
district hospitals, when required. This center acts as a referral unit for four primary
health centers and also considered as first referral units for intensive care, blood
storages, deliveries and new born childcare.
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4. District Hospitals Health Care System in India
The district hospitals are considered as a final referral center for the primary and
secondary health care for public. Every district is expected to have at least one
hospital in India, whereas in practice only 605 hospitals are available in 640 districts. NOTES
The number of beds required is between 70 to 500 which is depending upon the
population of the district and its needs.
5. Medical Colleges
There are medical colleges and research centers or hospitals that are controlled
by the national government, like one of the largest and renowned centers is All
India Institutes of Medical Sciences (AIIMS). These hospitals or centers are well
equipped with special and advanced facilities. There are also regional special centers
that may be controlled jointly by state and national government like regional cancer
center.
6. Profit and Non-profit Organizations
These organizations are categorized into the private sector. The private hospitals
are profit making units and may have the advanced and modern facilities based on
the hospital dimensions. The patients are required to pay for the health care services
themselves from out of their pocket. The private organizations are also responsible
to manage the hospitals on their own. On the other hand, non-profit organizations
have different sources of funding such as donations or under government schemes.
The patients do not have to take responsibility of the expenses or may have to do
a minor contribution towards health care expenses, while the organizations get
managed by the funding sources.
Nowadays, the number of hospitals is increasing which also increases the requirement
of healthcare facilities and therefore the demand for refined medical devices and
equipment. By the use of electronic and communication technologies, the medical
devices are equipped with many advanced features such as sensing, processing,
control, display, and accuracy. As per global medical device nomenclature, the
medical devices and products are of different types and the products are in the
range of 14,500. These products are selected by the hospital facilitators based on
the requirements of hospitals depending upon the health problems of population in
that area. Moreover, the medical technology is improving and advancing, making
significant efforts to encourage innovation in the healthcare sector which is also
providing the opportunity to be benefitted in the Indian market. In the past, the
healthcare system is significantly improved in India due to the advancement and
innovation in the medical technology, biotechnology and biomedical engineering
field.
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Health Care System in India The government health sector is also working to improve the healthcare
products with modern technologies. However, the improvement is only marginal
but increasing gradually due to the competition in the market. The government is
expecting from the medical product manufacturers to produce good quality products
NOTES for public healthcare sector. Moreover, the international contributions are also
tied up with the domestic manufacturers of the medical products to improve the
quality such as 3-Ms, Philips medical system, Becton Dickinson, naming a few.
Furthermore, some of the leading medical devices manufacturing industries are
GE Healthcare, India Medtronic, Johnson & Johnson, Wipro Technologies, HCL
Technologies, Texas Instruments, Nidhi Meditech System, Biopore Surgical, BPL
Healthcare India, etc.
There are a number of key challenges faced by the manufacturing sectors
such as:
 Low Penetration
 Affordability
 Accessibility
 Awareness
 Nascent Regulatory Environment
 Complex Rules and Guidelines
 High Capital requirement
 Low Indigenous Manufacturing
There are some recommendations given by the experts in view to make
improvement in the healthcare industry as follows:
 The legislative amendments need to improve, for enabling the widespread
Medical Device Regulations.
 Training and skill development is the necessity for resources and funds
allocation, whereas the upgrading is also required.
 Creating an ecosystem for the improvement in medical technology via
development, quality, testing, waste management, etc.
 To improve the provision of healthcare services, the GDP needs an increment
from 1% to 3%.
 The collaboration between medical universities and medical centers are
encouraged.
 Quality enhancement training is necessary for the medical and paramedical
staff members which can be resourceful for innovative and creative efforts.
 Improve the medical technology education in respect of curriculum.
 A unique reform is required in the insurance sector to motivate individuals
for accepting the insurance policy, largely.
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2.2.3 National Health Policies and Programs Health Care System in India
Ministry of Health and Family Welfare plays an important role in healthcare in

India while announcing and implementing the policies and programs related to
health care. It works towards providing universal access of quality healthcare. NOTES
The National Health Mission (NHM)
NHM has various goals to achieve in the healthcare structure through proper
mechanisms. The main mechanisms of NHM comprise strengthening of the
healthcare system in rural and urban areas in respect of the neonatal, child,
adolescent health and also the communicable and non-communicable diseases. It
has various levels of monitoring and evaluating the healthcare system at central,
states, districts and blocks. Many different programs have been introduced under
the umbrella of NHM as a part of the program.
National Rural Health Mission (NRHM)
NRHM pursues to provide affordable, quality and accessible healthcare to rural
inhabitants. The special focus is given to the Empowered Action Group States as
well as Jammu and Kashmir, Himachal Pradesh, and North Eastern States under
NRHM. A decentralized health delivery system is its mission to cover all levels of
healthcare. Some of the major initiatives taken by NRHM are ASHAs, Rogi Kalyan
Samiti, Untied Grants for Sub-Centers, Sanitation and Nutrition Committee for
Village Health, Janani Suraksha Yojana, Janani Shishu Suraksha Karyakarm,
Mother and Child Tracking System, Medical Mobile Units, National Ambulance
Services, Rashtriya Bal Swasthya Karyakram, Rashtriya Kishor Swasthya
Karyakram, Child and Mother Health Wings, Free Diagnostic Services and Free
Drugs, and adolescent Health Services, ‘Delivery Points’ identification, Universal
Coverage of Health care, Quality Assurance and many others. Some of the major
disease control national programs under NRHM are as follows:
 Vector Borne Diseases Control Programme
 Leprosy Eradication Programme
 Revised TB Control Programme
 Blindness Control Programme
 Iodine Deficiency Disorders Control Programme
ASHA: ASHA is known as Accredited Social Health Activist. It was launched by
NRHM in 2005 to fulfill and notice the rural needs, particularly for vulnerable
sections of humanity. ASHA is the first port of contact for women and children in
the rural population for any health related demands. She has been providing for
good health services in rural India. ASHAs are working for the following activities:
 ASHA provides information to the community on determining proper diet
and nutrition, sanitation, healthy living and working conditions and hygienic
practices at doorsteps.
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Health Care System in India  ASHA provides information to the pregnant women while visiting their homes
in the village. They are expected to deliver information to pregnant women
regarding safe delivery as well as breastfeeding practice, complementary
feeding, how to take care of young child, immunization, contraception and
NOTES infection’s preventions.
 ASHA also provides health care services for some diseases such as diarrhea,
fever, and first aid for small injuries.
Rashtriya Bal Swasthya Karyakram (RBSK): RBSK a pioneering and
motivating initiative was launched under the National Health Mission by the Ministry
of Health & Family Welfare, Government of India in the year 2013. The initiative
encourages the screening of child health and provides services for early intervention
with a universal and comprehensive approach of primary identification. The scheme
aims at early detection and management of diseases, deficiency conditions and
development delays in children and defects at birth. RBSK is an additional
component for the school health care system, since for the age group from birth to
18 years, anganwadi centres and government schools are also involved under the
scheme. Therefore, children will get free assured services through RBSK.
Janani Suraksha Yojana: Janani Suraksha Yojana was introduced by Ministry
of Health and Family Welfare under the national rural health mission in 2005, for
safe motherhood for poor pregnant women. The scheme was launched with the
objective of reducing the maternal and neonatal mortality. It has a clear linkage
between pregnant women and the government which is also identified by ASHAs.
The yojana is mainly focused in the states having low institutional delivery rates
hence called low performing states such as Uttar Pradesh, Bihar, Uttarakhand,
Orissa, Assam, Madhya Pradesh, Jharkhand, Rajasthan, Chhattisgarh, and Jammu
and Kashmir.
Health, Sanitation and Nutrition Committee at Village Level: Under the
National Rural Health Mission, the Village Health, Sanitation and Nutrition
committee was formed for collective actions on health related issues in the villages.
This committee also functions as a subcommittee of the gram panchayat, with the
minimum of 15 members. The responsibilities and roles are as follows:
 To register all pregnant women of village for antennal care.
 To survey on nutritional status and nutritional deficiencies, among women
and children of the village.
 To vaccinate children against vaccine preventable diseases
 To involve the ASHA, AWW, ANM and ICDS Supervisor.
 To monthly supervise and monitor the health and nutrition in the village.
 Supervising the functioning of Anganwadi Centre (AWC) of the village.
Rogi Kalyan Samiti: The provision of basic preventive, curative and promotive
services is a key motive of the government and policy creators. Therefore, Rogi
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Kalyan Samiti contributes to our government and policies on the same objective. Health Care System in India
It is a simple management structure of a group of hospitals’ trustees, local panchayati

raj institutions and NGOs. Some of the objectives involved are as follows:
 Ensuring the compliance to maintain the standards in hospital facilities and
NOTES
healthcare centers, in accordance to the government
 Ensuring accountability of the health care providers towards the community
 Ensuring transparency in respect to the financial resources received from
the management
 Improving and modernizing the health care services in the hospitals
 Supervising the working of National Health Programmes and schemes in
the hospitals
 Conducting the health camps
 Generating resources through aids, user charges and other resources
 Establishing affiliations with private institutions to improve
 Ensuring construction and expansion in the hospitals premises
 Ensuring proper biomedical waste management
National Urban Health Mission (NUHM)
NUHM, like NRHM is also a part of NHM. It was approved by the government
of India in 2013. It is primarily focused upon the urban inhabitants who are poor
and vulnerable. It aims to provide public health services such as sanitation, drinking
water and vector control. Urban Social Health Activist (USHA) and Mahila Arogya
Samiti are two important pillars of NUHM. Below are some of the major health
programs NUHM works upon:
 Control and Prevention of Diabetes, Cancer, Cardiovascular Disease and
Stroke
 Tobacco Control Program
 Mental Health
 Prevention and Control of Deafness
 Prevention and Control of Fluorosis
 Health Care of the Senior Citizen and Elderly Person
 Sexually Transmitted Diseases Control
Ayushman Bharat Yojana
Ayushman Bharat Yojana has been launched in 2018 and is also known as Ayushman
Bharat - National Health Protection Mission (AB-NHPM) or Pradhan Mantri
Jan Arogya Yojana (PMJAY) or Modicare. To address health care holistically,
this scheme extends beyond curative care, covering preventive and promotive
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Health Care System in India health care, taking actions at primary, secondary and tertiary care systems. This
mission is expected to make extensive impact on comprehensive health care and
insurance landscape. This scheme contemplates the adoption of the standard
treatment guidelines and specific packages costs for surgical procedures. It also
NOTES envisages extensive use of Information Technology and data analytics to observe
or monitor the implementation of the scheme and to manage any fraudulent claims.
This will further improvise the health sector and provide a future roadmap of
reducing deficiencies in health care systems.
In the later stage, this scheme is expected to strengthen primary care services,
including OPD treatment, and increasing the coverage to entire population, achieving
the target of universal health insurance.
Technological Advancements in India
The healthcare industry in India has become equipped with technological
advancements in various sectors, which have turned out to be very helpful for
medical practitioners. Moreover, from last few years, practice of robotic surgeries
has also increased in the hospitals. Numerous diagnostic centers are also established
in urban and rural areas. They are facilitated with modern healthcare devices /
equipment. On the other hand, the patients are also able to make a choice among
suitable doctors for their treatments. The individuals are also aware of the nearest
emergency healthcare centers, where the ambulance facilities are provided in a
critical situation.
Scientists and researchers are continuously working on improving the
healthcare technology like there are various health care devices such as watches
which are embedded with ECG sensors to count the heart beats or measure the
critical situations. A patient can wear a watch and the ECG is monitored
continuously. In case of any abnormality, the information of abnormal condition is
transferred to a doctor mobile or a healthcare centre via the Internet. Thereafter,
a doctor can advise special assistance accordingly. Similar to the above example,
is a tracking system embedded in the hospitals, where it can help to track patient
movements. The movements are captured and recorded to observe the activities
of a patient.
One eminent example of technology advancements is the use of lighting at
homes and hospitals. The research has given various evidence that the different
colours of light affect the health improvement in individuals. For example, the light
of blue colour is useful in the hospital for patients to have peace of mind.
These days healthcare is enabled with mobile wearable technology and
remote monitoring systems. These technologies are helpful to doctors for
determining the diagnosis and treatment. This makes the treatment fast, accurate,
and feasible.
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Check Your Progress

1. State the constituents of public healthcare.
2. What is a sub centre? NOTES
3. What do the major health programmes of NUHM work upon?
4. What does the main mechanism of NHM comprise of?

QUESTIONS
1. Public healthcare primarily constitutes community healthcare centers, primary

health centers and sub-centers.
2. A Sub Centre is planned in rural areas to provide healthcare services. They
are fully secured and covered by the national government. At least two
workers (one male and one female) are required in mandates to assist a
population of about 5000 people.
3. The major health programs NUHM works upon:
 Control and Prevention of Diabetes, Cancer, Cardiovascular Disease
and Stroke
 Tobacco Control Program
 Mental Health
 Prevention and Control of Deafness
 Prevention and Control of Fluorosis
4. The main mechanisms of NHM comprise strengthening of the healthcare
system in rural and urban areas in respect of the neonatal, child, adolescent
health and also the communicable and non-communicable diseases.
2.4 SUMMARY
 The individuals in India commonly rely on private sectors more than public
sectors because the public sectors are providing poor services. The private
sectors are providing eminent facilities with advanced features.
 The role of private healthcare providers is increasing nowadays in providing
services to people who need assistance. The private healthcare structure is
divided into two parts: profit and non-profit organizations.
 A Sub Centre is planned in rural areas to provide healthcare services. They
are fully secured and covered by the national government.
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Health Care System in India  The primary health care centers are established in advanced rural areas, for
the population of about 30,000 or more and it is limited to a population of
about 20,000 for dangerous or hilly or remote locations.
 The community health centers are also funded by the state government and
NOTES
have better and superior facilities than primary health centers.
 The district hospitals are considered as a final referral center for the primary
and secondary health care for public. Every district is expected to have at
least one hospital in India, whereas in practice only 605 hospitals are available
in 640 districts.
 There are medical colleges and research centers or hospitals that are
controlled by the national government, like one of the largest and renowned
centers is All India Institutes of Medical Sciences (AIIMS).
 These hospitals or centers are well equipped with special and advanced
facilities. There are also regional special centers that may be controlled
jointly by state and national government like regional cancer center.
 The government health sector is also working to improve the healthcare
products with modern technologies. However, the improvement is only
marginal but increasing gradually due to the competition in the market.
 Ministry of Health and Family Welfare plays an important role in healthcare
in India while announcing and implementing the policies and programs related
to health care. It works towards providing universal access of quality
healthcare.
 NRHM pursues to provide affordable, quality and accessible healthcare to
rural inhabitants. The special focus is given to the Empowered Action Group
States as well as Jammu and Kashmir, Himachal Pradesh, and North Eastern
States under NRHM.
 Under the National Rural Health Mission, the Village Health, Sanitation
and Nutrition committee was formed for collective actions on health related
issues in the villages. This committee also functions as a subcommittee of
the gram panchayat, with the minimum of 15 members.
 The provision of basic preventive, curative and promotive services is a key
motive of the government and policy creators. Therefore, Rogi Kalyan Samiti
contributes to our government and policies on the same objective.
 NUHM, like NRHM is also a part of NHM. It was approved by the
government of India in 2013. It is primarily focused upon the urban
inhabitants who are poor and vulnerable. It aims to provide public health
services such as sanitation, drinking water and vector control.
 The healthcare industry in India has become equipped with technological
advancements in various sectors, which have turned out to be very helpful
for medical practioners.
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 Moreover, from last few years, practice of robotic surgeries has also Health Care System in India
increased in the hospitals. Numerous diagnostic centers are also established

in urban and rural areas. They are facilitated with modern healthcare devices/
equipment.
NOTES
2.5 KEY WORDS
 AYUSH: The Ministry of Ayurveda, Yoga and Naturopath, Unani, Siddha

and Homoeopathy, abbreviated as AYUSH, is a governmental body in India
purposed with developing, education and research in the field of alternative
medicines including ayurveda, yoga, unani, naturopathy, siddha and
homoeopathy.
 The National Health Mission (NHM): It was launched by the
government of India in 2013 subsuming the National Rural Health Mission
and National Urban Health Mission.
 ASHA: ASHA is known as Accredited Social Health Activist. It was
launched by NRHM in 2005 to fulfill and notice the rural needs, particularly
for vulnerable sections of humanity.

EXERCISES

1. What are the key challenges faced by the manufacturing sector?
2. What are the recommendations for improving the healthcare industry?
3. Write a short note on National Rural Health Mission (NRHM).
1. Describe the healthcare structure in India with the help of a diagram.
2. Discuss some of the important national health policies and programmes.
3. Analyse the various technological advancements in India in the healthcare
industry.
Chokshi, M., Patil, B., Khanna, R., Neogi, S. B., Sharma, J., Paul, V. K., &
Zodpey, S. 2016. Health Systems in India. Journal of Perinatology: Official
Journal of the California Perinatal Association, 36(s3), S9-S12.
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Health Care System in India Websites
https://www.internationalstudentinsurance.com/india-student-insurance/healthcare-
system-in-india.php.
NOTES https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144115/.
http://shodhganga.inflibnet.ac.in/bitstream/10603/186490/10/09%20chapter%
202.pdf.
https://international.commonwealthfund.org/countries/india/.
https://www.pwc.in/assets/pdfs/publications/2018/ayushman-bharat-national-
health-protection-mission.pdf.
http://www.nrhmharyana.gov.in/WriteReadData/Guidelines/ASHAguidlines/
ASHAguidlines/ConceptandOperationalGuidelinesofASHA.pdf.
https://rbsk.gov.in/RBSKLive/.
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/janani-suraksha-
yojana/background.html.
http://www.nhm.gov.in/communitisation/village-health-sanitation-nutrition-
committee.html.
http://www.nhm.gov.in/nhm/nrhm/guidelines/nrhm-guidelines/constitution-of-rogi-
kalyan-samities.html.
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Private, Government and
UNIT 3 PRIVATE, GOVERNMENT Corporate Hospitals
AND CORPORATE
NOTES
HOSPITALS
Structure
3.0 Introduction
3.1 Objectives
3.2 Evolution and Development of Hospitals
3.4 Summary
3.5 Key Words
3.0 INTRODUCTION
Experts say that a large number of deaths occur due to the lack of medical treatment
and facilities, the number sums up to almost 27 per cent of India’s population
which consists of more than 1.5 billion people. For every 10,189 people there is
1 doctor while 2,046 people fight for a single bed.
Healthcare crisis call for basic healthcare needs like medical care, proper
medical professionals and aid, availability of quality hospitals and healthcare systems;
a criteria which urges the mass to choose between public and private healthcare
services in India. In this unit, we will describe the concept of private, government
and corporate hospitals.
3.1 OBJECTIVES

 Discuss the evolution and development of hospitals
 Analyse the technological development and advancement in hospitals
 Discuss the classification of hospitals
 Describe the factors supporting corporate hospitals
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Corporate Hospitals 3.2 EVOLUTION AND DEVELOPMENT
OF HOSPITALS
NOTES The word hospital originated from the Latin word root ‘hospice’ which means a
place to receive guests. In the early Roman and Egyptian civilizations, the hospitals
were not separate units but a part of the temples. These temples were constructed
with an aim to provide shelters to the poor, ill and homeless people. People used
prayers, magic spells and religious rituals to understand the causes of the diseases.
Diseases were considered to be the result of some supernatural forces. In the
Egyptian civilization, peppermint oil, opium and castor oil were used while honey,
salt, water of sacred springs were used by the Greeks to cure various diseases.
Historical evidences also show that cities in some civilizations were planned with
an aim of restricting the spreads of communicable diseases. In the ancient literature
many stories are available where Buddha and his son Upatiso made shelters for
the diseased people and pregnant women where they used to provide medical
services to them. The temples in the Christian era were replaced by specific
buildings for providing treatment to the people suffering from diseases. Before the
industrial revolution medical practice in Europe was provided by the barbers,
apothecaries, etc. and it was primarily aimed to provide comfort to the diseased
rather than medically curing them. Different types of flora and fauna were used as
remedies which was limited to some specific diseases only and rest of the diseases
were known as incurable diseases.
Mesopotamian Medicine (1728-1686 BC)
Medicine emerged as organized entity around 6000 years ago in Mesopotamia a
part of Southwest Asia. Mesopotamian civilization contributed a lot politically as
well as medically to the development of Egyptian, Persian and Indian civilizations.
Greek Medicine (460-136 BC)
460-136 BC was the traditional period of Greek Medicine. In 1200 BC
Aesculapius and his two daughters Hygeia and Panacea were the early leaders in
Greek medicine. Hygeia was considered to be the goddess of Health while Panacea
as the goddess of medicine and they were the pioneers in giving rise to curative
and preventive medicines. The Greeks identified the natural causes of different
diseases and logical mechanisms of healing. They believed that the matter was
composed of four elements viz. air, earth, water and fire which represented four
humors in the body.
Hippocrates (460-370 BC)
Also known as the father of medicine, Hippocrates was the pioneer in applying
non-religious application to medicine. He started using auscultation, performing
surgeries and keeping detailed records of his patients. He was an epidemiologist
who related health and disease with humans and their environment.
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Roman Medicine (130-205 A.D.) Private, Government and
Corporate Hospitals
Galen, a medicine teacher, contributed significantly to the fields of experimental
physiology and comparative anatomy. He gave the concept that diseases occur
because of three factors – predisposing factors, environmental factors and exciting NOTES
factors. In this era few military hospitals were built for a particular group but not
for common people. In 370 AD, in Cappadocia, a religious foundation was
established which included a hospital for sick and the elderly people with an isolated
unit for people suffering from leprosy.
Chinese Medicine
Yin and Yang developed the concept of acupuncture and acupressure to cure
certain diseases which is still used in the modern medicine. Some universities and
schools were established to impart medical education to the students.
Dark Ages of Medicine (500-1500 AD)
Unani medicine system was developed in this era. Mohammad was the first one to
establish a small mobile military hospital Bimaristan. Also, pharmacy and chemistry
were recognized as sciences. Some of the best hospitals in this era were in Baghdad
and Cairo. Religion still had a dominant impact in the development of hospital in
this age and Monasteries were still taking the responsibility of sick people.
Renaissance Age
This period lasted form 14th century to the 16th century and in Europe the
responsibility of healthcare was transferred from churches and monasteries to the
civil authorities leading to the foundation of voluntary hospitals.
Indian Medicine
Ayurveda and Siddha were the major developments in the Indian systems of
medicine. Dhanvantari was known as the “Hindu God of Medicine” while Susruta
as “Father of Surgery”. Charaka compiled his knowledge of medicine in a book
“Charaka Samhita”. In India some hospitals were established in 600 BC and
during the reign of King Asoka hospitals in India started looking like modern
hospitals. Doctors were appointed to take care of healthcare needs of the people.
In the seventeenth century the modern system of medicine was introduced in India
when Christian missionaries arrived in South India and the first hospital was
established in 1664 at Chennai during the British Empire. Medical training in an
organized way started in 1835 when the first medical college was opened in Calcutta.
Two medical colleges were opened in Delhi in 1835 and 1836, followed by one
medical college in Mumbai in 1845 and in Chennai in 1850.
The evolution and expansion of hospitals from an entity for providing shelter to the
poor to the modern hubs equipped with advanced medical technologies is a recent
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Private, Government and phenomenon. This transition has taken place during the latter half of the nineteenth
Corporate Hospitals
and early twentieth century when the hospitals endorsed a scientific biomedical
model of health for curing the diseases prevalent in the society. This biomedical
model focusses on three principles given below:
NOTES
 Health is analysed as the absence of biomedical abnormalities in the body.
 Human body is like a machine that has to be reconditioned to health with
the help of medical treatments aimed to oppose or counter the disease
processes.
 Health of the people largely depends upon the level of medical knowledge
and the accessibility of medical resources.
According to this model, a hospital is considered to be an organization to
cure diseases and deliver healthcare services to the people. Doctors have gained
significance as apart from the providers of medical care, they exercise best control
over the medical technologies, which are ever improving and gaining more accuracy.
To better understand the concept of hospital, it would be exemplary to
understand some definitions of a hospital. A hospital is defined as ‘An image of
physical buildings in which services are provided by skilled staff with a focus for
the delivery of interventions requiring special personnel skills and equipment,
monitoring of patients for therapeutic reasons.’
WHO defines hospital as ‘an integral part of a social and medical organization,
the function of which is to provide for the population, complete health care, both
curative and preventive, and whose out-patient services reach out to the family in
its home environment; the hospital is also a center for the training of health workers
and for bio social research’ and ‘an institution that provides inpatient accommodation
for medical and nursing care’.
With the passage of time the type and quality of hospitals has changed a lot.
Hospitals provide significant advantages to both patients and society. Some health
issues need intense medical treatment and personal care, which is not possible at
home or in the clinics. These facilities can be provided only in the hospitals where
a number of technically skilled professionals apply their knowledge and skills and
use advanced world-class sophisticated medical equipment. Most hospitals
nowadays are equipped with all the ultra-modern resources and are in the process
of becoming renowned world class hospitals.
The present health systems in India evolved from the Bhore Committee Report in
1946. The committee recommended a three-tier healthcare system for providing
curative and preventive healthcare services through health workers on the payroll
of the government. It was also recommended that private practice should be limited
so that primary care becomes independent of socioeconomic conditions of the
people. However, public health care systems were not found enough to provide
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quality care healthcare services to growing Indian population thereby resulting in Private, Government and
Corporate Hospitals
the simultaneous emergence of private healthcare services.
The governance and operational aspects of the Indian healthcare system is
divided between both the union governments and state governments because of
NOTES
federal government system. The national programs like National AIDS Control
Program, program to prevent and control communicable diseases and making
guidelines and policies are implemented by the Union Ministry of Health and Family
Welfare which can be adopted by the state governments. Ministry also helps the
states in the prevention and control of epidemics and endemics by providing
technical assistance. State government controls the areas like public health,
sanitation and hospitals, etc. Some areas like population control, provision of
medical education, quality control management techniques in the manufacturing
medicines and prevention and elimination of food adulteration come under both
union and state governments.
In India, mixed healthcare system is present consisting of both public and
private hospitals. However, private health service providers are mostly concentrated
in urban areas of the country and provide secondary and tertiary health services.
Till 1980s, healthcare services were mainly provided by the government and
charitable hospitals. But the last two decades have witnessed the emergence of
large number of corporate and private hospitals in India. The private healthcare
sector encompasses fifty eight per cent of the hospitals, twenty nine per cent of the
hospital beds and eighty one per cent of the doctors in India. India is ranked
among the top twenty countries of the world concerning private spending on
healthcare. Employers contribute to around 9% on private care, 5%-10% is
contributed by health insurance companies while 82% is spent personally from the
patients. People in India are choosing private hospitals for medical services because
of many reasons. First the infrastructural facilities in the public hospitals are
inadequate with unpleasant surroundings and long waiting lines. Second many
medicines and diagnostic tests are unavailable in the government hospitals due to
which patients are forced to go to private hospitals and laboratories. Third, a
doctor in government hospital has to examine more than 100 patients is one OPD
session.
Hospitals can be classified in various ways as given below:
1. According to the WHO
(a) Regional hospitals: Highly advanced, complex and specialized medical
procedures are provided in these hospitals. They serve larger area in
comparison to the local hospitals. For example: Government Medical
Colleges and Hospitals.
(b) District/Intermediate hospitals: These hospitals provide healthcare
services in major specialties in a particular locality.
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Private, Government and (c) Rural hospitals: These hospitals are located in remote areas and have less
Corporate Hospitals
number of beds and there is a provision of limited number of services.
2. According to objective
NOTES (a) General hospitals: These hospitals provide healthcare services for almost
all types of medical conditions, diseases, illness, injuries and deformities,
etc. Other services include maternity services, neonatal and child care
services laboratory investigations, diagnostic imaging facilities, emergency
services and pharmacy, etc. These hospitals should be equipped with the
facilities that are required to support certified healthcare professionals
rendering their services. Usually, these hospitals do not possess super-
specialized medical care services.
(b) Speciality hospitals: These hospitals specialize in a specific condition or
disease like eye hospitals like Venu Eye Institute and Centre for Sight in
Delhi NCR for eye disorders, cancer hospital like Sri Shankara Cancer
Hospital and Research Centre Karnataka and Apollo Speciality Cancer
Hospital in Tamil Nadu for treatment of cancers.
(c) Teaching cum research hospitals: These hospitals serve as teaching and
research centers for doctors and other healthcare professionals and are
attached with medical colleges and universities. For example AIIMS New
Delhi, CMC (Christian Medical College) Vellore, AFMC (Armed Forces
Medical College) Pune, etc.
3. According to administration/control/funding
(a) Government or public hospitals: These hospitals are under the
administration and control of the government and provide either free
healthcare services to the patients or at nominal rates. They receive funding
from the government and run under the Ministry of Health or any university.
(b) Non-government or private hospitals: These hospitals are owned by an
individual who may be a physician or a group of physicians or by private
organizations. Main objective of these hospitals is to earn profit.
(c) Semi government hospitals
(d) Corporate hospitals: A hospital which is run by a corporation with an
intention to expand in the form of hospital chain in the same way it has
expanded itself into a corporate unit is termed as a corporate hospital.
These hospitals follow the regulations of companies act.
4. According to length/duration of stay
(a) Short stay hospitals (Patient stay < 30 days): Patients stay for less than 30
days in these hospitals for the treatment and management of acute diseases
like ulcers, pneumonia, etc.
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(b) Long stay hospitals (Patient stay > 30 days): Patients stay for more than 30 Private, Government and
Corporate Hospitals
days in these hospitals
5. According to type of medical staff
(a) Closed staff hospitals: In these hospitals all the physicians are on the staff NOTES
panel of the hospitals and they are responsible for diagnosis and treatment
of patients. Doctors that are not on the staff panel do not have any access
to the hospital.
(b) Open staff hospitals: In these hospitals any doctor can request to use the
hospital facilities irrespective of their hospital affiliation i.e. other physicians
who are not on staff panel of the hospital may also admit and treat the
patients.
6. According to bed size/capacity
(a) Small sized hospitals (upto 100 beds)
(b) Medium sized hospitals (> 100 beds to < 300 beds)
(c) Large sized hospitals (> 300 beds)
7. According to type of care
(a) Primary care: It is the basic health care given on day to day basis to the
patients by the healthcare service providers who act as first point of contact
for the patients and also coordinates with other specialists if required. Services
provided by these hospitals include family planning, endemic disease control,
immunization, treatment and management of injuries, providing health
education and ensuring sufficient availability of safe drinking water. Primary
Health Centers and sub centers provide primary care in rural areas, while in
urban areas Family Welfare Centers provide these services in India.
(b) Secondary care: It is the second level of healthcare delivery system, when
from primary health care patients are referred for obtaining specialized
treatment. The Secondary healthcare centers in India include the District
hospitals and Community Healthcare Centers at the block level.
(c) Tertiary care: It is the third tier of healthcare system where specialized
care is given on receiving referrals from the primary and secondary care
centers. Specialized and exclusive units for Intensive Care, modern and
advanced diagnostic equipment and specialized healthcare professionals
are the important attributes of tertiary health care. This service in India is
provided by the medical colleges and research institutes.
8. According to teaching affiliation
(a) Teaching hospitals: These are the hospitals that are attached with colleges
for providing medical education. They are primarily aimed at providing
teaching based on medical research rather than healthcare services.
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Private, Government and (b) Non-teaching hospitals: These hospitals are aimed to provide clinical care
Corporate Hospitals
to the patients.
9. According to medicine systems
NOTES (a) Allopathic hospitals: Ayurvedic hospitals
(b) Homeopathic hospitals
(c) Unani hospitals
Emergence of corporate hospitals
Around twenty years ago the private sector was ruled by solo medical practitioners,
nursing homes, healthcare facilities run by charitable trusts and small hospitals
and the services provided by them were of best quality. After technological
advancements in healthcare sector smaller healthcare organizations have become
comparatively less able to compete. Larger corporations like pharmaceutical
companies, IT companies and rich NRIs started investing in healthcare sector
which are still dominating the market. Large hospitals owned by doctors trained in
foreign countries started providing services at high prices that can only be afforded
by the foreigners and the rich Indians. Globalization has also played a very significant
role in the growth of corporate hospitals in India. The private hospitals in India
offer good quality treatment at much less price comparable to that of developed
countries which has made it a favorable destination for medical tourists seeking
medical treatment at an affordable price. Large number of medical tourists from
Africa, Saudi Arabia, Bangladesh, Afghanistan, Pakistan and Middle East are
coming to India for availing complex healthcare services like cardiac surgeries,
liver transplantation, joint replacement surgeries which are not available in their
home countries. Also patients from developed countries like United Kingdom,
United States of America and Europe come to India to avoid long waiting lists for
the medical procedures.
Factors Supporting Corporate Hospitals
The healthcare sector in mid 80s gained recognition as an industry giving rise to
more possibility of investments from the financial institutions. The import duty on
medical and diagnostic equipment and technology was also decreased by the
government thereby providing ample opportunities for growth and development
of healthcare sector. Increase in the literacy rate, income level and media intervention
led to more awareness regarding health and regular health check-ups became a
necessity which contributed to the growth of corporate hospitals. Certain
pharmaceutical companies like Max India, entered this sector as it is related to
their business. Also, expansion of the insurance sector in India provided opportunities
for private healthcare providers to expand their chain.
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Corporate Hospitals
Check Your Progress
1. When did medicine emerge as an organised entity?
2. Who developed the concept of acupressure and acupuncture? NOTES
3. What were the major developments in the Indian system of medicine?
4. How has WHO defined hospital?

QUESTIONS
1. Medicine emerged as organized entity around 6000 years ago in

Mesopotamia a part of Southwest Asia. Mesopotamian civilization
contributed a lot politically as well as medically to the development of
Egyptian, Persian and Indian civilizations.
2. Yin and Yang developed the concept of acupuncture and acupressure to
cure certain diseases which is still used in the modern medicine.
3. Ayurveda and Siddha were the major developments in the Indian systems
of medicine.
4. WHO defines hospital as ‘an integral part of a social and medical organization,
the function of which is to provide for the population, complete health care,
both curative and preventive, and whose out-patient services reach out to
the family in its home environment; the hospital is also a center for the training
of health workers and for bio social research’ and ‘an institution that provides
inpatient accommodation for medical and nursing care’.
3.4 SUMMARY
 The word hospital originated from the Latin word root ‘hospice’ which
means a place to receive guests. In the early Roman and Egyptian civilizations,
the hospitals were not separate units but a part of the temples. These temples
were constructed with an aim to provide shelters to the poor, ill and homeless
people.
 Medicine emerged as organized entity around 6000 years ago in
Mesopotamia a part of Southwest Asia. Mesopotamian civilization
contributed a lot politically as well as medically to the development of
Egyptian, Persian and Indian civilizations.
 Ayurveda and Siddha were the major developments in the Indian systems
of medicine. Dhanvantari was known as the “Hindu God of Medicine” while
Susruta as “Father of Surgery”. Charaka compiled his knowledge of medicine
in a book “Charaka Samhita”.
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Private, Government and  In the seventeenth century the modern system of medicine was introduced
Corporate Hospitals
in India when Christian missionaries arrived in South India and the first
hospital was established in 1664 at Chennai during the British Empire.
 The evolution and expansion of hospitals from an entity for providing shelter
NOTES
to the poor to the modern hubs equipped with advanced medical technologies
is a recent phenomenon.
 This transition has taken place during the latter half of the nineteenth and
early twentieth century when the hospitals endorsed a scientific biomedical
model of health for curing the diseases prevalent in the society.
 With the passage of time the type and quality of hospitals has changed a lot.
Hospitals provide significant advantages to both patients and society. Some
health issues need intense medical treatment and personal care, which is
not possible at home or in the clinics.
 The present health systems in India evolved from the Bhore Committee
Report in 1946. The committee recommended a three-tier healthcare system
for providing curative and preventive healthcare services through health
workers on the payroll of the government.
 In India, mixed healthcare system is present consisting of both public and
private hospitals. However, private health service providers are mostly
concentrated in urban areas of the country and provide secondary and
tertiary health services.
 Till 1980s, healthcare services were mainly provided by the government
and charitable hospitals. But the last two decades have witnessed the
emergence of large number of corporate and private hospitals in India.
 Around twenty years ago the private sector was ruled by solo medical
practitioners, nursing homes, healthcare facilities run by charitable trusts
and small hospitals and the services provided by them were of best quality.
After technological advancements in healthcare sector smaller healthcare
organizations have become comparatively less able to compete.
 The healthcare sector in mid 80s gained recognition as an industry giving
rise to more possibility of investments from the financial institutions. The
import duty on medical and diagnostic equipment and technology was also
decreased by the government thereby providing ample opportunities for
growth and development of healthcare sector.
3.5 KEY WORDS
 Unani: Unani or Yunani medicine is the term for Perso-Arabic traditional

medicine as practiced in Mughal India and in Muslim culture in South Asia
and modern day Central Asia.
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 Yin and Yang: They are the underlying principles of Chinese philosophy Private, Government and
Corporate Hospitals
and medicine. Good health is believed to come from a balance of Yin
(negative, dark, and feminine) and Yang (positive, bright, and masculine).
NOTES
EXERCISES

1. Write a short note on the origin of hospitals.
2. State the principles of biomedical model of medicine.
3. How has the WHO classified hospitals?
4. State some of the factors supporting corporate hospitals.
1. Analyse the growth of medicine from the Mesopotamian Medicine to the
present times.
2. Describe the technological advancements in hospitals.
3. Discuss the healthcare system in India.
4. Classify hospitals according to the length, administration control and teaching
affiliation.
Prasad, Purendra. Jesani, Amar. 2018. Equity and Access: Health Care Studies
in India. New Delhi: Oxford University Press.
Peters, David H. 2002. Better Health Systems for India’s Poor. World Bank
Publications.
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Organisations for Health:
Voluntary Health Agencies
in India UNIT 4 ORGANISATIONS FOR
HEALTH: VOLUNTARY
NOTES
HEALTH AGENCIES IN
INDIA
Structure
4.0 Introduction
4.1 Objectives
4.2 Functions of Voluntary Organisations
4.3 Voluntary Health Agencies in India
4.3.5 Central Social Welfare Board (CSWB)
4.5 Summary
4.6 Key Words
4.0 INTRODUCTION
Voluntary organisations are the non-official, traditional organisations that are set-
up by groups of civic-minded and philanthropic people to serve the social and
health needs of the community. These organisations exist for humanitarian and
selfless motives, with focus on ‘service to the community’, and contribute significantly
to the public healthcare system of the nation. Voluntary healthcare organisations
are either endorsed by the contributions made voluntarily by the people or by the
paid services, and are liable to the contributors of the organisations, to the third
party payment sources, and are free to support and experiment, like Voluntary
Health Association of India.
4.1 OBJECTIVES

 Analyse the voluntary health organisations
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 Understand the functions of the voluntary health organisations Organisations for Health:
 Discuss the different voluntary health organisations working in India in India
4.2 FUNCTIONS OF VOLUNTARY NOTES

ORGANISATIONS
Voluntary organisations have a long term history of contributing in the promotion

of human well-being and welfare. These are the private undertakings for the progress
of society. Voluntary action is the soul and essence of the democracy as it acts as
a medium to ensure that people are actively involved from policy-making to the
enforcement of the social services. The programs run by the voluntary organisations
cover a wide variety of functions dealing with health and welfare of human beings.
These programs include specialised, highly professional, and technical people
assembled for a specific objective. Several national level organisations are linked
with the associations or federation at the international level. There are various
organisations, which have an indirect influence on the promotion of healthcare
programs instead of direct involvement. The programs of direct relevance to
healthcare administration and management include the projects for the improvement
of food production, nutrition and housing, promotion of literacy rate, provision of
potable and safe water, availability of instructional and educational material,
community development, women and child welfare, improve environmental
sanitation, etc. Therefore, they help to prevent illnesses and promote health. Some
of the major functions of Voluntary Health Agencies (VHAs) in India are:
 Providing direct services or assisting individuals involved in the activities
like programs for patient care, providing nursing services, consultations or
other professional healthcare services to the people
 Supporting directly or through funds and grants the research in the areas of
medical and health sciences as well as in the processes of financing and
distributing healthcare services. That is why, VHAs can better explore means
and ways of organizing new activities
 Assigning the jobs of supervision and training of the volunteer workforce
either to other organisations or directly providing supplementary services
 Supplementing the work of official agencies by preparing and disseminating
information material to general public. The official agencies are unable to
provide complete services because of certain statutory or financial limitations
and restrictions. The VHAs can contribute by raising funds for important
equipment or providing other supplementary support services to the agencies
 Assisting in recruiting and training of personnel by arranging scholarships
and grants for different demonstration services to continue the program
 Under other sources, guide the work of official agencies by criticising and
evaluating the official agencies
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in India Check Your Progress
1. List the programs, which are of direct relevance to voluntary organisations.
NOTES 2. Who endorses voluntary healthcare organisations?
4.3 VOLUNTARY HEALTH AGENCIES IN INDIA
There are several voluntary health agencies working in India since pre-independence
period of time. Initially the health services started in India with some voluntary
groups, for instance, the missionaries from other countries provided services for
children, women, and patients suffering from leprosy, some of which are still playing
a major role in the health care programmes in the country.
VHAI was established in 1970 as a registered, non-profit society. It is an association
of twenty seven State’s Voluntary Health Associations and links more than 4500
institutions, which are contributing to the health development in the country. They
advocate the policies, which are public-centric for dynamic program management
and health planning in India. They have supported and initiated innovative and
novel programs focusing on the health and development at the grass root level
with the active involvement of people. They strive to bring a strong and sturdy
healthcare movement in India for a developing, cost-effective, preventive, and
reformative health system. VHAIs are accountable for a responsible private and
public health sector and quality service. They promote various health issues related
to rights and comprehensive development of people. Following are its goals and
objectives:
 To make health development, a reality for the people of India
 To promote and strengthen a medically rational, economically sustainable,
and culturally acceptable health care system in the country
 To ensure equity, social justice, and human rights in the provision and
distribution of health care services to all, with focus on the less privileged
population
 To develop innovative and sustainable strategies to ensure health and overall
community development in the remote and vulnerable areas, through various
grass-root level initiatives
IRCS was formed in 1920 and operates with the help of organisations at national
and international levels. Presently, it has above four hundred functioning branches
in India. It provides training to the community members in various medical
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procedures and also focuses on some health issues. Following are its major Organisations for Health:
functions: in India
 Providing relief operations during disasters like wars, earthquakes, floods
or famine. For example, collecting and distributing clothes and food to the
NOTES
affected people.
 Supplying medicines, vitamin supplements, milk, etc. to the hospitals and
dispensaries. It also provides services related to family planning.
 Assisting in relevant research related activities and offering scholarships to
nurses for their upgrade.
 Offering first aid emergency training with the help of its branch i.e. ‘St John
Ambulance Association for men and home nursing courses for women’.
 Providing blood bank facility to the people.
 Publishing and distributing informative material related to mother and child
care.
Indian Red Cross Society has 35 state association regions divisions, along
with their 700 locale and sub-area divisions. The overseeing body is accountable
for the administration and management of the elements of the general public via
various number of advisory groups.
Impartiality, neutrality, humanity, independence, unity, voluntary benefits and
universality are the fundamental principles of Red Cross Society.
Indian Leprosy Association is a prestigious agency devoted to the cure and
rehabilitation of patients suffering from leprosy. Leprosy (Hansen’s disease) is a
chronic infection, which is caused by the bacteria Mycobacterium leprae and
Mycobacterium lepromatosis. There are approximately 40, 00, 000 diseased
patients in India. The phobia regarding the disease was particularly remarkable
and therefore, the mass scale treatment and restoration program moved the diseased
individuals, with the formation of Hind Kusht Nivaran Sangh, on an all India level
in 1949. Hon’ble Leader of India is the Leader of the Association and affiliation
health minister is the Chairman.
It provides financial assistance to various leprosy clinics and homes, and
conducts research and field investigation and training of medical workers. The
association has many branches in the country, which operate in collaboration with
the government and several other voluntary organisations. It arranges ‘All India
Leprosy Workers’ conferences and also publishes a quarterly journal Leprosy in
India. It renders healthcare education through informative posters and publications.
Following are the present activities of Sangh:
 Producing and distributing the material for health education and awareness
about leprosy
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Organisations for Health:  Publishing the Indian Journal of Leprosy quarterly and a news bulletin
in India ‘Kusht Vinashak’ bi-annually for the leprosy workers as well as general
population
 Producing and distributing the ‘leprosy seals’ to make the people aware
NOTES
about leprosy and assist other agencies to raise funds for their activities by
selling these seals
 Observing 30th January as Anti-Leprosy Day every year to spread general
awareness regarding leprosy
 Conducting training courses for the duration of nine months at two training
centres for leprosy in the country, one in Naini, Uttar Pradesh and other in
Purulia, West Bengal
 To organize ‘All India Leprosy Worker’s and Regional Leprosy Worker’s
Conferences’ in association with the other branches in the state and voluntary
agencies
 To support leprosy patients and other voluntary associations
 To maintain a house known as ‘Shanthi Illam’ at Vellore in Tamil Nadu,
where free boarding and lodging facilities are provided to the leprosy patients
coming for surgical treatment at CMC College and Hospital.
 To run two mobile leprosy treatment units funded by the government of
India in two districts of Delhi.
Indian Council for Child Welfare (ICCW) was established in 1952 and is affiliated
to ‘International Union for Child Welfare’. Its activities are focused on securing
those facilities and opportunities that will help in the physical, moral, psychological,
social, and spiritual development of the children in a normal and healthy manner,
with freedom and dignity. Ever since its establishment, it has created a networking
matrix of the district and state councils across the country. It is an association
working on the following:
 To advocate children’s rights
 Crèches for children of working and ailing mothers
 To organise training programs for child care workers
 Sponsoring under-privileged children for school education
 To scrutinize adoption cases
 To rehabilitate abandoned children
 To provide institutional and day care services for differently-abled children
 To run programs for children living in difficult circumstances
 To run programs with a special emphasis on girl child
 To run support services and education centres
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 To honour child artists Organisations for Health:
 To honour children for bravery in India
 To organise adventure/National Integration camps

4.3.5 Central Social Welfare Board (CSWB) NOTES
Central Social Welfare Board (CSWB) is a semi-official organisation that was

instituted in 1953 by the Government of India. Its establishment was the first attempt
by the government to start a non-government organisation that would operate
voluntarily. Its main aim was to operate as a connection between the people and
the government. Its major functions are:
 To survey the requirements of voluntary welfare agencies in India
 To synchronize and systematise welfare activities of the different departments
of the state governments
 To provide financial assistance to the voluntary social organisations to extend
their welfare services throughout the country, especially in remote and
underprivileged areas.
In 1963, CSWB assumed the status of an autonomous organisation and
started ‘Family and Child Welfare Services’ in the rural regions for children and
women. Important services under the project include upskilling the women through
crafts, balwadis, distributing milk, and developing play areas for children. In the
urban region, a scheme was initiated by the board to teach activities like sewing,
tailoring, etc. to the lower middle class women with the cooperation of the industries,
so that they can work and assist their families. In 1954, ‘The State Social Welfare
Boards’ was formed in all of the states as well as the union territories with an
objective to coordinate and systematise the developmental and welfare services
managed by the several state government departments to assist voluntary
organisations to expand their welfare activities all over the country. The main
schemes initiated by the board included the provision of compendious services to
the community in a united way. Some schemes and projects undertaken by the
board include ‘Mahila Mandals, Dairy Scheme, Welfare Extension Projects, Grant
in Aid, Socio Economic Programme, Awareness Generation Programme,
Condensed Education Programme for adolescent girls and women, Short Stay
Home Programme, National Creche Scheme, Integrated Scheme for Women’s
Empowerment for North Eastern States, Vocational Training Programme,
Innovative Projects and Family Counselling Centre Programme.’
In 1983, ‘Family Counselling Centre (FCC)’ scheme was initiated by the
board to help the children and women, who are the victims of family maladjustments,
atrocities, and social expulsion by providing counselling and rehabilitative services.
In the cases of manmade or natural catastrophes, it imparts counselling services
for crisis and trauma management. It works in collaboration with police, legal
cells, courts, local administration, vocational training centres, healthcare and
psychiatric organisations, etc. on the principle of ‘People’s Participation’.
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Organisations for Health: Since its inception it has made outstanding contributions for the weaker and
in India underprivileged people through its welfare and developmental programs. It has
also done significant work to empower children and women. The board is
continuously analysing and exploring contemporary and innovative channels to
NOTES meet the changing social pattern to formulate the suitable action plans.
It was established in 1944 after the death of Smt. Kasturba Gandhi in her
reminiscence. It raise the funds to help and serve rural masses through gram
sevikas, mainly in the field of health and welfare of rural women and children
working in a variety of difficult terrains all over the country from dense forests of
North-east states to snow clad Himachal Pradesh.
Instituted in 1949, FPAI is headquartered in Mumbai. It has done a tremendous
work to promote family planning programs in the country by working in
collaboration with the government. It has now various branches throughout the
country, which disseminate information on family life and sex, along with a broad
range of services in ‘Sexual and Reproductive Health Rights’ for bringing health
and happiness. It works on the following:
 Education of school, college students, and youth workers
 Helps the couples to plan spacing and number of children
 Organises conferences, seminars, and workshop
 Set up family life and marriage counselling
 Address reproductive and sexual concerns
 Focuses on sex instruction, advising, inquiring, preparing/treatment (SECRT)
 Specialised services on family life, marriage and sex counselling.
 Prevention and counselling of STI/STD/AIDS
 Training courses and workshop on human sexuality
Born in 1927, AIWC is the oldest national women’s organisation in India. It focuses
on education, liberation and empowerment of women. Its major functions include
developmental and welfare activities for children and women and to spread
awareness about the fundamental rights of the women. Their objective is to create
a society for women, where they don’t have to suffer from any type of violence.
They run computer centres, training programs, hostels for working women,
vocational training centres, etc.
It has conducted activities in the field of health, education, and self-
employment and also undertaken employment orientated training programs. With
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its dedication towards the upliftment and betterment of women and children, they Organisations for Health:
have started a literacy campaign through non-formal education for girls, who have in India
dropped out of school and a vocational training program for adult women through
its 530 branches all over India.
NOTES
Instituted in the year 1946, All India Blind Relief society coordinates activities of
various organisations working for the visually challenged people. Society organises
eye check-up, relief camps, and other interventions for the relief of the blind.
Check Your Progress

3. How many institutions are linked by Voluntary Health Association of India
(VHAI)?
4. Which bacteria causes Leprosy (Hansen’s disease)?
5. How does the Kasturba Memorial Fund contribute to the healthcare in
India?
6. When was the All India Blind Relief society established?

QUESTIONS
1. The programs, which are of direct relevance to voluntary organisations are

the projects for the improvement of food production, nutrition and housing,
promotion of literacy rate, provision of potable and safe water, availability
of instructional and educational material, community development, women
and child welfare, improve environmental sanitation, etc.
2. Voluntary healthcare organisations are either endorsed by the contributions
made voluntarily by the people or by the paid services.
3. More than 4500 institutions are linked by Voluntary Health Association of
India (VHAI).
4. Leprosy (Hansen’s disease) is a chronic infection, which is caused by the
bacteria Mycobacterium leprae and Mycobacterium lepromatosis.
5. Kasturba Memorial Fund raises the funds to help and serve rural masses
through gram sevikas, mainly in the field of health and welfare of rural women
and children working in a variety of difficult terrains all over the country
from dense forests of North-east states to snow clad Himachal Pradesh.
6. The All India Blind Relief society was established in the year, 1946.
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Voluntary Health Agencies 4.5 SUMMARY
in India
 Voluntary organisations are the non-official, traditional organisations that

NOTES are set-up by groups of civic-minded and philanthropic people to serve the
social and health needs of the community.
 The programs run by the voluntary organisations cover a wide variety of
functions dealing with health and welfare of human beings. These programs
include specialised, highly professional, and technical people assembled for
a specific objective.
 There are several voluntary health agencies working in India since pre-
independence period of time. Indian Red Cross Society (IRCS) was formed
in 1920 and operates with the help of organisations at national and
international levels.
 Indian Leprosy Association is a prestigious agency devoted to the cure and
rehabilitation of patients suffering from leprosy.
 Indian Council for Child Welfare (ICCW) was established in 1952 and is
affiliated to ‘International Union for Child Welfare’. Its activities are focused
on securing those facilities and opportunities that will help in the physical,
moral, psychological, social, and spiritual development of the children in a
normal and healthy manner, with freedom and dignity.
 Central Social Welfare Board (CSWB) is a semi-official organisation that
was instituted in 1953 by the Government of India. Its establishment was
the first attempt by the government to start a non-government organisation
that would operate voluntarily.
 Instituted in 1949, FPAI is headquartered in Mumbai. It has done a
tremendous work to promote family planning programs in the country by
working in collaboration with the government.
 Born in 1927, AIWC is the oldest national women’s organisation in India.
It focuses on education, liberation and empowerment of women.
4.6 KEY WORDS
 Balwadis: Indian pre-schools run for economically weaker sections of the

society, either by government or NGOs.
 Gram Sevikas: A woman employed to advise and assist villagers in matters
of community welfare and development.
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4.7 SELF ASSESSMENT QUESTIONS AND Voluntary Health Agencies
in India
EXERCISES
Short Answer Questions NOTES
1. Write a short note on Voluntary Health organisations.

2. How does Indian Red Cross Society (IRCS) function in India?
3. List the present activities of Indian Leprosy Association.
1. Discuss the functions of Voluntary Health Agencies (VHAs) in detail.
2. Evaluate the role of Central Social Welfare Board (CSWB) as voluntary
health agency in India.
3. Differentiate between Family Planning Association of India (FPAI) and All
India Women’s Conference (AIWC) in detail.
Joshi, D.C.; Joshi, Mamta. 2008. Hospital Administration. New Delhi: Jaypee
Brothers, Medical Publishers Pvt.
Gupta, J.D. 2009. Hospital Administration and Management: A Comprehensive
Guide. New Delhi: Jaypee Brothers, Medical Publishers Pvt.
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Primary Health Care:
An Introduction BLOCK - II
PRIMARY HEALTH CARE
NOTES
UNIT 5 PRIMARY HEALTH CARE:
AN INTRODUCTION
Structure
5.0 Introduction
5.1 Objectives
5.2 Components and Principles of Primary Health Care
5.3 Distribution of Primary Health Care Centres
5.5 Summary
5.6 Key Words
5.0 INTRODUCTION
Primary health care can be defined as an ‘Essential Health care based upon practical,
scientifically sound, and socially acceptable methods and technology that has been
made universally accessible to individuals and families in the community through
their full participation and at a cost that the country and the community can afford.’
According to the Universal Declaration of Human Rights at the international level
in 1948, ‘Everyone has the right to a standard of living adequately for the health
and well-being of themselves and their families.’ The preface to the constitution of
WHO, additionally declares that every individual has the privilege to appreciate
the ‘highest feasible standard of health’. The 30th World Health Assembly in May
1977 stated that ‘the main social target of governments and WHO in the coming
decades should be the fulfillment by all citizens of the world by the year 2000 of a
level of health that will permit them to lead a socially and economically productive
life’.
5.1 OBJECTIVES

 Analyse the primary health care system
 Understand the components and principles of the primary health care system
 Discuss the implications and distribution of primary care centres
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5.2 COMPONENTS AND PRINCIPLES OF An Introduction
PRIMARY HEALTH CARE
The components of primary health care system are: NOTES

 Educating people on current health problems and methods of preventing
and controlling them
 Promotion of suitable nutrition and food supply
 Sufficient supply of safe water and basic sanitation
 Maternal and child health care, along with family planning services
 Vaccination against communicable diseases
 Prevention and control of endemic diseases
 Suitable treatment of common diseases and injuries
 Continuous supply of essential drugs
Fig. 5.1 Components of Primary Health Care System
In the WHO–UNICEF global gathering at Alma–Ata (USSR) in 1978, the

legislatures of 134 nations and various deliberate offices required a progressive
way to deal with social insurance, proclaiming that the ‘existing gross inequality in
the health status of people particularly between developed and developing countries
as well as within countries is politically, socially and economically unacceptable’.
On the basis of that, there are four principles, which govern the primary health
care:
I. Appropriate technology: Appropriate technology means ‘Technology that
is scientifically sound, adaptable to local needs, and acceptable to those
who apply it and those for whom it is used, and that can be maintained by
the people themselves in keeping with the principle of self-reliance with the
resources the community and country can afford.’ There is no point in utilising
expensive technology, when there are cost-effective and scientifically
acceptable technologies available in the market.
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Primary Health Care: II. Equitable distribution of resources: Everyone, despite their paying ability,
An Introduction
must have equal access to healthcare services. In present scenario, the
healthcare services are more concentrated in the urban areas instead of in
slum areas, with vulnerable rural population, which leads to inequality.
NOTES Therefore, the objective of PHC is to reach the balance by moving the
focus of health system from urban areas to areas with more needy population.
III. Community participation: One of the fundamental factors of PHC is the
association of people, their families, and communities to encourage them
with respect to their own health and welfare. The general inclusion by PHC
can’t be accomplished, without the contribution and participation of the
local community. One of the Indian methodology to improve community
participation is through the utilisation of village health guides and trained
Dais. They are chosen by the local community and trained locally with the
conveyance of PHC. By overcoming social and communication barriers,
they provide PHC in manners that are acceptable to the community.
IV. Intersectoral coordination: In addition to health care sectors, PHC
includes related sectors and areas of national and society advancement,
particularly, horticulture, animal husbandry, food industry, training, education,
public works, communication, housing, and others. The country may need
to recheck its managerial structure and system, move their assets, and
propose suitable enactment to guarantee coordination in order to achieve
such co-ordination. An imperative part of it is also to plan with different
sectors to avoid any redundancy of exercises or rework.
In the WHO–UNICEF global gathering at Alma–Ata (USSR) in 1978, the primary
health care system was emphasised, especially with regards to developing countries.
It was stressed that the primary health care system should be considered as a first
point of contact between a person and the health care system. It should be available
and affordable for all, irrespective of the fact whether a country is developed or
not. It was also concluded that when it comes to design and administration, health
care personnel should work with other organisations and disciplines for complete
national development. With primary health care system, there is a rapid increase in
the number of practice nurses. Their role has also expanded from the traditional
caring services to other sophisticated ones like chronic disease management, health
promotion, new patient registration health checks, counselling, advice, investigation,
treatment, and health assessments of elderly people.
The benefits of primary health care, especially with regards to economic is
not easy to understand. This is because PHC’s impact has been on broad scale
and interrelated with other sectors, which makes it difficult to quantify it. However,
an international study of thirteen high income countries with regards to primary
care’s strength concluded that strong primary care is connected to improved
population health and lower health expenditure.
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5.3 DISTRIBUTION OF PRIMARY HEALTH CARE An Introduction
CENTRES
‘Government of India, Ministry of Health and Family Welfare Statistics Division NOTES
has been bringing out a publication titled ‘Rural Health Statistics’, which provides
detailed data on rural health infrastructure, human resources facilities, etc.’ The
following tables provides the data regarding the distribution of primary health care
centres. Among the population of 30,000 in rural areas, the primary health care
centre varies from year to year as depicted by Table 5.1. The number of health
care staff and technicians working at these centres have also seen tremendous
improvement as shown by Table 5.2. While the Table 5.3, exhibits the availability
of facilities at these centres.
Table 5.1 Coverage of Rural Health Infrastructure
CENTRE STATUS 2005 STATUS 2015 % SHORTFALL

PRIMARY HEALTH 23236 25308 22
CENTRE
Table 5.2 Manpower at Primary Health Care Centres

ROLE YEAR REQUIRED IN POSITION % SHORTFALL
TOTAL HEALTH 2005 169262 133194 21.4%
WORKERS
2015 178963 212185 *
DOCTORS IN PHC 2005 23236 20308 13%

2015 25308 27421 *
NURSING STAFF 2005 46658 28930 38%
2015 63080 65039 *
PHARMACISTS 2005 26582 177708 33%
2015 30704 23131 24.7%
LAB 2005 26582 12284 53.8%
TECHNICIANS
2015 30704 17154 44.2%
RADIOGRAPHERS 2005 3346 1337 60.1%
2015 5396 2150 60.2%
Table 5.3 Facilities at Primary Health Care Centres

FACILITIES AT PRIMARY CENTRES PERCENTAGE OF CENTRES HAVING
THESE FACILITIES
LABOUR ROOM 70.4%
OPERATION THEATRE 39.0%
AT LEAST 4 BEDS 70.3%
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Primary Health Care: Apart from the facilities and human resources, it is important to consider the
An Introduction
footfall at these centres. Without the users, any facility is bound to fail. However,
these centres have seen increase in footfall over the years, especially Family medicine
services.
NOTES
Check Your Progress
1. State the declaration made by the preface to the constitution of WHO?
2. What points were emphasised with regards to primary health care in the
WHO–UNICEF global gathering at Alma–Ata (USSR) in 1978?
3. What percentage of primary centres have the facility of operation theatres?

QUESTIONS
1. The declaration made by the preface to the constitution of WHO is that

every individual has the privilege to appreciate the ‘highest feasible standard
of health’.
2. In the WHO–UNICEF global gathering at Alma–Ata (USSR) in 1978, the
primary health care system was emphasised, especially with regards to
developing countries. It was stressed that the primary health care system
should be considered as a first point of contact between a person and the
health care system.
3. 39% of primary centres have the facility of operation theatres.
5.5 SUMMARY
 Primary health care can be defined as an ‘Essential Health care based upon
practical, scientifically sound, and socially acceptable methods and
technology that has been made universally accessible to individuals and
families in the community through their full participation and at a cost that
the country and the community can afford.’
 In the WHO–UNICEF global gathering at Alma–Ata (USSR) in 1978, the
primary health care system was emphasised, especially with regards to
developing countries. It was stressed that the primary health care system
should be considered as a first point of contact between a person and the
health care system.
 ‘Government of India, Ministry of Health and Family Welfare Statistics
Division has been bringing out a publication titled ‘Rural Health Statistics’,
which provides detailed data on rural health infrastructure, human resources
facilities, etc.’
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5.6 KEY WORDS An Introduction
 Intersectoral: Actions affecting health outcomes undertaken by sectors

outside the health sector, possibly, but not necessarily, in collaboration with NOTES
the health sector
 The Declaration of Alma-Ata: Adopted at the International Conference
on Primary Health Care (PHC), Almaty (formerlyAlma-Ata), Kazakhstan ,
6–12 September 1978, expressing the need for urgent action by all
governments, all health and development workers, and the world community
to protect and promote the health of all people.

EXERCISES

1. What are the components of primary health care system?
2. Write a short note on the implications of primary health care system.
1. Discuss the principles, which govern the primary health care.
2. Discuss the distribution of human resources at the primary health care centres
with tables.
Brothers, Medical Publishers Pvt. Ltd.
Guide. New Delhi: Jaypee Brothers, Medical Publishers Pvt. Ltd.
Starfield, B, L. Shi, ‘Policy Relevant Determinants of Health: An International
Perspective’. Health Policy. 60. 2002.
Websites
https://mohfw.gov.in/documents/statistics
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Hospitals vs Primary Health
Care: A False Antithesis
UNIT 6 HOSPITALS VS PRIMARY
HEALTH CARE: A FALSE
NOTES
ANTITHESIS
Structure
6.0 Introduction
6.1 Objectives
6.2 Hospitals and Primary Health Care
6.2.1 Administrative Functions of the Hospitals
6.3 Issues in Role of Hospitals in Primary Health Care
6.5 Summary
6.6 Key Words
6.0 INTRODUCTION
A hospital and a primary care system are considered almost opposite in its nature.
However, this established antithesis is nothing else but the problem with attitude.
As we all have experienced at some point in our life, hospitals are not pretty
places, with all the stress, panic, long lines, smell, etc. Thus, it goes without doubt
that a hospital should learn something from primary care system in terms of their
attitude.
6.1 OBJECTIVES

 Analyse the hospitals with regards to primary health care system
 Understand the roles and functions of the primary health care system
 Discuss the issues in role of hospitals in primary health care
6.2 HOSPITALS AND PRIMARY HEALTH CARE
According to WHO, a hospital is:

… an integral part of a social and medical organization, the function
of which is to provide for the population, complete health care, both
curative and preventive, and whose out-patient services reach out to
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the family in its home environment; the hospital is also a center for Hospitals vs Primary Health
the training of health workers and for bio social research’ and ‘an
institution that provides in-patient accommodation for medical and
nursing care.
Key services provided by hospitals are: NOTES
 Out Patient Department services including Daycare services, Auxiliary,
Ancillary, and Domiciliary services, etc.
 Inpatient Department services, including Nursing services, isolation services,
etc.
 Accident and Emergency services including ambulance services, Triaging,
Centralized Accident and Trauma services (CATS), etc.
 Operation Theatre, including Modular Theatres, Pre-op and Post-op
services, etc.
 Critical Care Services, including High Dependency Units, Intensive Care
Units (ICUs), Neonatal ICUs, Pediatric ICUs, etc.
6.2.1 Administrative Functions of Hospitals
 Personnel Administration, including job analysis, job description, strategic
human resource planning, recruitment, including selection processes–
interview, induction, training and development, job evaluation, salary
structure, wage regulations, grievance handling, etc.
 Financial management including capital structure, cash flows, budgeting,
etc.
 Hospital material management, including material codification, procurement,
tendering, purchasing, stores management and documentation, inventory
control, stock verification and disposal, equipment planning, etc.
Types of hospital functions
(a) Intramural Services: Services provided within the walls of the hospital
(b) Extramural Services: Services provided outside the walls of the hospital.
For example, Outreach programs, Medical Camps, Immunisation programs,
etc.
Organisational functions of hospital
 Patient care services
 Maintenance services
 Legal and statutory responsibilities
 Logistics and supplies
 Public relation
o Ethics and code of conduct
o Marketing management Self-Instructional
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Hospitals vs Primary Health o Hospital safety
o Quality management
o Management Information system
NOTES o Staff management
o Finance and budgeting
o Planning and decision making
Although similar in their objectives, both primary health care system and hospitals
differ in their approach towards dealing with people. In primary health care system,
doctors and other staff develop relationship with their patients, resulting in the
sense of familiarity and trust in patients and staff alike. However, in a hospital there
is a glaring absence of trust. In the beginning itself, a hospital seems to be an
unfamiliar territory, especially under stress. Then, there is a problem of temporary
nature of attending doctors and nurses who work on rotating shift. This turns the
whole atmosphere even more stressful for a patient, who is left without any solace.
However, no problem comes without a solution. A hospital just needs to adopt
strategies in order to establish connection between a patient and hospital. It should
start with establishing connection through digital tools like smartphone, where
patients can make appointments, fill admission forms, make payment. This will
help to alleviate patients’ stress while using hospital services.
Peculiarities of a hospital vis-à-vis primary health care are:
 Input as well as output is a human being
 Nature and volume of work is variable and diverse.
 No standardisation of treatment
 Doctors and nurses are professionals, entail various administrative and
operational problems.
 Single line of authority does not exist, instead there is a functional and parallel
line of authority
 Highly departmentalised, professionalised, and specialised organisation
 Hospitals are operating continuously; hence, bear high costs, personnel
issues, and scheduling problems.
 Psychological stress on staff, since they have to deal with life and death
situation every day
 Quantification of care and quality measurement is difficult
 Hospital is much more directly dependent on and responsive to its
surrounding community and its work is dependent on their needs and
demands.
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 Demand of much of the hospital work is of emergency nature and non- Hospitals vs Primary Health
deferrable.
 Low tolerance for error and clarity are highly desired
 Activities are highly interdependent, as organisation relies heavily on internal NOTES
coordination, motivation, and self-discipline.
 Increasing new information, market pressures, new procedures, new
research, ethics, and regulations
 Wide diversity of objectives and goals among professionals and various
sub systems
 Highly skilled and educated professionals are a necessity
The role and functions of hospital at first referral level are:
I. Supporting PHC exercises:
(a) Developing a referral framework
(b) Improvement of nature of care (including providing technical guidance to
health care workers)
II. Promoting community health development activities:
(a) Hospitals should play the role of a leader to ensure active involvement of
community at all levels of PHC
(b) Hospitals should aim at encouraging community decision making and assuring
and promoting health of the people
(c) Hospitals should give legitimate data to the community on medical issues
and approaches to eliminate them.
III. Fundamental ongoing education to healthcare specialists:
(a) Training and education, and consolidating essential parts of PHC
(b) Health instructions and training to both, staffs and community
(c) Participate in preparation of field workers
(d) Doctors working in the health care organisation to invest in visiting towns
from where the patients have come
(e) Health educators and PHC workers to use urban health centres and district
hospitals to disseminate health related data.
IV. Supporting health research and development:
(a) To find most productive and successful methods of applying suitable medical
advances
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Hospitals vs Primary Health (b) Remove obstructions in implementing and proving PHC
(c) Help individuals to take part in basic leadership about their own medical
concerns
NOTES (d) Aids in implementing health programs
6.3 ISSUES IN ROLE OF HOSPITALS IN

PRIMARY HEALTH CARE
Providing PHC or Primary health care is an essential role of hospital, as it reduces

the health complications and also helps in prevention, early detection and treatment.
However, there are various concerns with regards to this provision.
Lack of choice
Every medical service expert has a different method or approach in managing
patients and giving PHC services, which can be more suitable to some patients
and not all. Thus, it is imperative that patients are in a situation to make a choice
and locate the medical expert that takes into account their necessities. However,
in many areas there is a detectable absence of making that decision and patients
may not be able to avail all the advantages of PHC, since they don’t have the
access to the medical expert, best suitable to their necessity.
Variable quality
The nature of PHC considerably contrasts among the various medicinal services
and areas. This can be a worry, where the level of PHC is low and patients do not
get the full advantages. Moreover, variety in PHC models, including open and
private based models, show the above-mentioned disparity to a more prominent
degree. There are as of now couple of systems in place for encouraging better
quality practice like peer review, performance based incentives, etc. It has been
recommended that using these methods may improve the quality of healthcare
services.
Reactive versus proactive choices
One of the fundamental objective of PHC is for patients to have a trustworthy,
commendable doctor to discuss any symptoms or health problems, before they
aggravate and become significant problems, which will need advance care, involving
risks and side-effects.
Nonetheless, many of the administration choices are reactive instead of
proactive, which turns the avoidable complications unavoidable. Like in many
other countries, doctors may be incentivised for early management of few health
problems.
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Shortage of doctors Hospitals vs Primary Health
In order to meet the need of population, there has to be an adequate supply of
doctors to give quality services. It is in fact, a major problem as the health needs
are increasing at exponential level, while the number of doctors remains same. To NOTES
deal with this challenge, many techniques and approaches should be integrated,
which may involve expanding the quantity of skilled doctors, improving work
environment frameworks, and improving the service efficiency without trading off
the quality.
Facing the Challenges
It is evident that there are many concerns and difficulties facing PHC and it is
imperative that they are recognized so the solutions and strategies may be formulated
and implemented to address them. Specifically, the frameworks that are used in
the work environment are critical to make sure that the assets, which are accessible
are being utilised in the most gainful way. With the changing latest technology and
innovation, more progressively proficient procedures can be introduced in the
common repetitive tasks.
Check Your Progress

1. What are extramural services?
2. Mention any two key services provided by hospitals.
3. What can be done to make hospitals more proactive?

QUESTIONS
1. Extramural services are the services, which are provided outside the walls
of the hospital. For example, Outreach programs, Medical Camps,
Immunisation programs, etc.
2. The key services provided by hospitals are:
 Out Patient Department services including Daycare services, Auxiliary,
Ancillary, and Domiciliary services, etc.
 Inpatient Department services, including Nursing services, isolation
services, etc.
3. Like in many other countries, doctors may be incentivised for early
management of few health problems to make the hospitals more proactive.
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Hospitals vs Primary Health
Care: A False Antithesis 6.5 SUMMARY
 A hospital and a primary care system are considered almost opposite in its
NOTES nature. However, this established antithesis is nothing else but the problem
with attitude.
 Although similar in their objectives, both primary health care system and
hospitals differ in their approach towards dealing with people.
 Providing PHC or Primary health care is an essential role of hospital, as it
reduces the health complications and also helps in prevention, early detection
and treatment. However, there are various concerns with regards to this
provision.
6.6 KEY WORDS
 Ancillary services: Providing necessary support to the primary activities

or operation of an organization, system, etc.
 Domiciliary services: Services, such as meals-on-wheels, health visiting,
and home help, provided by a welfare agency for people in their own homes.
 Triaging: A process for sorting injured people into groups based on their
need for or likely to benefit from immediate medical treatment.

EXERCISES

1. State the need of hospital involvement.
2. What are the peculiarities of a hospital vis-à-vis primary health care?
1. Discuss the administrative and organisational functions of a hospital.
2. Describe the roles and functions of hospital at first referral level.
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Starfield, B, L. Shi, ‘Policy Relevant Determinants of Health: An International Hospitals vs Primary Health
Perspective’. Health Policy. 60. 2002.
Websites
http://www.egyankosh.ac.in/bitstream/123456789/31587/1/Unit-6.pdf NOTES
https://www.slideshare.net/zulfiquer732/role-of-hospitals-on-primary-health-care-
phc
https://www.news-medical.net/health/Challenges-in-Primary-Care.aspx
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Natural History of Disease
UNIT 7 NATURAL HISTORY OF

DISEASE
NOTES
Structure
7.0 Introduction
7.1 Objectives
7.2 Meaning of Natural History of Disease
7.3 Epidemiological Triad
7.4 Levels of Prevention/Intervention
7.5 Risk Approach in Health Care
7.7 Summary
7.8 Key Words
7.0 INTRODUCTION
It is important to understand the natural history of disease as it helps clinicians in

deciding the required treatment and make precise prognosis of the disease. It is
also beneficial to public health professionals in devising effective disease prevention
and control methods. In this unit, we will discuss the natural progression of disease
and the model depicting it. This unit also describes levels of prevention and risk of
the said diseases.
7.1 OBJECTIVES

 Analyse the concept of natural history of disease
 Understand the levels of preventions and risk approach in health care
 Discuss the measurement of the natural history of disease
7.2 MEANING OF NATURAL HISTORY OF

DISEASE
‘The natural history of disease is the uninterrupted progression in an individual of

the biological development of disease from the moment that it is initiated by exposure
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to the casual agents.’ In case of the contact with an external agent there are four Natural History of Disease
types of outcomes as depicted by Figure 7.1 (b):

 There will be no change after interaction with the agent, perhaps because:
o Dose of exposure was very low NOTES
o The host was not susceptible to the agent
 Damaging effect of agent can be cured
 Illness occurred but is controlled by the body due to strong immune system
 Illness progresses and ends in an irreversible dysfunction or demise.
The result will rely on the interplay between the host, the agent, and the
environment. In case of any intervention in terms of prevention or treatment, it will
be called the natural history of a disease. Natural history, outlined by the above
mentioned four outcomes is a concept of utmost interest to medical studies, including
epidemiology. Individuals living a healthy life, free from any disease is an ideal
concept, in actuality, they are likely to get exposed to various agents, some of
which can be disease causing. All of this collectively increases susceptibility to
disease and burden of the disease as depicted by Figure 7.1 (a).
DEMISE
(a)
Time
Complete health
Infant child adolescent adult aged
HEALING
EXPOSURE HOST DISEASE DISFUNCTION

(b) AGENT
DEATH
Fig. 7.1 (a) Natural Progression of Disease in a Healthy Person (b) Likely
Outcomes with Interaction between an Agent, Host, and Environment
In practice, natural history of a disease is difficult to study as the process is

interjected, either by treatment modality or immunisation. The information about
natural history of many diseases is not known because:
1. Diagnosis and follow up by a clinician can lead to changes in the disease
progression
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Natural History of Disease 2. The objective of observing a disease process clashes with ethical principle
to alleviate, contain, or treat the disease.
The concept of epidemiological studies of natural history states that the
studies can be carried out only with the consent of the individuals. Studies are
NOTES
allowed when there was no treatment modality applied for that condition. If during
the course of conducting the study, a successful treatment is discovered, then the
study will be discontinued or altered. The control group of study is provided with
the most effective treatment available, while the other one is studied using Cohort
studies or follow up studies for studying the natural course of disease. Repeated
collection of data from the same subjects is compulsory in chronic diseases.
There are four stages in the natural progression of a disease:
 Stage of Susceptibility
 Stage of Pre-symptomatic disease
 Stage of Clinical disease
 Stage of Reduced capacity
Fig. 7.2 Common Stages in Natural History
Susceptibility stage
This stage proceeds with the start of any disease. The disease has not yet started,
but the host is vulnerable because of the existence of risk factors related to the
disease. For example, individuals exposed to sun rays for a prolonged period of
time will have more chances of having skin cancer.
Pre-Symptomatic disease stage
By this stage, the pathological changes have started in the body, but there is absence
of signs and symptoms. In communicable diseases, this phase is called an incubation
period, which is the ‘time period between the invasion of an infectious disease
agent and the development of first signs or symptoms of the disease’. It varies
greatly from individual to individual. Diseases having long incubation periods are
called Late Onset Diseases. The term is formulated after observation of natural
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history in many individuals, not on the basis of clinical route in an individual. The Natural History of Disease
chances to prevent a chronic disease also get extended.

When incubation span ranges few days, few weeks, and sometimes month,
the diseases are called Early Onset Diseases. An acute disease can have irreversible
NOTES
(chronic) effects. The Figure 7.3 depicts the types of incubation period, where A,
inclined to the left, represents short incubation span and B, inclined to the right,
represents long incubation span.
Time
A B
Fig. 7.3 Types of Incubation Period in Disease Outbreak
Incubation period depends on:

 Portal of entrance into the host
 The capability of multiplication
 Quantity of agent
 Amount of antibody in the host
In non-communicable disease, this stage includes the latency period, which
can be defined as the period from disease initiation to disease detection. In addition,
the stage of susceptibility also includes the subclinical disease that is a disease
which is fully developed but produces no overt signs or symptoms in the host.
Clinical disease stage
By this stage, the condition is distinctly apparent and the host encounters one or
more noticeable signs or symptoms, typical of the disease. This stage involves
diagnosis and treatment by clinician. Clinical disease may vary in terms of extremity
and will progress slowly or rapidly depending upon host, agent and environmental
factors.
Reduced capacity stage
The final stage of natural history of disease is characterised by a convalescent
period or a residual disability. In the case of convalescence, there is a period
following completion of clinical disease, during which the individual has not yet
returned to his or her former level of health. Many moderate to serious infections
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Natural History of Disease require some convalescence after the disease has run its course. The convalescent
period represents the time taken by recovered individuals to get back on their
feet, while residual disability refers to the development of complications or disability
resulting directly from the clinical disease.
NOTES
The information about natural history is important for devising disease
prevention strategies, particularly for secondary prevention based on screening of
the individuals. The natural history is useful in individual cases and has important
implications on public health. Its importance lies with the fact that:
 Alterations in natural history in individuals affect the population pattern.
 Various paths of progression in different individuals provide knowledge about
alternatives that can be utilised in a population at large.
Natural history and population pattern of a disease are interconnected in the
following ways:
(a) Susceptibility: Decreased susceptibility will lower the cases diagnosed
with disease, thereby decreasing the frequency of disease, whereas increase
in susceptibility will lead to increase in frequency of disease. The length of
the disease depends on the susceptibility of individuals and their ability to
fight back.
(b) Span of a disease: A shorter span has better prognosis, with morbidity
and mortality rates. Prevalence rate will be affected but incidence rate would
not.
(c) Incubation span: The duration of incubation period has an influence on
disease patterns of population.
(d) Adversity of disease: The adversity of a disease can change depending
on altered virulence of an agent or susceptibility of the host, which will
affect the incidence and prevalence.
Spectrum of disease
An exposure to the same disease can have varied manifestations in different
individuals; this is known as disease spectrum. Spectrum of a disease denotes the
idea that a disease may present itself with varied signs, symptoms, and
complications. The objective is to find the nature and causative factors responsible
for variation, estimate the progression of disease in cluster population, and make
authentic predictions of consequences at both, individual and at population level.
For example, 100 people are exposed to a Legionnaires bacillus; around 90%
will show no perceptible problems. The remaining population will have mild
influenza episode to severe pneumonia. The mortality rate will be high in some
population groups. The incubation period will vary greatly. People survived will
either recover completely or have some dysfunction. The disease spectrum signifies
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the variability in the nature of a disease, while natural history denotes progression Natural History of Disease
of a disease.
Check Your Progress

NOTES
1. What could be the reasons for no change after interaction with the agent?
2. Why is natural history of a disease difficult to study?
3. What is the difference between disease spectrum and natural history of a
disease?
7.3 EPIDEMIOLOGICAL TRIAD
The epidemiological triad is the standard model used to represent infectious disease
causation by taking into consideration the interaction between three factors: agent,
host, and environment. These factors determine the occurrence of the condition,
disease, disability, or death. The concept flourished when epidemiology mostly
focused on the study of infectious conditions. It is equally useful and applicable in
the study of epidemiology of non-infectious conditions. Unless a situation exists,
which is favourable with reference to these three factors, the disease will not occur.
Imbalance and changing interrelationships may cause due to change in the agent,
host, or environment.
AGENT
AGENT ENVIRONMENT HOST
Fig. 7.4 Traditional Model of Infectious Disease Causation
Agent
An agent is an element or substance, animate or inanimate, which is responsible
for causation of the disease. Following are the types of an agent:
(a) Nutrient agent: Carbohydrates, vitamins and minerals, H2O, lipids,
proteins, etc. For examples, Diabetes, Hypo or Hyperglycaemia,
Kwashiorkor, Marasmus, rickets, Osteomalacia, dehydration, etc.
(b) Chemical agent: Pollutants, drugs, pesticides, etc.
(c) Physical agent: Dust particles, accident (fall or collision), weather (frost
bite), etc.
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Natural History of Disease (d) Infectious agent:
 Virus: Malaria
 Bacteria: Gram (+), Gram (–), Aerobes, Anaerobes, etc.
NOTES  Protozoa: Plasmodium, Amoeba, etc.
 Parasite: Round Worm, Tapeworm, etc.
 Fungi
Ingenious characteristics of an agent include Morphological structure,
reproductive method, locomotion, metabolism processes, requirement of oxygen,
climate, level of toxin released, antigen, life cycle, etc. Other characteristics of an
agent are:
(a) Infectivity: ‘The ability of an agent to attack, adapt, live, and multiply in
the host’ or the potential of a pathogen to establish an infection.
(b) Pathogenicity: ‘The ability of agent to produce a local or general reaction
in the host’ or the capability of an organism to cause a disease.
(c) Virulence: The ability to elicit a severe clinical manifestation. It is the disease
producing power or degree of pathogenicity. It quantifies pathogenicity.
(d) Toxigenicity: ‘The ability of agent to produce a toxin.’ The disease occurs
from the toxin produced by the agent, and not directly by the agent.
(e) Resistance: ‘The ability of agent to survive under adverse environmental
conditions.’
(f) Antigenicity: ‘The agent’s ability to stimulate host production of antibody
such as agglutinin, opsonic, precipitin, antitoxin, lysine, complement fixating
substance.’ For example:
 Typhoid fever: Highly antigenic
 Tuberculosis: Doubtful
 Influenza virus: Various strains available
(g) Tropism: The agent attacks and resides in a preferred location in the host.
 Cholera: Digestive tract
 Herpes zoster: Fifth cranial nerve
Reservoir of Agent
The normal habitat of the infectious agent is the location, where the agent lives and
grows. Common reservoir includes humans, animals, and the environment.
(a) Human reservoir: Actively infected persons as well as carriers, which is a
‘person who has no clinical signs or symptoms of the disease but nevertheless
harbours the causative agent, which can be transmitted to others’. There
are three types of a carrier:
 Asymptomatic carrier: A person who does not show any symptoms
during the time, in which they are infected.
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 Convalescent carrier: A person having the ability of transmitting agent Natural History of Disease
before or after they are clinically diagnosed ill.

 Chronic carrier: A person who continues to provide shelter to an agent
even after being treated.
NOTES
(b) Animal reservoir: Also called zoonotic diseases, which can be transferred
from animals to humans. Some of these zoonotic infections can be caused
by:
 Dog and cat: Toxoplasmosis, Rabies, etc.
 Rat: Plague
 Cattle: Cows, buffaloes, yak, goat (Anthrax, Bovine Tuberculosis)
 Arthropod: Cockroach, mosquito
(c) Soil reservoir
(d) Environmental reservoir: Clostridium (tetani, welchii), Helminths, etc.
Portal of entry and exit
The point at which the infectious agent enters and leaves the susceptible host is
called the portal of entry and exit respectively. It is important to know how the
disease is being transmitted and how can we prevent the transmission. The portal
of entry could take oral route–digestive tract; Nasal route–airway; skin; genitalia;
eyes; or blood stream. The portal of exit and entry are usually the same, however
some diseases have different exit and entry.
Host factors
A host can be defined as a ‘person or other living animal that affords subsistence
or lodgement to an infectious agent under natural condition’. These can be defined
as characteristics of the host, who are affected or not affected. The intrinsic factors
that affect the disease causation are age, gender, belief, occupation/profession,
marital status, background, genetic makeup, race, psychological status, habits,
immunity, history of infection, etc.
Environment
The environment can be defined as the accumulation of all the external conditions
that influence life and development of an organism. There are three types of
environment affecting the progression of a disease:
(a) Physical environment: Geography, climate, land, soil, etc.
(b) Biologic environment: Flora and fauna, living organisms in environment,
etc.
(c) Socio-Economic environment: Salary, education, urbanisation, economic
growth, poverty, etc.
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Natural History of Disease
Check Your Progress

4. Define epidemiological triad.
NOTES 5. What could be the portal of entry for an agent?
6. What are the intrinsic factors in a host that affect the disease causation?
7.4 LEVELS OF PREVENTION/INTERVENTION
The levels of prevention include prevention and control of diseases in human

population. This usually involves using one or more levels of prevention.
Primordial prevention
Prevention of appearance or development of risk factors in population, which has
not yet been exposed to them till date. Attempts are made to discourage children
from adopting harmful habits. Major interference is done by educating individuals
and masses on a large scale.
Primary prevention
It is directed to prevent occurrence of new cases of disease by controlling the
causative factors of disease. Thus, it is appropriately applied during the susceptibility
stage. On a community level, primary level prevention strategies involve health
promotion, decrease in risk factors, and health protective methods. The general
methods include educating the population about the importance of health and
conducting health promotion campaigns to improve environmental conditions and
safety. Health promotion includes providing education about good health,
importance of nutrients, living conditions, marriage counselling, routine health check-
up, etc. Specific protection includes immunisation and vaccination, encouraging
personal hygiene, clean and healthy environment, warning about job-related
hazards, safety from accidents/mishaps, specific nutrition, protection from
carcinogenic agents, avoidance of hypersensitive products, etc.
Secondary prevention
It attempts to identify existing cases of disease in an early stage, especially subclinical
cases, so as to cure or prevent any complications of the disease and reduce the
rate of progression or its influence on individuals or community. Therefore, it is
most effective in individuals going through pre symptomatic stage of disease or
nascent stage of clinical disease, where treatment is more likely to be effective. A
common strategy is to carry out screening of individuals for disease for early
detection, prevention of spread and complications, and reduction in disability.
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Tertiary prevention Natural History of Disease
This level aims to limit dysfunction and improve performance, where clinical disease
has been established or its complications have occurred. It involves therapy and
rehabilitative measures, once disease has occurred. Therefore, it is advantageous NOTES
in the later stage of the clinical disease. On a community level, health care of high
standards with ease of being accessible is crucial. The public health resources are
critical in assuring good primary, secondary, and tertiary prevention.
7.5 RISK APPROACH IN HEALTH CARE
Risk enhances an individual’s probability of suffering or threat or of catching disease.

Risk also refers to the chances (likelihood) of death or contacting a disease. In
epidemiology, we study the interplay between the probability of disease, the risk,
and all characteristics, which influence risk. ‘Risk factor’ does not always mean
that an exposure is a causative factor for a disease. In such cases, a risk factor is
called risk marker. For example, smoking is a cause of lung cancer but for some,
other risk factors may also be a causative factor. Associations rarely turn out to be
natural, so it is very important to determine whether an association exists, so that
we can prevent the disease from spreading.
Epidemiological studies quantify, demonstrate, and explain the frequency of disease
and causative agents that influence it. The epidemiology tries to solve the problem
of who (people) catches the disease and how and then, compare it with other
communities or larger population. The main epidemiology measures are incidence
and prevalence rates. Epidemiology requires precise information about:
 When and where the study is being carried out
 The quantity and characteristics of a disease
 Who is exposed to risk factors
 The population from whom the data is collected
Quantity of cases observed or individuals having risk factors constitute the
numerator, the population from which the cases are drawn constitute the
denominator. The value obtained by dividing numerator with the denominator is
called the rate in epidemiology and public health. In epidemiology, the term rate is
used to denote a ratio, when numerator and denominator have different
characteristics. A proportion is defined as a ratio when the numerator is a part of
the denominator therefore, they both have same characteristics.
Incidence
Incidence rate is defined as the ‘Number of new cases in a population exposed to
risk factors of the disease in a given period of time’. The term new is the main
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Natural History of Disease characteristic feature. For useful assessment of any disease, incidence rate needs
the quantity of new cases as numerator and the population, who is at risk as
denominator, the time period during which the observations were made, and location
of the study. There are two types of incidence rates:
NOTES
 Person-time incidence also called incidence rate, determines incidence
density, risk rate, and impact of morbidity or mortality. It ranges from 0 to
infinity.
 Cumulative incidence also called incidence proportion, or cumulative
proportion is often used interchangeably with risk. It varies from 0 to 1 or
0 to 100 %.
Newcases during a period of time
Incidence rate = Population at risk during that period of time
The resulting fraction is denoted as a percentage by multiplying with 100 or

1000 to obtain rate per thousand. When the baseline population constitutes the
denominator, the measure is called cumulative incidence rate. It is a measure of the
likelihood of a new encounter occurring in a population.
Prevalence
In epidemiology, prevalence is the measure of all events of the factor of interest in
a population being studied. There are three types of prevalence rates.
 The point prevalence rate comprises total cases of a disease that exist in a
place at a given point of time.
All cases of the factor being observed at time
Point prevalence rate = Population at risk at time
 Period prevalence is a method of finding and solving the drawbacks of

prevalence studies done at a given point of time. All cases (old and new)
are counted in a specific time period. The denominator is the average
population during that period.
Period prevalence rate =
Total number of cases of the factor of interest during a time period
Average population at risk inthat time period
 Lifetime prevalence is defined as the ‘Proportion of the population who

have ever had the disease’. It can be estimated from a birth cohort study
(where people are followed up from birth).
Lifetime prevalence =
Number of cases who ever had the factor of interest during lifetime
Population at risk ( At thebeginning of the study )
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Types of risks Natural History of Disease
There are three types of risks, which are identified with regards to a disease:
I. Relative risk: It is a measure of association. It represents how risk varies
between different populations. Alternatively, we can measure the relative risk as NOTES
the ratio of two incidence rates. The relative risk is of utmost importance. It gives
a measure of an amount of the effect of the risk factor on the rate and strength of
disease and is an association between risk and disease causation.
Relative risk (risk ratio) is the ratio between the two that is,
Risk inthe exposed
Risk in theunexposed
For example, a study was carried out to study the role of ACE inhibitors in
prevention of CHD during five year follow up. 120 diabetic patients out of 400,
who had taken ACE inhibitors developed acute coronary event. Over the same
time, 100 diabetic patients out of 250, who had not taken ACE inhibitors
experienced coronary events. The relative risk of developing heart event in patients
taking ACE inhibitors compared to patients not taking ACE inhibitors is:
Odds ratio is simply a ratio of two odds divided by the other. The odds are
the possibility in support of one in relation to the other.
Oddsthat case was exposed
Odds ratio = Oddsthat a control was exposed
ad
Exposure odds ratio =
cb
ad
Disease odds ratio =
bc
The odds ratio is a useful measure of association in epidemiology. First, in
various study designs, it approximates the prevalence rate and relative risk.
Secondly, in case control studies, we cannot calculate relative risk, so it provides
required information. Third, the odds permit easy modification in mathematical
models and statistical computations.
II. Absolute risk: It is a probability of an event happening over a stated period
of time. It is expressed in percentage. For example, if 28 out of 100 people get
28
Alzheimer disease in their lifespan, the absolute risk is or 28%
100
III. Attributable risk: It is the difference between risk in the exposed population
and risk in the unexposed population. Typically, in a retrospective cohort analysis
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Natural History of Disease of a disease outbreak, several exposures are examined simultaneously using an
attack rate table. It is done to determine which food is likely to be responsible for
the outbreak. For each item being examined, the number of ill cases is divided by
the number of ill and well and the result is multiplied by 100.
NOTES
Relative risk ratio is used to determine which food most likely served as a
vehicle for the outbreak. One could also determine the risk difference, for each
suspected food, by subtracting the attack rate among those who did not eat the
food from the attack rate who did eat the food. This measure is referred to in
disease outbreak investigations as the attributable risk, the risk of the disease
attributable to eating the particular food. In this case one would be looking for
food with highest attributable risk.
Check Your Progress

7. What is the aim of the tertiary prevention level?
8. What is person-time incidence?
9. Express the point prevalence rate in terms of an equation.
10. Why is odds ratio considered a useful measure of association in
epidemiology?

QUESTIONS
1. The reasons for no change after interaction with the agent could be:
(a) Dose of exposure was very low
(b) The host was not susceptible to the agent
2. The natural history of a disease is difficult to study as the process is
interjected, either by treatment modality or immunisation.
3. The disease spectrum signifies the variability in the nature of a disease,
while the natural history denotes progression of a disease.
4. An epidemiological triad is the standard model used to represent infectious
disease causation by taking into consideration the interaction between three
factors: agent, host, and environment. These factors determine the
occurrence of the condition, disease, disability, or death.
5. The portal of entry for an agent could be oral route–digestive tract; Nasal
route–airway; skin; genitalia; eyes; or blood stream.
6. The intrinsic factors in a host that affect the disease causation are age, gender,
belief, occupation/profession, marital status, background, genetic makeup,
race, psychological status, habits, immunity, history of infection, etc.
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7. The aim of the tertiary prevention level is to limit dysfunction and improve Natural History of Disease
performance, where clinical disease has been established or its complications

have occurred.
8. The Person-time incidence, also called incidence rate, determines incidence
NOTES
density, risk rate, and impact of morbidity or mortality. It ranges from 0 to
infinity.
9. The point prevalence rate can be expressed in terms of the following equation:
All cases of the factor being observed at time
Point prevalence rate = Population at risk at time
10. The odds ratio is considered a useful measure of association in epidemiology

because: First, in various study designs, it approximates the prevalence rate
and relative risk. Secondly, in case control studies, we cannot calculate
relative risk, so it provides required information. Third, the odds permit
easy modification in mathematical models and statistical computations
7.7 SUMMARY
 It is important to understand the natural history as it helps clinicians in deciding

the required treatment and make precise prognosis of the disease.
 An exposure to the same disease can have varied manifestations in different
individuals; this is known as disease spectrum.
 The epidemiological triad is the standard model used to represent infectious
disease causation by taking into consideration the interaction between three
factors: agent, host, and environment. The concept flourished when
epidemiology mostly focused on the study of infectious conditions.
 An agent is an element or substance, animate or inanimate, which is
responsible for causation of the disease. The normal habitat of the infectious
agent is the location, where the agent lives and grows.
 A host can be defined as a ‘person or other living animal that affords
subsistence or lodgement to an infectious agent under natural condition’.
 The environment can be defined as the accumulation of all the external
conditions that influence life and development of an organism.
 The levels of prevention include prevention and control of diseases in human
population. This usually involves using one or more levels of prevention.
 Risk enhances an individual’s probability of suffering or threat or of catching
disease. Risk also refers to the chances (likelihood) of death or contacting
a disease. In epidemiology, we study the interplay between the probability
of disease, the risk, and all characteristics, which influence risk.
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Natural History of Disease  Epidemiological studies quantify, demonstrate, and explain the frequency
of disease and causative agents that influence it. The epidemiology tries to
solve the problem of who (people) catches the disease and how and then,
compare it with other communities or larger population.
NOTES
7.8 KEY WORDS
 Prognosis: An opinion, based on medical experience, of the likely course

of a medical condition.
 Epidemiology: The branch of medicine, which deals with the incidence,
distribution, and possible control of diseases, and other factors relating to
health.
 Treatment Modality: The method used to treat a patient for a particular
condition.
 Cohort Studies: A type of medical research used to investigate the causes
of disease and to establish links between risk factors and health outcomes;
the word cohort means a group of people.
 Convalescent Period: The later stage of an infectious disease or illness
when the patient recovers and returns to previous health, but may continue
to be a source of infection to others even if he/she feels better.
 Osteomalacia: Caused by the lack of vitamin D, resulting in bone pain
and muscle weakness.
 Kwashiorkor: A nutritional disorder most often seen in regions experiencing
famine, caused by the lack of protein in the diet.
 Marasmus: Undernourishment causing a child’s weight to be significantly
low for their age.

EXERCISES

1. What is natural history of disease?
2. Write a short note on the spectrum of diseases.
3. What are the types of an agent?
4. What is the information required by epidemiology?
1. Describe the four stages of the natural progression of a disease.
2. Discuss the disease pattern of population.
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3. Explain the characteristics and reservoir of an agent. Natural History of Disease
4. Evaluate the levels of prevention/intervention in cases of diseases.
7.10 FURTHER READINGS NOTES
Bhopal, R.S. 2016. Concepts of Epidemiology: Integrating the ideas, theories,

principles, and methods of epidemiology. New York: Oxford University
Press.
Broadbent, Alex. 2013. Philosophy of Epidemiology. Basingstoke: Springer.
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Occupational Health
UNIT 8 OCCUPATIONAL HEALTH

NOTES Structure
8.0 Introduction
8.1 Objectives
8.2 Definition and Scope
8.2.1 Effects of Industrialisation on Health and Delivery of Healthcare
8.2.2 Health Problems due to Industrialisation
8.4 Summary
8.5 Key Words
8.0 INTRODUCTION
Occupational health aims at encouraging and preserving high standard of physical

condition, mental wellbeing and social status of workforce in every occupation.
This unit discusses the meaning and scope of occupational health, along with the
impact of industrialisation on the health of people.
8.1 OBJECTIVES

 Analyse the concept of occupational health
 Understand the meaning and scope of occupational health
 Discuss the health problems due to industrialisation
8.2 DEFINITION AND SCOPE
‘Occupational health is a specialist branch of medicine that focuses on the physical

and mental safety of the worker in the workplace.’ The scope of the occupational
health lies in the following points:
 Avoidance of health deprivation among workers caused by their working
environment
 Safety of workforce in the organization from probabilities that can be
disadvantageous to one’s health
 Assigning every worker, an area, suitable to his/her physiological and
psychological status
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The objectives of occupational health are: Occupational Health
 Advancement and care of employee’s health and their working capacity

 Advancement in working conditions and performing ability in a way, which
assists health and wellbeing at work places and also encourages a constructive NOTES
social environment and smooth functioning, which will result in increased
productivity
 To prevent unfavourable effects on health caused by working conditions
 Become aware of the managerial environment to cater physical and mental
needs of employees
 Deal with all the problems, which are related to business safety, occupational
health, industrial cleanliness, education, and learning.
8.2.1 Effects of Industrialisation on Health and Delivery of
Healthcare
Industrialisation is an evolution that has taken place by economic development all
over the world. It is a chain of progressive changes in the economic, cultural, and
scientific review of a particular place.
Impact of industrialisation on healthcare distribution
The impacts of industrialisation are quite apparent on health care distribution.
Following are the positive effects of industrialisation:
I. Promoting health: Through electronic media like TV, radio and internet,
individuals can access important health information that helps in maintaining
good health like hand washing, taking bath and brushing teeth help in
maintaining basic hygiene and therefore, promote good health of the
individual. Media makes sure that people learn about proper hygiene through
ads and commercials.
II. Promoting health by physical activities: Industrialisation has led to the
introduction of new, easy to use equipment, which aid in maintaining healthy
lifestyle through physical activity and exercise and help in the control of
diseases which usually occur due to sedentary lifestyle (like hypertension
and diabetes).
III. Treatment of disease: Technology has improved treatment of diseases
by use of medicines, which are effective in treating and preventing diseases.
Some medications make healthcare easier like anaesthetics are administered
prior to a surgical procedure, thus providing effective and adequate time to
perform the surgery.
IV. Prevention of disease: By studying about microorganisms, scientists can
learn about microorganisms that cause disease and prepare a vaccine, which
would prevent the disease from occurring, for example, polio vaccine to
prevent poliomyelitis.
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Occupational Health V. Education: Industrialisation has led to the advancement in education through
which people have learned to follow basic health practices and also are
able to understand them better, which has led to health promotion.
VI. Easy access to healthcare: Through good infrastructure like roads,
NOTES
individuals can now access healthcare services easily, for example, hospitals,
private health setups, and dispensaries. It has also aided in transportation
of healthcare specialists and their equipment to far off regions to provide
healthcare.
VII. Essential machines: Machines like defibrillators and ECG help in
diagnosing diseases and treat them. Therefore, improving health and
decreasing pain, along with helping healthcare practitioners to differentiate
between various body changes and prevent occurrence of complications.
VIII. Enhances knowledge about health hazards: Industrialisation helps in
research of factors that influence health and healthcare deliveries. This kind
of research has unfolded knowledge about various types of diseases, their
occurrence, and prevention.
IX. Better communication: Through industrialisation, better communication
is possible amongst medical care providers and other people in the
community. For example, through cell phones, internet, and email facilities,
patients are able to reach their doctors thus, improving healthcare delivery
system.
The industrialisation although advantageous to the human kind, also has negative
effects on healthcare delivery system:
I. Urbanisation: Industrialisation has led to people migrating from rural areas
to urban areas leading to overcrowding, which in turn, lead to poor health
practices. People are more prone to contacting diseases as a result of
overcrowding, for example, TB. This also leads to spread of diseases among
people in the crowded areas. Urbanisation has led to increase in the number
of the people more than the specialists providing healthcare.
II. Pollution: Because of rapid industrialisation and establishment of so many
industries, the lakes, sea, and water bodies are polluted, along with
environment, which can lead to diseases. For example, lung cancer and
genetic disorders, if someone is exposed to radioactive material, leading to
deformities affecting health of people.
III. Spread of diseases: Overcrowding in urban regions has led to the increase
of diseases, for example, cholera, TB, and all other communicable diseases,
deteriorating health of individuals. The diseases cannot be controlled easily
due to the massive number of people affected.
IV. Social class and corruption: This has led to unjust distribution of facilities
among health institutes affecting healthcare delivery. People of low income
groups are not able to access healthcare services well equipped with quality
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8.2.2 Health Problems due to Industrialisation Occupational Health
Apart from the negative effects of industrialisation on the social, economic, and
environmental state, industrialisation has increased the susceptibility to diseases in
the population. NOTES
 Environmental sanitary issues
 Communicable disease
 Food Contamination
 Psychological health
 Mishaps and social issues
 Mortality and diseases
In order to avoid such health problems, it is important to take some drastic
measures for health promotion of workers like:
 Nutrition
 Communicable disease control
 Psychological condition
 Measures for mother and child
 Health education
 Family planning
 Education of employee regarding good diet.
 Adequate immunisation against communicable diseases
 Environmental health
 Safe drinking water
 Clean food and proper food storage
 Enough space; recommended standard is at least 500 cubic feet
 Illumination standards, for high precision work 50-75 feet candles; Regular
work- 6 to 12 feet candles; and Corridors and passages- 0.5 feet candles
 Proper ventilation and temperature
 Protection against possible hazards
 Housing
 Mental condition
 Recognise signs of stress and eliminate stress, whenever possible
 Training of employees to tolerate mental strain and rehabilitation of ill
While for women and children, the measures are:
 Pregnant mothers should be allowed to take maternity leave of 12 weeks
 Free antenatal check-ups
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Occupational Health  Follow the Factories Act (Section 66) interject that is, night work between
7 p.m. and 6 a.m
 Follow the Indian Mines Act (1923), which forbids underground work
NOTES  Follow the Factories Act, 1976, issued for industries to have crèches, where
there are more than 30 female staff are employed.
In totality, prevention of occupational diseases can be accomplished by adopting
three kinds of measures:
I. Medical measures:
 Health education and counselling
 Maintenance and analysis of the records
 Supervision of the working environment
 Medical and health care services
 Periodical examination
 Examination of pre-placement
II. Engineering measures:
 Substitution
 Mechanisation
 General ventilation and local exhaust ventilation
 Good housekeeping and environmental monitoring
 Design of building based on statistical monitoring and research, for
example, dust-enclosure and isolation
III. Legislative measures: Under legislative measures, two acts hold
importance.
 Factories act, 1948: A factory means an organisation, where ten or
more workforce has been recruited during the preceding 12 months in a
manufacturing procedure, operating on power or where twenty or more
workforce has been recruited during the preceding 12 months in
manufacturing procedure, without power. The act includes:
i. Appointment and employment
ii. Examiner of factories
iii. Medical practitioners
iv. Requirements for Industrial staff:
o Provision of Employment
o Provision of Welfare
o Provision of Safety
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78 Material
 The Employee State Insurance Act, 1948: The ESI Act of 1948 closed Occupational Health
all power-using industries except seasonal industries, where 20 or more

people were recruited (excluding mines, railways, and defence organisations).
NOTES
Check Your Progress
1. Define occupational health.
2. How is urbanisation a negative effect of the industrialisation?
3. List the health problems due to industrialisation.

QUESTIONS
1. Occupational health can be defined as a ‘specialist branch of medicine that

focuses on the physical and mental safety of the worker in the workplace.’
2. Industrialisation has led to people migrating from rural areas to urban areas
leading to overcrowding, which in turn, lead to poor health practices. People
are more prone to contacting diseases as a result of overcrowding, for
example, TB. This also leads to spread of diseases among people in the
crowded areas. Urbanisation has led to increase in the number of the people
more than the specialists providing healthcare.
3. The health problems happening due to industrialisation are:
 Environmental sanitary issues
 Communicable disease
 Food Contamination
 Psychological health
 Mishaps and social issues
 Mortality and diseases
8.4 SUMMARY
 Occupational health aims at encouraging and preserving high standard of

physical condition, mental wellbeing and social status of workforce in every
occupation.
 Industrialisation is an evolution that has taken place by economic development
all over the world. It is a chain of progressive changes in the economic,
cultural, and scientific review of a particular place.
 The industrialisation although advantageous to the human kind, also has
negative effects on healthcare delivery system.
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Occupational Health  In order to avoid such health problems, it is important to take some drastic
measures for health promotion of workers
NOTES
8.5 KEY WORDS
 Poliomyelitis: An infectious disease caused by the poliovirus. In about 0.5

percent of cases there is muscle weakness resulting in an inability to move.
 Antenatal: Also called, prenatal care, it is a type of preventive healthcare,
whose goal is to provide regular check-ups that allow doctors to treat and
prevent potential health problems throughout the course of the pregnancy.

EXERCISES

1. What is the scope of the occupational health?
2. Which measures should be adopted for women working in the industries?
1. Describe the positive effects of the industrialisation on the health system.
2. Discuss the measures, which can help in the prevention of occupational
diseases.
Peterson, N.; Mayhew, N. 2018. Occupational Health and Safety: International

Influences and the New Epidemics. London: Routledge.
Gilbert, B., P. G. Benson, ‘The contribution of the supervisor behaviour to employee
psychological well-being’, Work and Stress. 18(3): 255-266, 2004.
Jex, S.M. 1998. Stress and Job Performance: Theory, Research, and Implications
for Managerial Practice. Thousand Oaks. SAGE Publications.
Horino, S., ‘Environmental factors and work performance of foundry workers’,
J Hum Ergol. 6(2): 159-166, 1977.
Kjellstrom, T., C. Corvalan, ‘Framework for the development of environmental
health indicators’, World Health Stat. 48:144–154, 1995.
Websites
https://www.slideshare.net/stephipoulose/occupational-health-55324122
https://www.who.int/occupational_health/publications/noise9.pdf
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Occupational Hazards
BLOCK - III
HOLISTIC APPROACH TO HEALTH
NOTES
UNIT 9 OCCUPATIONAL HAZARDS
Structure
9.0 Introduction
9.1 Objectives
9.2 Meaning of Occupational Hazards
9.2.2 Chemical Hazards
9.3 Prevention and Control of Hazards
9.5 Summary
9.6 Key Words
9.0 INTRODUCTION
Hazard is an agent with possible threat or peril to life, health, goods, or ecosystem.
Nearly all hazards are latent or probable, with a hypothetical risk of damage,
though, if the threat becomes functional, it can result in an urgency. Therefore, a
hazard is an emergence of possible harm or adverse effect from past, present, or
future actions. In this unit, we will discuss hazards in the context of occupational
health. The unit also describes different kinds of hazards, along with its prevention.
9.1 OBJECTIVES

 Describe the concept of occupational hazards
 Understand the different types of occupational hazards
 Discuss the prevention and control of occupational hazards
9.2 MEANING OF OCCUPATIONAL HAZARDS
The word hazardous pertains to a condition or mixture of factors that lead to

considerable risk or crisis by causing damage to persons or goods. It is
characteristically used to explain materials and elements that are harmful, which
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Occupational Hazards include inflammables, irritants, combustibles sensitizers, and corrosives, even when
these materials might be comparatively non-toxic in weak concentrations. It is
important to study occupational hazards in order to:
 Make all the workers aware of the dangers of most kinds of jobs or
NOTES
professions
 Check whether workers can adapt to the dangers of a profession or not
 Help workers in making appropriate job choices
Physical hazards include those hazards, which physically harm an individual. These
include noise nuisance, vibrations and blow, glare, radiations, excessive heat,
ventilation, water contamination, etc. Such exposures can result in disorders like
redness in eyes, genetic problems, risk of cancer, infertility, loss of hearing, nerve
damage, and many other problems. The different hazards can cause different
problems.
Heat
Direct effects of heat are:
(a) Burn: Can cause disfiguration or even death
(b) Heat exhaustion: Symptoms are headache, muscle weakness, and so on.
(c) Heat syncope or blacking out: Results from physical exhaustion at high
temperatures, causing the blood vessels to widen, which causes reduced
blood flow to the brain.
(d) Heat cramps: Muscle fit resulting from excessive loss of salt and water
because of excessive activity.
Indirect effects of heat are:
(a) Decreased efficiency
(b) Increased lethargy
Cold
 Chills
 Erythrocyanosis Crurum
 Frostbite in the feet and hands due to cutaneous vasoconstriction
 Hypothermia.
Light
The intense impact of low illumination are:
 Strain in the eyes
 Headache
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 Congestion over the cornea Occupational Hazards
 Eye fatigue
Occupational cataract is often observed in individuals, working with radiation
and x-ray beams (radiologists). Miner’s Nystagmus is an occupational problem NOTES
occurring among coal excavators, usually in middle aged or older workers, who
have been working for over 25 to 30 years in coal mines. The physical side effects
include poor visibility in low light, extreme sensitivity to glare, and rhythmic
oscillation of the eyeballs. This might result in defective perception about nearby
objects and lead to poor judgment of surroundings. Associated visual side effects
are cerebral pains and wooziness, especially while stooping or bending, and the
advancement of psychoneurotic side effects in later stages of disease. If the problem
is not diagnosed timely, the nervous disorder may lead to total disability.
Noise
Noise relates to sound-related impacts on an individual like:
 Temporary or irreversible hearing loss
 Nervousness
 Lethargy
 Reduced efficiency
 Irritation
Ionizing radiations
Radiation dangers include:
 Genetic changes
 Malformation
 Leukemia
 Ulceration
 Infertility
The preventive measures that can be adopted to fight against above-
mentioned hazards are:
 Continuous use of appropriate overalls and safety gear (gloves, ear sleeves,
scarf, caps, and so on)
 Proper ventilation
 The temperature in the working place must be regularly monitored
 Regular medical check-ups
 Employees should be trained, according to their working conditions
 Footwear (shoes, socks, and boots) should be washed/cleaned routinely
 Hot beverages should be accessible
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Occupational Hazards  More protein and fat intake in diet
 Foot gear should be impervious to water
 Avoid contact with cold metals with bare skin
NOTES  Keep a thermometer
 Bring covers and sheets, if somebody feels excessively cold
 Use gas or electrical radiators if required.
Physical hazards depend on the characteristic state of the compound. Later
these are sub-isolated into various classes based on the level of threat used to
categorize them. There are five primary classes of physical dangers.
Explosives
These are prone to blast, whenever exposed to flame, heat, shock, friction. One
could avoid it by:
 Avoid burning objects (flashes, blazes, heat, etc.)
 Wear protective gear
Flammables
These are the unstable substances that are prone to catch fire (sparks, heat).
Some flammable materials may even produce combustible gases on contact with
water. The preventive measures, one could adopt is:
 Keep away from ignition sources (flashes, flares, heat)
 Maintain distance
 Use protective gear while working
Oxidising chemicals
These are the chemicals that can catch fire even in the absence of air or can ignite
unstable/flammable substances. The preventive measures, one could adopt are:
 Stay away from combustible sources (sparks, flares, heat)
 Use protective gear
Gases stored at high pressure
The gases that are discharged might be extremely cold. Gas vessel may blast
whenever heated. It is important to adopt the following preventive measures:
 Never heat gas vessels
 Keep away from eyes and skin
Corrosives
These are the substances that may erode metals. One could avoid metals.
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9.2.2 Chemical Hazards Occupational Hazards
A chemical hazard is an exposure to chemicals in a working environment, which

can result in acute or long term health issues. Repeated exposure to chemicals like
silica dust, engine smoke, and smoking leads to increased chances of cardiovascular NOTES
disease, stroke, and hypertension. Chemical compounds can be classified into
risk classes causing threat to both, physical condition and overall health. It is to be
noted that these chemicals can cause more than one or multiple integrated hazards.
Numerous factors influence how the chemical will cause the response and how
extreme it will be. The common chemicals materials like fluorine, ammonia, ethylene
oxide, ozone, hydrocarbons (HC), sulphuric acid (H2SO4), tannic acid, limes and
alkalis harm the workers, when they come into contact with the skin, inhaled, or
ingested. Laborers may experience the ill effects of respiratory illnesses, skin
sicknesses, sensitivity, coronary illness, malignancy, and neurological issue or some
other problems. These diseases might be temporary or long standing. Generally, a
disease may be difficult to diagnose because the symptoms may start after a long
span of latent period or may not start at all. The effects of chemical hazards could
be:
 Skin inflammation
 Eczema/Atopic Dermatitis
 Ulcer/open sore
 Malignant growth by irritant
It is usually caused by inhalation of following:
(a) Dust: Dust particles are ‘barely divided solid particles with size ranging
from 0.1 to 150 microns’. Dust grains bigger than 10µ settle at the ground
from the air quickly, while the particles smaller than 5µ are straightaway
drawn into lungs and can cause pneumoconiosis/occupational lung disease.
Dust can be classified into:
 Organic and inorganic
 Soluble and insoluble
(b) Gases:
 Simple gases (Oxygen)
 Suffocating gases (eg Nitrogen, Helium, Sulfur Dioxide)
 Anesthetic gases (eg Isoflurane, Chloroform, Nitrous Oxide)
(c) Ingestion: Occupational diseases are also caused by ingestion of chemicals
such as lead, mercury, arsenic, zinc, chromium, phosphorus, etc.
Control of chemical hazards
It is done by risk-management action, implementation of control measures and
monitoring their efficiency. Until and unless the hazardous chemical is eliminated,
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Occupational Hazards a set of control measures is necessary to minimise the risk and implementation of
an effective series of defences to control their exposure. Following are the steps
for control:
(a) Elimination: Efficacious and dependable control measure is elimination of
NOTES
the hazardous chemical.
(b) Substitution: Replacement of the chemical agent by a less harmful chemical
agent is the next choice for control. However, care should be taken that the
new chemical should not expose workers to new risks. The new chemical
should be used in a form, which is less harmful (for example, use of chemical
in pellet form, instead of powder).
(c) Isolation: Isolation of the chemical agent in time or space from those
conceivably unprotected is an effective method for control (like shifting
individuals in a secured control room, putting a buffer region around a
chemical reactor, making use of the chemical when people are not in that
area, etc.).
(d) Engineering controls: Designing controls reduces the exposure at the
source (carrying out the process in pipes or using an exhaust for ventilation).
Avoiding unrestrained discharge is crucial and can be achieved by using
strategies like quantity limiting, segregation, safe storage, and temperature
control.
Hazards caused by biological substances that are dangerous for the health of a
living organism, mainly, humans, are called biological hazards. The perpetrators
include microorganisms, viruses, toxins, etc. There are three main pathways for
microorganisms to enter our body:
 Via respiratory tract
 Ingress by contact with body liquids of an infected person
 Infected objects
These harmful interactions may result in three outcomes in humans- infections,
allergies, and poisoning. Professions and work environments, where people might
be exposed to such threats are as follows:
 Medical staff, housekeeping staff, and lab worker in medical field
 Healthcare providers
 Housekeeping department
 Management of material
 Workers dealing with environmental waste like fluid waste and trash
accumulation and disposal
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 Horticulture, veterinary care, and building factories that utilise flora or fauna Occupational Hazards
derived raw material, for example, paper items, textiles, fur, leather, and
other items
Indoor working environments like clubs, eateries, and restaurants, where
NOTES
staff by and large work in encompassed places with central air conditioning,
a microbe can multiply inside the conditioning system. In an office setting, the
carpets, rugs, plants, or places that are moist can harbour microorganisms.
Preventing and controlling measures for biological hazards are:
 Removal of the source of infection is the first step to control biological
hazards.
 Engineering techniques like improving ventilation, partial segregation of the
infection source, establishing negative air gradient and independent ventilation
and air cooling system (wards for infectious diseases), and use of UV lamps
to avoid spread of infectious agents.
 A worker must always use personnel protection equipment and maintain
personal hygiene.
 The PPE includes face mask, gloves, protective overalls, eye protection,
head, and shoe covers.
Respiratory system safety includes:
 Use of proper protective gear to avoid contact with biological hazards.
Respiratory protective equipment includes:
o Surgical masks comprises three layers of non-woven material, which
act as a barrier.
o N95 or superior respirator strains out particulates and fluid droplets,
thereby providing safety from inhaling airborne microbes and aerosols.
 Correct selection of particulate respirators should be done considering its
filtration efficiency. In a healthcare centre, respirator of N series with filtration
up to 95% (type 95) or 99% (Type N-100) is suitable. When there are
considerable amount of oil mists present in the environment, then, the
R-series is utilised; R95 (where, R represents resistance to oil) or series
P95/P99 respirator or P100 (where, P represents oil verification) are utilised.
 Powered Air Purifying Respirator (PAPR) makes use of an electric blower
to transmit air from the filter to the user, making it more pleasant.
 Air providing respirators, which condense the air or provide clean air through
a high pressure vessel using hose.
 The suitable type of respiratory protection is chosen on the basis of the type
of biological hazard and the working environment. The workers should be
properly trained for using PAPR and air supplying respirators for their own
safety. It is mandatory to abide by the manufacturer’s instructions properly.
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Occupational Hazards It is crucial that the respirator must fit snugly on the wearer to form a
satisfactory seal and a seal check should be performed to ensure effective
protection.
 The disposable surgical mask act as a barrier and protect from inhaling
NOTES
possibly infectious droplets. It is essential to wear them properly. They
should be replaced, if they get soiled, wet, or if its surface is touched or
coughed on frequently. They should be carefully wrapped before they are
destroyed. Hands should be thoroughly washed later. Important points to
remember while wearing a surgical mask are:
o The masks should fit softly on the face
o Coloured side should be worn outwards with the metal strip lying on
the upper side
o Elastic handles should keep the mask firmly in place
o Mask should cover the nose, mouth, and chin
o Metallic band is pressed on either side of the nose bridge to keep the
mask relaxed over the face.
o Effort should be made to not touch the mask while wearing it. Hands
should be thoroughly washed, before contacting the cover.
o Under routine circumstances, a surgical mask needs to be changed
every day.
 N95 masks are used in departments such as casualty department, ICUs,
radiology department (Chest X-Ray units), and physiotherapy department.
Medical staff that deal with high-risk patients or assist high-risk treatments
choose N95 or high level respirators. Important points to remember while
wearing the N95 mask are:
o While wearing N-95 mask, the face-piece should fit snugly. Evaluate
the size of various brands to get the best and comfortable fit.
o Follow guidelines given by the manufacturer, while wearing the mask
o For reusing the N95 mask, it must be placed in a paper bag, when not
in use.
o N95 mask should be immediately replaced, if soiled or damaged.
o N95 mask cannot be shared with anybody or taken outside hospital
premises.
o Inappropriate use of mask will decrease its effectiveness.
o N95 masks should not be used by:
– Person having respiratory problems like emphysema and asthma.
– Person having trouble while breathing or feeling dizzy while using
it.
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Protective clothing Occupational Hazards
Protective clothing is a defensive cover with a hood, having an overall gown and
head and shoe covers. Protective gear should be impervious to fluids to safeguard
our body from contamination via body fluids, droplets, open injuries, or employee’s NOTES
own clothing; this diminishes the likelihood of cross infection or pathogen spread.
Important points to remember while wearing the protective clothing are:
 Protective gear is generally disposable, although can be reused after
disinfection
 Good quality protective gear should be chosen
 Protective wear should fit properly, without limiting movement
 Protective gear should be examined before use and changed if damaged
 Biologically infected clothing should be disposed of in a specially designated
container, which should be sealed with ‘biological hazard’ label
Goggles or face shields
Important points to remember while wearing the goggles or face shields are:
 Safety eyewear/glasses and face shields protect eyes from contacting
microbes carrying blood, droplets or other body fluids, which may ingress
the body through mucosa
 Standard goggles should be selected (EU EN 166, U.S. ANSI Z87.1-
1989)
 Glasses, with side shields should be used because they provide protection
to the front side as well as the sides from liquid splash Goggles fit easily and
are better than glasses for eye protection
 If needed, face shield can be used to protect entire face
 Face-shields and eye wear should be washed with liquid soap frequently.
In case of contamination by blood, they must be soaked in 1:49 diluted
liquid bleach and then, kept in clean water. They should be kept in plastic
bags after they are dry and stored in a cabinet
 Check routinely and replace, if they get out of shape, get cracked or get
scratches
Gloves
Important points to remember while wearing the gloves are:
 Gloves save and cover the hands from coming in contact with blood, droplets,
body fluids and body tissue of the contaminated, or microbe-infected objects
and protect from infection while touching the face. Gloves also prevent
contamination of open wounds by pathogens.
 Most gloves have to be disposed after use
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Occupational Hazards  Good quality gloves should be selected (EU EN 374; U.S. ASTM F1670,
ASTM F1671)
 Substance used should be resistant to chemicals.
NOTES  Gloves should fit comfortably and not limit a person’s movement
 Always keep short nails to avoid tearing of gloves
 Two pairs are worn while handling dangerous substances
 Always wash hands rigorously before and after use
 Check for any tearing before use
 Contaminated gloves should be disposed of immediately in a container,
sealed with ‘Biological hazard’ warning and label.
Shoe covers
Important points to remember while wearing the shoe covers are:
 Shoe covering prevent microbes from being carried outside the working
area
 Shoe gear is generally disposable
 Boot covers provide extended security. Cover the boots with the trousers
to stop microbes from getting inside the boots
 Shoe covers should be impervious to water
 Size should be suitable so that the movement of a person does not get
slowed down.
 Personal protective equipment needs the right selection and use, along with
proper preservation and storage. Equipment, which is to be reused should
be cleaned and sterilised properly before being used again. Damaged pieces
should be returned.
 While using the entire set, medical personnel should strictly follow hospital
protocols on infection control. Gloves should be disposed of so that there
won’t be any skin contact with the external surface of gloves, which will
prevent cross-contamination.
Sterilisation
Sterilisation is a method, which utilises high heat or high pressure to eliminate
micro-organisms, or by using bactericide to kill microbes, including spore forms.
A total sterilisation method should include sanitising the infected area and vigorous
removal of any remaining harmful material to guarantee that workers won’t be
harmed in the hazard area.
Appropriate sanitisation is decided based on the strain and quantity of
microbes, virulence of the organism, the time period, temperature, and concentration
of the steriliser used. Sterilisation should be done by abiding to safety instructions
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carefully to provide safety to the staff. There are numerous types of sterilising Occupational Hazards
agents, the most well-known ones are rubbing alcohol and liquid bleach. Hands
should be washed properly after removing any sort of protective gear.
Personal hygiene NOTES
Personal cleanliness starts with washing hands with fluid cleanser. It is the most
basic and easy way to stay away from contamination. Nonetheless, it is often
ignored. Always wash hands right before or after wearing protective gear, outfits,
or gloves to reduce the likelihood of disease.
Psychosocial hazard is an occupational hazard, which harms the psycho-social
wellbeing of the workforce, including their capability to engage in the working
environment with other workers. These hazards are recognised by the manner in
which work is planned, organised, directed, and coordinated, along with financial
as well as community context of the job and are associated with psychiatric,
psychological, or physical damage. Related to psychosocial threats are problems
like occupational tension and work pressure, which are of great concern to health
and safety.
A psychological hazard is a hazard that affects the mental health of the
worker substantially and requires coping techniques. Industrial/job stress caused
by different stressors such as task and job demands, leadership, lack of unity,
intergroup and interpersonal problems, career alterations, etc., lead to significant
distraction, which further leads to lethargy and demotivation. All of this affect the
health of workers. ‘Psychosocial’ pertains to the interrelationships between a
person’s ideas and behaviours, and their social surrounding. This term always
relates to social circumstances such as family of origin, socio-economic standing,
and extent of education. While it is necessary to be familiar with persons and non-
work related psychosocial factors, psychosocial hazards generally refer to hazards
caused only by work and working environment.
Occupational stress
The word ‘stress’ has been a much discussed and debated topic. The term supports
a diverse range of meanings, it is now possible to conclude different statements
together to summarise the characteristics of occupational stress. There are three
key factors, which needs to be examined:
 Firstly, it is vital to know that response to stress is multifactorial. It could be
a physiological, mental, or emotional response to a set of factors that can
translate into ill health.
 Secondly, it is not a disease per say, but a path that can affect health either
mentally or physically. The poor health pathway starts, when there is a
noticeable ‘imbalance’ between the demands made from an individual and
the ways that they cope up with them.
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Occupational Hazards  Lastly, the individual’s perception of their work attributes (which include
their opinions of their coping ability and how essential it is for them to deal
with it) is an important part of stress equation.
NOTES Psychosocial risk factors

There are certain factors, which increases the risk of psychosocial hazards in a
working environment:
I. Time pressure: When one requires to work very hard and at fast pace to
meet key performance indicators decided for a role, then that is referred to
as the time pressure. The pressure can occur from impractical deadlines or
insufficient resources to complete the given task. Work performed quickly
by machines and electronic monitoring of performance create time pressure,
if not well designed and executed.
II. Cognitive needs: Cognitive needs associated with a job can be various,
however, there are two main cognitive needs, which can negatively affect
the psychological and physical wellbeing, and lead to reduced outcomes.
These are activities with high concentration and activities requiring low mental
demands. The former require continuous undivided attention, focus, and a
lot of decision making, for example, Anaesthetist. Then, there are tasks that
require very little cognitive thinking (for e.g. sorting things, stacking material,
etc.). Monotonous tasks with few variations can be exhausting, stressful,
and prone to error.
Emotional demands: Work-related emotional load includes jobs requiring
workers to exhibit false demonstration of emotions like being happy or
wish to please, even in a state when the worker is feeling angry or dissatisfied.
The control of negative feelings leads to adverse effects on the worker’s
wellbeing, for example, flight crew and shop retailer. Workers who are
exposed to mentally distressing situations are associated with an increased
probability of illness (police officers and firefighters are exposed to such
risks).
III. Hours of work: Hours of work, including poorly designed work schedule,
can cause risk to health and safety by two means:
 Exposure time defined as ‘how long workers are exposed to psychosocial
hazards in a given working week and accordingly directly influence the
level of risk’.
 Fatigue caused by long working hours and shift schedule can lead to
mishaps at work
IV. Work roles: Role conflicts and obscurity refers to employees’
comprehension of their role in the organisation and whether the organisation
maintains distinction and avoids conflict between any two roles. This means
that people having an incomplete understanding of job expectations and
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position responsibilities, because of repeated or erratic changes in roles, Occupational Hazards
lead to overlapping of roles with others’ roles.

V. Conflict: Interpersonal disputes at workplace has been reported to be
among the causes of stress at work. Facts suggest that job related
NOTES
interpersonal disputes are associated with compromised psychological and
physical performance. In addition to psychological disturbance, age, stressful
work incidents, stressful life incidents, and support from work also play a
major role.
Decreasing and preventing psychological hazards
Possibilities to advance the well-being of employees and prevent occupational
stress depend on the specific institution, organisation of work, employees’
expectations and characteristics, existing resources, and much more, but the rule
of thumb for shaping a positive psychosocial working environment is to involve
employees in decisions about them, open information exchange, optimal workload,
and zero tolerance of occupational violence (including any signs of bullying and
harassment). When one is planning activities to improve the psychosocial working
environment, it should be remembered that it is always more efficient and cheaper
to prevent the problem on the organisation level through good management and
work organisation. In case, where risks cannot be fully avoided, it might help to
apply measures directed for supporting the risk groups or to rehabilitate employees
who have already suffered due to work pressure.
Examples of organisation-level measures are:
 Clear determination of employee’s responsibilities and corresponding
authorisation
 Determining clear principles and guidelines for coping with workplace bullying
and harassment
 Transparent personnel politics
 Enabling a flexible work organisation
 If risks cannot be completely eliminated, for example, due to type of job
(night-time job, a job that requires lot of communication), stress relief
measures should be directed to risk groups
 Organising training for employees on coping in tense situations
 Offering training for middle managers on how to cope with the stress of
subordinates and to help them
 Encouraging healthy lifestyle in employees (e.g. movement habit)
 Regardless of all applied measures, there are always employees who do
suffer from occupational stress due to one reason or other. To support
these individuals, the employer could:
o Offer the employees some psychological counselling and help
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Occupational Hazards o Enable training to improvise job-related skills
o Develop supportive systems to integrate employees back to work
who have been absent from work for a longer period of time (e.g. on
a sick list)
NOTES
9.3 PREVENTION AND CONTROL OF HAZARDS
Sound-induced hearing loss is, at present, untreatable and permanent, however, it

can be controlled. Thus, the implementation of an effective preventive programme
is important. Specific steps for the elimination and control of exposure to noise
should not be implemented temporarily, but as part of an inclusive strategy. The
above-mentioned example illustrate the aim of prevention and control of hazards,
which is to discuss basic principles for prevention and control, their management,
and incorporating them in the elimination or control of all kinds of hazards. A
programme is for taking care of employees from the harmful effects of physical/
chemical/biological/psychosocial hazards in the workplace. Hazard programmes
should be planned to cater to needs of every scenario, existing hazards, and other
factors that distinguish a workplace, moreover, programme should be opened to
developments in technology and scientific discoveries, and to changes in the socio-
economic factors. Usually, national legislation requires the implementation of all
kinds of measures in order to achieve the lowest possible levels of exposure to
harmful elements, taking into account:
 The state of the art on the topic of technical progress;
 Possibilities to reduce hazards from the source
 The planning should be appropriate
Requirements for efficient programmes
Hazard prevention and control programmes need:
 Political support and decision-making procedure
 Support from the top management
 Clear and well-designed policy
 Precise and distinct aim and objectives
 Adequate human and economic resources
 Technical awareness and exposure
 Founding of multidisciplinary team
 Continuous development of the programmes
Every hazard prevention and control programme requires measures
associated with the working condition and the workforce. Proficient control
measures generally depend on a mix of engineering (technical) control and personal
actions (e.g., work practices). Control measures should be able to meet the needs
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of every situation and perspectives such as effectiveness, cost, technical feasibility, Occupational Hazards
and socio-cultural aspects.
Check Your Progress

NOTES
1. Why is it important to study occupational hazards?
2. List the five primary classes of physical dangers.
3. What are the conditions that can be caused by repeated exposure to
chemicals?
4. What are the main pathways for microorganisms to enter our body?
5. Mention any one key factor, which needs to be examined with regards to
occupational stress.
6. State any three requirements of an efficient programme to control hazards
at workplace.

QUESTIONS
1. It is important to study occupational hazards in order to:

(a) Make all the workers aware of the dangers of most kinds of jobs or
professions
(b) Check whether workers can adapt to the dangers of a profession or
not
(c) Help workers in making appropriate job choices
2. The five primary classes of physical dangers are explosives, flammables,
oxidizing chemicals, gases stored at high pressure, and corrosives.
3. The repeated exposure to chemicals can lead to increased chances of
cardiovascular disease, stroke, and hypertension.
4. The main pathways for microorganisms to enter our body are:
(a) Via respiratory tract
(b) Ingress by contact with body liquids of an infected person
(c) Infected objects
5. The key factor, which needs to be examined with regards to occupational
stress is that the response to stress is multifactorial. It could be a physiological,
mental, or emotional response to a set of factors that can translate into ill
health.
6. The requirements of an efficient programme to control hazards at workplace
are:
(a) Political support and decision-making procedure
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Occupational Hazards (b) Support from the top management
(c) Clear and well-designed policy
NOTES 9.5 SUMMARY
 Hazard is an agent with possible threat or peril to life, health, goods, or

ecosystem. Nearly all hazards are latent or probable, with a hypothetical
risk of damage, though, if the threat becomes functional, it can result in an
urgency.
 Physical hazards include those hazards, which physically harm an individual.
These include noise nuisance, vibrations and blow, glare, radiations, excessive
heat, ventilation, water contamination, etc.
 A chemical hazard is an exposure to chemicals in a working environment,
which can result in acute or long term health issues.
 Hazards caused by biological substances that are dangerous for the health
of a living organism, mainly, humans, are called biological hazards.
 Psychosocial hazard is an occupational hazard, which harms the psycho-
social wellbeing of the workforce, including their capability to engage in the
working environment with other workers.
 The aim of prevention and control of hazards is to discuss basic principles
for prevention and control, their management and incorporating them in the
elimination or control of all kinds of hazards. A programme is for taking
care of employees from the harmful effects of physical, chemical, biological,
and psychosocial hazards in the workplace.
9.6 KEY WORDS
 Erythrocyanosis Crurum: A skin condition caused by chronic exposure

to cold.
 Emphysema: A type of COPD involving damage to the air sacs (alveoli) in
the lungs, as a result, the body does not get the oxygen it needs.

EXERCISES

1. How would you define physical hazards?
2. What are the causes of chemical hazards?
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3. Write a short note on protective clothing. Occupational Hazards
4. What is psychosocial hazard?

NOTES
1. Discuss the different types of physical hazards, along with its preventive
measures.
2. Describe the steps in the control of chemical hazards.
3. Explain the respiratory system safety techniques in detail.
4. Evaluate the factors posing risk for psychosocial hazards.
Peterson, N.; Mayhew, N. 2018. Occupational Health and Safety: International

Influences and the New Epidemics. London: Routledge.
Gilbert, B., P. G. Benson, ‘The contribution of the supervisor behaviour to employee
psychological well-being’, Work and Stress. 18(3): 255-266, 2004.
Jex, S.M. 1998. Stress and Job Performance: Theory, Research, and Implications
for Managerial Practice. Thousand Oaks. SAGE Publications.
Horino, S., ‘Environmental factors and work performance of foundry workers’,
J Hum Ergol. 6(2): 159-166, 1977.
Kjellstrom, T., C. Corvalan, ‘Framework for the development of environmental
health indicators’, World Health Stat. 48:144–154, 1995.
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Evolution of Health Care
Delivery System
UNIT 10 EVOLUTION OF HEALTH
CARE DELIVERY SYSTEM
NOTES
Structure
10.0 Introduction
10.1 Objectives
10.2 Brief History of Evolution
10.3 Changing Trends in the Evolution of Healthcare Delivery System
10.5 Summary
10.6 Key Words
10.0 INTRODUCTION
As we have seen in the last several decades, the face of healthcare delivery system
has changed rapidly. It is almost unrecognisable now, if we consider the traditional
healthcare delivery system, which leaves little room for any improvisation in terms
of roles played by healthcare staff and patients. The countless reforms and policies
converted the taut traditional system into a flexible one. In this unit, we will discover
this very evolution, with its history. This unit will also discuss the changing future
trends in the evolution of health care delivery system.
10.1 OBJECTIVES

 Describe the history of evolution of health care delivery system
 Understand the salient features of various committees
 Discuss the changing future trends in the evolution of health care delivery
system
10.2 BRIEF HISTORY OF EVOLUTION
Various public healthcare initiatives in India were introduced by the British during
pre-independence era including ‘Quarantine Act’ in 1825. In 1859, the need of
safe drinking water and environmental sanitation was pointed out by the Public
Health Commission, so that epidemics could be prevented. Sanitary commissioners
were appointed in 1864 in Bombay, Bengal, and Madras for studying the healthcare
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concerns and initiating measures for improving the sanitary practices. Following Evolution of Health Care
Delivery System
this, in 1885 ‘Local Self-Government Act’ was passed.
In 1919, health administration was decentralised with ‘Montague-Chelmsford
constitutional reforms’. Following this, the gaps in the coverage of health services
NOTES
were acknowledged and the responsibilities for the same were proclaimed; suitable
actions were thus, recommended, but resources were not provided for
implementation. In 1940, the National Planning Committee adopted the resolution
based on the recommendations of Sokheys Committee that is, the preventive and
curative functions should be integrated with training of health workers. Bhore
committee was then set up in 1943, which laid down the structure on which the
healthcare framework was subsequently built in India after independence. After
the introduction of Panchayati Raj, the healthcare system in the country, which
was initially the top down system was transformed into bottom up decentralised
community based system due to bureaucracy in the government, which was
propagated by Mahatma Gandhi. After independence, lots of improvements were
made in the quality and provision of healthcare services to the community. In 1950,
Planning Commission was established by the government and system of five year
plan was started for the country’s social and economic development, with health
being an integral part. Apart from planning commission, various committees were
also instituted by the government for reviewing existing healthcare conditions.
There were various committees, which came into existence solely for the purpose
of providing an efficient healthcare delivery system.
Bhore Committee (1943-1946)
Before independence, in 1938, the ‘National Planning Commission’ was constituted
by the INC (Indian National Congress) in the country for promoting, preventing,
and curative healthcare services. The British Empire at that time realised the
significance of Public Health and established the ‘Health Survey and Development
Committee’, in 1943 chaired by Sir Joseph Bhore. The committee was given the
responsibility of surveying the health conditions of the provinces and healthcare
organizsations in India and to provide recommendations for further development.
In 1946, the committee recommended that preventive and curative healthcare
services should be integrated and primary health centres should be established in
rural areas. Other important recommendations of the Bhore committee are:
 The development of primary health centres for the delivery of comprehensive
health services to the rural India. Each PHC should cater to a population of
40,000 with the secondary health centre (now called community health
centre) to serve as a supervisory, coordinating, and referral institution.
 In the long term (3 million plan), the PHC would have a 75 bedded hospital
for a population of 10,000 to 20,000.
 It also reviewed the system of medical education and research and included
compulsory three months training in community medicine. Self-Instructional
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Evolution of Health Care  Committee proposed the development of National Programmes of health
Delivery System
services for the country.
This document laid the utmost emphasis on primary health care; it is not a
surprise then that primary health care was later on recognised as the key strategy
NOTES
to achieve ‘Health for All (HFA) by 2000’ during Alma-Ata conference. The
Bhore committee model was based on the allopathic system of medicine. The
traditional health practices and indigenous system of medicine prevalent in rural
India, which had great influence and were part of their socio-cultural milieu were
not included in the model proposed by Bhore committee. The approach was not
entirely decentralised but had a top down approach. However, it provided a
readymade model at the time of independence and thus, was adopted as a blueprint
for both health policy and development of the country.
Mudaliar Committee (1962)
In the course of second five year plan, it was decided by the government that the
health requirements and resources in the country should be reviewed, so that
important guidelines for national health planning can be formulated. To review the
progress of recommendations of Bhore committee, ‘Health Survey and Planning
Committee’ was formed in 1959, under the chairmanship of Dr A. Lakshmanswami
Mudaliar to make recommendations for the future course of actions for the
development and extension of healthcare services. It was admitted that at least
half the country is still devoid of the basic healthcare facilities and a great irregularity
in the distribution of hospitals and beds exist in rural regions. It was also pointed
out by the committee that there is an inadequacy in the quality of services provided
by PHCs, along with poor functioning, unsatisfactory referral system, and lack of
staff because of lack of resources. Important recommendations made by the
Mudaliar committee were:
 Strengthening of existing PHCs and development of referral centres should
be done before new centres are established
 Strengthening of sub-divisional and district hospitals
 Integration of medical and health services
 It also suggested the constitution of an All India Health Service in the pattern
of Indian Administrative service.
Chadah Committee (1963)
DGHS of that time, Dr MS Chadha, was given the responsibility of reviewing the
specifications of National Malaria Eradication Program and PHCs. Important
recommendations of the Chadah committee were:
 Strict monitoring and vigilance in the implementation of NMEP is the
responsibility of general health services at all levels that is, health workers of
PHC, CHC, and ZP.
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 One basic health worker (now called Multi-Purpose worker) for every Evolution of Health Care
Delivery System
10,000 population was recommended.
 Basic health workers should visit house to house once in a month to
implement anti-malaria preventative measures.
NOTES
 Basic Health workers should take additional duties of collection of vital
statistics, counsel on family planning, etc.
Mukherji Committee (1965)
National Malaria Eradication Program and Family planning program suffered a
set-back when basic healthcare workers were recommended to take on additional
duties and responsibilities of multipurpose workers. So, a committee was appointed
under the chairmanship of Shri Mukherji, Healthcare Secretary of that time, for
reviewing the healthcare system at all levels from the view point of financial planning
and manpower requirement. Important recommendations of the Mukherji
committee were:
 Strengthening of the administrative set up at different levels from PHC to
state health services
 Separate staff was recommended for family planning program
 Basic health workers to be utilised for all duties except for family planning.
Jungalwalla Committee (1967)
Central Council of Health in 1967 appointed ‘Committee on integration of Health
Services’ headed by Dr N. Jungalwalla, who was the Director, National Institute
of Health Administration and Education at that time. Important recommendations
of the Jungalwalla committee were:
 Integrated health services with Unified cadre include common seniority,
recognition of extra qualifications, equal pay for equal work, no private
practise, special pay for specialised services, improvement in their service
conditions, etc.
 Medical care of the sick and conventional public health programmes
functioning under single administrator
Kartar Singh Committee (1973)
The committee headed by Shri Kartar Singh, who was the Additional Secretary of
MOH and Family Planning, was established to review and provide
recommendations regarding the framework for integrated health services at
supervisory and peripheral levels. Its aim was to review the feasibility of ‘bi purpose
and multipurpose workers’ in the field. Important recommendations of the Kartar
Singh committee were:
 It recommended Female Health Worker in place of ANM and Male Health
Worker in place of malaria surveillance worker, along with addition of
vaccinators, health education assistants, and family planning health assistants.
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Evolution of Health Care The committee proposed a PHC per 50,000 population with 16 sub-centres,
Delivery System
each covering a population of 3000-3500. Each sub-centre needs to have one
male and one female health worker.
 There should be one male and one female health supervisor at PHC to
NOTES
monitor and supervise the activities of staffs of 3-4 sub-centres.
 The MO in charge of PHC will be the overall in charge of all peripheral
staff.
 Training for all workers engaged in the field of health, family planning, and
nutrition should be integrated.
Shrivastav Committee (1974-75)
This committee was convened in 1974 by GOI and is also known as ‘Group on
Medical Education and Support Manpower’. It gave rise to the concept of
community participation in the healthcare sector that is, ‘people’s health in people’s
hand’. Formed under the chairmanship of Dr J B Shrivastav, Director General
Health Services, this committee gave the following recommendations:
 Creation of Village Health Guide (VHG) and participation of community
health volunteers from the community itself like teachers, postmasters, gram
sevaks, who can provide comprehensive health services as
paraprofessionals.
 Primary health care should be provided within the community itself through
specially trained workers, so that the health of the people is placed in the
hands of the people themselves.
 Creation of MPW and Health Assistants (HA) with the VHG and MO
being in charge of PHC.
On the basis of the above recommendations, in 1977-78, Rural Health
Scheme was introduced by the government and the training program of community
health workers was started. The important steps were:
 Involvement of medical colleges in health care of selected PHCs with the
objective of reorienting medical education according to rural population
called Re-Orientation of Medical education (ROME). It led to teaching
and training of undergraduate students and interns at PHCs.
 Training of village health guides and utilising their services in the general
health service system.
Shivaraman Committee Health Report
A committee on ‘Basic Rural Doctors’ was convened under the guidance of Shri
Shivaraman, the member of planning commission of that time. It was recommended
by the committee that a countrywide cadre of basic rural doctors comprising of
trained paraprofessionals should be established to expand healthcare service
delivery to the rural communities.
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V Ramalingaswamy Committee Health Report Evolution of Health Care
Delivery System
This committee was established under the chairmanship of Dr V Ramalingaswamy,
DGHS. Following were the recommendation of the committee:
 Involvement of community in health planning and health programme NOTES
implementation
 30 bedded hospital for every 1 lakh population
 Integration of health services at all levels
 Redefine the role of doctor in the community
 Recommended that PHC and District health centres should be under the
control of three tier Panchayati Raj System
Bajaj Committee Health Report (1986)
An expert committee for health manpower planning, production, and management
was convened under the chairmanship of Dr JS Bajaj, member of Planning
Commission to solve the issues of health manpower planning, production and
management. Important recommendations of the Bajaj committee were:
 Recommended the formulation of National Health Manpower planning based
on realistic survey
 Educational Commission for health sciences should be developed on the
lines of UGC.
 Recommended National and Medical education policy, in which teachers
are trained in health education science technology.
 Uniform standard of medical and health science education by establishing
universities of health sciences in all states
 Establishment of health manpower cells both at state and central level
 Vocational courses in paramedical sciences to get more health manpower.
Krishnan Committee Health Report (1992)
This committee headed by Dr Krishnan was formed to review the performance,
achievements, and progress of the previous health committee reports and also
provides constructive criticism. The committee addressed the urban healthcare
issues and formulated Health Post Scheme for slums in urban areas. It was
recommended that there should be one voluntary health worker (VHW) per 2,000
population with an honorarium of ` 100. Specific outlines are given in this report
regarding the services provided by the health post. These services have been
categorised into curative, outreach, family planning, preventive, and support and
referral services. Outreach services include elementary education, motivating people
to adopt family planning, and health education.
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Delivery System 10.3 CHANGING TRENDS IN THE EVOLUTION OF
HEALTHCARE DELIVERY SYSTEM
NOTES The changing trends in the evolution of healthcare delivery system is observable
since a last decade or so. With advanced technology and efficient management,
India has seen a significance dip in the infant mortality rate (IMR) and maternal
mortality ratio (MMR). According to United Nations’ report ‘Levels and Trends
in Child Mortality’ released in 2015, ‘IMR has fallen to 41 per 1,000 live births in
2013 from 88 in 1990, while according to a World Health Organization (WHO)’s
report released in 2014, ‘MMR in India has declined from 560 deaths per 100,000
live births in 1990 to 190 in 2013’. This result is evident as India has made great
strides in the health of women and children in rural areas. However, the cost of
accessing this improved healthcare system has also risen.
This is perhaps due to the government; reportedly, ‘allocation to healthcare
as a percentage of the country’s gross domestic product (GDP) has fallen to
1.05% in 2015-16 from 1.47% in 1986-87’. This evident from the health survey
conducted by National Sample Survey Organisation (NSSO), which shows an
upward spiral in the dependency of people on private health care. In the years
1986-87, around 60% people were accessing public health care, but by 2014,
only 41% people were accessing public health care. This trend is especially
prominent in the urban areas, where it went down from ‘60% in 1986-87 to
almost 32% in 2014’.
Check Your Progress

1. When was the ‘Local Self-Government Act’ passed?
2. What are the changing trends observed in the infant mortality rate (IMR)
in India?
3. Under whose chairmanship was the Srivastav committee formed?

QUESTIONS
1. The ‘Local Self-Government Act’ was passed in 1885.

2. According to United Nations’ report, ‘Levels and Trends in Child Mortality’
released in 2015, ‘IMR has fallen to 41 per 1,000 live births in 2013 from
88 in 1990’.
3. The Srivastav committee was formed under the chairmanship of Dr J B
Shrivastav, Director General Health Services.
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10.5 SUMMARY Delivery System
 As we have seen in the last several decades, the face of healthcare delivery
system has changed rapidly. It is almost unrecognisable now, if we consider NOTES
the traditional healthcare delivery system, which leaves little room for any
improvisation in terms of roles played by healthcare staff and patients.
 Various public healthcare initiatives in India were introduced by the British
during pre-independence era including ‘Quarantine act’ in 1825.
 After independence, lots of improvements were made in the quality and
provision of healthcare services to the community.
 There were various committees, which came into existence solely for the
purpose of providing an efficient healthcare delivery system.
 The changing trends in the evolution of healthcare delivery system is
observable since a last decade or so.
 With advanced technology and efficient management, India has seen a
significance dip in the infant mortality rate (IMR) and maternal mortality
ratio (MMR). However, the cost of accessing this improved healthcare
system has also risen.
10.6 KEY WORDS
 Decentralised: Transfer of authority from central to local government.

 Referral System: A system of transferring cases which are beyond the
technical competence of one infrastructure to a higher level infrastructure/
institution having technical competency and all other resources to provide
desired health services.

EXERCISES

1. What are the important recommendations of the Bhore committee?
2. Write a short note on Jungalwalla Committee.
1. Discuss the history of health care delivery system.
2. Describe the salient features of any four committees with regards to evolution
of health care delivery system.
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Delivery System 10.8 FURTHER READINGS
NOTES Brothers, Medical Publishers Pvt.
Websites
https://www.livemint.com/Politics/lz9De8e3TUkru2KTFJslBN/The-changing-
pattern-of-healthcare-in-India.html
http://s3.amazonaws.com/zanran_storage/.whoindia.org/ContentPages/
127626072.pdf
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Holistic Approach to Health
UNIT 11 HOLISTIC APPROACH

TO HEALTH
NOTES
Structure
11.0 Introduction
11.1 Objectives
11.2 Holistic Health
11.3 Evolution of Different Systems of Medicine
11.3.1 AYUSH
11.3.2 Naturopathy
11.3.3 Reiki
11.4 Traditional Chinese Medicine (TCM)
11.6 Summary
11.7 Key Words
11.0 INTRODUCTION
Holistic health is an ancient approach to health that does not focus on specific
illness or particular part of body rather it considers the whole person and how he
or she interacts with his or her environment. The holistic approach to health emphasis
on the connection of mind, body, and spirit. The unit discusses about the holistic
approach to health and evolution of medicines
The unit aims to analyse the significance of holistic approach to health, and
will also discuss in detail about the evolution of various types of medicines from
ancient times to contemporary times. The unit will also take few other healing
systems into consideration such as acupressure, acupuncture, reiki, homeopathy,
Siddha Vaidya system etc. In addition to this, you will also learn about the discovery
and importance of Traditional Chinese Medicine (TCM) and its types.
11.1 OBJECTIVES

 Understand the significance of holistic approach to health
 Discuss the evolution of various types of medicines
 Describe the benefits and significance of Ayurveda and Homeopathy
 Analyse Naturopathy and Sidda Vidya System treatments
 Explain the working and treatment of Traditional Chinese Medicine (TCM)
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Holistic Approach to Health  Understand how techniques like Reiki, body cupping, acupressure,
acupuncture work
NOTES
11.2 HOLISTIC HEALTH
It is defined as psychological, physiological, environmental, sociological, nutritional,

emotional and spiritual well-being. The peaceful state of mind, body and spirit is
holistic health.
Fig. 11.1 Holistic Health- Healing the Total Person
Holistic Medicine
 The approach of Holistic Medicine is to consider the individual as a whole
(mind-body and spirit) in the context of his environment.
 Holistic or Integrative Medicine is about incorporating conventional systems
of medicine (Ayurveda, Homeopathy, Naturopathy, Sidha, Unani) and
Complementary Therapies (Yoga, Acupuncture) to help and hasten healing.
 It addresses the psychological, spiritual, familial, societal, ethical and
biological dimensions of well-being and illness of an individual and group.
Fig. 11.2 Balance of Three Modalities- Body, Mind and Spirit

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Holistic approach lays stress on the following: Holistic Approach to Health
 Uniqueness of each patient care.

 Importance for mutuality of the patient-doctor relationship.
 Stating the responsibility of every person’s own well-being. NOTES
 Role of society’s responsibility for the promotion of health.
Holistic Understanding of Healing
Holistic Healing – True Healing
Nature of Healing of Body:
 Healing of body is normally visible in nature
 Little or Basic effort is required on the part of an individual in the healing
process like rest, diet etc.
Nature of Healing of Mind:
 It is not so visible in nature and may not be seen by other people in
surrounding.
 Person needs to open up and participate in this healing process.
Nature of Healing of Spirit:
 Healing of spirit is invisible in nature and may not be seen even by the
person.
 An individual needs to make a focused, conscious effort to help healing at
this level.
Causes of Illness
Following are the causes of illness according to holistic concept of health:
 Poor Lifestyle
 Lack of Rest
 Lack of Exercise
 Poor Eating Habits
 Poor Working Environment
 Wrong Posture
 Poor Interpersonal Relationships
 Environmental Pollution
 Stress
 Emotional Imbalance
 Sleep Disorders
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Holistic Approach to Health Holistic Approach to the Healing Process in an Individual
 Accept there is a problem
 Identify the problem
NOTES  Desire and a need from within to heal
 Seek for healing
 Believe in the process
 Be prepared and participate in the healing process
 Make changes to prevent the recurrence
 Be positive and move forward
Healing Process of the Body
 Detoxification
 Clean Environment
 Prevention of Illness
 Exercises
 Proper Rest
 Diet management
 Healthy Lifestyle
 Promotion of Health
Healing of the Mind

 Breathing Activities
 Self-Awareness
 Mindful Activities
 Control Emotions
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NOTES
Tools for Spiritual Healing

 Prayer Powers
 Meditation
 Expanse of Silence
 Dialogue of Self
 Depth of Introspection
Integrated Medicine
Incorporating Modern Medicine with
 Traditional Systems - Ayurveda, Homeopathy, Sidha, Unani Medicine,
Naturopathy
 Complementary therapy systems - Yoga, Reflexology, Acupuncture.
11.3 EVOLUTION OF DIFFERENT SYSTEMS OF

MEDICINE
 AYUSH
 Naturopathy
 Reiki
 Traditional Chinese Medicine
o Acupuncture
o Acupressure
o TCM herbs
o Body cupping therapy
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Holistic Approach to Health 11.3.1 AYUSH
India is a country of great ecological, cultural, political and economic diversity. Its
medical knowledge is procured from the Vedas that existed as Ayurveda which
NOTES was further supplemented with ancient Rishi’s siddha systems and yogic practices
that continued for years and became a part of Indian culture. Unani system of
medicine came to the country in the eighth century and eventually Allopathic system
of medicine which is based upon the biomedical concepts was also introduced in
India and got blended in the Indian system of medicine. In the eighteenth century,
homeopathic system was evolved in Germany, quickly became popular and got
assimilated in the conventional Indian medical system because of its similarity with
holistic principles of medicine. Subsequently, Naturopathy which is an ancient
practice and also considered as a drugless medicine system incorporating healthy
well-being practices also again gained popularity and became a part of medical
pluralism in India. This caused the evolution of a distinct medical paradigm which
signified the amalgamation of traditional medical practices with biomedicine.
Government has started supporting all these medical practices after independence
providing freedom to the people that they may choose any system of healthcare
they want.
AYUSH has been given prime importance in the “National Health Policy
(NHP) 2017” within a pluralistic system of Integrative healthcare. A new term
“Medical Pluralism” has been used in NHP 2017 to strive to integrate AYUSH in
the National Health Mission, education and research. It is defined as the adoption
of various medical systems or using conventional and alternative medicines together
for the treatment of diseases and illnesses. This term first came into light in the
middle of 1970 when alternative medicine systems other than conventional
biomedicine were explored by the people and in 1990 CAM (complementary
and alternative medicine) was employed within the state health administration giving
rise to medical pluralism. The Ministry of Health and Family Welfare strongly
recommended to advocate extensive scope to the integrative healthcare in the
NHP 2017. In 2018, Union Government has increased budget allocation for
AYUSH by 13 per cent for the regulatory bodies and councils for research in
AYUSH science. Autonomous bodies have been allocated ` 906.70 crores
compared to ` 804.30 in the previous budget.
Ayurveda
Ayurveda is an old arrangement of social insurance beginning from the Vedas
reported around 5000 years back. The learning of Ayurveda was first archived in
the book called “Charak Samhita and Sushruta Samhita”. All the living bodies on
this planet are made out of five fundamental components, and that are known as
the Pancha Mahabhootas as indicated by Ayurveda, that are:
Prithvi (earth), Jal (water), Agni (fire), Vayu (air) and Akash (ether).
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Ayurvedic approach is based on following elements of Tridosha: Holistic Approach to Health
 Vata (ether + air),

 Pitta (fire) and
 Kapha (earth + water) NOTES
The word Ayurveda is derived from two words ‘AYU which means life
and VEDA meaning science or knowledge’. Therefore Ayurveda is defined as the
‘Science of life’. According to Charaka, Ayurveda is ‘The science which deals
with advantage and disadvantage as well as happy and unhappy states of life along
with what is good and bad for life, its measurement and the life itself (Charaka
Sutra 1 - 4)’. Ayurveda is divided into three branches:
1. Nara Ayurveda which deals with life of humans and its associated diseases.
2. Satva Ayurveda which deals with life of animals and its diseases.
3. Vriksha Ayurveda which deals with life of plants, their growth and diseases.
Ayurveda is just not a system of medicine but it is also the way of life to
attain complete positive health and well-being. It is based on the principle that
positive health is the only basis for achieving the four most important objectives of
life ‘(chaturvidh purushartha) viz., Dharma, Artha, Kama, Moksha’. Without
positive health it is impossible to achieve these four objectives of life.
The preventive part of Ayurveda is called Svasth-Vritta and incorporates
individual cleanliness, every day and occasional regimens, proper social conduct
and utilization of materials and practices for solid maturing and counteractive action
of untimely loss of wellbeing trait. The corrective treatment comprises of Aushadhi
(drugs), Ahara (diet) and Vihara (way of life). Ayurveda generally utilizes plants as
crude materials for producing medications. Ayurvedic prescriptions are commonly
protected and have almost no known antagonistic symptoms. Ayurveda has turned
out to be successful for the cure of those metabolic disorders and life sicknesses
for which regular medication are not recommended. There are two lines of treatment
of diseases in Ayurveda: ‘Samana and Sodhana’. In Samana the Docas are only
subsidized but not eliminated from the body, whereas in Sodhana the vitiated Docas
are eliminated out of the body.
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Holistic Approach to Health Kshar Sutra and Panchakarma treatments of Ayurveda have turned out to
be famous among people throughout the years.
Panchkarma
NOTES Panchakarma acts as the cleansing system for the body and helps in the detoxication
and rejuvenation of mind, body and soul. It is aimed to remove the toxins from the
body to calm the mind and help in the strengthening of immune system of the body
to promote healthy lifestyle.
Panchakarma is aimed to promote health, prevent and cure the
diseases. Panchkarma believes that Prakopa of a specific Docha is eliminated at a
particular suitable time and thus the diseases of that season can be very well
prevented.
Two additional techniques are performed before (Purva) and after (Pascata)
the Panchakarma therapy. Snehana and Svedana are important to be carried out
before initiating Panchakarma. These two techniques are called as Purva Karma.
After performing the Panchakarma therapy the patient is gradually allowed to
start his normal daily routines of diet and other duties. Specific dietary regime that
is prescribed to the patients after Panchakarma is called as Samsarjana Krama.
 Panchakarma incorporates 5 detoxification procedures to treat ailments-

‘Vamana (Medicated emesis), Virechana (Medicated purgation), Basti
(Medicated enema), Nasya (medication through the route of nose),
Raktamokshana (Blood letting)’
 The Panchakarma treatment limits the repetitive infections in the body and
promote positive wellbeing by reviving the tissues of the body and bio-
decontamination.
 It removes the doshas and imbalances by eliminating the harmful toxins out
of the body through elimination tracts like sweat glands, lungs, colon, bladder,
urinary tract, intestines, stomach etc.
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Yoga Holistic Approach to Health
The term ‘Yoga’ is originated from the Sanskrit word “yuj” which signifies “to join
together or coordinate”. Yoga is about the association of an individual’s own
cognizance and all-inclusive awareness. Yoga is a science as well as art of healthy NOTES
living. Its main focus is to bring peace and harmony between the body and mind.
It follows the holistic approach of health and well-being and assists in the prevention
and treatment of diseases, promotion of good health and management of various
lifestyle disorders. Nowadays Yoga is very popular throughout the world as it not
only treat the diseases efficiently, but also provides strength and relief from
psychological and emotional problems.
The main objective of Yoga is “moksha (liberation)” and it has five principal
meanings:
1. A disciplined way for accomplishment of an aim.
2. An approach for the control of the mind and the human body.
3. A school’s name or methodology of philosophy.
4. An effective means of exploring and overcoming the dysfunctions of the
body.
5. A system which involves the Asanas and pranayama to promote healthy
lifestyle and well-being.
It comprises of eight segments in particular: ‘Restraint (Yama), observance

of austerity (Niyama), physical postures (Asana), breathing exercise (Pranayam),
restraining of sense organs (Pratyahar), contemplation (Dharna), Meditation
(Dhyan) and Deep meditation (Samadhi).’
Yoga practices are also useful in preventing psychosomatic diseases by
improving the resistance of body and enhancing the capability to overcome stressful
situations.
There are six branches of Yoga:
1. Hatha yoga: This branch is related with the physical and mental health of
the individual.
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Holistic Approach to Health 2. Raja yoga: It includes meditation and following a sequence of disciplinary
steps called as the ‘eight limbs of yoga’.
3. Karma yoga: This branch is aimed to establish a sound future that if free
from all types of negativities and ego.
NOTES
4. Bhakti yoga: It focuses on the establishment of a new pathway of devotion,
a positive means to control the emotions and induce tolerance.
5. Jnana yoga: It is focussed to inculcate wisdom, and to develop the intellect
through study.
6. Tantra yoga: It deals with the rituals, ceremonies or realization of importance
of relationships.
Fig. 11.3 Different Yoga Poses
There are thousands of yoga asans and poses which are known as ‘kriyas
(actions), mudras (seals), and bandhas (locks)’ that help in the conditioning of
body. Yoga asans focus on the efforts required for the flow of energy up and down
the spine.
Unani
As the name demonstrates, Unani framework started in Greece. The establishment
of Unani framework was laid down by Hippocrates and presented in India by the
Persians and Arabs around the eleventh century. The basic theory of Unani system
is based upon the well- known four- humors theory of Hippocrates. In Unani
system, herbal medicines, special diets and alternative therapies are used for the
prevention and cure of disease.
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NOTES
Principles of Unani Medicine

Unani medicine practitioners believe that ‘the four humours (blood, phlegm, yellow
bile, and black bile)’ are essential to achieve a balance of the fluids of the body to
maintain good health. It is also based on the principle that diseases are the result of
imbalances in the four elements of nature i.e. earth, air, water, and fire. Environmental
factors like the quality of air and water can have a significant impact on human
health. Unani Medicine system is effective for the treatment of arthritic disorders
like Rheumatoid Arthritis gouty arthritis, nervous and skin related problems,
respiratory and metabolic disorders etc. Unani system is not just a medical science
but it is a rich treasury of the philosophies and principles of medical system which
are extremely valuable and contribute a lot to the medical science. It is an exhaustive
system of medicine that extensively deals with different health states and diseases.
Unani system is completely based on the scientific and holistic principles of
health. It gives extreme importance to the temperament of the patient to diagnose
and treat the diseases and promote health. It uses exhilarants, elatives,
immunomodulatory medicines, temperament related drugs and purgatives for
treatment of diseases. Diet and digestive system is given due importance in Unani
medicine. Particular diet plans on the basis of temperament of the patients are
suggested, It is believed that proper, healthy and adequate diet produce good
humours whereas improper and unhealthy diets produce bad humours. The
imbalance in the humours can be rectified by Unani medicines along with good
diet.
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Holistic Approach to Health The four types of treatments in Unani system are: “Ilaj bil Dawa
(Pharmacotherapy), Ilaj bil Ghiza (Deitotherapy), Ilaj bil Tadbir (Regimenal
Therapy) and Ilaj bil Yad (Surgery).”
Some important regimen are:
NOTES
 Fasd (Blood-letting): Withdrawal of frequently little amounts of blood from
a patient to fix or anticipate ailment and infection.
 Dalk (Massage)
 Riyazat (Exercise)
 Hijama (Cupping): An incomplete vacuum is made in glasses put on the
skin either by methods for warmth or suction. This draws up the fundamental
tissues. At the point when the glass is left set up on the skin for a couple of
minutes, blood stasis is shaped and confined mending happens.
 Taleeq-e-Alaq (Leeching): utilization of a living parasite to the skin so as to
start blood stream or drain blood from a limited territory of the body.
 Hammame-Har (Turkish Bath)
 Amal-e-Kai (Cauterization).
Unani system believes that six factors are important for the maintaining good
health called “Asbab-e-Sittah Zaruriah”. These factors are – “Fresh Air (Hawa-
e-Muheet), Food and Drink (Makool-o-Mashroob), Body Movement and Repose
(Harkat-wa-Sukoon-e-Badania), Mental Movement and Repose (Harkat-wa-
Sukoon-e-Nafsania), Sleep and Wakefulness (Naum-o-Yaqzah) and Retention
and Evacuation (Ehtibas-o-Istafraagh).
Siddha
Siddha System is one of the oldest frameworks of Indian medication with its origin
linked to the Dravid culture. The Siddha medicine system takes into account
patient’s condition, age, gender, race, diet, hunger, physical, mental and physiological
health status for the treatment.
Diagnosis is done through the examination of heartbeat, urine, eyes, tongue
and the skin color of the individual. Siddha system uses metals and minerals as
medications and numerous infective maladies are treated with the drugs containing
uncommonly prepared mercury, silver, arsenic, lead and sulfur with no reactions.
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Three Humours in Siddha Holistic Approach to Health
People usually confuse Siddha system with Ayurvedic system because the
conceptual configuration of Siddha is similar to Ayurveda. The three humours in
Siddha are: NOTES
1. Vatha: It is concerned with ‘space’ and ‘air’, which regulates sensory and
motor activities in the body.
2. Pitta: It is concerned with the ‘fire’ and is accountable for the maintenance
of body heat.
3. Kapha: It is concerned with ‘earth’ and ‘water’ which maintains the strength,
energy and longevity.
Homoeopathy
According to Hippocrates healing process is based on two Laws- “The Law of
Opposites and the Law of Similars”. Homeopathic system treats the diseases with
medicines by using the “Law of Similars” traditional medicine treats diseases using
the “Law of Opposites”, e.g. anti-inflammatory and anticonvulsant medicines,
antibiotics, antihypertensive and anti-depressant medicines etc.
The word “Homeopathy” was first coined by a Physician from Germany,
S. Hahnemann (in Greek Homoios means similar and pathos means suffering). He
also believed that minimal concentration of a specific toxin might treat exactly the
similar symptoms it would cause in heavier doses (“like cures like”) which was
similar to the modern principles of vaccination and inoculation. Hahnermann
believed that dilute forms of several substances were safer than many medical
systems of his time.
Principle of Homeopathy
Homeopathic physicians treat the diseases using highly diluted amounts of many
natural products and substances. Homeopathic medicine believes that certain
specific substances could create side effects in healthy individuals like individuals
experiencing the infection.
The basis of homeopathic treatment is scrupulous dilution and mixing, known
as successions. The level of dilution is written on the medicine bottle. Usually the
homeopathic dilution is 30X, where the X denotes 10. Therefore, one part of the
toxin is generally mixed with 10 parts of water or alcohol. The mixture is shaken
and one part of this mixture is again added to 10 parts of water and the entire
process is repeated 30 times and finally one molecule of a particular medicine is
diluted in 10th to 30th power of molecules of solution.
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NOTES
Fig. 11.4 Homeopathic Medicines
Homoeopathic prescriptions are arranged form certain specific substances

from plant animals and minerals etc. Homoeopathy is especially helpful in treatment
for certain hypersensitivities, immune system disorders, viral diseases, many
gynecological, obstetrical and pediatric conditions.
Certain behavioral and neurological problems and metabolic disorders can
also be effectively treated by Homeopathy.
11.3.2 Naturopathy
Naturopathy is a science that promotes self-healing and healthy living based on
the well-established philosophy. It follows its own concepts of health and diseases.
It is an old age science and its references can be seen in our Vedas and ancient
texts. Naturopaths support a comprehensive methodology with non-obtrusive
treatment and maintain a strategic distance from using medical procedure and
medications. Naturopathic logic depends on a confidence in vitalism and self-
recuperating, and experts regularly rely on the body’s specific capacity to ensure
wellbeing using the five components of nature – “Earth, Water, Air, Fire and Ether”.
Naturopathy is based on the principle of “Better Health without Medicines”.
It works by strengthening the immune system of the body. The Naturopathy
treatment involves:
 Simple eating and living habits
 Fasting
 Hydrotherapy-body packs, baths
 Mud packs, massages
 Under Water Exercises
 Air therapy
 Magnet Therapy
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 Chromo-therapy Holistic Approach to Health
 Acupressure
NOTES
Naturopathy Treatments
 The practices of Naturopathy are based on the ability of the body’s to heal
on its own through the internal guiding processes and vital energy present in
the body. Naturopathy is focused on the prevention of illnesses through
dietary and lifestyle changes and stress reduction strategies rather than using
the methods of traditional medicine. Treatment typically involves detailed
interaction with the patients regarding their lifestyle, history, physical
characteristics and physical examination.
Naturopathic diet
It involves a number of therapies which include the natural elements like natural
heat, fresh air, cold therapy as well as dietary advices like fasting, following a
particular vegetarian and whole food diet or leaving alcohol and sugar. Naturopathy
also involves psychological counseling and stress management techniques like
meditation, relaxation exercises etc.
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Holistic Approach to Health The important hallmarks of Naturopathy are as follows:
 There is one common cause of all the diseases (except trauma and
environment) which is the accumulation of morbid and aberrant matter in
the human body. Also there is only one treatment for all diseases - removal
NOTES
of morbid and aberrant matter from the human body.
 Accumulation of morbid matter creates a favorable environment in the body
for the entry and growth of bacteria and viruses. Therefore, according to
the theory of naturopathy the primary cause of diseases is morbid matter
whereas bacteria and viruses are the secondary causes.
 Acute diseases are the result of the self-healing endeavors of our body. So
acute diseases are our friends, not the enemies. Chronic diseases occur
when wrong treatment is given and acute diseases are suppressed.
 Nature is the best healer. Our body itself possesses the healing power to
prevent itself from diseases.
 Naturopathy cures not only the disease but also the entire body of the
patient.
 It cures the chronic ailments of the patients successfully and in comparatively
lesser time.
 In Naturopathy the diseases which are suppressed are brought to the surface
and finally eliminated permanently.
 Naturopathy considers the body as a whole and treats all the aspects like
physical, psychological, social and environmental at the same time.
 Naturopathy believes that “Food is only the Medicine”, and no extraneous
medications are required.
11.3.3 Reiki
Reiki is originated from the Japanese word “Rei” that means “Universal Life” and
“KI” which means “Energy”. It is also known as a spiritual art of healing. Neither
Reiki is related to any specific religion or belief nor it is a massage. Mikao Usui is
known as the originator of Reiki approach. It is given by “laying on hands” and is
based on the principle that there is an unseen “life force energy” that flows through
all the human beings and we are alive because of that energy only. If our “life force
energy” is low, it means that we are more susceptible to fall sick or feel stressed
out. Also, if it is high, we will live more happy and healthy life. The Practitioners of
Reiki believe that anyone can use his own energy to treat diseases and can also
use this energy to help other people. Reiki gives the feeling of a beautiful glowing
and sparkling radiance flowing through and around the body. Reiki treats the person
as a whole including body, mind and soul providing several benefits like feeling of
relaxation, peace, well- being and security
Reiki is a natural, spiritual and safe self-healing and self-improvement method
that can be used by anyone. It is proved to be effective in treating every known
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disease and illness providing a significant impact. It can also be used with other Holistic Approach to Health
therapeutic techniques to provide relief from their side effects and promote health.
NOTES
 It is a simple technique but it cannot be taught in the usual manner, but is

passed on to the students while conducting a Reiki class. This capability is
transferred during an “attunement” given by a Reiki master allowing the
students to endorse an unlimited supply of “life force energy” to cure illnesses,
improve health and promote the quality of life.
 Reiki is an extraordinary technique for stress release and enhance wellbeing.
Reiki isn’t a solution for a disease, but it helps the body in creating a situation
to encourage healing.
 A session typically lasts for one hour or little more. Reiki practitioners gives
the session to the patient, offer him a chance to talk about a specific issues
they are encountering and ask what they are expecting to achieve from the
session.
 For administering Reiki, “life force energy” is channeled through the hands
of the practitioner to the affected areas of the patient and positive energy is
transferred to those areas. This results in the loosening the grip of negative
energy like stress, fear, anxiety, pain, confusion, etc. and allows the touch of
the Reiki practitioner to clear the energy channels.
 In the Reiki session, patient lies comfortably on a special massage table on
his/her back with shoes off. It can also be performed with the patient sitting
in a chair in comfortable position.
 The Reiki session is then started where the practitioner uses specific hand
positions starting from head of feet of the patient. During the session the
patient may feel a slight warm or tingling sensation or just relaxation.
Reiki is a great technique for stress relief. It induces relaxation and helps to
create environment to enhance healing.
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Check Your Progress

1. How does National Health Policy (NHP) 2017 advocate AYUSH?
NOTES 2. What do you understand by Ayurveda?
3. Name the three branches of Ayurveda.
4. Name the preventive part of Ayurveda and what does it incorporate?
5. List the eight segments of Yoga.
6. Who introduced Unani medicines in India?
7. What are the important six factors for good health, according to Unani
system?
8. Who coined the word ‘Homeopathy’?
9. What is Naturopathy?
10. What is Reiki and what are its benefits?
11.4 TRADITIONAL CHINESE MEDICINE (TCM)
It was originated in China thousands of years ago. Practitioners of TCM use some
herbal medicines and several mind and body techniques for the treatment or
prevention of health related problems. TCM is primarily used as a complimentary
healthcare approach in United States of America. It is based on the fundamental
principle of Qi which refers to “vitality”. There are various types of Qi in our body.
There may be “inherent Qi (hereditary qualities), Qi from sustenance we eat, Qi
from the air we inhale, pathogenic Qi that assaults our bodies and causes ailment,
guarded Qi that assaults these wrongdoers, Qi that moves our blood, and Qi that
has a place with our inward organ”.
Theory of TCM
There are five natural elements help in TCM diagnosis – water, fire, wood, earth
and metal. If any one of the component is in excess or is inadequate, it will affect
other components.
Twelve fundamental organs are targeted in TCM are:
1. Spleen
2. Stomach
3. Lungs
4. Large Intestine
5. Heart
6. Small Intestines
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7. Kidneys Holistic Approach to Health
8. Urinary Bladder
9. Liver
10. Gallbladder NOTES
11. Pericardium
12. Triple Warmer
Four Key TCM Principles
1. Our body is an integrated whole:
Every structure in our body is an integral and important part of the whole. Physical
structure of our body along with the mind, emotions, and soul/spirit creates a
complex, interrelated and comprehensive system which is powered by “life force
energy known as qi”.
2. We are completely associated with nature:
Any changes in the nature are reflected in our body. TCM takes into account
seasonal variations, geographical locations, different times of the day, age, genetic
factors and the condition of our body while diagnosing health issues.
3. We are born with a natural self-healing capacity:
Our body is a microcosm that reflects the macrocosm. Nature possesses a
regenerative ability and that is also present in our body. This natural healing capacity
may be lost sometimes which causes diseases. TCM aims to enhance this ability.
4. Prevention is the best cure:
Our body continuously gives signals about the state of our health. These signs or
symptoms are mostly ignored until complications arise. TCM approach teaches
us how to interpret what our body is trying to tell.
Main approaches of TCM are as follows:
 Acupuncture
 Herbs
 Acupressure
 Body cupping therapy
(a) Acupuncture
Acupuncture is a “traditional Chinese medicine system (TCM)” which was
originated several thousand years ago. It works on the principle that health problems
are the result of disturbances in the flow of energy of the body. In this technique,
extremely thin needles are inserted into the body at certain specific points with an
objective to balance the body’s energy, promote healing and stimulate relaxation.
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Holistic Approach to Health This helps in boosting well-being and treats various types of problems like headache,
respiratory and digestive disorders.
TCM theory states that there are more than one thousand acupressure points
NOTES in the body. Each point lies on an invisible channel of energy (also known as
Meridian) and every meridian is related to a separate organ system.
Mechanism of Acupuncture
Though it is not fully understood how acupuncture work, but there are several
theories. According to one theory acupuncture stimulates the release of endorphins,
the chemicals that relieve pain of the body. Another theory states that acupuncture
affect the autonomous nervous system of the body and release the chemicals which
control blood pressure and blood flow reducing inflammation and calming the
brain. It is also said to modify the flow of energy across the body (called as Qi
or chi).
Acupuncture addresses a number of health problems like:
 Anxiety
 Stress
 Arthritis
 Headache, back and neck pain)
 Depression
 Insomnia and Migraine
 Nausea
 Congestion of sinuses
Following additional techniques are also used during the acupuncture session:
 Moxibustion: This is also called as “moxa,” in which heated sticks are
prepared from the dry herbs and held close to the acupuncture needles.
This warms and stimulates the acupuncture points.
 Cupping: It involves the application of glass cups on the skin to create a
suction effect. This helps in relieving the stagnation of blood.
 Herbs: Some Chinese herbs are given in the form of pills, capsules and
tea.
Electroacupuncture: During the treatment a small electrical device is attached
to the acupuncture needles, which provides a feeble electrical current and stimulates
these needles.
A typical acupuncture session usually 20 to 30 minutes but it may be extended
to over an hour depending upon the requirement. The first visit takes around 60
minutes as detailed history of the patient is taken and physical examination is done.
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Where some people feel sleepy and relaxed after the treatment, others feel more Holistic Approach to Health
energetic. Needles are inserted at some specific locations in the body and a stinging
or sharp sensation may be felt for a moment. The depth of insertion of the needles
varies depending upon the treatment and precautions should be taken to protect
other organs from getting punctured. The needles are generally left in that place for NOTES
five to twenty minutes and then removed. After the session the patient is reassessed
and precautions are explained. Sometimes some Chinese herbs are given along
with acupuncture treatment to supplement energetic balance of the body.
(b) TCM Herbs
There are more than 3000 unique herbs which are divided into four main types
depending upon their properties i.e. cold, cool, warm and hot. Herbs having cool
or cold properties may be used for the treatment of illnesses which are categorized
as warm or hot in nature and vice versa. TCM herbs are also categorized into five
types of tastes depending upon their different characteristics and effects - sour,
sweet, bitter, salty and pungent. The herbs which are bitter in taste have cooling
properties and may be used in accumulated body heat cases because of inadequate
rest, whereas the herbs with pungent taste have dispersing effects and may be
used for the treatment of flu. Another characteristic of TCM herbs is that they are
associated with different meridians to cure different disorders and diseases
effectively. TCM herbs also possess “ascending” as well as “descending” effects
that are used to direct and guide the flow of Qi and blood in our body.
Some important TCM herbs are described below:
1. Aconite (Fu Zi): This herb falls into the category of “hot” herb and is
present in many traditional Chinese formulas. According to Chinese diagnosis
it is effective for the treatment of severe “cold” and includes different types
of arthritis. But raw aconite is severe cardiotoxic in nature and should be
boiled extensively for about one hour before use otherwise it may cause
toxicity. Its toxic dosage is just little higher than its therapeutic dose. Therefore
it should be taken with extreme care.
2. Ephedra (Ma Huang): This herb is widely used for the treatment of asthma,
allergies, hay fever and to induce sweating. It is also used for reducing
weight, treatment of flu, fever, headache and to improve athletic performance.
Ephedra can cause hypertension, tremors, restlessness, palpitations,
tachycardia and insomnia.
3. Astragalus (Huang Qi): It is used to build immune system of the body
and to enhance “Qi” or life energy, and moving it to the surface from deeper
levels of the body. It improves athletic performance and increase immunity
in the patients. Its side effects are - hypertension, insomnia, tinnitus, headache
and palpitations.
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NOTES
Fig. 11.5 Ephedra (Ma huang)
Fig. 11.6 Aconite (Fu Zi)
4. Licorice (Gan Cao): Licorice is the safest and most common herb that is
used in Chinese medicine because of its sweet taste. It is also used as a
“harmonizer” as it is mixed in small quantities with many other herbs to
diminish the potential side effects of the stronger herbs in the formula. But it
may cause hypertension and oedema.
Fig. 11.7 Astragalus (Huang Qi)

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NOTES
Fig. 11.8 Licorice (Gan Cao)
5. Panax Ginseng (Ren Shen): Panax Ginseng is also one of the most widely
used herbs in Chinese medicine. It acts as an energy enhancer, immune
system booster, and a quicker fatigue buster. Some adverse effects of the
herb are hypertension, headache, rashes and insomnia. This herb may be
relatively difficult for some people to digest leading to constipation, appetite
loss and other gastrointestinal disorders.
6. Rhubarb Root/Rhizome (Da Huang): This herb is used in Chinese
medicine for diagnosis related to “excess heat” and “blood stagnation”.
Generally it is safe, but it may cause pain in abdomen, cramps and diarrhoea.
This herb should also be boiled for up to one hour to diminish its potential
toxic effects.
7. Cinnabar (Zhu Sha): Cinnabar is most commonly used as a sedative in
China. But since this herb contains mercuric sulfide, it releases elemental
mercury when heated due to which it may cause symptoms of mercury
poisoning. Therefore it should be taken after proper consultation with
experiences practitioner.
Fig. 11.9 Panax Ginseng (Ren Shen)
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NOTES
Fig. 11.10 Cinnabar (Zhu Sha)
Fig. 11.11 Rhizome (Da Huang)
(c) Accupressure
Acupressure is also known as acupuncture without needles. In acupressure manual
pressure is applied generally with the fingertips on some specific points on the
human body. As indicated by the standards of conventional Chinese prescription,
our body has some invisible channels of energy called meridians. It is believed that
there are around fourteen meridians that associate the organs with other parts of
the body. Needle therapy and pressure point massage focus these meridians. Any
blockage in the flow of energy at any point in the meridians results in the illnesses.
Acupressure practitioners apply physical pressure by fingertips, elbow or
some specific devices on these acupressure points with an objective of clearing
these blockages in the meridians. Though it is not fully understood how acupressure
work, but there are several theories.
According to one theory acupuncture stimulates the release of endorphins,
the chemicals that relieve pain of the body. Another theory states that acupuncture
affect the autonomous nervous system of the body and release the chemicals which
control blood pressure and blood flow reducing inflammation and calming the
brain. It is also said to modify the flow of energy across the body
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NOTES
Fig. 11.12 Major Acupressure Points in Hand
Fig. 11.13 Acupressure Points on Feet
Acupressure is used in the following conditions:

 Headaches
 Musculoskeletal problems
 Stress management
 Menstrual disorders
 Cervical and lumbar spondylosis
 Sciatica
Acupressure Session
The patient is made to lie down on a massage table of sit comfortably on a chair.
Acupressure is often given by an experienced acupressure practitioner but it may
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Holistic Approach to Health be self-administered also after carefully understanding the instructions given by
the practitioner. A gentle but firm pressure is applied by using the thumb, fingertips
or knuckle to a specific point. The pressure is then generally increased for around
thirty seconds, held steadily for thirty seconds to two minutes and then gradually
NOTES decreased for thirty seconds. The process is repeated three to five times.
Adverse effects and Safety
Acupressure technique should not be painful. If any pain is experienced, it should
be immediately reported to the therapist. Some soreness or bruising may be felt
after an acupressure session on the acupressure points. Gentle pressure should be
applied over the sensitive areas like face. In some cases like osteoporosis, injury,
fracture, bleeding disorders, diabetes. pregnancy etc. it is always better to consult
the specialist before the acupressure session. Acupressure should never be done
over any area which is bruised or swollen.
(d) Body Cupping Therapy
Cupping treatment is an ancient system of alternative medicine in which special
cups are placed on the patient’s skin for a couple of minutes to create suction
effect. People take this treatment to get relief from pain and swelling and to promote
well-being. The cups for this treatment may be made up of glass, silicon, bamboo
or earthenware.
Mechanism of body cupping therapy:
Body cupping therapy also works on the theory of meridians like acupuncture. It
is believed that five meridian lines are present on the back and cups are placed on
these meridians only. Cupping also helps in aligning Qi by targeting meridian channels
which are opened and obstructions to the flow of life energy are removed. It is
considered to be a good deep tissue therapy as it affects the tissues up to 4 inches
deeper from the outer skin. Cupping releases the toxins, clears the blockages and
refresh the vessels.
The types of cupping technique are:
 Dry cupping
 Wet cupping
 Needle cupping
Dry Cupping
In this method, the therapist puts flammable substances like alcohol, paper or
herbs in the cup and sets it on fire. Later the fire is extinguished. The air within the
cup cools down and a vacuum is created. This causes the blood vessels to expand
due to which skin rises and turns red. The cup is usually left at that particular place
for about 3 minutes. In the more advanced method, instead of fire a rubber pump
is used for creating vacuum inside the cups. Silicon cups may be used sometimes
which can move form one place to other on the skin to provide a massaging effect.
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Wet Cupping Holistic Approach to Health
In this method the cup is left at that particular place for about three minutes and a
mild suction is created. The cup is then moved by the therapist and small cuts are
made on the skin using a small scalpel by the therapist. A second suction is then NOTES
done where a small amount of blood is drawn out. An antibiotic ointment is given
and bandaging is done to prevent infection. The skin becomes normal again within
ten days. It is believed that toxins and harmful substances are removed from the
body in this process thereby promoting healing.
Needle Cupping
In this method, acupuncture needle are embedded in the body at specific points
first and then cups are placed over them.
The cupping therapy is used to treat blood disorders like hemophilia, anemia,
Rheumatoid arthritis, gynecological problems, skin diseases, hypertension and
psychological problems like depression and anxiety, etc.
Fig. 11.14 Dry Cupping
Fig. 11.15 Wet Cupping

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Check Your Progress

11. What is qi in Traditional Chinese Medicine (TCM)?
NOTES 12. Mention the health problems addressed by acupuncture.
13. How does acupressure relive pain?

QUESTIONS
1. The National Health Policy (NHP) 2017 has strongly advocated the potential
AYUSH within a pluralistic system of Integrative healthcare. A new term
“Medical Pluralism” has been used in NHP 2017 to strive to integrate AYUSH
in the National Health Mission, education and research.
2. The word Ayurveda is derived from two words ‘AYU which means life
and VEDA meaning science or knowledge’. Therefore Ayurveda is defined
as the ‘Science of life’. Ayurveda is an old arrangement of social insurance
beginning from the Vedas reported around 5000 years back. The learning
of Ayurveda was first archived in the book called ‘Charak Samhita and
Sushruta Samhita’.
3. The three branches of Ayurveda are as follows:
(i) Nara Ayurveda
(ii) Satva Ayurveda
(iii) Vriksha Ayurveda
4. The preventive part of Ayurveda is called Svasth-Vritta and incorporates
individual cleanliness, every day and occasional regimens, proper social
conduct and utilization of materials and practices for solid maturing and
counteractive action of untimely loss of wellbeing trait.
5. Yoga comprises of eight segments in particular- Restraint (Yama),
observance of austerity (Niyama), physical postures (Asana), breathing
exercise (Pranayam), restraining of sense organs (Pratyahar), contemplation
(Dharna), Meditation (Dhyan) and Deep meditation (Samadhi).
6. The establishment of Unani framework was laid down by Hippocrates and
presented in India by the Persians and Arabs around the eleventh century.
In Unani system, herbal medicines, special diets and alternative therapies
are used for the prevention and cure of disease.
7. According to Unani System, the six factors that are important for maintaining
good health are: Fresh Air (Hawa-e-Muheet), Food and Drink (Makool-
o-Mashroob), Body Movement and Repose (Harkat-wa-Sukoon-e-
Badania), Mental Movement and Repose (Harkat-wa-Sukoon-e-Nafsania),
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Sleep and Wakefulness (Naum-o-Yaqzah) and Retention and Evacuation Holistic Approach to Health
(Ehtibas-o-Istafraagh).
8. The word “Homeopathy” was first coined by a Physician from Germany, S.
Hahnemann (in Greek Homoios means similar and pathos means suffering).
NOTES
9. Naturopathy is a science that promotes self-healing and healthy living based
on the well-established philosophy. It follows its own concepts of health
and diseases. It is an old age science and its references can be seen in our
Vedas and ancient texts.
10. Reiki is a natural, spiritual and safe self-healing and self-improvement method
that can be used by anyone. It is proved to be effective in treating every
known disease and illness providing a significant impact. It can also be used
with other therapeutic techniques to provide relief from their side effects
and promote health.
11. TCM is primarily used as a complimentary healthcare approach in the USA.
It is based on the fundamental principle of Qi which refers to “vitality”.
There are various types of Qi in our body. There may be “inherent Qi
(hereditary qualities), Qi from sustenance we eat, Qi from the air we inhale,
pathogenic Qi that assaults our bodies and causes ailment, guarded Qi that
assaults these wrongdoers, Qi that moves our blood, and Qi that has a
place with our inward organ”.
12. Acupuncture addresses a number of health problems like: anxiety, stress,
arthritis, headache, back and neck pain, depression, insomnia and migraine,
nausea, and congestion of sinuses.
13. In acupressure manual pressure is applied generally with the fingertips on
some specific points on the human body. Acupressure practitioners apply
physical pressure by fingertips, elbow or some specific devices on these
acupressure points with an objective of clearing these blockages in the
meridians. Though it is not fully understood how acupressure work, but
there are several theories.
11.6 SUMMARY
 Holistic health is defined as psychological, physiological, environmental,

sociological, nutritional, emotional and spiritual well-being. The peaceful
state of mind, body and spirit is holistic health.
 The approach of Holistic Medicine is to consider the individual as a whole
(mind-body and spirit) in the context of his environment.
 Different systems of medicine are ayush, naturopathy, reiki, traditional
Chinese medicine like acupressure, acupuncture, TCM herbs, and body
cupping therapy.
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Holistic Approach to Health  AYUSH has been given prime importance in the ‘National Health Policy
(NHP) 2017’ within a pluralistic approach of Integrative health. A new term
‘Medical Pluralism’has been used in NHP 2017 to strive to integrate AYUSH
in the National Health Mission, education and research.
NOTES
 Ayurveda is an old arrangement of social insurance beginning from the Vedas
reported around 5000 years back. The learning of Ayurveda was first
archived in the book called ‘Charak Samhita’ and ‘Sushruta Samhita’.
 The preventive part of Ayurveda is called Svasth-Vritta and incorporates
individual cleanliness, every day and occasional regimens, proper social
conduct and utilization of materials and practices for solid maturing and
counteractive action of untimely loss of wellbeing trait.
 Panchakarma acts as the cleansing system for the body and helps in the
detoxication and rejuvenation of mind, body and soul.
 The term ‘Yoga’ is originated from the Sanskrit word “yuj” which signifies
“to join together or coordinate”. Yoga is about the association of an
individual’s own cognizance and all-inclusive awareness.
 In Unani system, herbal medicines, special diets and alternative therapies
are used for the prevention and cure of disease.
 Unani medicine practitioners believe that “the four humours (blood, phlegm,
yellow bile, and black bile)” are essential to achieve a balance of the fluids
of the body to maintain good health.
 Siddha System is one of the oldest frameworks of Indian medication with
its origin linked to the Dravid culture. The Siddha medicine system takes
into account patient’s condition, age, gender, race, diet, hunger, physical,
mental and physiological health status for the treatment.
 People usually confuse Siddha system with Ayurvedic system because the
conceptual configuration of Siddha is similar to Ayurveda.
 According to Hippocrates healing process is based on two Laws- “The
Law of Opposites and the Law of Similars”. Homeopathic system treats
the diseases with medicines by using the “Law of Similars” traditional
medicine treats diseases using the “Law of Opposites”, e.g. anti-inflammatory
and anticonvulsant medicines, antibiotics, antihypertensive and anti-
depressant medicines etc.
 Naturopathy is a science that promotes self-healing and healthy living based
on the well-established philosophy. It follows its own concepts of health
and diseases.
 Reiki is originated from the Japanese word “Rei” that means “Universal
Life” and “KI” which means “Energy”. It is also known as a spiritual art of
healing. Reiki is a natural, spiritual and safe self-healing and self-improvement
method that can be used by anyone. It is proved to be effective in treating
every known disease and illness providing a significant impact.
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 Reiki is an extraordinary technique for stress release and enhance wellbeing. Holistic Approach to Health
Reiki isn’t a solution for a disease, but it helps the body in creating a situation
to encourage healing.
 Traditional Chinese Medicine (TCM) was originated in China thousands of
NOTES
years ago. Practitioners of TCM use some herbal medicines and several
mind and body techniques for the treatment or prevention of health related
problems. TCM is primarily used as a complimentary healthcare approach
in United States of America. It is based on the fundamental principle of Qi
which refers to “vitality”.
 There are five natural elements help in TCM diagnosis – water, fire, wood,
earth and metal. If any one of the component is in excess or is inadequate,
it will affect other components.
 Main approaches of TCM are acupuncture, acupressure, herbs, and body
cupping therapy.
 Another characteristic of TCM herbs is that they are associated with different
meridians to cure different disorders and diseases effectively. TCM herbs
also possess “ascending” as well as “descending” effects that are used to
direct and guide the flow of Qi and blood in our body.
 Acupressure is also known as acupuncture without needles. In acupressure
manual pressure is applied generally with the fingertips on some specific
points on the human body.
 Acupressure practitioners apply physical pressure by fingertips, elbow or
some specific devices on these acupressure points with an objective of
clearing these blockages in the meridians. Though it is not fully understood
how acupressure work, but there are several theories.
 Body cupping treatment is an ancient system of alternative medicine in which
special cups are placed on the patient’s skin for a couple of minutes to
create suction effect. People take this treatment to get relief from pain and
swelling and to promote well-being. The cups for this treatment may be
made up of glass, silicon, bamboo or earthenware.
 The types of body cupping technique are: dry cupping, wet cupping and
needle cupping.
11.7 KEY WORDS
 Naturopathy: It refers to a system of alternative medicine based on the

theory that diseases can be successfully treated or prevented without the
use of drugs, by techniques such as control of diet, exercise, and massage.
 Reiki: It refers to a healing technique based on the principle that the therapist
can channel energy into the patient by means of touch, to activate the natural
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Holistic Approach to Health healing processes of the patient’s body and restore physical and emotional
well-being.
 Traditional Chinese Medicine (TCM): It is a style of traditional
medicine based on more than 2,500 years of Chinese medical practice that
NOTES
includes various forms of herbal medicine.

EXERCISES

1. What are the principles of Ayurveda?
2. Write a note on ‘Panchkarma’ treatment of Ayurveda.
3. Prepare a short note on the main objectives of Yoga.
4. What are the four types of treatments in Unani system?
5. Write a short note on Siddha System.
6. What is homeopathy and how does it work?
7. What are the key principles of TCM?
8. Give a brief overview of additional techniques that are used during the
acupuncture session.
9. Write a note on acupressure session.
10. Briefly discuss the concept of body cupping therapy.
1. Discuss the six branches of Yoga.
2. Elaborate the principles of Unani Medicine.
3. Analyse the three humours in Siddha System.
4. On what principle is naturopathy based upon and what does the treatment
involve? Discuss.
5. How does Reiki heal? Elaborate.
6. Examine the significance of TCM herbs in treatment of illness.
7. Describe the mechanism of body cupping technique.
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Websites Holistic Approach to Health
http://s3.amazonaws.com/zanran_storage/.whoindia.org/ContentPages/ NOTES
127626072.pdf
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Education System: Medical
and Paramedical Education BLOCK - IV
COST BENEFIT ANALYSIS
NOTES
UNIT 12 EDUCATION SYSTEM:
MEDICAL AND
PARAMEDICAL
EDUCATION
Structure
12.0 Introduction
12.1 Objectives
12.2 Introduction to Medical and Paramedical Education
12.3 Paramedical Education System in India: Postgraduate Specialization
12.5 Summary
12.6 Key Words
12.0 INTRODUCTION
In the ancient times, medical knowledge was firstly described by Charaka and
Sushruta. Sushruta and Charaka are also well-known as Ayurveda Acharyas who
have written first books on medicine, called as Charaka Samhita and Sushruta
Samhita. They also wrote some of the celebrated books on Ayurveda. India is a
well-known country for Ayurvedic Therapy treatment. Atharvaveda also contained
prescription of herbs for varied health problems. Utilization of herbs to cure ailments
formed a major part of Ayurvedic medicine later on.
In this unit, we will discuss the development of medical and paramedical
education in India, the post-graduation specialization courses and the economics
of holistic medicine.
12.1 OBJECTIVES

 Analyse the importance of medical and paramedical education
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 Discuss the post graduate specialization in medicine Education System: Medical
and Paramedical Education
 Describe the logistics of training
 Understand the economics of holistic medicine
NOTES
12.2 INTRODUCTION TO MEDICAL AND
PARAMEDICAL EDUCATION
As we have already studied, in India medical treatment and medical education

started from Rishi-Muni. In India, seven types of medicines are available. The
Ayurveda is the oldest medicine in India. Treatment and education of this medicine
is in practice from the Rishi-Muni age. Every medical therapy has its own system
of treating patients. Thus, in India there are six types of medicines.
 Allopathy
 Ayurveda
 Homeopathy
 Siddha
 Unani
 Naturopathy and Yoga Therapy
Let us quickly recapitulate what we studied in Unit 11.
1. Allopathy
Allopathy is a modern scientific system to study human body and diseases by
conventional means. This system is well developed and is accepted all over the
world. Allopathic medicine is that branch of medical practice which utilizes
pharmacologically vital agents or physical involvement to treat or subside symptoms
of diseases or conditions.
The Medical Council of India (MCI) is an ordinance body formed under
the stipulation of the Indian Medical Council (IMC) in1956. The core objectives
of the Council are:
 Maintaining consistent standards of medical education throughout the country
 Dictating minimum requirements for the foundation of medical colleges
 Commendation to initiate new medical colleges or new courses
 Acknowledgement of medical qualifications
 Sustenance of Indian Medical Register
 Enforcing ethical protocols of proper conduct by medical professionals
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Education System: Medical Present Scenario of Medical Education in India
Sr. No. Types of Colleges Number of Medical colleges Number of seats
1 Govt. Medical Colleges 182 30,455
2 Private Medical 214 36,615
NOTES
Colleges
Total 396 67,070
Total post-graduate medical colleges in India:

Sr No. Type of College No. of Seats
1 Govt. Medical College 17,921
2 Private Medical College 10,794
Total Seats 28,715
Undergraduate courses: Three phase framework

 First - Preclinical MBBS of 12 months
 Second - Para clinical MBBS of 18 months
 Third - Clinical MBBS of 24 months
Post graduate medical courses:
SUBJECT DEGREE DIPLOMA
Diploma in
Anesthesia MD/DNB
anesthesia
Anatomy M.S./DNB/M.Sc. -
Biochemistry MD/DNB/MSc -
Community Medicine M.D/DNB DCM or DPH
Dermatology M.D/DNB DDVL or DVD
ENT MS/DNB DLO
Family Medicine MD/DNB -
Forensic Medicine MS/DNB Diploma in FM
General Medicine MD/DNB -
General Surgery MS/DNB -
Microbiology MD/DNB/M.Sc. -
Nuclear Medicine MD/DNB DRM
Orthopedics MS/DNB D Ortho
Ophthalmology MS/DNB DO
Obstetrics & Gynecology MS/DNB DGO
Palliative Medicine MD -
Pathology MD/DNB DCP
Pharmacology MD/DNB/MSc -
Physiology MD/DNB/MSc -
Pediatrics MD/DNB DCH
Psychiatrics MD/DNB DPM
Pulmonology MD/DNB DTCD
Radio diagnosis MD/DNB DMRD
Radio therapy MD/DNB DMRT
Tropical MD DTMH
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142 Material
Two year courses on allied health sciences: Education System: Medical
 Hospital Administration
 Epidemiology
 Bioengineering NOTES
 Nano-engineering
 Molecular biology, etc.
Three year research for a regular PhD degree on successful completion of
requisites.
Dental
This branch is related only to dental diseases and dental education providing
knowledge about how to control diseases and conditions pertaining to teeth. Current
scenario regarding the amount of Dentists in India is a very important issue to be
considered. Are we having a dearth of dentists in India?
To answer this question, one should know the geographical spread of dentists
in India. The problem is not with the number of dental surgeons, but their distribution.
Majority of the dentists reside in metropolitan cities in India. However, larger part
of our population resides in rural areas. Inadequate and poor oral care services
are available in rural areas.
Importance of oral health education is also very low among the rural
population, thus resulting in a despairing condition. Despite of a large number of
qualified dental professionals in our country, basic oral health care, and interventions
are also not accessible to a huge amount of population. There is high amount of
tobacco abuse in various forms raising the number of oral cancer, gum problems
and dental tooth decay.
Indian dental schools receive both B.D.S. degree from their University at
the time of graduation along with a certificate of successful completion of the 5-
year course, 4 years of academics and 1 year internship. They can then get a state
approved license to practice.
Total Undergraduate Dental Colleges in India
Sr No. Type of College No. of Seats
1 Govt. Medical College 2,930
2 Private Medical College 24,130
Total Seats 27,148
Total Post Graduate Dental Colleges in India:

There are 241 dental colleges having post-graduation course out of which 36 are
government colleges.
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Education System: Medical Sr No. Type of College No. of Seats
1 Govt. Medical College 678
2 Private Medical College 5250
NOTES Total Seats 5928
Recently, there were a total of 26,000 BDS and 6000 MDS seats in the
country, of which only 24,000 seats are filled up for the year 2016–2017, the
vacant seats for BDS in government colleges were 184, while in the private colleges,
it was 6,243.
In the 2017–2018, the vacant seats in government colleges were 329 and
private colleges 4213. Similarly, the vacant seats in the MDS in 2016–2017 in
government colleges were 105, while in private colleges, the number was 518.
In 2018–2019, vacant seats in government colleges were 232, while in
private dental colleges, it was 1,678. This is largely attributable to increased fee
structure particularly in private institutes, National Eligibility cum Entrance Test
(NEET) qualification marks and a lack of interest in non-clinical subjects in
postgraduate course.
2. Ayurveda
India officially recognizes the system of indigenous medicine and therefore
institutionalized a separate department of AYUSH which consists of namely:
Ayurveda, Unani, Siddha, Homeopathy and Yoga and Naturopathy.
The Central Council of Indian Medicine (CCIM) monitors matters related
to AYUSH.
The Ayuvedic treatment is one of the oldest methods in the world. It uses
the belief that a balance between body, mind, spirit and social wellbeing constitute
perfect health.
Ayurvedic Colleges of India grants the Degree of BAMS (Bachelor of
Ayurvedic Medicine & Surgery) at graduation. Duration of BAMS is 51/2 years
including 1 year of Internship
The Post graduate programmes have a duration of 3 years leading to degree
of Doctor of Medicine in Ayurveda (M.D.) and Master of Surgery in Ayurveda
(M.S.)
MBBS candidates who have completed 1 year of internship, recognized by
MCI can do Post Graduate course in Ayurveda.
Post-graduate programs are arranged into 16 branches for Doctorate in
Ayurveda. The 16 branches namely are:
 Ayurvedic Sidhants (Fundamental Principals of Ayurveda)
 Ayurvedic Samhita (Treatise)
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 Rachna Sharir (Anatomy) Education System: Medical
 Kriya Sharir (Physiology)
 Dravya Guna Vigyan (Pharmacology)
 Shastra Bhaishajya Kalpana (Pharmaceuticals) NOTES
 Kumar Bharitya (Paediatrics)
 Prasuti Tantra (Obs and Gynae)
 Swastha Vrita (Preventive Medicine)
 Kayachitiksa (Internal Medicine)
 Shalya Tantra (Surgery)
 Shalkya Tantra (Eye and ENT)
 Mano Roga (Psychiatry)
 Panchkarma (detoxification)
 Rog Nidan (Pathology)
 Materia Medica.
Total number of 261 colleges, 72 government and 189 private colleges
offer the degree of Bachelor in Ayurveda Medicine and Surgery (BAMS)
3. Unani
The Unani system of medicine also called Greek-Arab medicine is based on the
concept of Greek ideology. According to this conventional system, the human
body comprises four basic elements, namely: ‘Earth, Air, Fire and Water’.
The body liquids consist of four humors which have their own temperatures
and the nature and amount of these humors affect health of the body.
 Blood: Wet and Hot
 Phlegm: Hot and Cold
 Yellow bile: Dry and Hot
 Black bile: Dry and Cold
Concept of Health: When the humors are in an equilibrium state, the body
operates normally. Health is dependent on six vital elements:
 Air
 Beverage and food
 Sleep and awake time
 Excreta and holding
 Physical activity and relaxation
 Mental activeness & rest
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Education System: Medical Diagnosis in Unani system is made by examining the pulse, feces and urine
along with a physical checkup while treatment options are available in three modes:
 Regimental approach: Advising exercise, change of climate, massage
therapy, diet and nutrition etc.
NOTES
 Pharmacotherapy: Administration of drugs made from plants, animal or
minerals, alone or in combination.
 Surgery: Done as the last resort.
Present Education Scenario
In India, Unani Medicine education is supervised by Central Council of Indian
Medicine (CCIM).
There are 43 colleges in India imparting Bachelor of Unani Medicine and
Surgery (BUMS) degree of 5 ½ years. The candidates learn basic pre-clinical
and clinical subjects. BUMS course involves 1 year rotatory internship. Specialized
courses can be house job or PG.
PG courses are in two branches – MD in Unani medicine or MS Unani
surgery, in one or more of the following branches:
 Internal Medicine
 Principles in Unani system
 Obstetrics and Gynecology
 Pediatrics
 Unani Surgery
 Preventive and Social Medicine
 Pharmacology
Colleges of Unani Medicine in India
There are recognized colleges and institutions both government and private. Some
of the leading institutions are:
 Government Unani Medical College, Chennai
 Central Council for Research in Unani Medicine, New Delhi
 National Institute of Unani Medicine, Pune
 Nizamia Tibbia College and Hospital, Hyderabad
 Faculty of Unani Medicine, Jamia Hamdard, Delhi
 Government Unani Medical College, Bangalore
 HSZH Government Unani College, Bhopal
 Ajmal Khan Tibbia College, AMU, Aligarh
 A & U Tibbia College, Karol Bagh, New Delhi
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 Anjuman-i-Islam Tibbia College and Hospital, Mumbai Education System: Medical
 ZVM Unani College and Hospital, Pune
 Markaz Unani Medical College & Hospital, Calicut
 Tipu Sultan Unani Medical College, Karnataka NOTES
Source: Central Council of Indian Medicine: Ministry of AYUSH, Government of India
https://www.ccimindia.org/unani-colleges.php
4. Homeopathy
The homeopathy system was a famous system in India and was introduced by
Samuel Hahnemann and has been in use in India from the time of Mahabharata
some 3500 years ago. Homeopathic medicine has simplicity, is safe, non-toxic
and formed on scientific principles. It cures, prevents, promotes and covers
rehabilitation. It provides cure for acute and chronic infectious diseases as well as
for complicated diseases.
There are currently 186 UG homeopathic medical colleges in India, offering
5 and ½ years BHMS degree, 33 Post Graduate Medical Colleges in which MD
in homeopathy is being offered for duration of 3 years in 7 specialties.
 Organon of Medicine and Homeopathic Philosophy
 Homeopathic Materia Medical
 Repertory
 Homeopathic Pharmacy
 Practice of Medicine
 Pediatrics
 Psychiatry
S No Degree Courses in Homoeopathy Total Colleges
1 BHMS Bachelor of Homoeopathic Medicine & Surgery 213
2 Bachelor of Electro-Homeopathy Medicine and Surgery (BEMS) 19
3 MD (Homeo Pharmacy) Doctor of Medicine in Homeo Pharmacy 10
5. Naturopathy and Yoga Sciences

Naturopathy is based on body’s own healing power, and therefore encourages
self-cleansing and rehabilitation. It emphasizes on immunity, hormones, nerves and
elimination of the body to achieve this process. When all the systems are in harmony,
body will achieve homeostasis. Naturopathy treats patients in the absence of internal
or external intervention. The power of sunlight, earth, water and air are used to
speed up the healing. Natural elements are used to treat the ailment by motivating
the passive healing ability of nature.
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Education System: Medical Yoga therapy is a practice of yoga postures, mudras, breathing, massage,
healthy diet and other aspects of healthy living habits. These help a person to
make use of the self-healing capabilities inbuilt in the human body.
There are seventeen colleges in India that give degree in Bachelor of
NOTES
Naturopathy and Yoga Sciences (BNYS), the course is of 4½ years including 1
year internship. The topics of study are nutrition therapy, homeopathic medicine,
acupuncture, herbal medicine and natural medicine etc.
The degree is recognized by the Council of Naturopathic Medical Education.
In the first two years standard medicine knowledge is taught. The first year contains
biomedical sciences; the second year contains science of diagnosis. Holistic
approaches to body systems and naturopathic modalities are also taught during
the first two years. The last two years uncover naturopathic diagnostic techniques
and treatment approaches and involve extensive, clinical experience.
MD in Naturopathic Medicine, MD in Yoga Medicine, MD in Acupuncture
Medicine and PG Diploma in GO, CH, EM, PM. BNYS Medical Graduates can
pursue Post Graduation available in private and government institutions.
Postgraduate Diploma is of 2 years and Postgraduate degree of three years.
6. Siddha
Siddha medicine system is used in few parts of South India like Tamil Nadu. It has
close association to Ayurvedic medicine but maintains its own identity. The term
SIDDHA stands for achievement. SIDDHARS were the pioneers who obtained
knowledge in the field of medicine, yoga and meditation.
Before the reign of Aryans in India, a civilization thrived in South India on
the banks of river Kaveri. The system of medicine used in this community is the
present day Siddha system. The pharmacology of Siddha medicine depends mostly
on drugs of metal and minerals whereas Ayurveda used drugs of vegetable origin
for treatment.
The concept of Siddha states that matter and energy have enormous role in
shaping the nature of the Universe. These two elements are called Siva and Shakti.
Matter and energy cannot exist without each other. This science has a concept of
5 elements and 3 doshas applicable to them. Diagnosis in this system is established
by examining 8 sites on the human body, namely:
 Pulse (nadi)
 Tongue (na)
 Urine (neer)
 Complexion (varna)
 Voice (swara)
 Eyes (kan)
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 Touch (sparisam) Education System: Medical
 Faeces (mala)
These diagnostic methods are carried out in more detail compared to
ayurvedic medicine. NOTES
With close similarity to Ayurvedic medicine, Siddha also believes in ashtanga
concept for treatment procedures. Major focus is on the three branches –
Pediatrics, Toxicology and Ophthalmology. The treatment methods in Siddha and
Ayurveda are categorized into and Samana and Sodhana therapy. Siddha contains
well known techniques classified under panchakarma therapy, which is not very
well developed; just the Vamana therapy has achieved recognition of physicians
practicing Siddha.
One of the major classic difference between Siddha and Ayurveda is that
the remedial substances in the former one are made of mineral and metal origin, in
contrast to the drugs of vegetable origin in the latter.
The remedial drugs in Siddha System are categorized under the following
categories:
 Uppu (Lavanam) - medicines that can be melted in water and get
deciphered when exposed to fire turn into vapor.
 Pashanam - medicines that are not soluble in water but still gives off vapor
when exposed to fire.
 Uparasam - Similar to nava paashanam but has different actions.
 Uparatnas and Ratna - it consists of medicines based on precious and
semi-precious stones
 Loham - metals and metal alloys that do not disseminate in water but melts
once exposed to fire and solidifies when cooled.
 Rasam: drugs which have soft consistency, they are sublime when exposed
to fire and change into little crystals or unstructured powder.
 Gandhakam - sulphur is not soluble in water & burns when exposed to
fire.
All compound drugs are prepared from these basic drugs. 35 products are
incorporated from the animal family into the remedial drugs. Quantity of plant
derived preparations is also incorporated in Siddha medicine and is similar to
those used in Ayurvedic medicine.
Check Your Progress

1. What are the six types of medicines in India?
2. What are the core objectives of Indian Medical Council (IMC)?
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and Paramedical Education 12.3 PARAMEDICAL EDUCATION SYSTEM IN
INDIA: POSTGRADUATE SPECIALIZATION
NOTES Paramedics are trained medical professionals who diagnose any disease in a human
body with the help of blood test, X-ray, MRI, CT Scan, Ultrasound etc. In addition,
they actually support doctors in providing better treatment by doing various medical
checkups and therapies. Therefore these professionals have become an integral
part of the Paramedical sector in India. Even in the coming, there will be high
demand for Paramedics professionals in India.
Some Paramedical degree courses
 Bachelor of Physiotherapy
 BSc in Medical Lab Technology
 BSc in X-Ray Technology
 BSc in Radio diagnostics
 BSc in Dialysis
 BSc in Anesthesia
 BSc Perfusion Technology
 BSc in Ophthalmology
 BSc in Radiotherapy
 BSc in Critical care technology
 BSc in Medical Record Technology
 BSc in Operation Theatre Technology
 BSc. in Optometry
 Bachelor of Radiation Technology
 Bachelor of Occupational Therapy
 BSc in Medical Imaging Technology
 BSc Nuclear Medicine Technology
 BSc in Audiology and Speech Therapy
 BSc in Respiratory Therapy
 BSc in Renal Dialysis Technology
Some Paramedical diploma courses
 Diploma in X-Ray Technology
 Diploma - Medical Imaging Technology
 Diploma - Physiotherapy
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 Diploma - Medical Laboratory Education System: Medical
 Auxiliary Nurse Midwife
 Diploma - Operation Theatre Technology
 Diploma - Dialysis Technology NOTES
Some Paramedical post graduate degree courses
 Master of Neuro Physiotherapy
 Master in Sports Physiotherapy
 PG Diploma in Medical Radio-diagnosis
 MSc Medical Lab Technology
 PG Diploma in Perfusion Technology
 Masters in Optometry
 Masters in Audiology and Speech Language Pathology
Some Paramedical certificate courses in India
 Certificate in Dialysis Technician
 Certificate in X-Ray Technician
 Certificate in Lab Assistant or Technician
 Certificate in OT Assistant
 Certificate - Electrocardiogram and CT Scan Technician
 Certificate - Home Health Care
 Certificate - Family Education
 Certificate - Childcare and Nutrition
 Certificate in Rural Health Care
The requirements of Paramedical professionals like Lab Technicians,
Radiology Technicians, Physiotherapists and Pharmacists will surely increase.
According to a report, Indian Paramedical sector will increase with the growth
rate of 16.6 per cent in the coming 5 years.
India has the greatest number of medical colleges in the entire world, which reflects
the level of medical competence that we withhold. However, a major part of our
citizens have inadequate access to good health care. A minimal of three checkups
during pregnancy is not available for nearly 50 per cent pregnant women of our
country. There have been numerous conflicts surrounding the condition of medical
education in our country. The challenges of a lacking government hold over the
recognition process, dearth of skilled faculty, curriculum with insignificant data.
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Education System: Medical 1. Ratio of doctor to patient is less
A recent study has quoted that ‘India has one government doctor for every 11,528
people and one nurse for every 483 people. India has approximately 396 medical
NOTES colleges with 45,000 graduates passing out every year, whereas it is required that
500 new colleges should come up, producing 1 million doctors every year.’
2. Giving clinical skills more importance
Evaluation system of India is based on the memorizing power of large amount of
theoretical knowledge. The exam pattern is still the same, without taking humanity
into account. ‘Students face question papers having questions which are more of
knowledge based than on real clinical cases. One should expect to respond to
questions based on clinical cases or various drugs than remembering achievements
of a particular individual,’ says Dr Ravella.
3. Outdated syllabus and educating style
Everyday new revelations are made in medical field, but the syllabus taught to
medical students in India is not updated consistently. Science fields are still separated
from each other because of insufficient understanding of how different fields of
knowledge can be combined for better understanding and implementation. New
aspects of medical science are also rarely taken up.
4. Lack of proficient staff
Faculty in medical organizations is hired based on their qualifications and not based
on their clinical experience. This decreases the efficiency of the knowledge which
they bestow on their students. Moreover, teachers are not trained regarding teaching
innovations which is a big lack. The salary offered is low which makes only the
less talented available. Because of which the more talented prefer a private practice.
In government hospitals there is a forever transfer threat.
5. Inequality in infrastructure of different states
A 2010 report revealed inequality in the opportunities for medical education in
different parts of the country. Four states - Andhra Pradesh (AP), Karnataka,
Maharashtra and Tamil Nadu are having nearly 1.3 lac of total 2.5 lac medical
seats available in India.
6. Preference for super specialists
It is impossible to have one genre of doctors to serve all types of health issues
especially in a vast country. Some doctors need to be trained for providing suitable
healthcare in rural areas, while others are familiar with latest medical technologies
for most complex procedures. MBBS students specialize in various fields to get a
job because of which research is usually ignored. However, this specialization
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drive makes the students miss out on knowing about all these aspects. Colleges Education System: Medical
must familiarize students with all different aspects of medical sciences.
7. Problems with private medical colleges
NOTES
A law change in the late 19th century made it possible to establish private schools
and therefore a lot of medical institutes came up in the country, they got funds from
businessmen and politicians, who did not anything about running medical schools.
Hundred government medical colleges & 11 private medical colleges existed in
1980, today, the government institutions have doubled while the private institutions
have increased by 20 fold. Although this change came up to solve the problem of
the dearth of doctors, it made medical education a business.
8. Studying or practicing in other countries
There are nearly 48 thousand Indian doctors who are practicing in the US and
nearly 26,000 practicing in the UK. Therefore, India is the largest exporter of
medical professionals in the world.
Improvising the system
In order to serve the growing demand of doctors, government needs to take some
immediate and strict steps or else India won’t be able to cater for its ever growing
demand. It will happen only when the medical education is improvised, that the
health industry can improvise overall.
 Doctors should be trained by considering their social bearing.
 Intermingling of subjects, innovative educating systems, and universal use
of technology in classes is essential
 In order to fulfill rural healthcare needs, students must be familiarized with
latest advancements in technology so that good healthcare can be given
even from a distance.
 Students must be trained on holistic approach and whole body healing by
combining other medicine systems with modern science.
Economic evaluation requires information on both the health benefits (ie,
effectiveness) and costs of the therapies under consideration. There are many
challenges involved in determining the effectiveness of medicine.
 Appropriate and Well-defined Comparators
 Health Outcomes and Quality-adjusted Life-years
 Measuring the Costs
Economic evaluation adds information on costs to the information already
available on a therapy’s safety and effectiveness. Cost data are essential to allow
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Education System: Medical for efficient resource allocation—ie, to allow decision makers to identify the
distribution of resources (funds, staff, equipment and facilities across various
populations) that generates the greatest overall good. Because the results of
economic evaluation bring this additional crucial information to a decision, there is
NOTES sometimes the illusion that the results are “the answer.” However, there are many
considerations that go into a decision that are beyond the scope of an economic
evaluation.
Check Your Progress

3. What is the expected growth of the Indian paramedical sector in the coming
five years?
4. How is the faculty in medical organizations hired?

QUESTIONS
1. The six types of medicines in India are:

 Allopathy
 Ayurveda
 Homeopathy
 Siddha
 Unani
 Naturopathy and Yoga Therapy
2. The core objectives of the Council are:
 Maintaining consistent standards of medical education throughout the
country
 Dictating minimum requirements for the foundation of medical colleges
 Commendation to initiate new medical colleges or new courses
 Acknowledgement of medical qualifications
 Sustenance of Indian Medical Register
 Enforcing ethical protocols of proper conduct by medical professionals
3. According to a report, Indian Paramedical sector will increase with the
growth rate of 16.6 per cent in the coming 5 years.
4. Faculty in medical organizations is hired based on their qualifications and
not based on their clinical experience. This decreases the efficiency of the
knowledge which they bestow on their students.
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12.5 SUMMARY and Paramedical Education
 In India, seven types of medicine are available. The Ayurveda is the oldest
medicine in India. Treatment and education of this medicine is in practice NOTES
from the Rishi- Muni age.
 Allopathy is a modern scientific system to study human body and diseases
by conventional means. This system is well developed and is accepted all
over the world.
 Allopathic medicine is that branch of medical practice which utilizes
pharmacologically vital agents or physical involvement to treat or subside
symptoms of diseases or conditions.
 In the 2017–2018, the vacant seats in government colleges were 329 and
private colleges 4213. Similarly, the vacant seats in the MDS in 2016–
2017 in government colleges were 105, while in private colleges, the number
was 518.
 India officially recognizes the system of indigenous medicine and therefore
institutionalized a separate department of AYUSH which consists of namely:
Ayurveda, Unani, Siddha, Homeopathy and Yoga and Naturopathy.
 The Unani system of medicine also called Greek-Arab medicine is based
on the concept of Greek ideology. According to this conventional system,
the human body comprises four basic elements, namely: ‘Earth, Air, Fire
and Water’.
 The homeopathy system was a famous system in India and was introduced
by Samuel Hahnemann and has been in use in India from the time of
Mahabharata some 3500 years ago.
 Naturopathy is based on body’s own healing power, and therefore
encourages self-cleansing and rehabilitation. It emphasizes on immunity,
hormones, nerves and elimination of the body to achieve this process.
 Siddha medicine system is used in few parts of South India like Tamil Nadu.
It has close association to Ayurvedic medicine but maintains its own identity.
The term SIDDHA stands for achievement.
 One of the major classic difference between Siddha and Ayurveda is that
the remedial substances in the former one are made of mineral and metal
origin, in contrast to the drugs of vegetable origin in the latter.
 Paramedics are trained medical professionals who diagnose any disease in
a human body with the help of blood test, X-ray, MRI, CT Scan, Ultrasound
etc. In addition, they actually support doctors in providing better treatment
by doing various medical checkups and therapies.
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Education System: Medical  India has the greatest number of medical colleges in the entire world, which
reflects the level of medical competence that we withhold. However, a major
part of our citizens have inadequate access to good health care.
 A minimal of three checkups during pregnancy is not available for nearly 50
NOTES
per cent pregnant women of our country.
 In order to serve the growing demand of doctors, government needs to
take some immediate and strict steps or else India won’t be able to cater
for its ever growing demand. It will happen only when the medical education
is improvised, that the health industry can improvise overall.
12.6 KEY WORDS
 Holistic medicine: It is a form of healing that considers the whole

person—body, mind, spirit, and emotions—in the quest for optimal health
and wellness.
 Economic evaluation: It is the process of systematic identification,
measurement and valuation of the inputs and outcomes of two alternative
activities, and the subsequent comparative analysis of these.

EXERCISES

1. What are the sixteen branches of doctorate in Ayurveda?
2. What are the improvisations that can be taken to improve the medical system?
3. Write a short note on the economics of holistic medicine.
1. Analyse the six types of medicines in India.
2. Describe the present scenario of medical education in India.
3. Discuss the present education scenario in India.
4. Describe the challenges of medical education.
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Websites Education System: Medical
http://s3.amazonaws.com/zanran_storage/.whoindia.org/ContentPages/ NOTES
127626072.pdf
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Organizational Structure of
Healthcare System
at District Level UNIT 13 ORGANIZATIONAL
STRUCTURE OF
NOTES
HEALTHCARE SYSTEM AT
DISTRICT LEVEL
Structure
13.0 Introduction
13.1 Objectives
13.2 Health Care System at District Level and Functions of District Health Office
13.4 Summary
13.5 Key Words
13.6 Self-Assessment Questions and Exercises
13.0 INTRODUCTION
Healthcare system and policies of a country play an important role in the regulation
of healthcare services delivery, utilization and health outcomes. Health is the subject
matter of state; therefore, regardless of the guidelines issued by the central
government, the final decision with respect to the implementation of the new
healthcare initiatives is taken by the states.
Bhore Committee Report of 1946 is considered to be a major landmark
for India as it led to the development of the current healthcare policies and systems
of the country. The committee recommended the three-tier health system for
provision of curative and preventive healthcare services in the urban and rural
areas employing the healthcare professionals on the payroll of the government and
therefore limiting the requirement of private medical practitioners. The present
public health-care systems of the country are based on these principles only.
13.1 OBJECTIVES

 Discuss the organizational structure of health care system at the district
level
 Analyse the role of regulatory territories of health
 Describe the three tier structure of the rural self-government
 Anslyse the roles and responsibilities of anganwadis
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13.2 HEALTH CARE SYSTEM AT DISTRICT LEVEL Healthcare System
at District Level
AND FUNCTIONS OF DISTRICT HEALTH
OFFICE
NOTES
There are twenty nine states and seven union territories in India which are divided
into 597 districts for proper administration. Every district is further divided into
sub-divisions or taluka, under which community development blocks are situated.
Currently there are 600 community development blocks in the country.
In India, there are six regulatory territories in each region.
 Sub –divisions
 Tehsils/Talukas
 Community Development Blocks
 Municipalities and Corporations
 Villages
 Panchayats
Fig. 13.1 Regulatory Authorities
Subdivisions
The districts are divided into two or more subdivisions, each accountable to an
Assistant Collector or Sub Collector.
Talukas
The subdivision is further divided into taluks which are accountable to a Tehsildar.
Each taluk generally has two hundred to six hundred villages.
Community Development Blocks
Each block consists of around hundred villages of about 80000 to 200000
population and is the major unit of rural planning and development.
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Organizational Structure of The Local Self-Government has separate units of working in urban and
Healthcare System
at District Level rural areas of the districts.
Divisions in the urban areas
NOTES (a) Town area committee
They are set up in the regions with population range of around 5000-10000.
These committees work like panchayats and look after the provision and
maintenance of sanitary services of that area.
(b) Municipal boards
They are set up in those areas that have population range of about 10000-200000
and are headed either by the chairman or by the president who is generally elected
by the members of the board. The members of the board hold office for a term of
three to five years.
The functions of municipal boards are:
 Sanitation
 Water supply
 Drainage facilities
 Construction and maintenance of roads
 Birth and death registrations
 Education standards
 Working of hospitals and dispensaries, etc.
(c) Corporation
It is set up in the areas with population more than two lakhs and headed by a
mayor. Its members are the counsellors elected from the different wards of the
city. Its functions are similar to that of the municipal board but on a wider scale.
Divisions in the rural areas
Let us analyse the divisions in the rural level.
Panchayati Raj: It is a 3-tier structure of the rural local self-government in India
that links the villages to the districts. The three tier are:
 Panchayat
 Panchayat Samiti
 Zila Parishad
1. Panchayat – (at the village level)
 The Gram Sabha: It includes all the adults of the village, who at least meet
together twice a year. Functions include proposals for taxation policies,
discussion about the annual programs and electing the members of the gram
panchayat.
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 The Gram Panchayat: It is an agency that works for planning, management Organizational Structure of
Healthcare System
and development at the village level. It covers the population range of five at District Level
thousand to fifteen thousand and has a strength of 15-30. The term of the
members of Gram Panchayat is 3-4 years. Each panchayat is headed by an
elected president who can be a Sarpanch or Mukhiya and also has a vice NOTES
president and a panchayat secretary. The Panchayat secretary performs
numerous functions ranging from civil administration that includes sanitation
facilities and public health issues to the economic and social development of
the village.
 The Nyaya Panchayat: It includes five members from the panchayat and
strives to resolve the conflicts between people/societies/groups over different
issues.
2. Panchayat Samiti – (at block level)
The block is comprised of around hundred villages and covers population range
of 80000 to 120000. At the block level the executive agency is the ‘Panchayat
Samiti’ which consists of all the Sarpanches (mukhiyas) of the village Panchayats
in the Block; Member of Legislative Assemblies (MLAs); Member of Parliaments
(MPs) who are residing in the block; representatives of women, schedule castes,
schedule tribes and the cooperative societies. The Block development officer (BDO)
is its ex-office secretary and he/she along with the staff assist the village panchayats
in the developmental programs. It also controls and distributes the funds released
by the government.
3. Zila Parishad – (at the district level)
The members of the Zila Parishad include all heads of Panchayat Samities in the
District, Member of Legislative Assemblies (MLAs); Member of Parliaments
(MPs) who are residing in the block; representatives of women, schedule castes,
schedule tribes and two persons having experience in administration, public health
or rural development. Its members ranges from 40-70 and the collector of the
district is a non-voting member. It performs different functions in different states. It
also performs administrative functions in some states.
At village level
Following schemes are implemented to ensure that healthcare should also reach
the remote as well as rural areas:
 Village health guides
 Local dais
 Anganwadi workers
 ASHA
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Organizational Structure of (a) Village health guides
Healthcare System
at District Level
The village health guide scheme was introduced on 2nd October 1977. The health
guides are the first point of contact between the people and healthcare systems
NOTES and are chosen from the community where they are working.
The guidelines for their selection are:
 The individuals should be the permanent residents of the local community
and preferably females.
 They should be formally educated at least up to sixth standard and able to
read and write.
 They should be willingly accepted by all the sections of their community.
 They can dedicate at least two to three hours every day to the community
welfare health work.
Training:
Place/training site - Nearest health Centre or sub-center
Training duration - 200 hours for 3 months
Stipend during training – ` 200 per month
Responsibilities and duties of health guide:
 Treatment of simple illnesses and performing first aid activities.
 Awareness about the methods and importance of family planning including
Mother and Child health among the people of the village.
 Providing health education to the people and create awareness about
sanitation.
A manual or booklet containing detailed description of clinical care of some
of the common and simple ailments with dos and don’ts is provided to the health
guides so that they may understand what to do in emergency situations, how to
start the treatment on their own and when to refer the patients to the nearest
healthcare center
(b) Local dais
Under rural health scheme, a comprehensive program has been introduced with a
goal to provide training to all categories of local dais (TBA) in India to improve
and enhance their knowledge about the fundamental concepts of mother and child
health, obstetric and sterilization techniques.
Training:
Duration of training: Thirty working day
Stipend: ` 300 per dias during training.
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Place: Primary Health Center (PHC)/subcenter/MCH center for two days/week Organizational Structure of
Healthcare System
and they go along with female health workers to the villages for rest four days of at District Level
the week.
NOTES
Fig. 13.2 Functions of Dias
(c) Anganwadi worker

Under the Integrated Child Development (ICDS) Scheme, an anganwadi worker
(female) is there for a population of 1000 who is chosen from the community she
belongs to and where she is expected to work. They are given training regarding
different aspects of child development and nutritional requirements for the mothers.
They are part time workers and paid ` 200-250/month for the services provided.
Fig. 13.3 Major Functions of Anganwadi Worker
Detailed description, roles and responsibilities of Anganwadi:

 To obtain the support of community in running health programs and
encourage people to participate.
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Organizational Structure of  To calculate the weight of all the children every month, prepare growth
Healthcare System
at District Level card and graphically document the weight in it, use referral cards to refer
mother and child cases to the nearest sub-centers or PHCs etc. and make
child cards for the children less than six years of age and show these cards
NOTES to the medical and para-medical professionals during their visit.
 To conduct a survey of all mothers, their children and other family members
in their working areas once a year.
 To conduct non-formal play based pre-school activities for the children of
three to six years of age in the anganwadis.
 To plan a menu according to availability of local foods and recipes with a
goal to arrange the supplementary healthy nutrition for children of up to six
years of age.
 To council and educate the mothers regarding breastfeeding, nutrition and
health.
 To create awareness about family planning measures among the married
woman and to motivate them to adopt these measures.
 To share the information regarding births and deaths that have occurred in
a month with the Registrar of births and deaths in the village who may be
Panchayat Secretary or Gram Sabha Sewak or Auxiliary Nurse Midwife.
 To do home visits in order to educate the parents so that they can play a
efficacious role in the growth and development of their children especially
the new born infant.
 To document and maintain all the records properly as prescribed.
 To help the Primary Healthcare staff in organizing and implementing various
immunization programs and anti-natal and post-natal health checkups.
 To provide all the information that has been collected under Integrated Child
Development Scheme to the ANM.
 To inform the supervisors about the important developments in the village
that may need their intervention, especially regarding the work involving the
coordination with several departments.
 To liaison with other organizations like mahila mandals and encourage girl
students and women school teachers of primary and middle schools to
participate in welfare activities.
 To provide guidance to the Accredited Social Health Activists regarding
the health care service delivery and documentation of records under the
Integrated Child Development Scheme.
 To organize various social awareness programs and help in the
implementation and execution of ‘Kishori Shakti Yojana’.
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 To help in the implementation of Nutrition Programme for Adolescent Girls Organizational Structure of
Healthcare System
(NPAG) and maintain the records described under the NPAG scheme. at District Level
 To assist in identifying the disabilities among children while conducting home
visits and immediately refer the case if any to the nearest Primary Healthcare
NOTES
or District Disability Rehabilitation Centre.
 To help in organizing and implementing Pulse Polio Immunization programs.
 To provide information to the ANMs in medical emergency cases such as
diarrhea, cholera etc.
(d) Accredited Social Health Activist (ASHA)
National Rural Health Mission (NRHM) was launched by the Government of
India in 2005 to cater to the health requirements of the rural population, particularly
the vulnerable and deprived sections. An important component of NRHM is to
provide a well-trained female Accredited Social Health Activist in every village in
India. ASHAs are selected from the villages and are trained so that they can work
as an interface between the communities and the public healthcare systems.
The key components of ASHA are:
 ASHA should be a female resident of the village preferably in the age group
of 25-45 years and may be married/widow/divorcee.
 Preference should be given to the woman who is educated up to 10th
standard. Relaxation in education may be given only if there is unavailability
of the suitable woman with this qualification.
 ASHA is selected through a rigorous selection process that involves several
community groups, Anganwadis, the Block Nodal officers, District Nodal
officers, the Village Health Committees and the Gram Sabhas.
 Training of ASHA workers is an ongoing process. They undergo a number
of training sessions to attain the knowledge, competence and confidence
required to perform her duties and responsibilities.
 They are incentivized according to their performance in promoting
immunization programs, referral activities and various other healthcare
programs.
 They will act as the first point of contact regarding any demand related to
healthcare particularly of vulnerable sections of the society with emphasis
on women and children, who feel difficulties in accessing healthcare services.
 ASHA will work as health activist in the society to create awareness with
regard to healthcare and its social determinants and motivate the people to
contribute to health planning at the local level and encourage them to utilize
the existing healthcare services.
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Organizational Structure of Roles and responsibilities of ASHA
Healthcare System
at District Level 1. Creating awareness and providing information to the people in the community
regarding the determinants of health like healthy diet, basic sanitation and
hygiene practices, good working conditions, proper information with regard
NOTES
to existing healthcare services.
2. Conducting home visits for the pregnant women, lactating mothers and
newborns under Home Based Post Natal Care (HBPNC), and counselling
the pregnant ladies to prepare them for birth, teaching the significance of
safe delivery, breastfeeding practices, immunization programs, contraceptive
measures and prevention of different infections.
3. Mobilizing the community people and facilitating them to access public
health services that are available at the village/sub-center levels like general
immunization, Ante Natal and post natal check-ups and various other services
provided by the Government.
4. Working with the Village Health Sanitation Nutrition Committee/Village
Level Committee (VHSNC/VLC) of the Gram Panchayat to assist in the
village health and development plan along with Auxiliary Nurse Midwives,
Anganwadi workers and members of Panchayati Raj Institutions.
5. Encouraging the community people to celebrate Village Health Nutrition
Days at least once in a month at their Anganwadi Centers with ANMs,
AWWs and members of Village Health Sanitation and Nutrition Committee.
6. Arranging/escorting/accompanying pregnant ladies and children who require
treatment to the nearest healthcare facility
7. Providing primary healthcare for simple ailments like diarrhea, fever and
minor injuries.
8. Working as Dot Providers of Directly Observed Treatment Short-course
(DOTS) under Revised National Tuberculosis Control Programme
(RNTCP).
9. Promoting of healthy practices and providing a curative care that is
appropriate and feasible for her and making timely referrals.
10. Providing information to the people on determinants of healthcare like
nutrition, sanitation and hygiene practices
Check Your Progress

1. What is a town area committee?
2. What is the three-tier structure of panchayati raj?
3. When was the village health guide scheme introduced?
4. When and why was the National Rural Health Mission (NRHM) launched?
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166 Material
13.3 ANSWERS TO CHECK YOUR PROGRESS Healthcare System
at District Level
QUESTIONS
1. Town area committees are set up in the regions with population range of NOTES
around 5000-10000. These committees work like panchayats and look
after the provision and maintenance of sanitary services of that area.
2. The three tier are:
 Panchayat
 Panchayat Samiti
 Zila Parishad
3. The village health guide scheme was introduced on 2nd October 1977.
4. National Rural Health Mission (NRHM) was launched by the Government
of India in 2005 to cater to the health requirements of the rural population,
particularly the vulnerable and deprived sections.
13.4 SUMMARY
 There are twenty nine states and seven union territories in India which are
divided into 597 districts for proper administration. Every district is further
divided into sub-divisions or taluka, under which community development
blocks are situated.
 In India, there are six regulatory territories in each region.
o Sub-divisions
o Tehsils/Talukas
o Community Development Blocks
o Municipalities and Corporations
o Villages
o Panchayats
 Panchayati Raj is a 3-tier structure of the rural local self-government in
India that links the villages to the districts. The three tier are:
o Panchayat
o Panchayat Samiti
o Zila Parishad
 The village health guide scheme was introduced on 2nd October 1977. The
health guides are the first point of contact between the people and healthcare
systems and are chosen from the community where they are working.
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Material 167
Organizational Structure of  Under rural health scheme, a comprehensive program has been introduced
Healthcare System
at District Level with a goal to provide training to all categories of local dais (TBA) in India
to improve and enhance their knowledge about the fundamental concepts
of mother and child health, obstetric and sterilization techniques.
NOTES
 Under the Integrated Child Development (ICDS) Scheme, an anganwadi
worker (female) is there for a population of 1000 who is chosen from the
community she belongs to and where she is expected to work.
 They are given training regarding different aspects of child development
and nutritional requirements for the mothers.
 National Rural Health Mission (NRHM) was launched by the Government
of India in 2005 to cater to the health requirements of the rural population,
particularly the vulnerable and deprived sections.
 An important component of NRHM is to provide a well-trained female
Accredited Social Health Activist in every village in India.
13.5 KEY WORDS
 Anganwadi: It is a type of rural child care centre in India. They were

started by the Indian government in 1975 as part of the Integrated Child
Development Services program to combat child hunger and malnutrition.
Anganwadi means “courtyard shelter” in Indian languages.
 Tehsil/Taluka: It is an administrative division of some countries of South
Asia. In India, there are currently 5410 Tehsil or Sub-District unit from 712
districts. In India, the term tehsil is used to some extent in all states.
13.6 SELF-ASSESSMENT QUESTIONS AND

EXERCISES

1. Write a short note on community development blocks.
2. State the functions of local dias.
3. What are the major functions of Anganwadi Workers?
1. Differentiate between the divisions in the urban and rural areas.
2. Discuss the organizational structure of health care system at the district
level.
3. Analyse the role of regulatory territories of health.
4. Describe the three tier structure of the rural self-government.
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168 Material
13.7 FURTHER READINGS Healthcare System
at District Level
Government of India.1983. Statement on National Health Policy, Ministry of Health

and Family Welfare: New Delhi. NOTES
Government of India. 2002. National Health Policy, Ministry of Health and Family
Welfare. New Delhi.
Banerji, D. 1985. Health and Family Planning Services in India: An Epidemiological,
Socio-Cultural and Political Analysis and a Perspective. Lok Paksh:
New Delhi.
Websites
https://www.who.int/management/district/overall/en/index1.html
http://www.nhm.gov.in/communitisation/village-health-sanitation-nutrition-
committee.html.
Self-Instructional
Material 169
Cost Benefit Analysis in
Healthcare Services
UNIT 14 COST BENEFIT ANALYSIS
IN HEALTHCARE
NOTES
SERVICES
Structure
14.0 Introduction
14.1 Objectives
14.2 Economic Evaluation and Cost Benefit Analysis
14.4 Summary
14.5 Key Words
14.0 INTRODUCTION
Economic evaluation can be used to assess the best way of achieving a given goal
within a given budget. This is a technical efficiency question that can be measured
by cost-effectiveness analysis or cost-utility analysis.
There are three basic types of economic evaluation methodology:
 Cost-Effectiveness Analysis (CEA)
 Cost-Utility Analysis (CUA)
 Cost-Benefit Analysis (CBA)
Cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) are two
important components of the science of decision-making for health. In this unit,
we will study cost-benefit analysis in detail.
14.1 OBJECTIVES

 Understand the three basic types of economic evaluation
 Describe the meaning of economic evaluation
 Describe the cost-benefit analysis in detail
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170 Material
14.2 ECONOMIC EVALUATION AND COST Healthcare Services
BENEFIT ANALYSIS
The term economic evaluation can be defined as the comparative analysis of NOTES
alternative courses of action in terms of their costs and consequences. For a range
of techniques it is a collective term which may be used to collect evidence and
compare the expected costs and their outcomes for various processes. Generally
the term ‘Economic Evaluation’ operatively evaluates the efficacy of a medical
procedure. It is the comparative evaluation of different courses of action taking
into account their costs as well as outcomes. Economic evaluation is usually done
in healthcare programs to allocate the resources by assigning priorities for preparing
health policies and guidelines but this is only a secondary objective. The primary
objective is to improve efficiency by transforming inputs such as capital, labour,
etc. into outputs like improving quality of life, saving life, health gain, etc. Economic
evaluation in healthcare is focused on achieving proficiency to gain the maximum
health benefits from the utilization of available resources. It enables the decision-
makers to determine the dissemination of resources like equipment, funds, personnel
and facilities across various departments.
Generally two terms i.e. Allocative efficiency and Technical efficiency are
used by the economists.
 Allocative Efficiency: It is concerned with choosing of the type of health
care to be provided for maximization of benefits using the available resources.
Therefore from a given resource, the aim is to take as much benefits of
healthcare program as possible. Allocative-efficiency is all about finding the
best or most favorable services which can provide the highest possible
benefits. Here resources are the interventions that are relatively better (i.e.
effective) in transforming inputs into those healthcare benefits that need greater
inputs for relatively lower healthcare gain.
 Technical Efficiency: It is concerned with choosing the ways to provide
healthcare services with minimized inputs for given outputs.
Evaluation needs to be comparative to some benchmark or alternative and
then it can be called as complete evaluation.
Following conditions can be the reason for partial evaluation:
 If under any circumstances an evaluation is not comparable and does not
consider neither costs nor outcomes, it is considered as a partial evaluation.
It can be understood as description of either only the cost or only the benefits
of an intervention.
 In this case if both the costs and outcomes are taken into account but no
comparison is provided, it is again said to be partially evaluated.
Self-Instructional
Material 171
Cost Benefit Analysis in  If alternatives are compared but only in the terms of costs or benefits and
Healthcare Services
not as a whole (or both) then again it is again said to be partial evaluation
hence it becomes an effectiveness study (cost analysis) and not an efficiency
study. It would rather be comparative but only one-dimensional.
NOTES
Let us analyse the basic principles of economic evaluation.
Decision-making Tool
Economic evaluations are generally performed for providing information to various
decision makers who face options for example, whether or not a new treatment
should be provided or new healthcare approach should be adopted.
Economic evaluation provides thorough and simultaneous information on
efficacy and cost. The dimension of cost is significant as few decision makers may
ignore the cost implications of their choices. Addition of costs to the analysis allows
to consider effectiveness and efficiency together.
It is to be taken into consideration that the effect health intervention does
not always occur at a same time. Cost might be incurred today but benefits might
not be observed until the next year.
Cost and Benefits
There are various ways to define cost but most commonly cost can be defined as
direct cost, indirect cost and intangible cost. Most types of economic evaluations
consider cost in the similar unit i.e. monetary.
 Direct costs: This includes drugs, nursing services, medical supplies,
diagnostic imaging, rehabilitation and food services that are completely
attributed to the production of any goods or services.
 Indirect costs: It includes general IT services, administration, physical plant,
health records and maintenance, HR services, volunteer services, capital
expenses, and other regional services they are basically the costs that are
not directly accountable.
 Intangible costs: Pain and anxiety of patient, quality, etc. the costs that are
not physical in nature.
Benefits have been analyzed in three different ways based on economic
analysis used in evaluation.
 Direct benefit: They are medically defined units appropriate to the areas
of study, like decreased tumor size, lives saved, alterations in blood pressure,
etc.
 Indirect benefit: Benefits that are valued in monetary terms.
 Intangible benefit: This includes happiness, well-being, satisfaction etc.
that are usually described in terms of utilities.
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172 Material
The utility which is derived by an individual through its benefit and can be Cost Benefit Analysis in
Healthcare Services
quantified by quality adjusted life year (QALY).
Identification of variables
In any evaluation, costs and benefits need to be determined first. The identification NOTES
of relevant benefits and costs define the variables in the study. All relevant cost and
benefit variables must be:
 Identified
 Quantified
 Valued
Variables are presented in terms of ‘natural’ quantities (i.e. work hours or
clinical units) and are broadly classified into changes in productive output, changes
in resource use and changes in health state.
Measuring changes in variables
The next stage is to measure changes in these variables brought about by the
intervention in question. Resources in terms of land, labour, capital and raw materials
or consumables must be quantified. Labour, the most important element of most
health care, is often expressed in units of time (i.e. hours worked). Raw materials
include amount of drugs, appliances and dressings etc. can be quantified as these
are counted and costs can be estimated. Simultaneously labour and consumables
are less problematic but for quantifying a specific intervention there are various
accountancy techniques such as capital stock and land (equipment, overheads,
and buildings). There are several issues to consider in the assessment of costs and
benefits. Externality costs and benefits may arise since interventions but do not
just affect the patient receiving care.
A number of techniques have been described for full economic evaluation.
Theoretically the evaluation should be linked with a clinical trial so that both costing
and consequence data can be collected simultaneously. This is a lengthy and
expensive process and evaluations often uses existing medical literature in order to
provide data on consequences. For full economic evaluation following techniques
are used:
 Cost-Minimization
 Cost-Effectiveness
 Cost-Utility
 Cost-Benefit
1. Cost Minimization Analysis: Cost-minimization analysis (CMA) compares
the costs of different interventions that are assumed to provide equivalent benefits.
The costs related to all the interventions are evaluated and the one with least cost
Self-Instructional
Material 173
Cost Benefit Analysis in can be chosen. For better understanding a good example can be a comparison
Healthcare Services
between a generic drug and its branded equivalent. If the assumption of equal
effectiveness is substantiated, the decision hinges on finding the least expensive
way of obtaining that health benefit—only the costs are compared and not the
NOTES benefits. The decision rule is therefore simple because the cheapest intervention
will provide the best value for money. However in practice, there are relatively
few CMAs because it is rare for two health care interventions to provide exactly
the same benefits.
2. Cost-Effectiveness Analysis: It is a technique where unit cost is compared
with measurable effect (qualitative measure). It is similar to cost benefit analysis
except that benefit instead of being expressed in monetary terms is expressed in
terms of result achieved. It may be used where there are variations in outcomes
but expressed in common units which enables the analysts to do comparisons.
For example, costs can be compared using common units, such as ‘per
lives saved’ or ‘per pain free day’. A CEA can therefore be used to compare heart
surgery and kidney transplantation, when the common unit of measurement to be
used is the number of life years saved. In summary, CEA studies express
effectiveness in a single dimension in order to enable direct comparison of costs.
For example - number of days free from disease or number of lives saved or the
number of years by which life is extended as a result of the intervention. Quality of
life scores are also used which can be obtained from Health Related Quality of
Life (HRQoL) that measure the quality of life for the patient with respect to physical,
emotional and social perspective and provide scores for each. CEA is used to
evaluate the procedures with different units of outcome. Procedures with similar
units of outcome cannot be measured by CEA. For example it is not used for
comparison of dental caries reduction and mouth cancer treatment as outcome
units are different. Comparisons can be made between different health programmes
in terms of their cost effectiveness ratios: cost per unit of effect.
Under CEA, effects are measured in terms of the most appropriate uni-
dimensional natural unit. For example what is the best way of treating renal failure?
Then the most appropriate ratio which compares programmes might be ‘cost per
life saved’. In deciding whether long-term care for the elderly should be provided
in nursing homes or the ‘cost per disability day avoided’ might be the most
appropriate measure. The advantage of the CEA approach is that it is relatively
straightforward to carry out and is often sufficient for addressing many questions
in health care.
The main restriction in CEA is that it is one-dimensional and is not
comprehensive. Only one domain of benefits can be explored at a time. So it
becomes difficult to choose which single outcome best represents the intervention.
One possibility is to conduct a cost-consequence analysis. This is a particular type
of CEA that evaluates multiple outcomes and reports costs and benefits in a
disaggregated form, leaving the analyst to decide which benefit to select.
Self-Instructional
174 Material
3. Cost Utility analysis: Cost Utility Analysis is concerned with allocative Cost Benefit Analysis in
Healthcare Services
efficiency within the health care sector and technical efficiency, since it also makes
comparisons between health programs in terms of cost-effect ratios. It overcomes
the limitations of CEA as it compares various interventions through the use of
outcome units based on utility. Utility is a cardinal value which measures the states NOTES
of health and diseases for individuals. It is a numerical value that expresses the
consolidation of various parameters affecting an individual’s health and well-being.
Unlike CEA, CUA it is multidimensional and incorporates considerations of quality
of life as well as quantity of life gained as a result of a health programme using a
common unit. Valuing ‘healthy years’ reflects that a preference has been expressed
for being in one health state rather than another.
In health economics a utility is that measure of the preference or value that
an individual or society places upon a particular health state. It is generally a number
between zero (representing death) and one (perfect health). These utility values
are then combined with survival data to derive quality-adjusted life years (QALYs)
for different health programmes.
Utilities can be measured using direct methods such as the ‘standard gamble’
or ‘time tradeoff’.
(1) The standard gamble: It is a technique widely used in economics which is
based on the idea that something is only of value if we are prepared to give
another thing up in order to get it. The respondent is asked to make a trade-
off between the certainty of having a chronic disease for a period (t) and a
gamble that has two possible alternatives: staying in good health for the
same period or death. Finding the point where the respondent is indifferent
between being in the chronic condition and the gamble, provides us with a
value that reflects the quality of life that the respondent attaches to the chronic
condition.
(2) Time trade off: This technique is based on concepts which are similar to
the standard gamble. The respondent here is asked how many years of life
in a health state are with a disease. Similarly he or she would be willing to
give up to be in full health but for a shorter period. For better understanding
let us take an example- the respondent may be asked if he or she would
prefer to live for five years in health state with a specified chronic condition,
or three years in perfect health. The process goes on until the point till the
respondent is indifferent between the two health states because these
techniques are complex, simpler methods have been devised to obtain health
state utilities.
Generic health state questionnaires are then used to ask respondents a
number of simple, health - related questions and then convert the results into utilities
using pre-scaled responses obtained by standard gamble or time trade off, from a
relevant reference group. Health state utilities can be elicited directly from patients,
but when this is not possible significant family members, caretakers or health
Self-Instructional
Material 175
Cost Benefit Analysis in professionals may be also be asked to respond. The most widely used measure of
Healthcare Services
benefit in CUA is the quality adjusted life year (QALY), but other measures include
disability adjusted life years (DALYs) and healthy year equivalents (HYEs)
Measures of Benefits
NOTES
Quality Adjusted Life Years: A quality adjusted life year (QALY) is used to
quantify the effectiveness of a new medicine versus the current one. In other words,
the current standard of care is taken as the baseline and the QALY gained from
the new (improved) intervention are counted in addition.
FORMULA: Years of Life × Utility Value = QALY
It is calculated by estimation of the total number of life-years gained from
treatment and weighting each year with a quality of life score (or utility) to reflect
the quality of life in that year.
This means:
 If a person lives in perfect health for one year, that person will have
1 QALY.
(2 Year of Life × 2 Utility Value = 2 QALY)
 If a person lives in perfect health but only for half a year, that person will
have 0.5 QALYs.
(0.5 Years of Life × 1 Utility Value = 0.5 QALY)
Example: If a person lives for 3 years with a disease and the current standard of
care for that disease means he lives with a utility level of 0.7, that person will have
2.1 QALYs. (3 Years of Life × 0.7 Utility Value = 2.1 QALY)
 If that person takes a new medicine (Medicine A) whereby his utility level
increases to 0.9, that person will now have 2.7 QALYS. Hence the benefit
of the new medicine will be counted as 0.6 QALYs as this is the increase
over the current standard of care.
(3 Years of Life × 0.2 Additional Utility Level = 0.6 QALY)
 Similarly, if a new medicine (Medicine B) prolongs the patient’s life by
2 years, at a utility level of 0.7, the new medicine will provide the person
with 1.4 additional QALY.
(2 Years of Additional Life × 0.7 Utility Value = 1.4 QALY)
Healthy Year Equivalents: Healthy year equivalents (HYEs) also provide a
measure of quantity and quality of life. Whereas QALYs weigh each year lived in
a health state independently, HYE on the other hand consider a sequence of health
states and their duration and then ask respondents how many healthy years of life
this scenario is equivalent to.
For example: A respondent could be asked the following:
If you live with a disabling hip fracture for three years, how many years of
healthy life would this be equivalent to?
Self-Instructional
176 Material
Whereas QALY approach would ask the respondent to rate one year lived Cost Benefit Analysis in
Healthcare Services
with a disabling hip fracture, irrespective of whether he or she had the condition
for one year or 10 years. In practice, HYEs have not been used often because of
the complexities involved in their measurement.
NOTES
4. Cost-Benefit Analysis: In healthcare evaluation cost-benefit analysis (CBA)
is a comparison of interventions and their consequences in which both costs and
resulting benefits (health outcomes and others) are expressed in monetary terms.
This enables two or more treatment alternatives to be compared using the summary
metric of net monetary benefit, which is the difference between the benefit of each
treatments (expressed in monetary units) less the cost of each. Monetary valuations
of benefits are commonly obtained through willingness to pay (WTP) surveys
or discrete choice experiments (DCEs). Although popular in other fields, CBA is
not commonly used in health technology assessment due to difficulty of associating
monetary values with health outcomes such as (increased) survival. Most commonly
CBAs have been used to assess large capital development projects (new hospital
facilities) or interventions that improve waiting times or location/access to services.
Under the concept of CBA the decision rule on whether to fund an
intervention is simple, if the benefits of implementing the programme are greater
than the costs then the programme should be funded. Ideally CBA can provide
information on whether a health programme is worthwhile funding from the point
of view of society in comparison to other health programmes simultaneously
comparing with other areas of social policy such as the environment and transport.
However in practice, CBAs are rarely used in health care because of the
difficulties faced on expressing health benefits directly in monetary terms. In this
method the economic benefits of any program are compared with the total cost of
that program. The benefits are expressed in monetary terms to determine whether
a given program is economically sound and to select the best out of several alternate
program. The final result is expressed as the net monetary gain (or loss) or as a
cost- benefit ratio.
Still the main problem with the CBA approach in health care is to convert
health programs into monetary values. Generally under this method two techniques
are applied for determining the monetary valuation of benefits: the ‘human capital’
and the ‘willingness to pay’ approaches.
Check Your Progress

1. Define the term economic evaluation.
2. What is allocative efficiency?
3. What are the conditions for all relevant cost and benefit variables?
4. State the techniques of full economic evaluation.
Self-Instructional
Material 177
Healthcare Services 14.3 ANSWERS TO CHECK YOUR PROGRESS
QUESTIONS
NOTES 1. The term economic evaluation can be defined as the comparative analysis
of alternative courses of action in terms of their costs and consequences.
For a range of techniques it is a collective term which may be used to
collect evidence and compare the expected costs and their outcomes for
various processes.
2. Allocative Efficiency is concerned with choosing of the type of health care
to be provided for maximization of benefits using the available resources.
healthcare program as possible.
3. All relevant cost and benefit variables must be:
 Identified
 Quantified
 Valued
4. For full economic evaluation following techniques are used:
 Cost-Minimization
 Cost-Effectiveness
 Cost-Utility
 Cost-Benefit
14.4 SUMMARY
 The term economic evaluation can be defined as the comparative analysis

of alternative courses of action in terms of their costs and consequences.
For a range of techniques it is a collective term which may be used to
collect evidence and compare the expected costs and their outcomes for
various processes.
 Economic evaluation in healthcare is focused on achieving proficiency to
gain the maximum health benefits from the utilization of available resources.
 It enables the decision-makers to determine the dissemination of resources
like equipment, funds, personnel and facilities across various departments.
 Economic evaluations are generally performed for providing information to
various decision makers who face options for example, whether or not a
new treatment should be provided or new healthcare approach should be
adopted.
Self-Instructional
178 Material
 There are various ways to define cost but most commonly cost can be Cost Benefit Analysis in
Healthcare Services
defined as direct cost, indirect cost and intangible cost. Most types of
economic evaluations consider cost in the similar unit i.e. monetary.
 In any evaluation, costs and benefits need to be determined first. The
NOTES
identification of relevant benefits and costs define the variables in the study.
All relevant cost and benefit variables must be:
o Identified
o Quantified
o Valued
 A number of techniques have been described for full economic evaluation.
Theoretically the evaluation should be linked with a clinical trial so that both
costing and consequence data can be collected simultaneously.
 A quality adjusted life year (QALY) is used to quantify the effectiveness of
a new medicine versus the current one. In other words, the current standard
of care is taken as the baseline and the QALY gained from the new
(improved) intervention are counted in addition.
 Healthy year equivalents (HYEs) also provide a measure of quantity and
quality of life. Whereas QALYs weigh each year lived in a health state
independently, HYE on the other hand consider a sequence of health states
and their duration and then ask respondents how many healthy years of life
this scenario is equivalent to.
14.5 KEY WORDS
 Allocative Efficiency: It is concerned with choosing of the type of health

care to be provided for maximization of benefits using the available resources.
healthcare program as possible.
 Technical Efficiency: It is concerned with choosing the ways to provide
healthcare services with minimized inputs for given outputs.

EXERCISES

1. State the conditions for partial evaluation.
2. Differentiate between standard gamble and time trade off.
3. What are the benefits of economic evaluation?
Self-Instructional
Material 179
Cost Benefit Analysis in Long Answer Questions
Healthcare Services
1. Analyse the basic principles of economic evaluation.
2. Describe the techniques of economic evaluation.
NOTES 3. Discuss the measures of benefit with the help of the formula.
Websites
http://s3.amazonaws.com/zanran_storage/.whoindia.org/ContentPages/
127626072.pdf
Self-Instructional
180 Material

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ALAGAPPA UNIVERSITY

[Accredited with ‘A+’ Grade by NAAC (CGPA:3.64) in the Third Cycle

Directorate of Distance Education

P.G. Diploma in Hospital Administration

HEALTH CARE SYSTEM

"The copyright shall be vested with Alagappa University"

Vikas® is the registered trademark of Vikas® Publishing House Pvt. Ltd.

BLOCK I: BASICS OF HEALTH CARE SYSTEM Unit 1: Health Care

BLOCK III: HOLISTICAPPROACH TO HEALTH Unit 9: Occupational Hazards

UNIT 2 HEALTH CARE SYSTEM IN INDIA 10-22

UNIT 3 PRIVATE, GOVERNMENT AND CORPORATE HOSPITALS 23-33

UNIT 4 ORGANISATIONS FOR HEALTH: VOLUNTARY

BLOCK 2: PRIMARY HEALTH CARE SYSTEM

UNIT 6 HOSPITALS VS PRIMARY HEALTH CARE: A FALSE ANTITHESIS 50-57

UNIT 7 NATURAL HISTORY OF DISEASE 58-73

UNIT 8 OCCUPATIONAL HEALTH 74-80

BLOCK 3: HOLISTIC APPROACH TO HEALTH

UNIT 10 EVOLUTION OF HEALTH CARE DELIVERY SYSTEM 98-106

UNIT 11 HOLISTIC APPROACH TO HEALTH 107-139

BLOCK 4: COST BENEFIT ANALYSIS

UNIT 12 EDUCATION SYSTEM: MEDICAL AND PARAMEDICAL

UNIT 13 ORGANIZATIONAL STRUCTURE OF HEALTHCARE SYSTEM

UNIT 14 COST BENEFIT ANALYSIS IN HEALTHCARE SERVICES 170-180

Health is a state subject as per the constitution of India. It is the responsibility of

Health is declared as a fundamental human right. Health is influenced by a number

After going through this unit, you will be able to:

Fig. 1.1 Levels of Health Care

1.2.1 Levels of Health Care

1.3 PRIMARY HEALTH CARE

Check Your Progress

community participation, inter-sectoral coordination and appropriate

 Tertiary care: It is a specialized consultative health care, usually

1.7 SELF ASSESSMENT QUESTIONS AND

Short Answer Questions

1.8 FURTHER READINGS

Suryakantha, AH. 2017. Community Medicine with Recent Advancements.

UNIT 2 HEALTH CARE SYSTEM

After going through this unit, you will be able to:

2.2 INTRODUCTION TO HEALTHCARE SYSTEM

In the following section, the structure of healthcare system in India is discussed

Fig. 2.1 Healthcare Structure in India

Ministry of Health and Family Welfare plays an important role in healthcare in

It is a simple management structure of a group of hospitals’ trustees, local panchayati

Check Your Progress

2.3 ANSWERS TO CHECK YOUR PROGRESS

1. Public healthcare primarily constitutes community healthcare centers, primary

increased in the hospitals. Numerous diagnostic centers are also established

 AYUSH: The Ministry of Ayurveda, Yoga and Naturopath, Unani, Siddha

2.6 SELF ASSESSMENT QUESTIONS AND

Short Answer Questions

2.7 FURTHER READINGS

UNIT 3 PRIVATE, GOVERNMENT Corporate Hospitals

After going through this unit, you will be able to:

3.3 ANSWERS TO CHECK YOUR PROGRESS

1. Medicine emerged as organized entity around 6000 years ago in

3.5 KEY WORDS

 Unani: Unani or Yunani medicine is the term for Perso-Arabic traditional

Short Answer Questions

3.7 FURTHER READINGS

After going through this unit, you will be able to:

4.2 FUNCTIONS OF VOLUNTARY NOTES

Voluntary organisations have a long term history of contributing in the promotion

4.3 VOLUNTARY HEALTH AGENCIES IN INDIA