SELF DIRECTED E-LEARNIG

Section 1: Target audience

Program: 4th yr BPT

Semester / Term: 4th term

Course (Subject): community based rehabilitation

Module prepared by: Ms. Priyanka Nayak

Section 2: Title for module: - HEALTH CARE DELIVERY SYSTEM

Section 3:

Specific Learning Outcomes

SLO46: List the organizations in national and district level(K)

SLO47: Enumerate the role of different organizations in CBR

SLO48: Explain the need of Primary Rehabilitation Unit

SLO49: Explain the need of regional training centre

SLO50: Explain the need of district training centre

SLO51: Explain the need of primary health centre

SLO52: Explain role of village rehabilitation worker

At the end of the unit of learning students will be able to.

definition

levels of health care delivery system in india

health care requirement of elderly as special group

delivery of health care to elderly at various levels

 CONTENTS

Introduction

Definition

Levels of Health Care Delivery system in India

Health Care Requirement of Elderly as Special Group

Delivery of Health Care to Elderly at Various levels

HEALTH CARE AGENCIES

Summary

References

quiz
 Introduction

Health care system may be defined as the industry which provides health
services so as to meet the health needs and demands of individuals, the family
and the community. Health care systems are composed of individuals and
organizations that aim to meet the health care needs of target populations.

The health care system of a society can also be defined as a set

of ideas, practices and organisations which have been developed to
deal with problems of health and illness in the society.

Statistics about ageing population:

The world is ageing. With people living longer and fewer children being
born, the absolute number of older people is increasing. Today, worldwide, there
are some 600 million persons aged 60 and over; this total will double by 2025
and will reach virtually two billion by 2050 when there will be more people aged

60. Indian scenario 7.7% population is ›60. The vast majority of older persons
will be living in developing countries which are often least prepared to meet the
challenges of rapidly ageing societies & rapidity of population ageing is expected
to continue to outpace social and economic development in developing countries.

The health care system has to gear up for the needs of elderly. Though
elderly people are more prone for ill health, yet their health care facility utilization
is poor on account of physical, socioeconomic and psychological reasons. The
best way to provide health care to the enormous number of under served rural
people and urban poor is to develop effective primary health care services
supported by an appropriate referral system. Health care services must be
curative, preventive and promotive.

Levels of Health Care Delivery system in India

In India the health care delivery system is represented by five major

sectors or agencies that differ from each other by the health technology applied
and by the source of funds for operation:

A. Public sector

1. Primary health care :

a. Primary health centers (PHC)
b. Subcentres

In 1977, the government of India launched a Rural Health Scheme,

based on the principle of ”lacing people’s health in people’s hand”. It is a three
tier system of health care delivery in rural areas. Govt. of India is committed to
achieve the goal of health for all through primary health care at a cost which is
affordable. The National Health Policy has laid down five year plans towards
achieving health for all. One of the basic tenets of primary health care is
universal coverage & equitable distribution of health resources. The National
Health plan proposed reorganization of one PHC for every 30,000 rural
population in plains & one PHC for every 20,000 population in hilly, tribal &
backward areas for more effective coverage.

2. Hospitals/health centres
a. Community health centres
b. Rural hospitals
c. District hospitals/health centres
 d. Specialist hospitals
e. Teaching hospitals

In 1996 community health centres were established by upgrading the

primary health centres, each covering a population of 80,000 to 1.20 lakh ( one in
each community development block ) with 30 beds & specialists in surgery,
medicine, obstetrics & gynaecology and paediatrics with xray & laboratory
facilities. The specialist at a community health centre may refer a patient directly
to the state level hospital or the nearest appropriate Medical college hospital, as
may be necessary, without the patient having to go first to the sub- divisional or
district hospital.

Apart from the PHC’s , the present organization of health services of the
govt. sector consists of rural hospitals, sub-divisional / tehsil / taluka hospitals,
district hospitals, specialist hospitals & teaching institutions.

3. Health insurance scheme

a. Employees state insurance
b. Central government health scheme

There is no universal health insurance in India. Health insurance is

presently limited to industrial workers & their families. The central govt.
employees are also covered by the health insurance, under the Central Govt.
Health Scheme. The Employees state insurance (ESI) scheme introduced by
parliament act in 1948 has introduced for 1 st time in India the principle of
contribution by the employer & the employee. The act provides for medical care
in cash & kind, benefits in the contingency of sickness, maternity, employment
injury & pension for dependents on the death of worker on duty.
 The Central Government Health Scheme for central govt. employee was
introduced in 1954 it covers all usual medical care requirements of the employee
& family also gradually extended over years to cover population such as
employees autonomous organizations, retired central govt. servents, widows
receiving family pension, members of parliament, Ex-governers & retired judges.

4. Other agencies
a. Defense services
b. Railways

Defense services have their own organization for medical care to defense
personnel under “Armed Forces Medical Services”. The services provided are
integrated & comprehensive embracing preventive, promotive & curative
services. The railways provide comprehensive health care services through the
agency of railway hospitals, health units & clinics.

B. Private sector

1. Private hospitals, polyclinics, nursing homes, dispensaries

2. General practitioners from.

In a mixed economy such as India’s private practice of medicine provides a

large share of the health services available. There has been a rapid extension in
number of qualified allopathic physicians from the time of independence. The
general practitioners constitute 70% of medical profession. Mostly in the urban
area, they provide mainly curative services. Their services are available to those
who can pay. The private sector of health services is not organized.
C. Indigenous systems of medicine

1. Ayurveda
2. Unani
3. Homeopathy
4. Unregistered Practitioners

The practitioners of indigenous systems of medicine provide the bulk of

medical care to the rural people. Most of them are local residents & remain very
close to the people socially & culturally. In recent years there has been
considerable state patronage to foster these medicine systems. Many ayurvedic
dispensaries are state- run. Indian govt. has established a National Institute of
Ayurveda in Jaipur & a National Institute of Homeopathy in Kolkata. A central
council of Indian medicine was established in 1971 to prescribe minimum
standards of education in Indian medicine.

D. Voluntary health agencies

Voluntary health agencies occupy an important place in community

health programmes. These organization is administered by an autonomous
board which holds meetings, collects funds for its support chiefly from private
sources & expands money, whether with or with out paid workers in conducting a
program directed primarily to furthering the public health by providing health
services or health education, or by advancing research or legislation for health or
by combination of these activities. Their function include; Supplementing the
work of govt. agencies, Pioneering, Education, Demonstration, Guarding the
work of govt. agencies, Advancing health legislation. Eg: Indian Red Cross
Society, Indian Council of Child Welfare, Tuberculosis Association of India, The
All- India Blind Relief Society.

E. National health programmes

National health programmes have been launched by central govt. for

the control/eradication of communicable diseases, improvement of environmental
sanitation, nutrition, control of population & rural health. Eg: National Anti–
malarial Programme, National Leprosy Eradication Programme, National
Tuberculosis Programme, National Programme for Control of Blindness etc.
various international agencies like WHO, UNICEF, World Bank etc have been
providing technical & material assistance in the implementation of these
programmes.

Health Care Requirement of Elderly as Special Group:

The normal aging process involves gradual decreases in organ system

capabilities and homeostatic controls that are relatively subclinical or
asymptomatic in the absence of disease or stress. The steady decreases of
physiologic reserves make older adults potentially vulnerable to functional
decline as a result of acute or chronic illnesses. Aging, an integral part of living,
typically is accompanied by gradual but progressive physiologic changes and an
increased prevalence of acute and chronic illness including:

 Decreased reserve capacity of organ systems, which is apparent only

during periods of exertion or stress
 Decreased internal homeostatic control (e.g., blunting of the
thermoregulatory system, decline in baroreceptor sensitivity)
  Decreased ability to adapt in response to different environments (e.g.,
vulnerability to hypothermia and hyperthermia with changing
temperatures, orthostatic hypotension with change in position)
 Decreased capacity to respond to stress (e.g., exertion, fever, anemia)

The end result of these age-related declines is an increased vulnerability to

disease and injury.

The concept of Geriatric Care is of a recent origin in India requiring an

adequate attention to provide positive intervention and action strengthening
social support systems for the older persons. In view of the increased life
expectancy and accelerated pace of increase in the proportion of older persons
as compared to total population of the nation, it is essential to educate & train
young persons, family members and others concerned with the welfare of older
persons with the active participation of the elderly, to equip them with the
theoretical and practical knowledge, skill and attitude, necessary for giving care
to the vulnerable section of the elderly.

In India, the elderly people suffer from dual medical problems, i.e.,
both communicable as well as non-communicable diseases. This is further
compounded by impairment of special sensory functions like vision and hearing.
A decline in immunity as well as age-related physiologic changes leads to an
increased burden of communicable diseases in the elderly, also the rapid
urbanization and societal modernization has brought in its wake a breakdown in
family values and the framework of family support, economic insecurity, social
isolation, and elderly abuse leading to a host of psychological illnesses. Without
the safe, secure and dignified status in the family, the elderly are finding
themselves vulnerable.

Older adults can experience acute (sudden) onset of disability from

conditions like frequent falls, stroke, amputation, spinal cord injury, and traumatic
brain injury. However, many experience a gradual progression of difficulties in
function. The effects of multiple and chronic illnesses usually are gradual over
time leaving the elderly person reasonably functional with various adaptations,
such as walking more slowly or taking more frequent rests.

Elderly individual may be only marginally functional with little or no

reserve capacity, so that even a relatively minor superimposed acute
complication or disease process may result in functional decompensation. Even
greater concern is that this significant functional decompensation may be difficult
to reverse even though the acute illness is appropriately treated and resolves.
There is often an altered response to illness in the elderly, which contributes to
delayed or incorrect diagnosis.

Many specific diseases present with atypical and non classic signs and
symptoms also a wide variety of diseases may present with similar nonspecific
symptoms, including confusion, weakness, weight loss & hence the differential
diagnosis of possible disease processes is much broader in elderly patients.
Older people also are more prone to a wide variety of concomitant and
complicating diseases, which may further cloud diagnosis and treatment
decisions like thrombophlebitis, dehydration, fluid and electrolyte disturbances,
adverse drug interactions or toxicity, decubitus ulcers, pneumonia, and general
deleterious effects of deconditioning as a result of inactivity, which occurs earlier
and with greater severity in older adults.

Hence palliation and prevention of secondary complications is a more

appropriate and realistic goal than cure of the primary condition. Prevention
strategies are being proposed both to improve the number of disability-free years
of life. Prevention can be organized according to the concepts of primary,
secondary, and tertiary prevention. Primary prevention involves preventing the
onset of a disease, whereas secondary prevention involves the diagnosis and
treatment of asymptomatic diseases to prevent the development of symptoms &
tertiary prevention involves treatment once a disease becomes symptomatic to
avoid complications.

Delivery of Health Care to Elderly at Various levels:

Health care system should achieve better performance on the six

dimensions outlined by the Institute of Medicine in Crossing the Quality Chasm:
A New Health System for the 21stCentury:

Safety: Avoiding injury and harm from care that is meant to aid patients.

Effectiveness: Assuring that “evidence-based” care is actually delivered

by avoiding overuse of medically unproven care and under use of medically
sound care.

Patient centeredness: Involving patients thoroughly in their care decision

making process, thereby respecting their culture, social circumstances, and
needs.

Timeliness: Avoiding unwanted delays in treatment.

Efficiency: Seeking to reduce waste low-value added processes and products in

all its forms, including supplies, equipment, capital, and space.

Equity: Closing racial, ethnic, gender, and socioeconomic gaps in care

and outcomes.
 A health care system that makes advances along these six dimensions
would be far more able to meet patient needs. Care would be safer, more
reliable, more integrated, and timely. Patients could rely on receiving the full
range of preventive, acute, and chronic services that are proven effective. They
could also know that they would not be subjected to the risks and costs of
excessive, ineffective, and unscientific care that does not help them. Health care
providers would benefit through increased satisfaction at being able to deliver
care that produces greater health and longevity for their patients, and reduces
pain and suffering.

These aspirations, taken together, are best understood by considering

their application to individuals in different circumstances: those who are well, at
risk, acutely ill, chronically ill, or at the end of life. The “well” are relatively healthy,
seeking care only when they feel it is needed, and are less likely to recognize or
act on their need for health promotion and preventive services. The “at risk”
experience unmet care needs, dissatisfaction with the system, or expectations
that go unmet.

These are individuals who attempt to access preventive and health-

promoting services but who may not receive these services efficiently. The
“acutely ill” have time limited or curable health problems, and typically receive
outpatient care for an accident or infection. The “chronically ill” have persistent
medical problems, such as diabetes or hypertension, that can be managed but
last for months and in many cases cannot be definitively cured. The last
population, those “at the end of life,” comprise individuals whose proper care
is palliative rather than curative.

The World Health Organization has recognized the critical role health
centres play in the health of older people worldwide and the need for these
centres to be accessible and adapted to the needs of older population. Primary
health centres (PHC) is the principal vehicle for the delivery of health care at the
most local level of a country’s health system were preventive health care and
screening for early disease detection and management takes place at the
community level. These primary health care centres to which people can self
refer, also provide the bulk of ongoing management and care.

It is estimated that 80% of front-line health care is provided at the

community level where PHC centres form the backbone of the health care
system. Elderly already account for a sizeable proportion of PHC centre patients
and as populations age and chronic disease rates climb, that proportion will
increase. PHC centers are on the frontline of health care and are thus familiar to
older people and their families. They are ideally positioned to provide the regular
and extended contacts and ongoing care that older persons need to prevent or
delay disabilities resulting from chronic health conditions .

Despite the critical role that health care system play in older persons
health and well-being, tailoring care, identifying specific barriers, and making it
friendly to the special needs of specific population groups. Older people
encounter many barriers to care. Transport to the centre may be unavailable or
too expensive. They may encounter difficulty completing the required forms.
Older patients may become discouraged from seeking or continuing treatment
with potentially serious health consequences.

Recommendations to reduce the physical barriers to accessing

healthcare centres:

 Ensure there are sufficient number of centers that are located at

reasonable distances for older people.

 Review and strengthen the public transport system to ensure it is age

friendly and affordable to older people.

 Review and strengthen the physical environment, for example, inclusion of

older people in designing new centres, the centres planned and
constructed with age-friendly features, and renovate older centres to
incorporate age-friendly features.

These centres may be public or private, large or small and offer a range of
services including consultation with doctors, nurses and other health care
workers, laboratory investigation and X-rays, medications, counseling,
treatments, referrals and health education programmes or, as in some
developing countries, only consultation services by volunteer health workers.
They also aims to sensitize and educate workers about the specific needs of their
older clients.

The public healthcare system is seen as an important source of

healthcare services due to the escalating costs in the private sector. And, the
government has sought to strengthen the primary health care infrastructure
through special assistance to regions with more health needs and encouraging
the involvement of voluntary organizations.

Health Care Centres does not favour older people, but instead benefits
all patients & serve as a guide for community-based PHC centers to modify
management and clinical services, staff training and environments to better fit the
needs of their older patients. They recognizes the important influences of earlier
life experiences, gender and culture on how individuals age. It takes into account
the determinants of health to include the behavioural, environmental, social,
economic, biological and psychological processes that operate across all stages
of the life course and determine health and well being in later life. Among these
determinants is life-long access to health care services.

There is an unquestionable lack of adequate healthcare services for

older people in the country. The situation is in a very poor state in the rural and
remote parts. Vast majority of older people in underserved areas are
malnourished, live with a weak immunity and are prone to a wide range of
infectious and chronic diseases.

Concerned with the gravity of the situation, Indian government declared

the National Policy for Older People (NPOP) in 1999 which strongly stresses on
the needs of age-friendly healthcare interventions. Subsequently, efforts have
been made by the government to mobilize resources and partner with various
stakeholders. Nevertheless, desirable progress has not been made in this
regard. Furthermore, geriatric healthcare remains an area of “lack-of-interest”
among healthcare professionals and in medical schooling.
Recommendations to reduce the cost and other barriers to accessing primary
healthcare centres:

National budgets
Develop adequate budgetary allocations for affordable PHC services for older
people, which includes allocations for health promotion, prevention,
management, diagnostics, medicine (both standard and patented), and home
based care.

Income security of older people

Support the introduction and strengthening of cash transfers and other social
protection schemes, which will ensure ability to pay for services

Disaster risk reduction

Develop disaster risk reduction plans that take into account older people (as a
vulnerable group), and ensure older people are included in the planning, design
and implementation of plan.

Recommendations to improve the quality of health care services:

Training and capacity building

Ensure healthcare professionals (including medical doctors, nurses, community
health workers, and traditional practitioners) receive appropriate training in
healthy ageing and geriatrics.
Ensure care-givers receive appropriate training (both formal and informal) on
ageing and elderly care.

Carry-out self-management training (patient education) for older people with

chronic diseases.

PHC facilities
Ensure that health centres are adequately equipped and provide age-friendly
health and social services.

Exchanges
Support the sharing of experiences through exchanges and best practices that
support the overall development of health care services.

Recommendations for improving the integration of health care services

Medical care
Ensure coordination between PHC facilities and other health facilities, such as
hospitals, long-term care providers and specialists.

Ensure coordination with different organizations, such as Older People

Associations, community-based organizations, traditional healers, and insurance
providers.

Develop older people-centred care policies, rather than a disease centered

orientation.

Social services
Introduce and strengthen systems that provide linkages and formal coordination
between various social support services that address day-to-day and
psychosocial needs of older people.

Health professionals need to:

 Ensure they are adequately trained in the palliative care of older people,
including pain and symptom management, communication skills and care
coordination.

 Ensure that older people with palliative care needs are regarded as
individuals, that their right to make decisions about their health and social
care is respected & they receive the unbiased information they need
without experiencing discrimination because of their age.

 Ensure that their organizations work in a coordinated fashion with other

statutory, private or voluntary organizations that may
help older people needing palliative care.

Physiatrist role towards geriatrics:

 Provide a safe and supportive environment for chronically ill and

dependent people.
 Restore and maintain the highest possible level of functional
independence.
 Preserve individual autonomy.
 Maximize quality of life, perceived well-being, and life satisfaction.
 Provide comfort and dignity for terminally ill patients and their loved
ones.
  Stabilize and delay progression, whenever possible, of chronic medical
conditions.
 Prevent acute medical and iatrogenic illnesses and identify and treat

them rapidly when they do occur.

Strategies to Improve the Role of the Geriatric Health Care System :

At present, most of the geriatric outpatient department services are

available at tertiary care hospitals. Most of the government facilities such as day
care centers, old age residential homes, counselling and recreational facilities
are urban based. Since 75% of the elderly reside in rural areas, it is mandatory
that geriatric health care services be made a part of the primary health care
services. This calls for specialized training of Medical Officers in geriatric
medicine. Among the secondary level health facilities, which mainly include the
district hospitals, sub-district, and medium size private hospitals, mostly under
the public sector, it is seen that India has about 12,000 hospitals with 7 lakh beds
with facilities for the elderly people.

The need of the hour is to set up geriatric wards that would fulfill the
specific needs of the geriatric population. At the tertiary care level a multi-
disciplinary team, specifically trained to meet the needs of the geriatric population
need to be created. This team would be comprised of a physician, psychiatrist,
orthopaedician, diabetologist, gynecologist, cardiologist, urologist, eye surgeon,
psychologist, physiotherapist, dietician, dentist, and nurses trained in geriatric
medicine. Last but not the least, capacity building of the community leaders is
essential for the success of community-based geriatric and rehabilitative health
services. Community leaders can play an important role in identifying the felt
needs of the elderly and in resource generation.
Voluntary health Agency

A voluntary health agency is defined as “ an organisation that is administered by

an autonomous board which holds meetings, collects funds for its support,
from private source and expends money with or without, paid workers in
programme directed firstly to further public health by providing health scheme
or education or by advising research or legislation for health or combination
of this activity

Main objectives – health education

• Supplementing work of government agencies

• Pioneering research work or education
• Demonstration
• Guarding the work of national agencies
• Advising health legislation
•
International health organisations
• Major organizations provide long-term health care, the focus shifts to
those that specialize in giving aid to victims of war, famine and natural
disasters
Organizations Providing Long-term Health Care
• International health organizations are usually divided into three groups:
 - multilateral organizations,
- bilateral organizations, and
- non-governmental organizations (NGOs)

Multilateral Agencies :
The term multilateral means that funding comes from multiple governments (as
well as from non-governmental sources) and is distributed to many different
countries.
The major multilateral organizations are all part of the United Nations. The World
Health Organization (WHO) is the premier international health organization
• The principal work of WHO is directing and coordinating international
health activities and supplying technical assistance to countries
• It develops norms and standards, disseminates health information,
promotes research, provides training in international health, collects and
analyzes epidemiologic data, and develops systems for monitoring and
evaluating health programs
Three subsidiary agencies of the UN Economic and Social Council are heavily
committed to international health programs.
• The United Nation Children's Fund (UNICEF)
• The United Nations Population Fund (UNPF)
• United Nations Development Programme (UNDP)

UNICEF :
Spends the majority of its program (non-administrative) budget on health
care. UNICEF makes the world's most vulnerable children its top priority,
so it devotes most of its resources to the poorest countries and to children
younger than 5 years

The United Nations Development Programme (UNDP) :

 is the UN’s global development network, advocating for change and
connecting countries to knowledge, experience and resources to help
people build a better life on the ground in 177 countries and territories,
working with governments and people on their own solutions to global and
national development challenges.
• As they develop local capacity, they draw on the people of UNDP and our
wide range of partners that can bring about results

The Rockefeller Foundation is a prominent philanthropic organization

and private foundation based at 420 Fifth Avenue, New York City. The
preeminent institution established by the six-generation Rockefeller family, it was
founded by John D. Rockefeller ("Senior"), along with his son John D.
Rockefeller, Jr. ("Junior"), and Senior's principal business and philanthropic
advisor, Frederick Taylor Gates, in New York State May 14, 1913, when its
charter was formally accepted by the New York State Legislature. Its central
historical mission is "to promote the well-being of mankind throughout the world.“
Some of its objectives and achievements include:
Financially supported education in the United States "without distinction of race,
sex or creed"
Helped establish the London School of Hygiene and Tropical Medicine in the
United Kingdom;
Established the Johns Hopkins School of Public Health and Harvard School of
Public Health, two of thefirst such institutions in the United States;
Deeloped the vaccine to prevent yellow fever;
Developed and funded various German eugenics programs, including the one
that Josef Mengele worked in before he went toAuschwitz.
Funded the work of dozens of Nobel Laureates
Supported the establishment of a large range of American and international
cultural institutions;
Funded agricultural development to expand food supplies around the world
The International Committee of the Red Cross (ICRC)
is an impartial, neutral and independent organization whose exclusively
humanitarian mission is to protect the lives and dignity of victims of armed
conflict and other situations of violence and to provide them with assistance.
• The ICRC also endeavours to prevent suffering by promoting and
strengthening humanitarian law and universal humanitarian principles
• Established in 1863, the ICRC is at the origin of the Geneva Conventions
and the International Red Cross and Red Crescent Movement.
• It directs and coordinates the international activities conducted by the
Movement in armed conflicts and other situations of violence
 SUMMARY

The health care delivery system are the set of ideas, practices and
organizations which have been developed to deal with problems of health
and illness in the society & aim to meet the health care needs of target
populations.

As elderly are more prone for ill health, yet their health care facility
utilization is poor on account of physical, socioeconomic & psychological
reasons hence the health care system has to gear up to meet the needs of
elderly.

Hence geriatric health care services should be mandatory at all the levels
of the health care delivery system. The need of the hour is to set up
geriatric wards that would fulfill the specific needs of the geriatric
population.

Last but not the least, capacity building of the community leaders is
essential for the success of community-based geriatric and rehabilitative
health services as they play an important role in identifying the felt needs
of the elderly and in resource generation.
 References

Delisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, Geinger SR
et al. Physical Medicine & Rehabilitation: Principles and Practice. 4th ed.
New Jersey: Lippincott Williams & Wilkins; 2005.p.1531- 56

Park K. Preventive And Social Medicine. 18 th ed. Jabalpur: Banarsidas

Bhanot; 2002.p.652-63
Item Item Key References
no
1 Which of the following would be D Park K. Preventive And
considered components of Public Social Medicine
Health Nutrition?

A)Dietary guidelines

B)Nutritional epidemiology

C)Fortification of foods with

vitamins and minerals

D)All of the options listed are

correct

2 International health D Park K. Preventive And

organisations-multilateral does Social Medicine

not Involves:
WHO
UNICEF
UNDP
IRC

3 The UNICEF model of the causes a Park K. Preventive And

of malnutrition identifies several Social Medicine
levels of causes: immediate,
underlying and basic. Which of the
following is not one of the
underlying causes in the UNICEF
model?

A) Insufficient rainfall for

agriculture

B) Inadequate access to food

C) Inadequate care for

mothers and children
 D) Insufficient health services
and unhealthy environment

4 National health programmes d Park K. Preventive And

have been launched by central Social Medicine
govt. for the control/eradication
of
a)communicable diseases,

b)improvement of
environmental sanitation,
nutrition,

c) control of population & rural

health.

d) all of the above

5 Why is family planning important? A Park K. Preventive And
A)For birth control issues Social Medicine
B For having unwanted
pregnancies
C For having child every year
D To get pregnant before the age
of twenty issues