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MBAHCS Semester 3 MH0051 Health Administration (4 Credits) (Book ID: B1212) Assignment Set- 1 (Marks 60)

Note: Each question carries 10 Marks. Answer all the questions. Q.1 Explain healthcare delivery system in India and its functions in detail. [10 Marks] Answer: In India Healthcare Delivery system is represented by five major sectors or agencies that differ from each other by the health technology applied and by the source of funds for operation. Public sector Primary Healthcare Primary health centers Sub-centers Hospital/health centers Community health centers Rural Hospitals District hospitals/health centers Specialist hospitals Teaching hospitals Health Insurance Scheme Employees state insurance Central government health scheme Other agencies Defence services Railways Private sector

Private hospitals, polyclinics, nursing homes, dispensaries General practitioners Indigenous systems of medicine Ayurveda & Siddha Unani Homeopathy Unregistered Practitioners Voluntary health agencies Jan Aakansha Shiksha Give India The Art of Living Foundation Vision Age India People Institute for Development and Training (PIDT) Child Line India Foundation Provision for Recognition, Education, Rejuvenation, and Awareness Generation for Needy Anonymous (PRERANA) Action for Development of Human and Rural Neglected Areas (ADHARANA) Seva Bharti Mandal Voluntary Health Association of India (VHAI) Savera Samaj Kalyan Sansthan, etc. National health programs Major Programs National AIDS Control Program National Cancer Control Program National Diarrheal Disease Control Program National Filaria Control Program* National Family Welfare Program National Iodine Deficiency Disorders Control Program National Leprosy Eradication Program National Malaria Eradication Program* National Program for Control of Blindness & Visual Impairment National Reproductive and Child Health Program National Program for Surveillance Program for Communicable Diseases

National Tuberculosis Control Program Minor Programs National Mental Health Program National Japanese Encephalitis Control Program National Diabetes Control Program National Kala-azar Control Program National Water Supply and Sanitation Program (*Programs are merged into National Vector Borne Control Program since 2003-04) Core functions of healthcare delivery system in India are as follows: Monitoring health situation Disease surveillance Health promotion Regulations Partnerships Planning & Policies Human Resource Development Reducing impact of emergencies on health 1 Growing population and economy One driver of growth in the healthcare sector is Indias booming population, currently 1.1 billion and increasing at a rate of 2 percent per annum. By 2030, India is expected to surpass China as the worlds most populous nation. By 2050, the population is projected to reach 1.6 billion. This population increase is due in part to a decline in infant mortality, the result of improved healthcare facilities and the governments emphasis on eradicating diseases such as hepatitis and polio among infants. In addition, life expectancy is rapidly approaching the levels of the western world. By 2025, an estimated 189 million Indians will be at least 60 years of age triple the number in 2004, thanks to greater affluence and better hygiene. The growing elderly population will place an enormous burden on Indias healthcare infrastructure. The Indian economy, estimated at roughly $1 trillion, is growing in tandem with the population. Goldman Sachs predicts that the Indian economy will expand by at least 5 percent annually for the next 45 years, and that it will be the only emerging economy to maintain such a robust pace of growth. Population growth and its relation to economic growth has been a matter of debate for over a century. The

early Malthusian view was that population growth is likely to impede economic growth because it will put pressure on the available resources, result in reduction in per capita income and resources; this, in turn, will result in deterioration in quality of life. Following are the adverse effects of population growth on the Indian Economy: adverse effects on savings unproductive investment slow growth of Per Capita Income underutilization of labour growing pressure on land adverse effect on quality of population and adverse social impact. 2 Expanding middle class India traditionally has been a rural, agrarian economy. Nearly three quarters of the population still lives in rural areas, and as of 2004, an estimated 27.5 percent of Indians were living below the national poverty line. Some 300 million people in India live on less than a dollar a day, and more than 50 percent of all children are malnourished. However, Indias thriving economy is driving urbanization and creating an expanding middle class, with more disposable income to spend on healthcare. While per capita income was $620 in 2005, over 150 million Indians have annual incomes of more than $1,000, and many who work in the business services sector earn as much as $20,000 a year. While this is a fraction of the income that their US peers earn, it is the equivalent of more than $100,000 per year when adjusted for purchasing power parity. More women are entering the workforce as well, further boosting the purchasing power of Indian households. Between 1991 and 2001, the percentage of women increased from 22 percent to 26 percent of the total workforce, according to the latest Indian government census. Many of these women are highly educated: the ratio of women to men who have a college degree or higher level of education is 40:60. Today at least 50 million Indians can afford to buy Western medicines a market only 20 percent smaller than that of the United Kingdom. If the economy continues to grow faster than the economies of the developed world, and the literacy rate keeps rising, much of western and southern India will be middle class by 2020.

3 Rise of diseases Another factor driving the growth of Indias healthcare sector is a rise in both infectious and chronic degenerative diseases. While ailments such as poliomyelitis, leprosy, and neonatal tetanus will soon be eliminated, some communicable diseases once thought to be under control, such as dengue fever, viral hepatitis, tuberculosis, malaria, and pneumonia, have returned in force or have developed a stubborn resistance to drugs. This troubling trend can be attributed in part to substandard housing, inadequate water, sewage and waste management systems, a crumbling public health infrastructure, and increased air travel. In addition to battling infectious diseases, India is grappling with the emergence of diseases such as AIDS as well as food-and water-borne illnesses. And as Indians live more affluent lives and adopt unhealthy western diets that are high in fat and sugar, the country is experiencing a rise in lifestyle diseases such as hypertension, cancer, and diabetes, which is reaching epidemic proportions. 4 Deteriorating infrastructure Indias healthcare infrastructure has not kept pace with the economys growth. The physical infrastructure is woefully inadequate to meet todays healthcare demands, much less tomorrows. While India has several centers of excellence in healthcare delivery, these facilities are limited in their ability to drive healthcare standards because of the poor condition of the infrastructure in the vast majority of the country. Of the 15,393 hospitals in India in 2002, roughly two-thirds were public. After years of under-funding, most public health facilities provide only basic care. With a few exceptions, such as the All India Institute of Medical Studies (AIIMS), public health facilities are inefficient, inadequately managed and staffed, and have poorly maintained medical equipment. The number of public health facilities also is inadequate. For instance, India needs 74,150 community health centers per million population but has less than half that number. In addition, at least 11 Indian states do not have laboratories for testing drugs, and more than half of existing laboratories are not properly equipped or staffed. The principal responsibility for public health funding lies with the state governments, which provide about 80 percent of public funding. The federal government contributes another 15 percent, mostly through national health programs and the rest of the 5 percent comes from the individual donations, charity funds and non-governmental organisations.

Q.2. Explain National Health Policy 2002 in detail. Also mention its aims and objectives. [10 Marks] Answer: The main objective of the revised National Health Policy, 2002 is to achieve an acceptable standard of good health among the general population of the country and has set goals to be achieved by the year 2015. The major policy prescriptions were as follows: Increase public expenditure from 0.9 percent to 2 percent by 2010. Increase allocation of public health investment in the order of 55 percent for the primary health sector; 35 percent and 10 percent to secondary and tertiary sectors respectively. Gradual convergence of all health programmes, except the ones (such as TB, Malaria, HIV/AIDS, RCH), which need to be continued till moderate levels of prevalence are reached. Need to levy user charges for certain secondary and tertiary public health services, for those who can afford to pay. Mandatory two year rural posting before awarding the graduate medical degree. Decentralizing the implementation of health programmes to local self governing bodies by 2005. Setting up of Medical Grants Commission for funding new Government Medical and Dental colleges. Promoting public health discipline. Establishing two-tier urban healthcare system Primary Health Centre for a population of one lakh and Government General Hospital. Increase in Government funded health research to a level of 2 percent of the total health spending by 2010. Appreciation of the role of private sector in health, and enactment of legislation by 2003 for regulating private clinical establishments. Formulation of procedures for accreditation of public and private health facilities. Co-option of NGOs in national disease control programmes. Promotion of tele-medicine in tertiary healthcare sector. Full operationalisation of National Disease Surveillance Network by 2005. Notification of contemporary code of medical ethics by Medical Council of India.

Encouraging setting up of private insurance instruments to bring secondary and tertiary sectors into its purview. Promotion of medical services for overseas users. Encouragement and promotion of Indian System of Medicine. The National Health Policy (NHP) of 1983 was revisited by the Government of India in 2002. The revisited policy reiterates to achieve an acceptable standard of good health amongst the general population of the country. The precise approach of the stated policy is to increase the access to decentralized public health system, ensure equitable access, increase the public health investment through contribution of central government, to enhance the contribution of NGO and private sector in health, to regulate the services of private and public sector, to initiate user charges and above all strengthen the delivery of primary health care in public sector. The policy has set time bound goals for identified national problems of malaria, tuberculosis, blindness, gastroenteritis, cholera and water vector borne diseases, leprosy, HIV/AIDS etc. The national health policy also identifies the other public health problems of concern such as trauma and accidents, macro and micro nutrient deficiencies, life style diseases and problems of aged to be tackled through efforts. Comparative differences The first National Health Policy framed in 1983 gave a general exposition of the policies which necessitated recommendation in the conditions then prevailing in the countrys health sector. The notable initiatives under that policy were as follows: 1. A phased, time-bound programme for setting up a well-dispersed network of Comprehensive Primary Health care services, associated with extension and health education, projected in the context of the ground reality that elementary health problems can be settled by the people themselves; 2. Intermediation through Health volunteers having suitable knowledge, simple skills and needed technologies; 3. Establishment of a well-worked out referral system to make certain that patient load at the higher levels of the hierarchy is not unnecessarily burdened by those who can be treated at the decentralized level; 4. An integrated network of evenly spread speciality and super-speciality services; encouragement of such facilities through private investments for patients who can pay, so that the draw on the Governments facilities is limited to those entitled to free use of those services.

Government initiatives in the pubic health sector have showed some remarkable successes over time. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can be expected to be eliminated in the foreseeable future. There has been a substantial drop in the Total Fertility Rate and Infant Mortality Rate. The success of the initiatives taken in the public health field are reflected in the progressive improvement of many demographic/epidemiological/infrastructural indicators over time (Table ). Table : Achievements through the Years 1951-2000

RGI: Registrar General of India; SRS: Sample Registration System; SC: Sub Centers; PHC: Primary Health Center; CHC: Community Health Center; RHS: Rural Health Statistics; CBHI: Central Bureau of Health Intelligence; MCI: Medical Council of India; INC: Indian Nursing Council. In India, there is no regular system for collecting data on non-communicable diseases (NCDs)-which can be said to be of adequate coverage or quality.

Thus, most of these estimates at best may be taken as approximation only. According to SRS-1998 estimates NCDs are responsible for 32% of all deaths in the country. Of these, cardiovascular diseases constituted 13%, injuries 8.7% and chronic respiratory diseases 6.7%. Cancers with 3.4% and diabetes with 0.2% were the other contributors. Rheumatic heart disease (RHD) is prevalent in the range of 5 to 7/1000 in the 5 to 15 years agegroup. RHD constitutes 20% to 30% of hospital admission due to all cardiovascular diseases (CVD) in India.

Q.3. Explain in detail the types of epidemiological studies. [10 Marks] Answer: Epidemiology is the study of diseases in large number of humans or other animals, in particular how, when and where they occur. Epidemiologists endeavor to determine what factors are related with diseases (risk factors), and what factors may protect people or animals against disease (protective factors). The science of epidemiology was first developed to discover and understand possible causes of contagious diseases like smallpox, typhoid and polio among humans. It has expanded to include the study of factors associated with non-transmissible diseases like cancer, and of poisonings caused by environmental agents. Types of Epidemiological Studies (Observational and Experimental) Epidemiological studies can be divided into two basic types depending on (a) whether the events have already happened (retrospective) or (b) whether the events may happen in the future (prospective). The most common studies are the retrospective studies which are also called casecontrol studies. A case-control study may begin when an outbreak of disease is noted and the causes of the disease are not known, or the disease is unusual within the population studied. The first step in an epidemiological study is to strictly define exactly what requirements must be met in order to classify someone as a "case." This seems relatively easy, and often is in instances where the outcome is either there or not there (a person is dead or alive). The strength of an epidemiological study depends on the number of cases and controls included in the study. The more individual cases that are included in the study, the more likely it is that a significant association will be found between the

disease and a risk factor. Just as important is determining what behavioral, environmental, and health factors will actually be studied as possible risk or protective factors. If inappropriate factors are chosen, and the real factors are missed, the study will not provide any useful information. Please see the pictorial representation of the different types of epidemiological studies in Figure.

1 Observational studies In observational studies, the epidemiologist does not assign a treatment but rather observes. For example, if the epidemiologist wanted to see if smoking is related to lung cancer, she would not be able to ethically assign people to smoke and not smoke, but rather would observe the prevalence of who (smokers vs. non) develops cancer. Case control studies The "why me?" study investigates the prior exposure of individuals with a particular health condition and those without it to infer why certain subjects, the "cases," become ill and others, the "controls," do not. The main advantage of the case-control study is that it enables us to study rare health outcomes without having to follow thousands of people, and is therefore generally quicker, cheaper and easier to conduct than the cohort study. Cohort studies The "What will happen to me?" study follows a group of healthy people with different levels of exposure and assesses what happens to their health over time. It is a desirable design because exposure precedes the health outcome a condition necessary for causation and is less subject to bias because exposure is evaluated before the health status is known. The cohort study is also expensive, timeconsuming and the most logistically difficult of all the studies. It is most useful for relatively common diseases. To assess suitability, we find out the commonality of the disease we wish to study.

2 Experimental studies In experimental studies, the epidemiologist assigns subjects treatments. This is in contrast to the observational study, where the researcher observes subjects and, in a sense, 'waits' for the 'treatment' or results to happen. The hallmark of the experimental study is that the allocation or assignment of individuals is under control of investigator and thus can be randomized. The key is that the investigator controls the assignment of the exposure or of the treatment but otherwise symmetry of potential unknown confounders is maintained through randomization. Properly executed experimental studies provide the strongest empirical evidence. The randomization also provides a better foundation for statistical procedures than do observational studies. One type of experimental study is the Randomized Control Trial.

Q4. Write short notes on the following:

i. ii.

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

Answer: i. Communicable disease problem in India. : A number of endemic communicable diseases present a serious public health hazard in India. Over the years, the government has set up a variety of national programs aimed at controlling or eradicating these diseases, including the National Malaria Eradication Programme and the National Filaria Control Programme. Other initiatives seek to limit the incidence of respiratory infections, cholera, diarroheal diseases, trachoma, goiter, and sexually transmitted diseases. Smallpox, formerly a significant source of mortality, was eradicated as part of the worldwide effort to eliminate that disease. India was declared smallpox-free in 1975.
Malaria remains a serious health hazard; although the incidence of the disease declined sharply in the post-independence period, India remains one of the most heavily malarial countries in the world. Only the Himalaya region above 1,500 meters is spared. In 1965 government sources registered only 150,000 cases, a notable drop from the 75 million cases in the early post-independence years. This success Complete answer after payment, for details visit