CONCEPTS AND PRINCIPLES OF PUBLIC HEALTH PROGRAMS:

 Over the decades public health is trying to deliver to its best of capacity and has brought
about changes in various health indicators. They are

1) Reduction in child mortality

2) Reduction in vaccine preventable diseases

3) Access to safe water and sanitation

4) Malaria prevention and control

5) Prevention and control of HIV/AIDS

6) TB control

7) Control of neglected tropical diseases

8) Global road safety and awareness

9) tobacco control &

10) Improved preparedness and response to global health threats.

 Public health experts must understand some basic concepts of

a) Health and disease

b) Estimation of disease burden

c) Interpretation of health situation

d) Making community diagnosis

e) Planning

f) Designing on the basis of scientific facts

g) Implementation and evaluation of various preventive and control measures.

 To start with public health we must have baseline statistics about the community.

 So first ……

i. Compare the health status of one community or country with other

ii. Decide on which type of intervention for a disease or a health problem is required

iii. Plan the intervention and then evaluate it for the changes needed for future interventions.

CHALLENGES FOR PUBLIC HEALTH:

1. Poverty:

 Biggest epidemic that global public health community faces

 Underlines most cases of undernutrition

 Fuels the spread of many diseases

  Deepens vulnerability to the effect of illness & trauma

 Based on Tendulkar committee report in 2012, population BPL= 21.9%

 Rural poverty – 25.7%

 Urban poverty – 13.7%

2. Inequity:

 Equity is a value of maintaining fairness or justice.

 Equity issues arises at many levels of the health care system

 Eg. National ministry of health is concerned with fail allocation of budget rupee across
regional health districts and professionals throughout the country.

 Similarly the regional health districts are concerned with fair allocation of primary and
secondary health services between urban and rural population or among other groups such
as women, children, elderly and poor.

3. Public Demands:

 Public demand is also increasing due to increase in population.

 In majority of regions demand for public health services is increasing. But

 There is very little demand for the most vulnerable section of society.

 Increasing demand for health services increases the accountability and responsibility to
community.

4. Marginalizing Public Health Services:

 For a long period the central government policies have neglected public health services.

 Separation of public health engineering from health department has jeopardized the impact
of public health services

 Implementing multi-purpose worker scheme where all male sanitary inspectors are
converted into MSWs and work for small pox, malaria or other priority programs

 Male health workers are not appointed and most of the work is entrusted to ASHA focusing
on RCH

 Once again public health issues such as water, sanitation, nutrition, transport are neglected.

5. Public health delivery:

 Major concerns in public health delivery are equality, secularism, freedom, justice and
dignity of an individual.

 Health services should be of quality.

 The delivery system faces challenges in the following areas.

 Health sector reform/ NGO, PPP

  Issues of decentralization of health care

 Appropriate use of health information technology

 Quality assurance

 Ethical issues and public health laws

 Cost effective intervention and health economics

 Dealing with limited resources/ mobilizing resources

 Standardization and accreditation of public health

 Medical education and services.

 Outreach and referral services through

6. Epidemiological transition:

 Patterns of mortality are shifting from a high burden of infectious disease to an increase in
chronic degenerative diseases.

 Morbidity patterns are also showing a similar increase in non-fatal but disabling conditions.

 This is called epidemiological transition

 Major issues of ET concerned with public health

 Emerging and reemerging diseases

 Rapid industrialization, environmental pollution and health impact assessment.

6. Epidemiological transition:

 Patterns of mortality are shifting from a high burden of infectious disease to an increase in
chronic degenerative diseases.

 Morbidity patterns are also showing a similar increase in non-fatal but disabling conditions.

 This is called epidemiological transition

 Major issues of ET concerned with public health

 Emerging and reemerging diseases

 Rapid industrialization, environmental pollution and health impact assessment.

 Immunization

 Preventive health check ups

 Specific food interventions

 Use of highly developed curative technology.

 Some developing countries are experiencing triple burden of disease.

i. One which is caused by communicable diseases, maternal and perinatal diseases

 ii. Second is adopting lifestyles similar to the people of the developed world leading to
diabetes, cardiovascular diseases etc and

iii. Third is population, poverty, poor water supply and sanitation and low standard of livings

7. Climatic change and Environmental Health:

 Climatic change leading to global warming is a big challenge for public health. The causes are

 Continuous industrialization

 Urbanization

 Changing lifestyle pressing energy consumption.

 Global warming leads to human and environmental calamities such as

 Flood

 Earthquake

 Cyclones

 Raising sea levels etc

 These changes have impact on epidemiology of vector borne and other diseases

 United states interagency working on climate change has identified at least 11 categories of
diseases due to climate change

 Asthma and respiratory diseases

 Cancer

 Cardiovascular diseases and stroke

 Food borne diseases and nutrition

 Human development effects

 Mental health and stress related disorders

 Neurological diseases

 Vector borne and zoonotic diseases

 Water borne diseases

 Water related morbidity and mortality.

 The wildlife conservation society has identified 12 pathogens that could spread into new
region due to climate change.

 Avian flu

 Tuberculosis

 Ebola virus

 Cholera
  Babesiosis

 Parasites

 Lyme disease

 Plague

 Rift valley fever

 Sleeping sickness

 Yellow fever

 Red tides (algal blooms)

9. New psychosocial issues:

 Are a result of

 changes in life style

 Acculturation

 Globalization

 Industrialization and

 Social values.

 They result is varied issues which are a challenge to PH, such as

 Social pathology, eg. Substance abuse, violence, suicide

 Gender sensitive services: health services should be equitable and more focus towards
female gender.

 Behavioral change:

 Stress related diseases

 Gender sensitive services focusing more towards female

 Health programs should be culture specific

10. Rapid population growth:

 Leads to scarcity of resources and limited training facilities in developing countries resulting
in challenge for health care service delivery.

Newer Challenges:

1. User fees & the denial of access to essential health care:

i. Proponents of user charges argue that this will increase efficiency, equity, quality and
sustainability.

ii. Its justified as a revenue generated to improve the financial sustainability of health care
service delivery.
 iii. Influences consumer behavior and controls demand for hospital services.

iv. Its necessary to improve the quality of health care services through availability of drugs and
supplies.

Criticism:

i. Effect of health care reform was promotion of greater privatization of health care financing
including out of pocket payments for health care in public sector, to offset reduced level of
public expenditure.

ii. Passive privatization lead to growth in user charges.

iii. Impact of transferring health care financing to households has been disastrous for poor.

o This has Deterred people from accessing health care resulting in untreated sickness and
avoidable death

o User fees Discouraged people from taking full dosage of their medication eg. Anti-retroviral
treatment and increase the risk of drug resistance.

iii. User fees generates poverty& deepens already existing poverty.

o Households cut down on their food consumption, sell off precious assets, withdraw children
from school

o User fees are a major & widespread barrier to essential health care and a cause for long-
term impoverishment.

2. Segmentation of health care system:

I. Providing separate health care for systems for rich & poor as opposed to universal health
care system.

II. World bank advocates govt of poorer countries direct their

o scarce resources in providing basic preventive and curative services to poor and withdraw
direct provision of other services.

o Encourage relatively rich sections of society to use private sector.

o iii. Tax breaks on private insurance to entice higher-income groups & keep them away from
public health care services

o iv. Health care system in India encourages private providers to foreign medical tourist from
high income countries or high income groups. Results in increased inequality as middle class
opt out of public sector.

o v. Public sector is taken as “ poor service for poor people”.

o vi. Segmentation is attractive to private investors where there is enough rich and upper
middle class market to sustain the development & financing of private health sector.

v. Rising level of Private insurance & corporate investments.

 Govts come under pressure to from private sector & trade related policies to break up
universal social security funds & to open the market for foreign investments.
  Some health care providers who profit from the privileged and better resourced market will
challenge any reforms aimed at universalization of health care system.

 They claim of reduced standards of care & invoke the rights of individuals to the best care
they can afford.

 It is common that private companies dump their patients arbitrarily onto the public sector
when their health care costs become too great.

3. The commercialization of health care:

 The collapse of Public health sector has lead to the emergence of private sector which is
disorganized, unregulated and chaotic particularly at the primary level of care.

 The incapacity of public services has lead to the relying on NGO S, UN agencies, charities,
religious groups & humanitarian organizations.

 Private care is clearly associated with profit, exploitation & preferential service.

 This results in inefficient, inequitable, poor quality care & over-servicing.

 Reasons why market driven health care does not promote efficiency or quality…..

 Patients do not have enough knowledge to make informed choices about……

 Relative quality/merits of different health care providers

 Not able to be assertive enough to negotiate price and quality esp during emergency.

 When illiteracy and poverty are prevalent.

 Most people do not want choice but assurance that their local accessible provider will
provide good quality care. Instead, commercialization eats away patient- provider trust.

 Competition results in duplication and inequity as for profit providers gravitate towards
affluent population.

 Market based system with multiple independent providers are a barrier to developing public
health instruments such as disease surveillance system.

 Competition results in duplication and inequity….HOW????

 Because for profit, providers gravitate towards affluent populations.

 Competition harms collaboration between different providers, often an important ingredient

of good quality healthcare. Eg….

• In china competition between the public sector harmed the intr-provider cooperation
necessary for effective disease surveillance.

 Market based system with multiple independent providers pose barriers to developing
important public health instruments such as disease surveillance system.

 Commercialized healthcare systems often have significant transaction costs along with trying
to regulate the market.

 4. Vertical programming:
 Vertical programs means separate health structures with strong central management
dedicated to planning, management and implementation.

 Interventions are selective partly because of a lack of adequate healthcare infrastructure

and

 partly because it often reflects a scientific and biomedical orientation that emphasizes the
delivery of ‘medical technologies’ amenable to vertical programs.

 Eg. Small pox was eradicated through a concentrated global effort.

 It is argued that diarrhoeal disease, malaria, HIV, TB, Leprosy, Polio and other communicable
diseases can be tackled in a similar way.

 But there are questions on the appropriateness of certain technologies.

 Eg. Biomedical orientation results in the promotion of manufactured oral rehydration salts
rather than more appropriate & accessible rehydration fluids that could be prepared locally.

 Vertical programs can lead to de-skilling of primary health workers…How???

 Their focus narrows to achieving selected targets rather than addressing the immediate and
pressing needs of sick people when they present to healthcare services.

 For eg. Thousands of Family planning volunteers have been deployed in many countries but
many opportunities to promote health were lost because….

 Their training focused on the single technical issue of contraception & did not include the
other elements of community health promotion, such as Nutrition and Hygiene education.

 Vertically organized health services are inconvenient to service users…why??

 The need to make several visits to access different services constitutes a significant barrier to
access.

 Eg..pulse polio mass immunization campaigns have often been prioritized t an extent that
other services have disrupted and long erm development of sustainable routine
immunization services hindered.

 In many countries immunization coverage rate are stagnant or declining.

 In others, the reduction in child mortality have slowed down.

 Narrow, selective and disease based programs are not inherently bad or always influenced
by commercial consideration.

 For some health intervention vertical and centralized approach may be entirely appropriate.
Eg. Vector control for malaria, acute disease outbreak.

 World bank proposes that only the vertical package should qualify for public – funding
services. Anything outside the package is deemed not cost effective. So they have to be OOP
expenditure or insurance.

 5. Public sector failure:

 The root cause of the failure of public health sector are

  Illegitimate and corrupt governments that steal from the public purse

 Governments that practice and tolerate human right abuses

 Allocation of inappropriately high budgets to the military or to projects that benefit the
elites of the society.

 Undemocratic conditions link with public health failure such as

 Richer countries or institutions endorse and support corrupt governments and in return they
do arms trade.

 Western governments paying bribes for getting clearance from local governments.

 Some research suggests an independent positive association between health & democracy,
political rights & civil liberties.

 Bureaucratic Failures:

 Rigid civil service rules and regulations combined with poor management and leadership can
impair….

 Innovation, efficiency and community responsiveness

 Civil servants can bend rules to serve personal needs

 Govt health department have vast responsibilities and varied challenges.

 They cannot function without a minimum degree of management and administrative

capacity and competence at all levels of healthcare system

 The donors and international agencies influence the functioning of ministries of health
enormously in developing countries.

INVESTMENT IN HEALTH:

 Higher labour productivity:

 Healthier workers are more productive

 Earn higher wages

 Miss fewer days of work than those who are ill

 Higher rates of domestic and foreign investments:

 Increase LP increase incentive for investment

 Controlling endemic and epidemic diseases like HIV/AIDS encourages foreign investments.

 Improved human capital:

 Healthy children better cognitive potential

 Rates of absenteeism and early drop outs falls

 Children learn better leading to…

 Growth in human capital base.

 Higher rates of national savings:

 Healthy people have more resources to devote to savings

 People who live long save for retirement

 These savings in turn provides funds for capital investment.

 Demographic changes:

 Improvements in health and education contributes to lower rates of fertility and mortality.