History of public health in developing countries

Framework

• Introduction • Public Health in India• History of services in India• History of legislation act• History of health education• Public Health in China• Comparison in health systems in China and India

Public health

“the science and art of preventing disease, prolonging life and promoting health and efficiency

through organized community effort”CEA Winslow (1920)

Public health in India

• Ancient public health• During colonial period• During post independence• Comparison between 1st and 12th five year plan• History of legislative act• History of evolution of health education

Ancient public healthIndian system of medicine

• Indus valley civilisation (3500BC to 1500 BC)

• First Urban sanitation systems

• Knowledge of dentistry

• Vedic times: Ayurveda originated

• Purity and cleanliness central to Indian medicine (Manu

samhita)

• Charaka has described the objective of medicine as two

fold; preservation of good health and combating disease.

• Post Vedic times• Ayurveda continued• Dominated by Buddhist and Jain teachings• Surgery suffered a setback• Institutional setup was strengthened• Hospital system was established: Ashokan

inscriptions• Fa Hsien (337–422 AD) described the institutional

approach of Indian medicine• Medical education in Universities• Reached a peak during Gupta times (300-700 AD)

Public Health during the Colonial Period• 1600- first medical officer arrived in India

• 1760s: Indian Medical Service

• 1785: Medical colleges established

• 1869: public health commissioner and statistical officer to GOI

• 1873: Birth and Death registration act

• 1904: Plague commission

• AIIHPH, Haffkine Institute, Malaria Institute

• 1911: Indian Research Fund Association

• Infectious diseases rampant

• Undermining of the Indigenous systems

• 1938: NPC subcommittee (Sokhey committee)

• 1946: Bhore committee report

• Integration of preventive and curative services

• Provision of health centres

• Setting up of central institutes

• Medicalisation of health

• 1860s and 1870s, Dr. James L. Bryden, India's first epidemiologist

• G.A. Hansen's discovery in 1873 that leprosy is spread by contact, H.V. Carter of the Bengal Medical Department gained an authority over leprosy control in India

• 1897- Sir Ronald Ross demonstrated the life cycle of the malarial parasite stating that anopheles mosquitoes carried the protozoan parasites called “plasmodia”

• Evolution of public health system during the colonial period followed the same path that was followed in Britain.• Public health efforts were focused largely on

protecting British civilians and army cantonments.• Sanitation was given the top priority.• Focus was also on early detection and control of

contagious diseases – cholera and plague.

• Training and research Institutions in public health.• Public health legislation.• Sanitary departments• Ascertaining local sanitary conditions.• Vital registration.• Monitoring disease trends.• Vaccination program.• Technical advice on control of epidemics.

• Restriction of public health efforts to British civilians and military established was a major constraint.• Majority of Indian masses remained deprived of

the dividends of these efforts.• At the time of Independence only 3 per cent

households in India had toilets.• Water, drainage and waste disposal services

were utterly lacking

• Although, public health efforts were restricted to British civilian and military establishment, they had impact on Indian masses.• Mortality spikes were sharply reduced.• Mortality from cholera and plague was sharply

reduced.• Diseases like malaria and gastro-enteritis

continued to take heavy

Public Health in Independent India

• Evolution of public health care system in Independent India was shaped by two important factors:• The Report of First Health Survey and

Development Committee (Bhore Committee) constituted during the colonial rule.• Emergence of modern medical technology for

the prevention and control of diseases, especially communicable diseases.

Bhore Committee

• Appointed in 1946.• Recommended comprehensive remodeling of

health services.• Integration of preventive and curative health

services at all levels.• Hospital-based health care system.• Development of primary health centres in two

stages.• Training in Preventive and Social Medicine.

• The short-term plan• A PHC for every 40000 population.• PHC to be manned by 2 doctors, 4 PHN, 4

Midwife, 1 Nurse, and others.• The long-term plan• A primary health unit for every 10-20 thousand

population with 75 beds.• Secondary unit with 650 bedded hospital.• District unit with 2500 bedded hospital.

Medical Technology

• Mass production of antibiotics.• Availability of vaccines for diseases having high

mortality and disability rates• Tetanus• Diphtheria• Pertussis (Whooping Cough)• Measles• Poliomyelitis

Public Health in Independent India

• The recommendations of Bhore Committee and the availability of preventive and curative medical technology resulted in the evolution of hospital-based public health system.• The public health arrangements created during

the colonial period were replaced by hospitals and health centres.• Public health services were merged with the

medical services.

• Bhore Committees recommendations were accepted only partially.• One primary health centre for every 30

thousand population.• Only 6 beds in each primary health centre.• Only one doctor.• Truncated paramedical staff.

• The situation has remained largely unchanged.

• Since Bhore Committee, numerous committees were constituted to evolve the public health system.• Some of the recommendations of these

committees were adopted; some were not by the government.• All committees retained the core of the model

recommended by the Bhore Committee.

1948: India joins WHO, ESI act

1951: first five year plan, BCG vaccination launched

1953: National Malaria control program

1954: National Leprosy control program

1955: National Filaria control program

1961: Mudaliar Committee

1975: Last Smallpox case reported

1978: Alma Ata declaration

1983: National Health Policy approved

1990s: Economic liberalisation

Government spending fell from 1.3% to 0.9% (of

GDP)

DOTS pilot project, RCH launched

Beginning of ‘public-private partnerships’

1994: Surat epidemic

2000: Signatory to UN milleniam declarationIndia ranks 128 in HDI, malnutrition persistsPublic health found to be

Too disease orientedToo program orientedlacking in multidisciplinary approach

2002: National Health Policy launched2003: Tobacco Control legislation2005:

RCH IINRHM and JSY

Increasing realization of need for inter-sectoral coordination

2008: national urban health mission Non-communicable disease Program2011: Geriatric Health program launchedPublic health foundation of India (PHFI)

Comparison between 1st and 12th five year plan• 1st five year plan:• Conditions during previous year and health manpower• Program with priorities formed:• Provision of water supply & sanitation• Control of malaria• Preventive health care of rural population• Health services for mother & children• Self sufficiency in drugs• Family planning & population control

•

• 12 th five year plan:• Strengthen initiatives to expand the reach of health care &

work towards objective of establishing system of universal health coverage in country

• Outcome indicators• Focus areas :

access to services• Special services• Representation in community fora• Training

Legislation• An Indian Expert Committee on Public Health System in1996

recommended development of a contemporary national health policy, a modern Public Health Act, development of a career track for public health professionals ,and establishment of regional schools of public health

• The Government of India Act 1935 gave further autonomy to provincial governments.

• In 1937, the Central Advisory Board of Health was set up with the Public Health Commissioner as secretary to coordinate the public health activities in the country.

• In 1939, the Madras Public Health Act• In 1873, the Birth and Death Registration act

• In 1881, the first Indian Factories Act was passed and the first all-India census

• The Epidemic Diseases Act was passed in 1897 • The government of India passed the All-India Leprosy Act in

1898

HISTORY AND EVOLUTION OF HEALTH EDUCATION• Establishment of the Calcutta Medical College 1835• Two-year course for training of Hospital Assistants 1846• Establishment of Calcutta, Bombay and Madras Universities 1857• Establishment of the Indian Medical Services 1896• New department for education and health 1912• Transfer of public health, sanitation, and vital statistics to the

provinces 1919• Establishment of the School of Tropical Medicine, Kolkata 1922• Establishment of the All India Institute of Hygiene and Public

Health, Kolkata 1932• Establishment of the Medical Council of India 1934• The Health Survey and Development (Bhore) Committee 1946• Report of the WHO Expert Committee on Professional and

Technical Education of medical and ancillary personnel 1952

• 1st World Medical Education Conference 1953• Medical Education Conference in India 1955• Indian Public Health Association 1956• The Mudaliar Committee 1959• Medical Education Committee 1960• 2nd Medical Education Conference 1968• Indian Association of Preventive and Social Medicine 1974• Report of the group on Medical Education and Support

Manpower (Shrivastava Committee Report) 1975• Re-orientation of Medical Education Scheme 1977• National Institute of Health and Family Welfare 1977• The Medical Education Review Committee 1983• The Health Manpower Planning, Production and Management

1987

• Expert Committee on Public Health System 1996• Calcutta Declaration 1999• Task Force on Medical Education 2005• Public Health Foundation of India 2006• Initiation of Post Graduate Diploma in Public Health

Management 2008• Public Health Education and Research Consortium 2009• India Public Health Education Institution Network 2010

Public health in china

Before eighteenth century

• The Yellow Emperor’ s Canon Medicine • Disease involves two aspects: pathogen and

body resistance.• Holistic health: regular life, a proper diet, an

appropriate exercise, harmony in mental and emotional activities

Eighteenth- nineteeth century

• Book on epidemic febrile diseases

• Experience of diagnosing and treating

• Western(modern) medicine into China in 1830s,

by Christian missionaries

the Twentieth Century

• The western medical hospital in China, represented by Peking Union Medical College Hospital • The first Department of Public Health within PUMC in

1921, by Dr. John B. Grant, who was the Far-East representative of RF• A model of health-care community in Ding County,

Hebei province, as an educational field of department of PH in 1928• An early example of primary health care system was

established in Ding county during 1932-1937 by Prof. Chen Zhi-qian

• The rapid development of public health in China reform and open policy development of science and technology and

education the primary health care in China international collaboration• Established and perfected health three-tiered

network • Strengthened maternal and child health • Expanded program immunization • 2004- china CDC

• Coping the public health system of the former Soviet Union in 1950s• Setting up an anti-epidemic system in 1950s• Separate public health school from clinical

medicine in 1950s• Forming Patriotic Health Campaign, established

PHC • Barefoot doctor system in rural areas in 1960s• Red cross clinic system in urban areas in 1960s

Period Indicators China India

Late 1940s to early 1980s

Strategies or policies

Priority given to preventive care and health education

Priority given to curative care

Providers or entities

Completely publicly owned; CMS delivers care in rural areas; a three-tiered system is established

Public and private providers coexist; a three-tiered system is established

Health gains Substantial Moderate

Early 1980s to early 2000sP

Disease trend Chronic diseases replace infectious diseases as top causes of death; aging population

Infectious disease remains the top cause of death; HIV/AIDS spreads aggressively

Period Indicators China India

Early 1980s to early 2000sP

Providers or entities

CMS collapses; emerging privatization

Further privatization; PHCs suffer a seback

Early 2000s to present

Policy context Health system reform

No clear action

• India and China, the most populous countries in the world, are experiencing rapid economic development and modernization. Both countries have made great strides in public health education systems over the past several decades

• India’s public health situation is currently much worse than China’s, with higher infant and maternal mortality and limited expenditure on health .

• India suffers from excess mortality and morbidity from preventable communicable and non-communicable diseases.

• Its infrastructure lacks trained public health personnel and its public health education model, based in medical schools, is inadequate to meet the needs of the country.

• Issues for consideration include the establishment of independent schools of public health, separate from medical institutions, with multidisciplinary faculty and a student body with both undergraduate and postgraduate training capacities.

• China’s public health status is far stronger than India’s and it has benefitted from the universal system developed with barefoot doctors and universal health coverage systems in the last half of the 20th century.

• However, the current situation also requires schools of public health achieving recognized international standards to provide the leadership, research and advocacy necessary to meet the new challenges of public health in a rapidly changing society.

References • M. Harrison, Public Health in British India: Anglo-Indian

Preventive Medicine 1859-1914. Cambridge: Cambridge University Press; 1994

• Monica Das Gupta (2005). ‘Public Health in India Dangerous Neglect’. Economic and Political Weekly December 3, 2005

• World Health Organization: The world health report 2000 Health systems: improving performance Geneva: World Health Organization 2000

• Than S and Uton MR: The history and development of public health in developing countries In Oxford Textbook of Public Health Fourth edition. Edited by: Detels R. Oxford: Oxford University Press; 2002:39-62.

• Than S and Uton MR: The development of discipline of public health in countries in economic transition In Oxford Textbook of Public Health Fourth edition. Edited by: Detels R. Oxford: Oxford University Press; 2002:39-62.

• History and Evolution of Public Health Education in India Himanshu Negandhi1, Kavya Sharma2, *Sanjay P. Zodpey Indian Journal of Public Health, Volume 56, Issue 1, January-March, 2012

• Public Health in British India: A Brief Account of the History of Medical Services and Disease Prevention in Colonial India Muhammad Umair Indian J Community Med. Jan 2009; 34(1): 6–14.

• Public health workforce: challenges and policy issues Robert Beaglehole and Mario R Dal Poz available from URL:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC179882/

• Public Health Education in India and China: History, Opportunities, and Challenges Bangdiwala, Shrikant I.; Tucker, Joseph D.; Zodpey, Sanjay; Griffiths, Sian M.; Li-Ming Li; Reddy, K. Srinath; Cohen, Myron S.; Gross, Miriam; Sharma, Kavya; Jin-Ling Tang Public Health Reviews (2107-6952);2011, Vol. 33 Issue 3, p204 Available from URL: http://connection.ebscohost.com/c/articles/73530757/public-health-education-india-china-history-opportunities-challenges