Hospital Management – BM2304

V - semester
Clinical engineering is a specialty within Biomedical engineering
responsible primarily for applying and implementing medical
technology to optimize healthcare delivery. Roles of clinical engineers
include training and supervising biomedical equipment technicians
(BMETs), working with governmental regulators on hospital
inspections/audits, and serving as technological consultants for other
hospital staff (i.e. physicians, administrators, I.T., etc.). Clinical
engineers also advise medical device producers regarding prospective
design improvements based on clinical experiences, as well as monitor
the progression of the state-of-the-art in order to redirect hospital
procurement patterns accordingly.

Their inherent focus on practical implementation of technology has

tended to keep them oriented more towards incremental-level
redesigns and reconfigurations, as opposed to "revolutionary" R&D or
cutting-edge ideas that would be many years from clinical adoptability;
however, there is nonetheless an effort to expand this time-horizon
over which clinical engineers can influence the trajectory of biomedical
innovation. In their various roles, they form a sort of "bridge" between
product originators and end-users, by combining the perspectives of
being both close to the point-of-use ("front lines"), while also trained in
product and process design. Clinical Engineering departments at large
hospitals will sometimes hire not just biomedical engineers, but also
industrial/systems engineers to help address operations research,
human factors, cost analyses, safety, etc.

India

A Post Graduate course, M. Tech. in Clinical Engineering has been

recently started in India through joint efforts of the three premier
institutions of the country, namely Indian Institute of Technology,
Madras, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Thiruvananthapuram and Christian Medical College,
Vellore. It is the first course of its kind in the country and the minimum
essential qualification for joining this course is bachelors degree in any
discipline of engineering except civil engineering and a valid GATE
score.

This course aims at training graduate engineers to effectively manage

technology in hospitals by closely involving themselves into equipment
procurement, routine maintenance and safety testing activities.
Furthermore, an important aspect of this training is simultaneous, long
term and detailed exposure to clinical environment as well as to
medical device development activity. This is aimed at making students
understand the process of identifying 'unmet clinical need' and thus,
contributing to the development of new medical devices in the country.

The Definition

A Clinical engineer is defined by ACCE as "a professional who

supports and advances patient care by applying engineering and
managerial skills to healthcare technology." This definition was first
adopted by the ACCE Board of Directors on May 13, 1991. Clinical
Engineering is also recognized by the Biomedical Engineering Society
(BMES), the major professional organization for biomedical
engineering, as being a branch within Biomedical Engineering.

There are at least two issues with the ACCE definition that cause some
confusion. First, it is phrased so broadly that it's not readily evident
that "clinical engineer" is but one subset of "biomedical engineer."
Many times the terms actually get used interchangeably: some
hospitals refer to their relevant departments as "Clinical Engineering"
departments, while others call them "Biomedical Engineering"
departments. Indeed, as noted above, the technicians are almost
universally referred to as "biomedical equipment technicians,"
regardless of the name of the department that they might work under.
However, the term "biomedical engineer" is generally thought to be
more all-encompassing, including engineers who work in the primary
design of medical devices for manufacturers, or in original R&D, or in
academia—whereas clinical engineers generally work in hospitals
solving problems that are very close to where equipment is actually
used in a patient care setting. The other issue not evident from the
ACCE definition is the appropriate educational background for a clinical
engineer. Generally, the expectation of the certification program is that
an applicant for certification as a clinical engineer will hold an
accredited bachelor's degree in engineering (or at least engineering
technology).

The Future

The management of healthcare technology is becoming increasingly

complex. The driving factors and opportunities presented are
examined inThe Future of Clinical Engineering, published in the IEEE
EMBS magazine in 2003.

Eligibility Requirements
To be eligible for certification in clinical engineering (CCE), a candidate
must hold appropriate professional or educational credentials (an
accredited engineering or possibly engineering-technology degree)
have certain relevant experience, and pass an examination. The
Examination for Certification in Clinical Engineering involves a written
examination composed of a maximum of 150 multiple-choice objective
questions with a testing time of three (3) hours, and a separate oral
exam.. Particular weight is given to applicants for CE certification (CCE)
who are already licensed as registered Professional Engineers (PE) --
which itself has extensive requirements (including an accredited
engineering degree and engineering experience).

Organizational Structure of a Hospital

1 I. Importance of Understanding Organizational Structure of
Hospital
1 A. facilitates the understanding of the hospital’s chain of
command
2 B. shows which individual or department is accountable for
each area of the hospital
2 II. Complexity of Organizational Structure Depends on Size of
Healthcare Facility; large acute care hospitals have complicated
structures, whereas, the smaller institutions have a much simpler
organizational structure
3 III. Grouping of Hospital Departments Within the Organizational
Structure
1 A. Although each hospital department performs specific
functions, departments are generally grouped according to
similarity of duties.
2 B. Departments are also grouped together in order to
promote efficiency of the healthcare facility.
3 C. Common organizational categories might include:
4 1. Administration Services (often referred to simply as
“administration”)
5 2. Informational Services
6 3. Therapeutic Services
7 4. Diagnostic Services
8 5. Support Services (sometimes referred to as
“Environmental Services”)
4 IV. Administration Services—business people who “run” the
hospital
1 A. Hospital Administrators
2 1. manage and oversee the operation of departments
3 a. oversee budgeting and finance
4 b. establish hospital policies and procedures
5 c. perform public relation duties
 62. generally include: Hospital President, Vice
Presidents, Executive Assistants, Department Heads
5 V. Informational Services—documents and process information
1 A. Admissions-often the public’s first contact with hospital
personnel
2 1. checks patients into hospital
3 a. responsibilities include: obtaining vital
information (patient’s full name, address, phone
number, admitting doctor, admitting diagnosis,
social security number, date of birth, all
insurance information)
4 b. frequently, admissions will assign in-house
patients their hospital room

1 B. Billing and Collection Departments - responsible for

billing patients for services rendered
2 C. Medical Records - responsible for maintaining copies of
all patient records
3 D. Information Systems - responsible for computers and
hospital network
4 E. Health Education - responsible for staff and patient
health-related education
5 F. Human Resources - responsible for recruiting/ hiring
employees and employee benefits
2 VI. Therapeutic Services – provides treatment to patients
1 A. includes the following departments:
2 1. Physical Therapy (PT)
3 a. provide treatment to improve large-muscle
mobility and prevent or limit permanent
disability
4 b. treatments may include: exercise, massage,
hydrotherapy, ultrasound, electrical stimulation,
heat application
5 2. Occupational Therapy (OT)
6 a. goal of treatment is to help patient regain fine
motor skills so that they can function
independently at home and work
7 b. treatments might include: arts and crafts that
help with hand-eye coordination, games and
recreation to help patients develop balance and
coordination, social activities to assist patient’s
with emotional health
8 3. Speech/Language Pathology
9 a. identify, evaluate, and treat patients with
speech and language disorders
 10 b. also help patients cope with problems created
by speech impairments
11 4. Respiratory Therapy (RT)
12 a. treat patient’s with heart and lung diseases
13 b. treatment might include: oxygen,
medications, breathing exercises
14 5. Medical Psychology
15 a. concerned with mental well-being of patients
16 b. treatments might include: talk therapy,
behavior modification, muscle relaxation,
medications, group therapy, recreational
therapies (art, music, dance)
17 6. Social Services
18 a. aid patients by referring them to community
resources for living assistance (housing,
medical, mental, financial)
19 b. social worker specialties include: child
welfare, geriatrics, family, correctional (jail)
20 7. Pharmacy
21 a. dispense medications per written orders of
physician, dentists, etc.
22 b. provide information on drugs and correct
ways to use them
23 c. ensure drug compatibility
24 8. Dietary - responsible for helping patients maintain
nutritionally sound diets
25 9. Sports Medicine
26 a. provide rehabilitative services to athletes
27 b. teaches proper nutrition
28 c. prescribe exercises to increase strength and
flexibility or correct weaknesses
29 d. apply tape or padding to protect body parts
30 e. administer first aid for sports injuries
31 10. Nursing (RN, LVN, LPN)
32 a. provide care for patients as directed by
physicians
 1 b. many nursing specialties include: nurse
practitioner, labor and delivery nurse, neonatal
nurse, emergency room nurse, nurse midwife,
surgical nurse, nurse anesthetist
2 c. In some facilities, Nursing is a service in and
of itself.
2 VII. Diagnostic Services – determines cause(s) of illness or
injury
1 A. includes the following departments:
2 1. Medical Laboratory (MT) - studies body tissues to
determine abnormalities
3 2. Imaging
4 a. image body parts to determine lesions and
abnormalities
5 b. includes the following: Diagnostic Radiology,
MRI, CT, Ultra Sound
6 3. Emergency Medicine - provides emergency
diagnoses and treatment
3 VIII. Support Services—provides support to entire hospital
1 A. includes the following departments:
2 1. Central Supply
3 a. in charge of ordering, receiving, stocking and
distributing all equipment and supplies used by
healthcare facility
4 b. sterilize instruments or supplies
5 c. clean and maintain hospital linen and patient
gowns
6 2. Biomedical Technology
7 a. design and build biomedical equipment
(engineers)
8 b. diagnose and repair defective equipment
(biomedical technicians)
9 c. provide preventative maintenance to all
hospital equipment (biomedical technicians)
10 d. pilot use of medical equipment to other
hospital employees (biomedical technicians)
11 3. Housekeeping and Maintenance
12 a. maintain safe clean environment
13 b. cleaners, electricians, carpenters, gardeners

NATIONAL HEALTH POLICY - 2002

1. INTRODUCTORY
1.1 A National Health Policy was last formulated in 1983, and since
then there have been marked changes in the determinant factors
relating to the health sector. Some of the policy initiatives outlined in
the NHP-1983 have yielded results, while, in several other areas, the
outcome has not been as expected.

1.2 The NHP-1983 gave a general exposition of the policies which

required recommendation in the circumstances then prevailing in the
health sector. The noteworthy initiatives under that policy were:-

(i) A phased, time-bound programme for setting up a well-dispersed

network of comprehensive primary health care services, linked with
extension and health education, designed in the context of the ground
reality that elementary health problems can be resolved by the people
themselves;

(ii) Intermediation through ‘Health volunteers’ having appropriate

knowledge, simple skills and requisite technologies;

(iii) Establishment of a well-worked out referral system to ensure that

patient load at the higher levels of the hierarchy is not needlessly
burdened by those who can be treated at the decentralized level;

(iv) An integrated net-work 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
Government’s facilities is limited to those entitled to free use.

1.3 Government initiatives in the pubic health sector have recorded

some noteworthy 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 – (Box-I).

Box-1 : Achievements Through The Years - 1951-2000

Indicator 1951 1981 2000

Demographic Changes

Life Expectancy 36.7 54 64.6(RGI)

Crude Birth Rate 40.8 33.9(SRS) 26.1(99 SRS)

Crude Death Rate 25 12.5(SRS) 8.7(99 SRS)

IMR 146 110 70 (99 SRS)

Epidemiological Shifts

Malaria (cases in million) 75 2.7 2.2

Leprosy cases per 10,000 38.1 57.3 3.74

population

Small Pox (no of cases) >44,887 Eradicate

d

Guineaworm ( no. of cases) >39,792 Eradicated

Polio 29709 265

Infrastructure

SC/PHC/CHC 725 57,363 1,63,181 (99-RHS)

Dispensaries &Hospitals( all) 9209 23,555 43,322 (95–96-CBHI)

Beds (Pvt & Public) 117,198 569,495 8,70,161 (95-96-

CBHI)

Doctors(Allopathy) 61,800 2,68,700 5,03,900 (98-99-MCI)

Nursing Personnel 18,054 1,43,887 7,37,000 (99-INC)

1.4 While noting that the public health initiatives over the years have
contributed significantly to the improvement of these health indicators,
it is to be acknowledged that public health indicators / disease-burden
statistics are the outcome of several complementary initiatives under
the wider umbrella of the developmental sector, covering Rural
Development, Agriculture, Food Production, Sanitation, Drinking Water
Supply, Education, etc. Despite the impressive public health gains as
revealed in the statistics in Box-I, there is no gainsaying the fact that
the morbidity and mortality levels in the country are still unacceptably
high. These unsatisfactory health indices are, in turn, an indication of
the limited success of the public health system in meeting the
preventive and curative requirements of the general population.
1.5 Out of the communicable diseases which have persisted over time,
the incidence of Malaria staged a resurgence in the1980s before
stabilising at a fairly high prevalence level during the 1990s. Over the
years, an increasing level of insecticide-resistance has developed in
the malarial vectors in many parts of the country, while the incidence
of the more deadly P-Falciparum Malaria has risen to about 50 percent
in the country as a whole. In respect of TB, the public health scenario
has not shown any significant decline in the pool of infection amongst
the community, and there has been a distressing trend in the increase
of drug resistance to the type of infection prevailing in the country. A
new and extremely virulent communicable disease – HIV/AIDS - has
emerged on the health scene since the declaration of the NHP-1983. As
there is no existing therapeutic cure or vaccine for this infection, the
disease constitutes a serious threat, not merely to public health but to
economic development in the country. The common water-borne
infections – Gastroenteritis, Cholera, and some forms of Hepatitis –
continue to contribute to a high level of morbidity in the population,
even though the mortality rate may have been somewhat moderated.

1.6 The period after the announcement of NHP-83 has also seen an
increase in mortality through ‘life-style’ diseases- diabetes, cancer and
cardiovascular diseases. The increase in life expectancy has increased
the requirement for geriatric care. Similarly, the increasing burden of
trauma cases is also a significant public health problem.

1.7 Another area of grave concern in the public health domain is the
persistent incidence of macro and micro nutrient deficiencies,
especially among women and children. In the vulnerable sub-category
of women and the girl child, this has the multiplier effect through the
birth of low birth weight babies and serious ramifications of the
consequential mental and physical retarded growth.

1.8 NHP-1983, in a spirit of optimistic empathy for the health needs of

the people, particularly the poor and under-privileged, had hoped to
provide ‘Health for All by the year 2000 AD’, through the universal
provision of comprehensive primary health care services. In retrospect,
it is observed that the financial resources and public health
administrative capacity which it was possible to marshal, was far short
of that necessary to achieve such an ambitious and holistic goal.
Against this backdrop, it is felt that it would be appropriate to pitch
NHP-2002 at a level consistent with our realistic expectations about
financial resources, and about the likely increase in Public Health
administrative capacity. The recommendations of NHP-2002 will,
therefore, attempt to maximize the broad-based availability of health
services to the citizenry of the country on the basis of realistic
considerations of capacity. The changed circumstances relating to the
health sector of the country since 1983 have generated a situation in
which it is now necessary to review the field, and to formulate a new
policy framework as the National Health Policy-2002. NHP-2002 will
attempt to set out a new policy framework for the accelerated
achievement of Public health goals in the socio-economic
circumstances currently prevailing in the country.

2. CURRENT SCENARIO

2.1 FINANCIAL RESOURCES

2.1.1 The public health investment in the country over the years has
been comparatively low, and as a percentage of GDP has declined from
1.3 percent in 1990 to 0.9 percent in 1999. The aggregate expenditure
in the Health sector is 5.2 percent of the GDP. Out of this, about 17
percent of the aggregate expenditure is public health spending, the
balance being out-of-pocket expenditure. The central budgetary
allocation for health over this period, as a percentage of the total
Central Budget, has been stagnant at 1.3 percent, while that in the
States has declined from 7.0 percent to 5.5 percent. The current
annual per capita public health expenditure in the country is no more
than Rs. 200. Given these statistics, it is no surprise that the reach and
quality of public health services has been below the desirable
standard. Under the constitutional structure, public health is the
responsibility of the States. In this framework, it has been the
expectation that the principal contribution for the funding of public
health services will be from the resources of the States, with some
supplementary input from Central resources. In this backdrop, the
contribution of Central resources to the overall public health funding
has been limited to about 15 percent. The fiscal resources of the State
Governments are known to be very inelastic. This is reflected in the
declining percentage of State resources allocated to the health sector
out of the State Budget. If the decentralized pubic health services in
the country are to improve significantly, there is a need for the
injection of substantial resources into the health sector from the
Central Government Budget. This approach is a necessity – despite the
formal Constitutional provision in regard to public health, -- if the State
public health services, which are a major component of the initiatives
in the social sector, are not to become entirely moribund. The NHP-
2002 has been formulated taking into consideration these ground
realities in regard to the availability of resources.

2.2 EQUITY

2.2.1 In the period when centralized planning was accepted as a key

instrument of development in the country, the attainment of an
 equitable regional distribution was considered one of its major
objectives. Despite this conscious focus in the development process,
the statistics given in Box-II clearly indicate that the attainment of
health indices has been very uneven across the rural – urban divide.

Box II : Differentials in Health Status Among States

Sector Populati IMR/Per <5Mort- Weight MMR/Lak Lepros Malaria

on BPL 1000Live ality For h y +ve
(%) Births(199 per Age-%of (Annual cases Cases in
9-SRS) 1000 Children Report per year
(NFHS Under 3 2000) 10000 2000(in
II) years popula thousand
-tion s)
(<-2SD)

India 26.1 70 94.9 47 408 3.7 2200

Rural 27.09 75 103.7 49.6 - - -

Urban 23.62 44 63.1 38.4 - - -

Better
Performin
g States

Kerala 12.72 14 18.8 27 87 0.9 5.1

Maharashtr 25.02 48 58.1 50 135 3.1 138

a

TN 21.12 52 63.3 37 79 4.1 56

Low
Performin
g States

Orissa 47.15 97 104.4 54 498 7.05 483

Bihar 42.60 63 105.1 54 707 11.83 132

Rajasthan 15.28 81 114.9 51 607 0.8 53

UP 31.15 84 122.5 52 707 4.3 99

MP 37.43 90 137.6 55 498 3.83 528

Also, the statistics bring out the wide differences between the
attainments of health goals in the better- performing States as
compared to the low-performing States. It is clear that national
averages of health indices hide wide disparities in public health
facilities and health standards in different parts of the country. Given a
situation in which national averages in respect of most indices are
themselves at unacceptably low levels, the wide inter-State disparity
implies that, for vulnerable sections of society in several States, access
to public health services is nominal and health standards are grossly
inadequate. Despite a thrust in the NHP-1983 for making good the
unmet needs of public health services by establishing more public
health institutions at a decentralized level, a large gap in facilities still
persists. Applying current norms to the population projected for the
year 2000, it is estimated that the shortfall in the number of
SCs/PHCs/CHCs is of the order of 16 percent. However, this shortage is
as high as 58 percent when disaggregated for CHCs only. The NHP-
2002 will need to address itself to making good these deficiencies so
as to narrow the gap between the various States, as also the gap
across the rural-urban divide.

2.2.2 Access to, and benefits from, the public health system have been
very uneven between the better-endowed and the more vulnerable
sections of society. This is particularly true for women, children and the
socially disadvantaged sections of society. The statistics given in Box-
III highlight the handicap suffered in the health sector on account of
socio-economic inequity.

Box-III : Differentials in Health status Among Socio-Economic Groups

Indicator Infant Under 5 % Children

Mortality/1000 Mortality/1000 Underweight

India 70 94.9 47

Social Inequity

Scheduled Castes 83 119.3 53.5

Scheduled Tribes 84.2 126.6 55.9

Other 76 103.1 47.3

Disadvantaged

Others 61.8 82.6 41.1

2.2.3 It is a principal objective of NHP-2002 to evolve a policy structure
which reduces these inequities and allows the disadvantaged sections
of society a fairer access to public health services.

2.3 DELIVERY OF NATIONAL PUBLIC HEALTH

PROGRAMMES

2.3.1 It is self-evident that in a country as large as India, which has a

wide variety of socio-economic settings, national health programmes
have to be designed with enough flexibility to permit the State public
health administrations to craft their own programme package
according to their needs. Also, the implementation of the national
health programme can only be carried out through the State
Governments’ decentralized public health machinery. Since, for various
reasons, the responsibility of the Central Government in funding
additional public health services will continue over a period of time, the
role of the Central Government in designing broad-based public health
initiatives will inevitably continue. Moreover, it has been observed that
the technical and managerial expertise for designing large-span public
health programmes exists with the Central Government in a
considerable degree; this expertise can be gainfully utilized in
designing national health programmes for implementation in varying
socio-economic settings in the States. With this background, the NHP-
2002 attempts to define the role of the Central Government and the
State Governments in the public health sector of the country.

2.3.2.1 Over the last decade or so, the Government has relied upon a
‘vertical’ implementational structure for the major disease control
programmes. Through this, the system has been able to make a
substantial dent in reducing the burden of specific diseases. However,
such an organizational structure, which requires independent
manpower for each disease programme, is extremely expensive and
difficult to sustain. Over a long time-range, ‘vertical’ structures may
only be affordable for those diseases which offer a reasonable
possibility of elimination or eradication in a foreseeable time-span.

2.3.2.2 It is a widespread perception that, over the last decade and a

half, the rural health staff has become a vertical structure exclusively
for the implementation of family welfare activities. As a result, for
those public health programmes where there is no separate vertical
structure, there is no identifiable service delivery system at all. The
Policy will address this distortion in the public health system.

2.4 THE STATE OF PUBLIC HEALTH INFRA-STRUCTURE

2.4.1 The delineation of NHP-2002 would be required to be based on
an objective assessment of the quality and efficiency of the existing
public health machinery in the field. It would detract from the quality of
the exercise if, while framing a new policy, it were not acknowledged
that the existing public health infrastructure is far from satisfactory.
For the outdoor medical facilities in existence, funding is generally
insufficient; the presence of medical and para-medical personnel is
often much less than that required by prescribed norms; the
availability of consumables is frequently negligible; the equipment in
many public hospitals is often obsolescent and unusable; and, the
buildings are in a dilapidated state. In the indoor treatment facilities,
again, the equipment is often obsolescent; the availability of essential
drugs is minimal; the capacity of the facilities is grossly inadequate,
which leads to over-crowding, and consequentially to a steep
deterioration in the quality of the services. As a result of such
inadequate public health facilities, it has been estimated that less than
20 percent of the population, which seek OPD services, and less than
45 percent of that which seek indoor treatment, avail of such services
in public hospitals. This is despite the fact that most of these patients
do not have the means to make out-of-pocket payments for private
health services except at the cost of other essential expenditure for
items such as basic nutrition.

2.5 EXTENDING PUBLIC HEALTH SERVICES

2.5.1 While there is a general shortage of medical personnel in the

country, this shortfall is disproportionately impacted on the less-
developed and rural areas. No incentive system attempted so far, has
induced private medical personnel to go to such areas; and, even in
the public health sector, the effort to deploy medical personnel in such
under-served areas, has usually been a losing battle. In such a
situation, the possibility needs to be examined of entrusting some
limited public health functions to nurses, paramedics and other
personnel from the extended health sector after imparting adequate
training to them.

2.5.2 India has a vast reservoir of practitioners in the Indian Systems of

Medicine and Homoeopathy, who have undergone formal training in
their own disciplines. The possibility of using such practitioners in the
implementation of State/Central Government public health
programmes, in order to increase the reach of basic health care in the
country, is addressed in the NHP-2002.

2.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS

2.6.1 Some States have adopted a policy of devolving programmes and
funds in the health sector through different levels of the Panchayati Raj
Institutions. Generally, the experience has been an encouraging one.
The adoption of such an organisational structure has enabled need-
based allocation of resources and closer supervision through the
elected representatives. The Policy examines the need for a wider
adoption of this mode of delivery of health services, in rural as well as
urban areas, in other parts of the country.

2.7 NORMS FOR HEALTH CARE PERSONNEL

2.7.1 It is observed that the deployment of doctors and nurses, in both

public and private institutions, is ad-hoc and significantly short of the
requirement for minimal standards of patient care. This policy will
make a specific recommendation in regard to this deficiency.

2.8 EDUCATION OF HEALTH CARE PROFESSIONALS

2.8.1 Medical and Dental Colleges are not evenly spread across various
parts of the country. Apart from the uneven geographical distribution
of medical institutions, the quality of education is highly uneven and in
several instances even sub-standard. It is a common perception that
the syllabus is excessively theoretical, making it difficult for the fresh
graduate to effectively meet even the primary health care needs of the
population. There is a general reluctance on the part of graduate
doctors to serve in areas distant from their native place. NHP-2002 will
suggest policy initiatives to rectify the resultant disparities.

2.8.2.1 Certain medical disciplines, such as molecular biology and

gene-manipulation, have become relevant in the period after the
formulation of the previous National Health Policy. The components of
medical research in recent years have changed radically. In the
foreseeable future such research will rely increasingly on the new
disciplines. It is observed that the current under-graduate medical
syllabus does not cover such emerging subjects. The Policy will make
appropriate recommendations in respect of such deficiencies.

2.8.2.2 Also, certain speciality disciplines – Anesthesiology, Radiology

and Forensic Medicine – are currently very scarce, resulting in critical
deficiencies in the package of available public health services. This
Policy will recommend some measures to alleviate such critical
shortages.

2.9 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH’ AND

‘FAMILY MEDICINE’

2.9.1 In any developing country with inadequate availability of health

services, the requirement of expertise in the areas of ‘public health’
and ‘family medicine’ is markedly more than the expertise required for
other clinical specialities. In India, the situation is that public health
expertise is non-existent in the private health sector, and far short of
requirement in the public health sector. Also, the current curriculum in
the graduate / post-graduate courses is outdated and unrelated to
contemporary community needs. In respect of ‘family medicine’, it
needs to be noted that the more talented medical graduates generally
seek specialization in clinical disciplines, while the remaining go into
general practice. While the availability of postgraduate educational
facilities is 50 percent of the total number of qualifying graduates each
year, and can be considered adequate, the distribution of the
disciplines in the postgraduate training facilities is overwhelmingly in
favour of clinical specializations. NHP-2002 examines the possible
means for ensuring adequate availability of personnel with
specialization in the ‘public health’ and ‘family medicine’ disciplines, to
discharge the public health responsibilities in the country.

2.10 Nursing Personnel

2.10.1 The ratio of nursing personnel in the country vis-à-vis

doctors/beds is very low according to professionally accepted norms.
There is also an acute shortage of nurses trained in super-speciality
disciplines for deployment in tertiary care facilities. NHP-2002
addresses these problems.

2.11 USE OF GENERIC DRUGS AND VACCINES

2.11.1 India enjoys a relatively low-cost health care system because of

the widespread availability of indigenously manufactured generic
drugs and vaccines. There is an apprehension that globalization will
lead to an increase in the costs of drugs, thereby leading to rising
trends in overall health costs. This Policy recommends measures to
ensure the future Health Security of the country.

2.12 URBAN HEALTH

2.12.1.1 In most urban areas, public health services are very meagre.
To the extent that such services exist, there is no uniform
organizational structure. The urban population in the country is
presently as high as 30 percent and is likely to go up to around 33
percent by 2010. The bulk of the increase is likely to take place
through migration, resulting in slums without any infrastructure
support. Even the meagre public health services which are available do
not percolate to such unplanned habitations, forcing people to avail of
private health care through out-of-pocket expenditure.

2.12.1.2 The rising vehicle density in large urban agglomerations has

also led to an increased number of serious accidents requiring
treatment in well-equipped trauma centres. NHP-2002 will address
itself to the need for providing this unserved urban population a
minimum standard of broad-based health care facilities.

2.13 MENTAL HEALTH

2.13.1 Mental health disorders are actually much more prevalent than
is apparent on the surface. While such disorders do not contribute
significantly to mortality, they have a serious bearing on the quality of
life of the affected persons and their families. Sometimes, based on
religious faith, mental disorders are treated as spiritual affliction. This
has led to the establishment of unlicensed mental institutions as an
adjunct to religious institutions where reliance is placed on faith cure.
Serious conditions of mental disorder require hospitalization and
treatment under trained supervision. Mental health institutions are
woefully deficient in physical infrastructure and trained manpower.
NHP-2002 will address itself to these deficiencies in the public health
sector.

2.14 INFORMATION, EDUCATION AND COMMUNICATION

2.14.1 A substantial component of primary health care consists of

initiatives for disseminating to the citizenry, public health-related
information. IEC initiatives are adopted not only for disseminating
curative guidelines (for the TB, Malaria, Leprosy, Cataract Blindness
Programmes), but also as part of the effort to bring about a
behavioural change to prevent HIV/AIDS and other life-style diseases.
Public health programmes, particularly, need high visibility at the
decentralized level in order to have an impact. This task is difficult as
35 percent of our country’s population is illiterate. The present IEC
strategy is too fragmented, relies too heavily on the mass media and
does not address the needs of this segment of the population. It is
often felt that the effectiveness of IEC programmes is difficult to judge;
and consequently it is often asserted that accountability, in regard to
the productive use of such funds, is doubtful. The Policy, while
projecting an IEC strategy, will fully address the inherent problems
encountered in any IEC programme designed for improving awareness
and bringing about a behavioural change in the general population.
2.14.2 It is widely accepted that school and college students are the
most impressionable targets for imparting information relating to the
basic principles of preventive health care. The policy will attempt to
target this group to improve the general level of awareness in regard
to ‘health-promoting’ behaviour.

2.15 HEALTH RESEARCH

2.15.1 Over the years, health research activity in the country has been
very limited. In the Government sector, such research has been
confined to the research institutions under the Indian Council of
Medical Research, and other institutions funded by the States/Central
Government. Research in the private sector has assumed some
significance only in the last decade. In our country, where the
aggregate annual health expenditure is of the order of Rs. 80,000
crores, the expenditure in 1998-99 on research, both public and
private sectors, was only of the order of Rs. 1150 crores. It would be
reasonable to infer that with such low research expenditure, it is
virtually impossible to make any dramatic break-through within the
country, by way of new molecules and vaccines; also, without a
minimal back-up of applied and operational research, it would be
difficult to assess whether the health expenditure in the country is
being incurred through optimal applications and appropriate public
health strategies. Medical Research in the country needs to be focused
on therapeutic drugs/vaccines for tropical diseases, which are normally
neglected by international pharmaceutical companies on account of
their limited profitability potential. The thrust will need to be in the
newly-emerging frontier areas of research based on genetics, genome-
based drug and vaccine development, molecular biology, etc. NHP-
2002 will address these inadequacies and spell out a minimal quantum
of expenditure for the coming decade, looking to the national needs
and the capacity of the research institutions to absorb the funds.

2.16 ROLE OF THE PRIVATE SECTOR

2.16.1 Considering the economic restructuring under way in the

country, and over the globe, in the last decade, the changing role of
the private sector in providing health care will also have to be
addressed in this Policy. Currently, the contribution of private health
care is principally through independent practitioners. Also, the private
sector contributes significantly to secondary-level care and some
tertiary care. It is a widespread perception that private health services
are very uneven in quality, sometimes even sub-standard. Private
health services are also perceived to be financially exploitative, and
the observance of professional ethics is noted only as an exception.
With the increasing role of private health care, the implementation of
statutory regulation, and the monitoring of minimum standards of
diagnostic centres / medical institutions becomes imperative. The
Policy will address the issues regarding the establishment of a
comprehensive information system, and based on that the
establishment of a regulatory mechanism to ensure the maintaining of
adequate standards by diagnostic centres / medical institutions, as well
as the proper conduct of clinical practice and delivery of medical
services.

2.16.2 Currently, non-Governmental service providers are treating a

large number of patients at the primary level for major diseases.
However, the treatment regimens followed are diverse and not
scientifically optimal, leading to an increase in the incidence of drug
resistance. This policy will address itself to recommending
arrangements which will eliminate the risks arising from inappropriate
treatment.

2.16.3 The increasing spread of information technology raises the

possibility of its adoption in the health sector. NHP-2002 will examine
this possibility.

2.17 THE ROLE OF CIVIL SOCIETY

2.17.1 Historically, it has been the practice to implement major

national disease control programmes through the public health
machinery of the State/Central Governments. It has become
increasingly apparent that certain components of such programmes
cannot be efficiently implemented merely through government
functionaries. A considerable change in the mode of implementation
has come about in the last two decades, with the increasing
involvement of NGOs and other institutions of civil society. It is to be
recognized that widespread debate on various public health issues has,
in fact, been initiated and sustained by NGOs and other members of
the civil society. Also, an increasing contribution is being made by such
institutions in the delivery of different components of public health
services. Certain disease control programmes require close inter-action
with the beneficiaries for regular administration of drugs; periodic
carrying out of pathological tests; dissemination of information
regarding disease control and other general health information. NHP-
2002 will address such issues and suggest policy instruments for the
implementation of public health programmes through individuals and
institutions of civil society.

2.18 NATIONAL DISEASE SURVEILLANCE NETWORK

2.18.1 The technical network available in the country for disease
surveillance is extremely rudimentary and to the extent that the
system exists, it extends only up to the district level. Disease statistics
are not flowing through an integrated network from the decentralized
public health facilities to the State/Central Government health
administration. Such an arrangement only provides belated
information, which, at best, serves a limited statistical purpose. The
absence of an efficient disease surveillance network is a major
handicap in providing a prompt and cost-effective health care system.
The efficient disease surveillance network set up for Polio and HIV/AIDS
has demonstrated the enormous value of such a public health
instrument. Real-time information on focal outbreaks of common
communicable diseases – Malaria, GE, Cholera and JE – and the
seasonal trends of diseases, would enable timely intervention,
resulting in the containment of the thrust of epidemics. In order to be
able to use an integrated disease surveillance network for operational
purposes, real-time information is necessary at all levels of the health
administration. The Policy would address itself to this major systemic
shortcoming in the administration.

2.19 HEALTH STATISTICS

2.19.1 The absence of a systematic and scientific health statistics data-

base is a major deficiency in the current scenario. The health statistics
collected are not the product of a rigorous methodology. Statistics
available from different parts of the country, in respect of major
diseases, are often not obtained in a manner which make aggregation
possible or meaningful.

2.19.2.1 Further, the absence of proper and systematic documentation

of the various financial resources used in the health sector is another
lacuna in the existing health information scenario. This makes it
difficult to understand trends and levels of health spending by private
and public providers of health care in the country, and, consequently,
to address related policy issues and to formulate future investment
policies.

2.19.2.2 NHP-2002 will address itself to the programme for putting in

place a modern and scientific health statistics database as well as a
system of national health accounts.

2.20 WOMEN’S HEALTH

2.20.1 Social, cultural and economic factors continue to inhibit women

from gaining adequate access even to the existing public health
facilities. This handicap does not merely affect women as individuals; it
also has an adverse impact on the health, general well-being and
development of the entire family, particularly children. This policy
recognises the catalytic role of empowered women in improving the
overall health standards of the community.

2.21 MEDICAL ETHICS

2.21.1 Professional medical ethics in the health sector is an area which

has not received much attention. Professional practices are perceived
to be grossly commercial and the medical profession has lost its
elevated position as a provider of basic services to fellow human
beings. In the past, medical research has been conducted within the
ethical guidelines notified by the Indian Council of Medical Research.
The first document containing these guidelines was released in 1960,
and was comprehensively revised in 2001. With the rapid
developments in the approach to medical research, a periodic revision
will no doubt be more frequently required in future. Also, the new
frontier areas of research – involving gene manipulation, organ/human
cloning and stem cell research _ impinge on visceral issues relating to
the sanctity of human life and the moral dilemma of human
intervention in the designing of life forms. Besides this, in the
emerging areas of research, there is the uncharted risk of creating new
life forms, which may irreversibly damage the environment as it exists
today. NHP – 2002 recognises that this moral and religious dilemma,
which was not relevant even two years ago, now pervades mainstream
health sector issues.

2.22 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD

AND DRUGS 2.22.1 There is an increasing expectation and need of the

citizenry for efficient enforcement of reasonable quality standards for
food and drugs. Recognizing this, the Policy will make an appropriate
policy recommendation on this issue.

2.23 REGULATION OF STANDARDS IN PARA MEDICAL

DISCIPLINES

2.23.1 It has been observed that a large number of training institutions

have mushroomed, particularly in the private sector, for para medical
personnel with various skills – Lab Technicians, Radio Diagnosis
Technicians, Physiotherapists, etc. Currently, there is no
regulation/monitoring, either of the curriculae of these institutions, or
of the performance of the practitioners in these disciplines. This Policy
will make recommendations to ensure the standardization of such
training and the monitoring of actual performance.
2.24 ENVIRONMENTAL AND OCCUPATIONAL HEALTH

2.24.1 The ambient environmental conditions are a significant

determinant of the health risks to which a community is exposed.
Unsafe drinking water, unhygienic sanitation and air pollution
significantly contribute to the burden of disease, particularly in urban
settings. The initiatives in respect of these environmental factors are
conventionally undertaken by the participants, whether private or
public, in the other development sectors. In this backdrop, the Policy
initiatives, and the efficient implementation of the linked programmes
in the health sector, would succeed only to the extent that they are
complemented by appropriate policies and programmes in the other
environment-related sectors.

2.24.2 Work conditions in several sectors of employment in the country

are sub-standard. As a result, workers engaged in such employment
become particularly vulnerable to occupation-linked ailments. The
long-term risk of chronic morbidity is particularly marked in the case of
child labour. NHP-2002 will address the risk faced by this particularly
vulnerable section of society.

2.25 PROVIDING MEDICAL FACILITIES TO USERS FROM

OVERSEAS

2.25.1 The secondary and tertiary facilities available in the country are
of good quality and cost-effective compared to international medical
facilities. This is true not only of facilities in the allopathic disciplines,
but also of those belonging to the alternative systems of medicine,
particularly Ayurveda. The Policy will assess the possibilities of
encouraging the development of paid treatment-packages for patients
from overseas.

2.26 THE IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR

2.26.1 There are some apprehensions about the possible adverse

impact of economic globalisation on the health sector. Pharmaceutical
drugs and other health services have always been available in the
country at extremely inexpensive prices. India has established a
reputation around the globe for the innovative development of original
process patents for the manufacture of a wide-range of drugs and
vaccines within the ambit of the existing patent laws. With the
adoption of Trade Related Intellectual Property Rights (TRIPS), and the
subsequent alignment of domestic patent laws consistent with the
commitments under TRIPS, there will be a significant shift in the scope
of the parameters regulating the manufacture of new drugs/vaccines.
Global experience has shown that the introduction of a TRIPS-
consistent patent regime for drugs in a developing country results in
an across-the-board increase in the cost of drugs and medical services.
NHP-2002 will address itself to the future imperatives of health security
in the country, in the post-TRIPS era.

2.27 INTER-SECTORAL CONTRIBUTION TO HEALTH

2.27.1 It is well recognized that the overall well-being of the citizenry

depends on the synergistic functioning of the various sectors in the
socio-economy. The health status of the citizenry would, inter alia, be
dependent on adequate nutrition, safe drinking water, basic sanitation,
a clean environment and primary education, especially for the girl
child. The policies and the mode of functioning in these independent
areas would necessarily overlap each other to contribute to the health
status of the community. From the policy perspective, it is therefore
imperative that the independent policies of each of these inter-
connected sectors, be in tandem, and that the interface between the
policies of the two connected sectors, be smooth.

2.27.2 Sectoral policy documents are meant to serve as a guide to

action for institutions and individual participants operating in that
sector. Consistent with this role, NHP-2002 limits itself to making
recommendations for the participants operating within the health
sector. The policy aspects relating to inter-connected sectors, which,
while crucial, fall outside the domain of the health sector, will not be
covered by specific recommendations in this Policy document.
Needless to say, the future attainment of the various goals set out in
this policy assumes a reasonable complementary performance in these
inter-connected sectors.

2.28 POPULATION GROWTH AND HEALTH STANDARDS

2.28.1 Efforts made over the years for improving health standards
have been partially neutralized by the rapid growth of the population.
It is well recognized that population stabilization measures and general
health initiatives, when effectively synchronized, synergistically
maximize the socio-economic well-being of the people. Government
has separately announced the `National Population Policy – 2000’. The
principal common features covered under the National Population
Policy-2000 and NHP-2002, relate to the prevention and control of
communicable diseases; giving priority to the containment of HIV/AIDS
infection; the universal immunization of children against all major
preventable diseases; addressing the unmet needs for basic and
reproductive health services, and supplementation of infrastructure.
The synchronized implementation of these two Policies – National
Population Policy – 2000 and National Health Policy-2002 – will be the
very cornerstone of any national structural plan to improve the health
standards in the country.

2.29 ALTERNATIVE SYSTEMS OF MEDICINE

2.29.1 Under the overarching umbrella of the national health frame

work, the alternative systems of medicine – Ayurveda, Unani, Siddha
and Homoeopathy – have a substantial role. Because of inherent
advantages, such as diversity, modest cost, low level of technological
input and the growing popularity of natural plant-based products,
these systems are attractive, particularly in the underserved, remote
and tribal areas. The alternative systems will draw upon the substantial
untapped potential of India as one of the eight important global
centers for plant diversity in medicinal and aromatic plants. The Policy
focuses on building up credibility for the alternative systems, by
encouraging evidence-based research to determine their efficacy,
safety and dosage, and also encourages certification and quality-
marking of products to enable a wider popular acceptance of these
systems of medicine. The Policy also envisages the consolidation of
documentary knowledge contained in these systems to protect it
against attack from foreign commercial entities by way of malafide
action under patent laws in other countries. The main components of
NHP-2002 apply equally to the alternative systems of medicines.
However, the Policy features specific to the alternative systems of
medicine will be presented as a separate document.

3. OBJECTIVES

3.1 The main objective of this policy is to achieve an acceptable

standard of good health amongst the general population of the
country. The approach would be to increase access to the
decentralized public health system by establishing new infrastructure
in deficient areas, and by upgrading the infrastructure in the existing
institutions. Overriding importance would be given to ensuring a more
equitable access to health services across the social and geographical
expanse of the country. Emphasis will be given to increasing the
aggregate public health investment through a substantially increased
contribution by the Central Government. It is expected that this
initiative will strengthen the capacity of the public health
administration at the State level to render effective service delivery.
The contribution of the private sector in providing health services
would be much enhanced, particularly for the population group which
can afford to pay for services. Primacy will be given to preventive and
first-line curative initiatives at the primary health level through
increased sectoral share of allocation. Emphasis will be laid on rational
use of drugs within the allopathic system. Increased access to tried
and tested systems of traditional medicine will be ensured. Within
these broad objectives, NHP-2002 will endeavor to achieve the time-
bound goals mentioned in Box-IV.

Box-IV: Goals to be achieved by 2000-2015

Eradicate Polio and Yaws 2005

Eliminate Leprosy 2005

Eliminate Kala Azar 2010

Eliminate Lymphatic Filariasis 2015

Achieve Zero level growth of HIV/AIDS 2007

Reduce Mortality by 50% on account of TB, Malaria and Other 2010

Vector and Water Borne diseases

Reduce Prevalence of Blindness to 0.5% 2010

Reduce IMR to 30/1000 And MMR to 100/Lakh 2010

Increase utilization of public health facilities from current Level 2010

of <20 to >75%

Establish an integrated system of surveillance, National Health 2005

Accounts and Health Statistics.

Increase health expenditure by Government as a % of GDP from 2010

the existing 0.9 % to 2.0%

Increase share of Central grants to Constitute at least 25% of 2010

total health spending

Increase State Sector Health spending from 5.5% to 7% of the 2005

budget Further increase to 8% 2010

4. NHP-2002 - POLICY PRESCRIPTIONS

4.1 FINANCIAL RESOURCES

4.1.1 The paucity of public health investment is a stark reality. Given
the extremely difficult fiscal position of the State Governments, the
Central Government will have to play a key role in augmenting public
health investments. Taking into account the gap in health care
facilities, it is planned, under the policy to increase health sector
expenditure to 6 percent of GDP, with 2 percent of GDP being
contributed as public health investment, by the year 2010. The State
Governments would also need to increase the commitment to the
health sector. In the first phase, by 2005, they would be expected to
increase the commitment of their resources to 7 percent of the Budget;
and, in the second phase, by 2010, to increase it to 8 percent of the
Budget. With the stepping up of the public health investment, the
Central Government’s contribution would rise to 25 percent from the
existing 15 percent by 2010. The provisioning of higher public health
investments will also be contingent upon the increase in the absorptive
capacity of the public health administration so as to utilize the funds
gainfully.

4.2 EQUITY

4.2.1 To meet the objective of reducing various types of inequities and

imbalances – inter-regional; across the rural – urban divide; and
between economic classes – the most cost-effective method would be
to increase the sectoral outlay in the primary health sector. Such
outlets afford access to a vast number of individuals, and also facilitate
preventive and early stage curative initiative, which are cost effective.
In recognition of this public health principle, NHP-2002 sets out an
increased allocation of 55 percent of the total public health investment
for the primary health sector; the secondary and tertiary health sectors
being targeted for 35 percent and 10 percent respectively. The Policy
projects that the increased aggregate outlays for the primary health
sector will be utilized for strengthening existing facilities and opening
additional public health service outlets, consistent with the norms for
such facilities.

4.3 DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES

4.3.1.1 This policy envisages a key role for the Central Government in
designing national programmes with the active participation of the
State Governments. Also, the Policy ensures the provisioning of
financial resources, in addition to technical support, monitoring and
evaluation at the national level by the Centre. However, to optimize
the utilization of the public health infrastructure at the primary level,
NHP-2002 envisages the gradual convergence of all health
programmes under a single field administration. Vertical programmes
for control of major diseases like TB, Malaria, HIV/AIDS, as also the RCH
and Universal Immunization Programmes, would need to be continued
till moderate levels of prevalence are reached. The integration of the
programmes will bring about a desirable optimisation of outcomes
through a convergence of all public health inputs. The Policy also
envisages that programme implementation be effected through
autonomous bodies at State and district levels. The interventions of
State Health Departments may be limited to the overall monitoring of
the achievement of programme targets and other technical aspects.
The relative distancing of the programme implementation from the
State Health Departments will give the project team greater
operational flexibility. Also, the presence of State Government officials,
social activists, private health professionals and MLAs/MPs on the
management boards of the autonomous bodies will facilitate well-
informed decision-making.

4.3.1.2 The Policy also highlights the need for developing the capacity
within the State Public Health administration for scientific designing of
public health projects, suited to the local situation.

4.3.2 The Policy envisages that apart from the exclusive staff in a
vertical structure for the disease control programmes, all rural health
staff should be available for the entire gamut of public health activities
at the decentralized level, irrespective of whether these activities
relate to national programmes or other public health initiatives. It
would be for the Head of the District Health administration to allocate
the time of the rural health staff between the various programmes,
depending on the local need. NHP-2002 recognizes that to implement
such a change, not only would the public health administrators be
required to change their mindset, but the rural health staff would need
to be trained and reoriented.

4.4 THE STATE OF PUBLIC HEALTH INFRASTRUCTURE

4.4.1.1 As has been highlighted in the earlier part of the Policy, the
decentralized Public health service outlets have become practically
dysfunctional over large parts of the country. On account of resource
constraints, the supply of drugs by the State Governments is grossly
inadequate. The patients at the decentralized level have little use for
diagnostic services, which in any case would still require them to
purchase therapeutic drugs privately. In a situation in which the
patient is not getting any therapeutic drugs, there is little incentive for
the potential beneficiaries to seek the advice of the medical
professionals in the public health system. This results in there being no
demand for medical services, so medical professionals and paramedics
often absent themselves from their place of duty. It is also observed
that the functioning of the public health service outlets in some States
like the four Southern States – Kerala, Andhra Pradesh, Tamil Nadu and
Karnataka – is relatively better, because some quantum of drugs is
distributed through the primary health system network, and the
patients have a stake in approaching the Public Health facilities. In this
backdrop, the Policy envisages kick-starting the revival of the Primary
Health System by providing some essential drugs under Central
Government funding through the decentralized health system. It is
expected that the provisioning of essential drugs at the public health
service centres will create a demand for other professional services
from the local population, which, in turn, will boost the general revival
of activities in these service centres. In sum, this initiative under NHP-
2002 is launched in the belief that the creation of a beneficiary interest
in the public health system, will ensure a more effective supervision of
the public health personnel through community monitoring, than has
been achieved through the regular administrative line of control.

4.4.1.2 This Policy recognizes the need for more frequent in-service
training of public health medical personnel, at the level of medical
officers as well as paramedics. Such training would help to update the
personnel on recent advancements in science, and would also equip
them for their new assignments, when they are moved from one
discipline of public health administration to another.

4.4.1.3 Global experience has shown that the quality of public health
services, as reflected in the attainment of improved public health
indices, is closely linked to the quantum and quality of investment
through public funding in the primary health sector. Box-V gives
statistics which clearly show that standards of health are more a
function of the accurate targeting of expenditure on the decentralised
primary sector (as observed in China and Sri Lanka), than a function of
the aggregate health expenditure.

Box-V: Public Health Spending in select Countries

Indicator %Populatio Infant %Health %Public

n with Mortality Expenditure Expenditure on
income of Rate/1000 to GDP Health to Total
<$1 day Health Expenditure

India 44.2 70 5.2 17.3

China 18.5 31 2.7 24.9

Sri Lanka 6.6 16 3 45.4

UK - 6 5.8 96.9

USA - 7 13.7 44.1

Therefore the Policy, while committing additional aggregate financial

resources, places great reliance on the strengthening of the primary
health structure for the attaining of improved public health outcomes
on an equitable basis. Further, it also recognizes the practical need for
levying reasonable user-charges for certain secondary and tertiary
public health care services, for those who can afford to pay.

4.5 EXTENDING PUBLIC HEALTH SERVICES

4.5.1.1 This policy envisages that, in the context of the availability and
spread of allopathic graduates in their jurisdiction, State Governments
would consider the need for expanding the pool of medical
practitioners to include a cadre of licentiates of medical practice, as
also practitioners of Indian Systems of Medicine and Homoeopathy.
Simple services/procedures can be provided by such practitioners even
outside their disciplines, as part of the basic primary health services in
under-served areas. Also, NHP-2002 envisages that the scope of the
use of paramedical manpower of allopathic disciplines, in a prescribed
functional area adjunct to their current functions, would also be
examined for meeting simple public health requirements. This would
be on the lines of the services rendered by nurse practitioners in
several developed countries. These extended areas of functioning of
different categories of medical manpower can be permitted, after
adequate training, and subject to the monitoring of their performance
through professional councils.

4.5.1.2 NHP-2002 also recognizes the need for States to simplify the
recruitment procedures and rules for contract employment in order to
provide trained medical manpower in under-served areas. State
Governments could also rigorously enforce a mandatory two-year rural
posting before the awarding of the graduate degree. This would not
only make trained medical manpower available in the underserved
areas, but would offer valuable clinical experience to the graduating
doctors.

4.6 ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS

4.6.1 NHP-2002 lays great emphasis upon the implementation of public

health programmes through local self-government institutions. The
structure of the national disease control programmes will have specific
components for implementation through such entities. The Policy urges
all State Governments to consider decentralizing the implementation
of the programmes to such Institutions by 2005. In order to achieve
this, financial incentives, over and above the resources normatively
allocated for disease control programmes, will be provided by the
Central Government.

4.7 NORMS FOR HEALTH CARE PERSONNEL

4.7.1 Minimal statutory norms for the deployment of doctors and

nurses in medical institutions need to be introduced urgently under the
provisions of the Indian Medical Council Act and Indian Nursing Council
Act, respectively. These norms can be progressively reviewed and
made more stringent as the medical institutions improve their capacity
for meeting better normative standards.

4.8 EDUCATION OF HEALTH CARE PROFESSIONALS

4.8.1.1 In order to ameliorate the problems being faced on account of

the uneven spread of medical and dental colleges in various parts of
the country, this policy envisages the setting up of a Medical Grants
Commission for funding new Government Medical and Dental Colleges
in different parts of the country. Also, it is envisaged that the Medical
Grants Commission will fund the upgradation of the infrastructure of
the existing Government Medical and Dental Colleges of the country,
so as to ensure an improved standard of medical education.

4.8.1.2 To enable fresh graduates to contribute effectively to the

providing of primary health services as the physician of first contact,
this policy identifies a significant need to modify the existing
curriculum. A need-based, skill-oriented syllabus, with a more
significant component of practical training, would make fresh doctors
useful immediately after graduation. The Policy also recommends a
periodic skill-updating of working health professionals through a
system of continuing medical education.

4.8.2 The Policy emphasises the need to expose medical students,

through the undergraduate syllabus, to the emerging concerns for
geriatric disorders, as also to the cutting edge disciplines of
contemporary medical research. The policy also envisages that the
creation of additional seats for post-graduate courses should reflect
the need for more manpower in the deficient specialties.

4.9 NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH’ AND ‘FAMILY

MEDICINE’
4.9.1 In order to alleviate the acute shortage of medical personnel with
specialization in the disciplines of ‘public health’ and ‘family medicine’,
the Policy envisages the progressive implementation of mandatory
norms to raise the proportion of postgraduate seats in these discipline
in medical training institutions, to reach a stage wherein ¼ th of the
seats are earmarked for these disciplines. It is envisaged that in the
sanctioning of post-graduate seats in future, it shall be insisted upon
that a certain reasonable number of seats be allocated to `public
health’ and `family medicine’. Since the `public health’ discipline has
an interface with many other developmental sectors, specialization in
Public health may be encouraged not only for medical doctors, but also
for non-medical graduates from the allied fields of public health
engineering, microbiology and other natural sciences.

4.10 NURSING PERSONNEL

4.10.1.1 In the interest of patient care, the policy emphasizes the need
for an improvement in the ratio of nurses vis-à-vis doctors/beds. In
order to discharge their responsibility as model providers of health
services, the public health delivery centres need to make a beginning
by increasing the number of nursing personnel. The Policy anticipates
that with the increasing aspiration for improved health care amongst
the citizens, private health facilities will also improve their ratio of
nursing personnel vis-à-vis doctors/beds.

4.10.1.2 The Policy lays emphasis on improving the skill -level of

nurses, and on increasing the ratio of degree- holding nurses vis-à-vis
diploma-holding nurses. NHP-2002 recognizes a need for the Central
Government to subsidize the setting up, and the running of, training
facilities for nurses on a decentralized basis. Also, the Policy recognizes
the need for establishing training courses for super-speciality nurses
required for tertiary care institutions.

4.11 USE OF GENERIC DRUGS AND VACCINES

4.11.1.1 This Policy emphasizes the need for basing treatment

regimens, in both the public and private domain, on a limited number
of essential drugs of a generic nature. This is a pre-requisite for cost-
effective public health care. In the public health system, this would be
enforced by prohibiting the use of proprietary drugs, except in special
circumstances. The list of essential drugs would no doubt have to be
reviewed periodically. To encourage the use of only essential drugs in
the private sector, the imposition of fiscal disincentives would be
resorted to. The production and sale of irrational combinations of drugs
would be prohibited through the drug standards statute.
4.11.1.2 The National Programme for Universal Immunization against
Preventable Diseases requires to be assured of an uninterrupted
supply of vaccines at an affordable price. To minimize the danger
arising from the volatility of the global market, and thereby to ensure
long-term national health security, NHP-2002 envisages that not less
than 50% of the requirement of vaccines/sera be sourced from public
sector institutions.

4.12 URBAN HEALTH

4.12.1.1 NHP-2002 envisages the setting up of an organised urban

primary health care structure. Since the physical features of urban
settings are different from those in rural areas, the policy envisages
the adoption of appropriate population norms for the urban public
health infrastructure. The structure conceived under NHP-2002 is a
two-tiered one: the primary centre is seen as the first-tier, covering a
population of one lakh, with a dispensary providing an OPD facility and
essential drugs, to enable access to all the national health
programmes; and a second-tier of the urban health organisation at the
level of the Government general hospital, where reference is made
from the primary centre. The Policy envisages that the funding for the
urban primary health system will be jointly borne by the local self-
government institutions and State and Central Governments.

4.12.1. 2 The Policy also envisages the establishment of fully-equipped

‘hub-spoke’ trauma care networks in large urban agglomerations to
reduce accident mortality.

4.13 MENTAL HEALTH

4.13.1.1. NHP – 2002 envisages a network of decentralised mental

health services for ameliorating the more common categories of
disorders. The programme outline for such a disease would involve the
diagnosis of common disorders, and the prescription of common
therapeutic drugs, by general duty medical staff.

4.13.1. 2 In regard to mental health institutions for in-door treatment

of patients, the Policy envisages the upgrading of the physical
infrastructure of such institutions at Central Government expense so as
to secure the human rights of this vulnerable segment of society.

4.14 INFORMATION, EDUCATION AND COMMUNICATION

4.14.1 NHP-2002 envisages an IEC policy, which maximizes the

dissemination of information to those population groups which cannot
be effectively approached by using only the mass media. The focus
would therefore be on the inter-personal communication of information
and on folk and other traditional media to bring about behavioural
change. The IEC programme would set specific targets for the
association of PRIs/NGOs/Trusts in such activities. In several public
health programmes, where behavioural change is an essential
component, the success of the initiatives is crucially dependent on
dispelling myths and misconceptions pertaining to religious and ethical
issues. The community leaders, particularly religious leaders, are
effective in imparting knowledge which facilitates such behavioural
change. The programme will also have the component of an annual
evaluation of the performance of the non-Governmental agencies to
monitor the impact of the programmes on the targeted groups. The
Central/State Government initiative will also focus on the development
of modules for information dissemination in such population groups,
who do not normally benefit from the more common media forms.

4.14.2 NHP-2002 envisages giving priority to school health

programmes which aim at preventive-health education, providing
regular health check-ups, and promotion of health-seeking behaviour
among children. The school health programmes can gainfully adopt
specially designed modules in order to disseminate information
relating to ‘health’ and ‘family life’. This is expected to be the most
cost-effective intervention as it improves the level of awareness, not
only of the extended family, but the future generation as well.

4.15 HEALTH RESEARCH

4.15.1 This Policy envisages an increase in Government-funded health

research to a level of 1 percent of the total health spending by 2005;
and thereafter, up to 2 percent by 2010. Domestic medical research
would be focused on new therapeutic drugs and vaccines for tropical
diseases, such as TB and Malaria, as also on the sub-types of HIV/AIDS
prevalent in the country. Research programmes taken up by the
Government in these priority areas would be conducted in a mission
mode. Emphasis would also be laid on time-bound applied research for
developing operational applications. This would ensure the cost-
effective dissemination of existing / future therapeutic drugs/vaccines
in the general population. Private entrepreneurship will be encouraged
in the field of medical research for new molecules / vaccines, inter alia,
through fiscal incentives.

4.16 ROLE OF THE PRIVATE SECTOR

4.16.1.1 In principle, this Policy welcomes the participation of the

private sector in all areas of health activities – primary, secondary or
tertiary. However, looking to past experience of the private sector, it
can reasonably be expected that its contribution would be substantial
in the urban primary sector and the tertiary sector, and moderate in
the secondary sector. This Policy envisages the enactment of suitable
legislation for regulating minimum infrastructure and quality standards
in clinical establishments/medical institutions by 2003. Also, statutory
guidelines for the conduct of clinical practice and delivery of medical
services are targeted to be developed over the same period. With the
acquiring of experience in the setting and enforcing of minimum
quality standards, the Policy envisages graduation to a scheme of
quality accreditation of clinical establishments/medical institutions, for
the information of the citizenry. The regulatory/accreditation
mechanisms will no doubt also cover public health institutions. The
Policy also encourages the setting up of private insurance instruments
for increasing the scope of the coverage of the secondary and tertiary
sector under private health insurance packages.

4.16.1.2 In the context of the very large number of poor in the country,
it would be difficult to conceive of an exclusive Government
mechanism to provide health services to this category. It has
sometimes been felt that a social health insurance scheme, funded by
the Government, and with service delivery through the private sector,
would be the appropriate solution. The administrative and financial
implications of such an initiative are still unknown. As a first step, this
policy envisages the introduction of a pilot scheme in a limited number
of representative districts, to determine the administrative features of
such an arrangement, as also the requirement of resources for it. The
results obtained from these pilot projects would provide material on
which future public health policy can be based.

4.16.2 NHP-2002 envisages the co-option of the non-governmental

practitioners in the national disease control programmes so as to
ensure that standard treatment protocols are followed in their day-to-
day practice.

4.16.3 This Policy recognizes the immense potential of information

technology applications in the area of tele-medicine in the tertiary
health care sector. The use of this technical aid will greatly enhance
the capacity for the professionals to pool their clinical experience.

4.17 THE ROLE OF CIVIL SOCIETY

4.17.1 NHP-2002 recognizes the significant contribution made by NGOs

and other institutions of the civil society in making available health
services to the community. In order to utilize their high motivational
skills on an increasing scale, this Policy envisages that the disease
control programmes should earmark not less than 10% of the budget
in respect of identified programme components, to be exclusively
implemented through these institutions. The policy also emphasizes
the need to simplify procedures for government – civil society
interfacing in order to enhance the involvement of civil society in
public health programmes. In principle, the state would encourage the
handing over of public health service outlets at any level for
management by NGOs and other institutions of civil society, on an ‘as-
is-where-is’ basis, along with the normative funds earmarked for such
institutions.

4.18 NATIONAL DISEASE SURVEILLANCE NETWORK

4.18.1 This Policy envisages the full operationalization of an integrated

disease control network from the lowest rung of public health
administration to the Central Government, by 2005. The programme
for setting up this network will include components relating to the
installation of data-base handling hardware; IT inter-connectivity
between different tiers of the network; and in-house training for data
collection and interpretation for undertaking timely and effective
response. This public health surveillance network will also encompass
information from private health care institutions and practitioners. It is
expected that real-time information from outside the government
system will greatly strengthen the capacity of the public health system
to counter focal outbreaks of seasonal diseases.

4.19 HEALTH STATISTICS

4.19.1.1 The Policy envisages the completion of baseline estimates for

the incidence of the common diseases – TB, Malaria, Blindness – by
2005. The Policy proposes that statistical methods be put in place to
enable the periodic updating of these baseline estimates through
representative sampling, under an appropriate statistical methodology.
The policy also recognizes the need to establish, in a longer time-
frame, baseline estimates for non-communicable diseases, like CVD,
Cancer, Diabetes; and accidental injuries, and communicable diseases,
like Hepatitis and JE. NHP-2002 envisages that, with access to such
reliable data on the incidence of various diseases, the public health
system would move closer to the objective of evidence-based policy-
making.

4.19.1.2 Planning for the health sector requires a robust information

system, inter-alia, covering data on service facilities available in the
private sector. NHP-2002 emphasises the need for the early completion
of an accurate data-base of this kind.
4.19.2 In an attempt at consolidating the data base and graduating
from a mere estimation of the annual health expenditure, NHP-2002
emphasises the need to establish national health accounts, conforming
to the `source-to-users’ matrix structure. Also, the policy envisages the
estimation of health costs on a continuing basis. Improved and
comprehensive information through national health accounts and
accounting systems would pave the way for decision-makers to focus
on relative priorities, keeping in view the limited financial resources in
the health sector.

4.20 WOMEN’S HEALTH

4.20.1 NHP-2002 envisages the identification of specific programmes

targeted at women’s health. The Policy notes that women, along with
other under-privileged groups, are significantly handicapped due to a
disproportionately low access to health care. The various Policy
recommendations of NHP-2002, in regard to the expansion of primary
health sector infrastructure, will facilitate the increased access of
women to basic health care. The Policy commits the highest priority of
the Central Government to the funding of the identified programmes
relating to woman’s health. Also, the policy recognizes the need to
review the staffing norms of the public health administration to meet
the specific requirements of women in a more comprehensive manner.

4.21 MEDICAL ETHICS 4.21.1.1 NHP – 2002 envisages that, in order to

ensure that the common patient is not subjected to irrational or profit-
driven medical regimens, a contemporary code of ethics be notified
and rigorously implemented by the Medical Council of India.

4.21.1. 2 By and large, medical research within the country in the

frontier disciplines, such as gene- manipulation and stem cell research,
is limited. However, the policy recognises that a vigilant watch will
have to be kept so that the existing guidelines and statutory provisions
are constantly reviewed and updated.

4.22 ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS

4.22.1 NHP – 2002 envisages that the food and drug administration will
be progressively strengthened, in terms of both laboratory facilities
and technical expertise. Also, the policy envisages that the standards
of food items will be progressively tightened up at a pace which will
permit domestic food handling / manufacturing facilities to undertake
the necessary upgradation of technology so that they are not shut out
of this production sector. The Policy envisages that ultimately food
standards will be close, if not equivalent, to Codex specifications; and
that drug standards will be at par with the most rigorous ones adopted
elsewhere.

4.23 REGULATION OF STANDARDS IN PARAMEDICAL

DISCIPLINES

4.23.1 NHP-2002 recognises the need for the establishment of

statutory professional councils for paramedical disciplines to register
practitioners, maintain standards of training, and monitor performance.

4.24 ENVIRONMENTAL AND OCCUPATIONAL HEALTH

4.24.1 This Policy envisages that the independently -stated policies

and programmes of the environment -related sectors be smoothly
interfaced with the policies and the programmes of the health sector,
in order to reduce the health risk to the citizens and the consequential
disease burden.

4.24.2 NHP-2002 envisages the periodic screening of the health

conditions of the workers, particularly for high- risk health disorders
associated with their occupation.

4.25 PROVIDING MEDICAL FACILITIES TO USERS FROM

OVERSEAS

4.25.1 To capitalize on the comparative cost advantage enjoyed by

domestic health facilities in the secondary and tertiary sectors, NHP-
2002 strongly encourages the providing of such health services on a
payment basis to service seekers from overseas. The providers of such
services to patients from overseas will be encouraged by extending to
their earnings in foreign exchange, all fiscal incentives, including the
status of "deemed exports", which are available to other exporters of
goods and services.

4.26 IMPACT OF GLOBALISATION ON THE HEALTH SECTOR

4.26.1 The Policy takes into account the serious apprehension,

expressed by several health experts, of the possible threat to health
security in the post-TRIPS era, as a result of a sharp increase in the
prices of drugs and vaccines. To protect the citizens of the country
from such a threat, this policy envisages a national patent regime for
the future, which, while being consistent with TRIPS, avails of all
opportunities to secure for the country, under its patent laws,
affordable access to the latest medical and other therapeutic
discoveries. The policy also sets out that the Government will bring to
bear its full influence in all international fora – UN, WHO, WTO, etc. – to
secure commitments on the part of the Nations of the Globe, to lighten
the restrictive features of TRIPS in its application to the health care
sector.

5. SUMMATION

5.1 The crafting of a National Health Policy is a rare occasion in public

affairs when it would be legitimate, indeed valuable, to allow our
dreams to mingle with our understanding of ground realities. Based
purely on the clinical facts defining the current status of the health
sector, we would have arrived at a certain policy formulation; but,
buoyed by our dreams, we have ventured slightly beyond that in the
shape of NHP-2002, which, in fact, defines a vision for the future.

5.2 The health needs of the country are enormous and the financial
resources and managerial capacity available to meet them, even on
the most optimistic projections, fall somewhat short. In this situation,
NHP-2002 has had to make hard choices between various priorities and
operational options. NHP-2002 does not claim to be a road-map for
meeting all the health needs of the populace of the country. Further, it
has to be recognized that such health needs are also dynamic, as
threats in the area of public health keep changing over time. The
Policy, while being holistic, undertakes the necessary risk of
recommending differing emphasis on different policy components.
Broadly speaking, NHP – 2002 focuses on the need for enhanced
funding and an organizational restructuring of the national public
health initiatives in order to facilitate more equitable access to the
health facilities. Also, the Policy is focused on those diseases which are
principally contributing to the disease burden – TB, Malaria and
Blindness from the category of historical diseases; and HIV/AIDS from
the category of ‘newly emerging diseases’. This is not to say that other
items contributing to the disease burden of the country will be ignored;
but only that the resources, as also the principal focus of the public
health administration, will recognize certain relative priorities. It is
unnecessary to labour the point that under the umbrella of the macro-
policy prescriptions in this document, governments and private sector
programme planners will have to design separate schemes, tailor-
made to the health needs of women, children, geriatrics, tribals and
other socio-economically under-served sections. An adequately robust
disaster management plan has to be in place to effectively cope with
situations arising from natural and man-made calamities.

5.3 One nagging imperative, which has influenced every aspect of this
Policy, is the need to ensure that ‘equity’ in the health sector stands as
an independent goal. In any future evaluation of its success or failure,
NHP-2002 would wish to be measured against this equity norm, rather
than any other aggregated financial norm for the health sector.
Consistent with the primacy given to ‘equity’, a marked emphasis has
been provided in the policy for expanding and improving the primary
health facilities, including the new concept of the provisioning of
essential drugs through Central funding. The Policy also commits the
Central Government to an increased under-writing of the resources for
meeting the minimum health needs of the people. Thus, the Policy
attempts to provide guidance for prioritizing expenditure, thereby
facilitating rational resource allocation.

5.4 This Policy broadly envisages a greater contribution from the

Central Budget for the delivery of Public Health services at the State
level. Adequate appropriations, steadily rising over the years, would
need to be ensured. The possibility of ensuring this by imposing an
earmarked health cess has been carefully examined. While it is
recognized that the annual budget must accommodate the increasing
resource needs of the social sectors, particularly in the health sector,
this Policy does not specifically recommend an earmarked health cess,
as that would have a tendency of reducing the space available to
Parliament in making appropriations looking to the circumstances
prevailing from time to time.

5.5 The Policy highlights the expected roles of different participating

groups in the health sector. Further, it recognizes the fact that, despite
all that may be guaranteed by the Central Government for assisting
public health programmes, public health services would actually need
to be delivered by the State administration, NGOs and other
institutions of civil society. The attainment of improved health levels
would be significantly dependent on population stabilisation, as also on
complementary efforts from other areas of the social sectors – like
improved drinking water supply, basic sanitation, minimum nutrition,
etc. - to ensure that the exposure of the populace to health risks is
minimized.

5.6 Any expectation of a significant improvement in the quality of

health services, and the consequential improved health status of the
citizenry, would depend not only on increased financial and material
inputs, but also on a more empathetic and committed attitude in the
service providers, whether in the private or public sectors. In some
measure, this optimistic policy document is based on the
understanding that the citizenry is increasingly demanding more by
way of quality in health services, and the health delivery system,
particularly in the public sector, is being pressed to respond. In this
backdrop, it needs to be recognized that any policy in the social sector
is critically dependent on the service providers treating their
responsibility not as a commercial activity, but as a service, albeit a
paid one. In the area of public health, an improved standard of
governance is a prerequisite for the success of any health policy.