Understanding public health in India according to PARK 2

1. Concept of health and disease

2. Concept of health
 Biomedical concept
 Absence of disease
 Has the basis in the germ theory of disease
 It has minimized the role of the environmental, social, psychological and
cultural determinants of health
 Inadequate to solve health problems like malnutrition, chronic diseases,
accidents, drug abuse, mental illness, environmental pollution, population
explosion etc.
 Ecological concept
 Health as a dynamic equilibrium between man and his environment, and
disease a maladjustment of the human organism to environment.
 Psychosocial concept
 Health is influenced by social, psychological, cultural, economic and political
factors of the people.
 Holistic concept
 Health implies a sound mind, in a sound body, in a sound family, in sound
environment.
 All sectors of society have an effect on health.

3. Health
• Definition - Health is the state of complete
physical, mental and social wellbeing and not
merely an absence of disease or infirmity.
- WHO 1948
Operational definition of health
Health can be seen as a condition or quality of
human organism expressing the adequate
functioning of the organism in a given
conditions, genetic or environmental.

4. New philosophy of health
• Health is a fundamental human right.
• Health is the essence of productive life, and not the
result of ever increasing expenditure on medical care.
• Health is inter-sectoral.
• Health is integral part of development.
• Health is the central to the concept of quality of life.
• Health involves individuals, state and international
responsibility.
• Health and its maintenance is a major social
investment
• Health is worldwide social goal.

5. Dimensions of health
Physical dimension
Mental dimension
Social dimension
Spiritual dimension
Emotional dimension
Vocational dimension

6. Dimension of health
 Physical dimension
 state in which every cell and every organ is functioning at
optimum capacity and in perfect harmony with the rest of the
body.
 Mental dimension
 Ability to respond to the many varied experiences of life with
flexibility and sense of purpose.
 Social dimension
 Quality and quantity of an individuals interpersonal ties and the
extent of involvement with the community.
 Spiritual dimension
 Integrity, principles and ethics, the purpose in life, commitment
to some higher being.

7. Dimension of health
Emotional dimension
Emotional health relate to the feeling.
Vocational dimension
Part of human existence
Other dimension
Philosophical dimension
Cultural dimension
Socio-economical dimension
Environmental dimension
Educational dimension etc.

8. Positive health
• Perfect functioning of the body and mind.
• Positive health always remain the mirage,
because everything in our life is subject to
change.
• Health described as a potentiality the ability of an
individual or a social group to modify himself or
itself continually, in the face of changing
condition of life.
• Positive health depends not only on medical
action, but on all the other economic, cultural
and social factors operating in the community.

9. Spectrum of health
Positive health
Better health
Freedom from sickness
Unrecognized sickness
Mild sickness
Severe sickness
Death

10. DETERMINANTS OF HEALTH
Biologicaldeterminants
Behavioral&Socio-culturalconditions
Environmental/Socio–economicconditions
Healthservices
Agingofpopulation

11. DETERMINANTS OF HEALTH
Biologicaldeterminants
Physical,mental,geneticmakeup
Behavioral&Socio-culturalconditions
lifestyle,cultural,behavior,personal habits&addiction(eg.smoking,alcohol)
EnvironmentalSocio–economicconditions

12. DETERMINANTS OF HEALTH
Social–economicconditions
economicstatus, education,occupation, politicalsystem
Healthservices
familywelfareservices,treatmentofdiseases

13. DETERMINANTS OF HEALTH
Agingofpopulation
increaseschronicdiseases&disability
Gender
Nutrition,reproductivehealth,violence,
aging,lifestylecondition

14. DETERMINANTS OF HEALTH
VHealth
Communities
SocietiesFamilies
Individuals
Biological
Human rights
Equity and social
justice
Gender
Behavioural
Environmental
Socio-economic
Health system
Socio-cultural
Aging of the population
Science &
technology
Information &
communication
Health

15. Health care Indicators
• Indicator ?
variable which help to measure changes
(WHO)
• How healthy is a given community?
• Indicators requires - to know health status of
country
- to compare health status with
another
- to assess the health care need
- for allocation of scarce resources
- monitoring & evaluation of health
services, activities & programmes

16. Health Indicators Vs Health index(indice)
In relation Amalgamation of
to health trend health indicators

17. Characteristics of Indicators
Ideal indicator should be
Valid
Reliable & objective
Sensitive
Specific
Feasible
Relevant

18. Classification on indicators
1. Mortality indicators
2. Morbidity indicators
3. Disability rates
4. Nutritional status indicators
5. Health care delivery indicators
6. Utilization rate
7. Indicators of social and mental health
8. Environmental indicators
9. Socio-economic indicators
10. Health policy indicators
11. Indicators of quality of life
12. Other indicators

19. Mortality indicator
• Crude death rate
• Expectation of life _ at birth
• _ at age of 1
• _ at age of 5
• Infant mortality
• Child mortality rate
• Under-5 proportionate mortality rate
• Maternal(puerperal) mortality rate
• Disease –specific mortality
• Proportional mortality rate

20. Morbidity indicators
• Incidence & prevalence
• Notification rate
• Attendance rate at OPD, health centers etc.
• Admission ,readmission & discharge rate
• Duration of stay in hospitals
• Spell of sickness or absence from work or
school

21. Disability rates
A) Event type indicators
1) number of days of restricted activity
2) bed disability days
3) work loss days (or school loss days)
with in a specific period
B) person type indicators
1)limitation of mobility
2)limitation of activity
Sullivan’s index (expectation of life free of disability)
HALE
DALY
QALY

22. Nutritional status indicators
• Anthropometric measurement of preschool
children
• Height (or weight)of children at school entry
• Prevalence of low birth weight (<2.5kg)

23. Health care delivery indicators
• Doctor- population ratio
• Doctor –nurse ratio
• Population- bed ratio
• Population per health / sub center
• Population per traditional birth attendant

24. Utilization rates
• Proportion of infant fully immunized against
6EPI diseases
• Proportion of pregnant women who receive
antenatal care
• Percentage of population using the various
methods of family planning

25. Indicators of social & mental health
• Suicide , homicide, violence ,alcohol ,drug
abuse, smoking
• Family violence ,battered baby or battered
wife syndrome

26. Environmental indicators
• Air & water pollution
• Radiations
• Solid waste
• Exposure to toxic
• Access to safe water & sanitation

27. Socio –economic indicators
• Rate of population increase
• Per capita GNP
• Level of unemployment
• Dependency ration
• Literacy rate
• Family size
• Housing : number of person per room
• Per capita calorie availability

28. Developed & developing region
• Social & economic
• Demographic characteristics
• Contrast in health (health gap)

29. Developing
countries-high
mortality
Developing
countries-low
mortality
Developed
countries
Intentional injury
Unintentional injury
Cardiovascular ds
Neuropsychiatric disorder
Chronic respiratory Ds
Nutritional defeciencies
Respiratory Ds
Maternal & perinatal condition
Infectious & parasitic Ds
Amount & pattern of burden Ds in Developing & developed countries

30. Selected health & socio-economic indicators
Lest
developed
countries
Other
developing
countries
Developed
countries
1.Life expectancy at birth (2004) 52 65 79
2.IMR(per 1000 live birth)(2004) 98 52 5
3.Under 5 mortality/1000live birth
(2004)
155 87 6
4.Matarnal mortality /100000live birth (2000) 890 440 13
5.Doctor -population ratio per 10000
(1993)
1.4 8.4 25.2
6.Nurse –population ratio /10000 2.2 9.6 74.2
7.GNI per capita (US$) 2004 345 1524 32232
8.Per capita public expenditure on health ,US$ in
% of GDP (1999)
5 4 14
9.Adult literacy (%) 2004 54 77 97
10.Access to safe water % population 2002 58 79 100
11.Per capita calorie(1997) 2099 2663 3371

31. Health services philosophies
• Health care : “multitude of services rendered to
individuals ,families or communities by the
agents of the health services or professions for
the purpose of promoting, maintaining or
restoring health.”
• Health care include -“medical care” refers chiefly
to those personal services that are provided
directly by physicians or rendered as a result of
the physician’s instruction”

32. Characteristics of health care
• Appropriateness
• Comprehensiveness
• Adequacy
• Availability
• Accessibility
• Affordability
• Feasibility

33. Health system
• To deliver health services
• Constitute the management sector & involve
Organizational matters e.g. planning ,
determining priority, mobilizing &
allocating resources, translating policies in
services, evaluation &health education.

34. Components of health system
• Concepts
• Ideas
• Objects
• Persons
Aim of health system- health development

35. Levels of health care
• Primary health care
“Essential” health care
PHC, Sub centers
• Secondary health care
mostly curative services
CHC, District hospitals
• Tertiary health care
super-speciality care
provide manangerial skill
teaching specialized staff

36. Health team concept
• Group of persons who shares common health
goals & objectives, determined by community
need & toward the achievement of which each
member of the team contributes in
accordance with her/his competence &
skill,and the respecting the functions of others.
• Health team In hospital
In community

37. Health for all
• May 1977-World health assembly
• “Attainment by all the people of world by the
year 2000 AD of level of health that will permit
them to lead socially & economically
productive life”
• Health for all by 2000- essential principle is
concept “equity in health”

38. Primary health care
• 1978-Alma-Ata,USSR
Essential health care based on practical, scientifically sound &
socially acceptable methods & technology made universally
accessible to individuals & families in the community through
their full participation & at the cost that the community and
the country can afford to maintain at every stage of their
development in the spirit of self-determination
• Accepted to achieve the goal of “Health for all by 2000”
• “Health by people” “placing peoples health in people’s
hands”

39. Declaration of Alma Ata
Primary health care include at least
• Education about prevailing health problems and methods of
preventing & controlling them
• Promotion of food supply & proper nutrition
• An adequate supply of safe water basic sanitation
• Maternal & child health care ,including family planning
• Immunization against infectious diseases
• Prevention & control of endemic diseases
• Appropriate treatment of common diseases & injuries
• provision of essential drug

40. Millennium Development Goal
Sep 2000 ----
Govt set date of 2015
GOALS are-
Eradicate extrime poverty & hunger
Achieve universal primary education

41. Concept of Disease
• Disease ?
• Oxford English dictionary: a condition of the body or same part or organ
of the body in which its function are disrupted or deranged.
• Webster: a condition in which body health is impaired, a departure from a
state of health, an alteration of the human body interapting the
performance of vital fufncions
• Ecological view : a maladjustment of the human organism to environment
• Sociology view: disease is considered as social phenomenon, occurring in
all societies & define & fought in terms of the the perticular cultural forces
prevalent in society
• Simplest definition is : any deviation from normal functioning or state of
completeness physical & mental well-being- since health & disease is
mutually exclusive .

42. Concept of Disease
Disease – is physiological/psychological
dysfunction
Illness – is a subjective state of the person who
feels aware of not being well
Sickness – is a social dysfunction , i.e. the role
that the individual assumes when ill
(sickness roll)

43. Concept Of Causation
Supernatural theory of disease, theory of humors, concept of
contagion,miasmatic theory of disease, theory of
spontaneous generetion
• Germ theory of disease
• Epidemiological triad
Environment
Agent Host
• Multifactorial causation
• Web causation

44. Changes in life style Stress
Smoking
Abundance of food lack of Emotional
physical disturbances
exercise Aging &
other factor
Obesity Hypertension
Hyperlipidaemia Increase catacholamines
thrombotic tendency Changes in walls of
arteries
Coronary atherosclerosis coronary occlusion
Myocardial ischaemia
Web of causation for Myocardial infarction

45. Natural History Of Disease
• Prepathogenesis phage
disease agent not yet entered but the factors which
favour its interaction with human host already existing in
environment
i.e the process in environment
• Pathogenesis phage
this phage begins with the entry of the disease Agent in
the susceptible human host
i.e. the process in the man

46. Prepathogenesis phage
Epidemiologic concept of interaction of Agent
,Host and Environment

47. Agent factors
 Biological agent
Infectivity
Pathogenicity
Virulence
 Nutrient agent
 Physical agent
 Chemical agent
 Mechanical agent
 Absence or insufficiency or excess of a factor necessary to
health

48. Host factor
• Demographic characteristics-e.g. age, sex, ethnicity
• Biological characteristics –genetic, blood group,
enzymes, cellular constitute of blood
• Social & economic characteristics- socio-economic
status, education, occupation , stress, marital status
• Life style factor – personality trait ,living habits,
nutrition ,physical activity, smoking, use of alcohol

49. Environmental factors (extrensic)
• Physical environment – non –living things & physical
factors (air,water,soil,housing,climate etc.)
• Biological environment – living
things(viruses,bacteria,insect etc.) surrounding man, including
man himself
• Psychosocial environment –those factors affecting personal
health ,health care and community wellbeing that stem from
the psychosocial make up of individual & function of social
group. It include cultural values, customs,habits,beliefs.

50. PERIOD OF PRE-PATHOGENESIS PERIOD OF PATHOGENESIS
DISEASE
PROCESS
Before man is involved
Agent Host
environmental factors
(known & unknown)
Bring agent & host together
or produce a disease
provoking stimulus
LEVELS OF
PREVENTION
PRIMARY PREVENTION SECONDARY TERTIARY
PREVENTION PREVENTION
MODES OF
INTERVENTION
HEALTH SPECIFIC
PROMOTION
PROTECTION
DISABILITY REHABILITATION
LIMITATION
In the
Human
host

51. Risk factors• Where the disease agent is not firmly established ,the etiology is generally
discussed in terms of “risk factor”
• 2 meanings
a. an attributes or exposure that is significantly associated with the
development of disease
b.a determinant that can be modified by intervention, thereby reducing
the possibility of occurrence of disease or other specified outcome
Disease Risk factors
Heart disease Smoking,high blood pressure,elevated serum
cholesterol,diabetes,obesity,lack of exercise
Cancer Smoking,alcohol,solar radiation,ionising
radiation,work site hazards,environmental
pollution,infectious agent ,dietary factors
Stroke High blood pressure,elevated
cholesterol,smoking
Motor vehicle
accidents
Alcohol ,non-use of seat belts,speed, roadway
desing,automobile desing
Diabetes Obesity,diet
Cirrhossis of alcihol

52. Risk groups
guideline for defining “at-risk” group
a.Biological situation:
- Age group e.g.Infants(LBW),toddlers,elderly
- Sex eg females in reproductive age group
- Physiological state pregnancy,cholesterol level
- Genetic factors –family h/o genetic disease
- Other health conditions(disease,physical functioning,unhealthy
behaviour)
b.Physical situation :
-rural,urban slums
-living conditins,overcrowding
-environment : water supply,proximity to industry
c.Sociocultural & cultural situatiion:
-social class
-ethnic & cultural group
-family disrruption ,education

53. Spectrum of disease
Subclinical
infection
Mild ,moderate ,severe
cases
Fatal
illness

54. Iceberg Of Disease
Symptomatic disease
Pre-symptomatic disease
What physician sees
What
physician
does not sees

55. CONCEPTS OF CONTROL
• AIM IS REDUCE
1. The incidence of disease
2. The duration of disease & risk of
transmission
3.The effect of infection , including
both physical & psychosocial
complication
4.the financial burden to the community

56. Control Elimination Eradication
disease agent is permitted to persist in
community at a level where it ceases to be a public health
problem according to the local population.
A state of equilibrium between
Agent e.g. Malaria control
Host Environment

57. Control Elimination Eradication
Interruption of transmission of disease from
large geographical region or area
It is intermediate goal
e.g. Measles, Polio , Diphtheria

58. Control Elimination Eradication
Termination of all transmission of infection
by extermination of the infectious agent .
Cessation of infection or disease from whole
world
“Tear out by roots”
e.g. Smallpox
In future – Polio , Measles , Dracunculiasis

59. Monitoring & Surveillance
• The performance & analysis of routine measurements aimed
at detecting changes in environmental or health status of
population
• In management – the continuous oversight of activities to
ensure that they are proceeding according to plan. It keeps
track of achievements, staff movements and utilisation
,supplies & equipment & the money spent in relation to the
resources available so that if any thing goes wrong
,immediate corrective measures can be taken.

60. Monitoring & Surveillance
• The continuous scrutiny of the factor that determined the
occurrence & distribution of disease & other condition of
illness.
• Objectives:
1.To provide information about new & changing trend in health
status of population .e.g. morbidity .mortality ,nutritional
status, environmental hazards .
2.To provide feed-back which expected to modify the policy &
system itself &lead to redefinition of objective.
3. Timely warning of public health disasters so that intervention
can be modify.
“Sentinel surveillance”

61. CONCEPTS OF PREVENTION
Successful prevention depends on
-Knowledge of causation
-Dynamics of transmission
-Identification of risk factor & groups
-Availability of prophylactic or early
detection & treatment
-An organization to apply these
measures

62. LEVELS OF PREVENTION
Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention

63. MOdES OF INTERVENTION
• Health promotion
• Specific protection
• Early diagnosis & treatment
• Disability limitation
• Rehabilitation

64. Health promotion
- Health education
- Environmental modification
- Nutritional intervention
- Lifestyle & behavioral changes

65. Specific Protection
 Immunization
 Use of specific nutrients
 Chemoprophylaxisis
 Protection against occupational hazards
 Protection against accidents
 Protection from carcinogens
 Avoidance of allergens
 The control of general environment e.g.air pollution, noise
control
 Control of consumer product quality safety of food, drugs,
cosmetic

66. Early diagnosis & treatment
• Early detection of health impairment- “the
detection of disturbance of homoeostatic &
compensatory mechanism while biochemical,
morphological & functional changes are still reversible.”
(WHO)
• MASS TREATMENT APPROCH

67. Disability limitation
• Disease Impairment Disability Handicaps

68. Impairment
“Any loss or abnormality of psychological, physiological or
anatomical structure or function”
e.g. loss of foot, defective vision , mental retardation
Impairment may
Visible or invisible
Temporary or permanent
Progressive or regressive
One may leads to other

69. Disability
• “Any restriction or lack of ability to perform
an activity in the manner or within the range
considered normal for human being”

70. HANDICAP
• “A disadvantage for a given individual,
resulting from an impairment or a disability
,that limits or prevents the fulfillment of a role
that is normal for (depending on age ,sex,
social & cultural factors) that individual”

71. Example--Accident
• Accident……..Disease( or disorder)
• Loss of foot…………impairment(extrinsic 0r intrensic)
• Can not walk …………Disability(objectified)
• Unemployment ……………Handicap(socialized)

72. Rehabilitation
• Medical rehabilitation- restoration of function
• Vocational rehabilitation- restoration of the
capacity to earn
• Social rehabilitation- restoration of family and
social relation
• Psychological rehabilitation-restoration of
personal dignity & confidence

73. CHANGING PATTERN
OF DISEASE
Developed Country
The leading cause of
death in the United
Stastes 1900 & 1994
Cause of death % death from cause
1900
Pneumonia 11.8
Tuberculosis 11.3
Diarrhoea & enteritis 8.3
Heart disease 8.0
Cerebrovascular disease 6.2
Chronic nephritis 4.7
Accidents 4.2
Cancer 3.7
Certain disease of infancy 3.6
Diphtheria 2.3
1994
Heart disease
32.1
Cancer 23.5
Cerebrovascular disease 6.8
Accidents 3.9
COPD 4.5
Pneumonia & influenza 3.6
Diabetes 2.4
Suicide 1.4
Chronic liver Ds & cirrhosis of liver 1.1
HIV infection 1.8
All other cause 18.9

74. CHANGING PATTERN
OF DISEASE
• Developing Country
In typical developing country 40% Deaths
from infectious , parasitic and respiratory
disease .
Diarrhoeal disease is wide spread.

75. CHANGING PATTERN
OF DISEASE
Devloped country
“Silent epidemic”
e.g. Alzheimer’s disease,
Mental disorders
Developing country
Mixture of old & “Modern”

76. • Knowledge about human health & disease
classified as
Basic Sciences
Clinical Sciences
Population Medicine
POPULATION MEDICINE
-Public Health
-Preventive Medicine
-Community Health
-Social Medicine
-Community Medicine

77. Public Health
• The science & art of preventing disease, prolonging life &
promoting health & efficiency through organized community
effort for the sanitation of the environment ,the control of
communicable infection, the education of the individual in
personal hygiene, the the organization of medical & nursing
services for early diagnosis & preventive treatment of diseases
& the development of social machinery to ensure every
individual a standard of living adeqaute for the maintanance
of health,so organizing these benefits as to enable every citizen
to realize his birthright of health & longevity.
(WHO,Winslow 1920)

78. Preventive Medicine
• Not only the organized activity of community
to prevent occurrence as well as progression of
disease,disability ,mental &physical,but timely
application of all means to promote the health
of individual ,and the community as the the whole ,
including prophylaxisis, health education & similar work
done by good doctor in looking after individuals &
families.

79. Social Medicine
• Social medicine stands up on two pillars,medicine &
sociology .social medicine, by derivation is concerned
with the health of group of individual & individuals
within these group with a view to create ,promote,
preserve and maintain health optimum health.the
laboratory to practice social medicine is the whole
whole community; tool for diagnosis community llness
is epidemiology & biostatastics:and social therapy
does not consist in administration of drug but social
&political action for the betterment of condition of life
of man. Social medicine is one more link in the chain
of social organizations of civilized community ,

80. Community medicine
• The field concerned with the study of health and disease in
the population of a defined community or group.
• Goal – To identify health problem and needs of defined
population.
– To plan, evaluate, the extent to which health measures
effectively meet these needs.
• Diagnosis of the state of health of a community is an
important foundation of community medicine.
• Focus on health need of community as a whole.

81. Hospital & Community
• Diagnosis of the patient in an individual patient in hospital
based on signs and symptoms.
• In community diagnosis is based on pattern of disease in
community described in terms of important factors which
influence this pattern.
• Hospital care – assessment of state of health of individual,
clinical diagnosis, laboratory diagnosis, individual state of
nutrition, level of development, social and emotional state.
• Community care – physician is the leader of “health team”.
Provides primary health care through health team at grass
root level. Familier with community diagnosis.