Public health in India : an overview

Public health services, which reduce a population's exposure to disease through such measures as sanitation and vector control, are an essential part of a country's development infrastructure. In the industrial world and East Asia, systematic public health efforts raised labor productivity and life expectancies well before modern curative technologies became widely available, and helped set the stage for rapid economic growth and poverty reduction. The enormous business and other costs of the breakdown of these services are illustrated by the current global epidemic of avian flu, emanating from poor poultry-keeping practices in a few Chinese villages. For various reasons, mostly of political economy, public funds for health services in India have been focused largely on medical services, and public health services have been neglected. This is reflected in a virtual absence of modern public health regulations and of systematic planning and delivery of public health services. Various organizational issues also militate against the rational deployment of personnel and funds for disease control. There is strong capacity for dealing with outbreaks when they occur, but not to prevent them from occurring. Impressive capacity also exists for conducting intensive campaigns, but not for sustaining these gains on a continuing basis after the campaign. This is illustrated by the near eradication of malaria through highly organized efforts in the 1950s, and its resurgence when attention shifted to other priorities such as family planning. This paper reviews the fundamental obstacles to effective disease control in India and indicates new policy thrusts that can help overcome these obstacles.Health Monitoring&Evaluation,Health Economics&Finance,Brown Issues and Health,Public Sector Management and Reform,Rural Development Knowledge&Information Systems

Lifeboat ethics versus corporate ethics - social and demographic implications of stem and joint families

The author distinguishes the lifeboat ethic of Northern Europe's stem family system from the corporate ethic of North India's joint family system, which has much in common with that of China. She contrasts these family systems to show how norms of residence and inheritance: a) Profoundly influence our values and social constructs. b) Shape patterns of conflict and cooperation between people, thus influencing many basic aspects of social organization and behavior. c) Influence health outcomes by categorizing people according to whether their health is promoted or allowed to fail. d) Shape a wide range of other development outcomes, including migration, strategies of household resource management, ways of exploiting commercial opportunities, and the operation of civil society. The author develops a number of hypotheses about the nature of these relationships. Some of these are substantiated quantitatively, and others can be tested empirically.Population&Development,Social Inclusion&Institutions,Health Monitoring&Evaluation,Education and Society,Public Health Promotion,Health Monitoring&Evaluation,Population&Development,Education and Society,Agricultural Knowledge&Information Systems,Anthropology

Liberte, egalite, fraternite : exploring the role of governance in fertility decline

Within a short span of human history, a secular decline in fertility has taken place around the world. The timing and pace of this decline correspond broadly with changes in sociopolitical institutions indifferent parts of the world. The author hypothesizes that this shift in childbearing behavior is related to cognitive changes wrought by the move from deeply hierarchical sociopolitical institutions to more egalitarian institutions of modern governance. These changes have enabled socioeconomic mobility and improved people's ability to shape their own lives, internalizing more of the positive and negative implications of their decisions, including those about childbearing. Recent work in development economics argues that policies that foster local accountability are the most conducive to rapid development. The author argues that they also foster personal efficacy and rapid fertility decline. If true, her hypotheses indicate that one can expect development and fertility decline to be associated. Some policy environments may lead to"win-win"situations of rapid developments and fertility decline, while others may generate"lose-lose"outcomes.Decentralization,Early Child and Children's Health,Public Health Promotion,Reproductive Health,Health Economics&Finance,Governance Indicators,Reproductive Health,Health Monitoring&Evaluation,Health Economics&Finance,Early Child and Children's Health

Does Hepatitis B infection or son preference explain the bulk of gender imbalance in China ? : a review of the evidence

China has a large deficit of females, and public policies have sought to reduce the son preference that is widely believed to cause this. Recently a study has suggested that up to 75 percent of this deficit is attributable to hepatitis B infection, indicating that immunization programs should form the first plank of policy interventions. However, a large medical dataset from Taiwan (China) shows that hepatitis B infection raises women's probability of having a son by only 0.25 percent. And demographic data from China show that the only group of women who have elevated probabilities of bearing a son are those who have already borne daughters. This pattern makes it difficult to see how any biological factor can explain a largepart of the imbalance in China's sex ratios at birth -- unless it can be shown that it somehow selectively affects those who have borne girls, or causes them to first bear girls and then boys. The Taiwanese data suggest that this is not the case with hepatitis B, since its impact is unaffected by the sex composition of previous births. The data support the cultural, rather than the biological, explanation for the"missing women."Population Policies,Gender and Health,Disease Control&Prevention,Gender and Law,Reproductive Health

Why is son preference declining in South Korea ? the role of development and public policy, and the implications for China and India

For years, South Korea presented the puzzling phenomenon of steeply rising sex ratios at birth despite rapid development, including in women's education and formal employment. This paper shows that son preference decreased in response to development, but its manifestation continued until the mid-1990s due to improved sex-selection technology. The paper analyzes unusually rich survey data, and finds that the impact of development worked largely through triggering normative changes across the whole society - rather than just through changes in individuals as their socio-economic circumstances changed. The findings show that nearly three-quarters of the decline in son preference between 1991 and 2003 is attributable to normative change, and the rest to increases in the proportions of urban and educated people. South Korea is now the first Asian country to reverse the trend in rising sex ratios at birth. The paper discusses the cultural underpinnings of son preference in pre-industrial Korea, and how these were unraveled by industrialization and urbanization, while being buttressed by public policies upholding the patriarchal family system. Finally, the authors hypothesize that child sex ratios in China and India will decline well before they reach South Korean levels of development, since they have vigorous programs to accelerate normative change to reduce son preference.Population Policies,Gender and Law,Gender and Development,Access to Finance,Gender and Health

Gender bias in China, the Republic of Korea, and India 1920-90 - effects of war, famine, and fertility decline

Kinship systems in China, the Republic of Korea, and North India have similar features that generate discrimination against girls, and these countries have some of the highest proportions of girls"missing"in the world. The authors document how the excess mortality of girls was increased by war, famine, and fertility decline - all of which constrained household resources - between 1920 and 1990. Of the three countries, China experienced the most crises during this period (with civil war, invasion, and famine). The resulting excess mortality of girls in China offset the demographic forces making for a surplus of wives as overall mortality rates declined. India had the quietest history during this period, and consequently followed the expected pattern of a growing surplus of available wives. These changes in sex ratios had substantial social ramifications. The authors hypothesize that these demographic factors: 1) Encourages the continuation of bride-price in China, while in India there was a shift to dowry. 2) Influenced the extent and manifestations of violence against women. An oversupply of women is the worst scenario for women, as there are fewer constraints to domestic violence. A shortage of women leads to better treatment of wives, as people become more careful not to lose a wife. However in situations of shortage, a small proportion of women may be subject to new types of violence such as being kidnapped for marriage. Ironically, then, higher levels of discrimination against girls can help reduce violence against women. When women are in short supply, their treatment improves. But their autonomy can increase only with fundamental changes in their family position, changes that are taking place only slowly.Health Monitoring&Evaluation,Public Health Promotion,Population&Development,Anthropology,Demographics,Health Monitoring&Evaluation,Population&Development,Anthropology,Demographics,Adolescent Health

Public management and essential public health functions

The authors provide an overview of how different approaches to improving public sector management relate to so-called core or essential public health functions, such as disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development. The authors summarize key themes in the public management literature and draw lessons for their application to these core functions.Decentralization,Health Monitoring&Evaluation,Health Systems Development&Reform,Public Health Promotion,Enterprise Development&Reform,Health Monitoring&Evaluation,National Governance,Agricultural Knowledge&Information Systems,Banks&Banking Reform,Health Economics&Finance

India's public health system - how well does it function at the National level?

India has relatively poor health outcomes, despite having a well-developed administrative system, good technical skills in many fields, and an extensive network of public health institutions for research, training, and diagnostics. This suggests that the health system may be misdirecting its efforts, or may be poorly designed. To explore this, the authors use instruments developed to assess the performance of public health systems in the United States and Latin America based on the framework of the Essential Public Health Functions, identified as the basic functions that an effective public health system must fulfill. The authors focus on the federal level in India, using data obtained from senior health officials in the central government. The data indicate that the reported strengths of the system lie in having the capacity to carry out most of the public health functions. Its reported weaknesses lie in three broad areas. First, it has overlooked some fundamental public health functions such as public health regulations and their enforcement. Second, deep management flaws hinder effective use of resources-including inadequate focus on evaluation, on assessing quality of services, on dissemination and use of information, and on openness to learning and innovation. Resources could also be much better usedwith small changes, such as the use of incentives and challenge funds, and greater flexibility to reassign resources as priorities and needs change. Third, the central government functions too much in isolation and needs to work more closely with other key actors, especially with sub-national governments, as well as with the private sector and with communities. The authors conclude that with some reassessment of priorities and better management practices, health outcomes could be substantially improved.Public Health Promotion,Agricultural Knowledge&Information Systems,Health Monitoring&Evaluation,Health Systems Development&Reform,Disease Control&Prevention,Agricultural Knowledge&Information Systems,Health Systems Development&Reform,Health Economics&Finance,Housing&Human Habitats,Health Monitoring&Evaluation

How can donors help build global public goods in health ?

Aid to developing countries has largely neglected the population-wide health services that are core to communicable disease control in the developed world. These mostly non-clinical services generate"pure public goods"by reducing everyone's exposure to disease through measures such as implementing health and sanitary regulations. They complement the clinical preventive and treatment services which are the donors'main focus. Their neglect is manifested, for example, in a lack of coherent public health regulations in countries where donors have long been active, facilitating the spread of diseases such as avian flu. These services can be inexpensive, and dramatically reduce health inequalities. Sri Lanka spends less than 0.2% of GDP on its well-designed population-wide services, which contribute to the country's high levels of health equity and life expectancy despite low GDP per head and civil war. Evidence abounds on the negative externalities of weak population-wide health services. Global public health security cannot be assured without building strong national population-wide health systems to reduce the potential for communicable diseases to spread within and beyond their borders. Donors need greater clarity about what constitutes a strong public health system, and how to build them. The paper discusses gaps in donors'approaches and first steps toward closing them.Health Monitoring&Evaluation,Health Systems Development&Reform,Disease Control&Prevention,Population Policies,Gender and Health

Current and evolving approaches for improving the oral permeability of BCS Class III or analogous molecules

The Biopharmaceutics Classification System (BCS) classifies pharmaceutical compounds based on their aqueous solubility and intestinal permeability. The BCS Class III compounds are hydrophilic molecules (high aqueous solubility) with low permeability across the biological membranes. While these compounds are pharmacologically effective, poor absorption due to low permeability becomes the rate-limiting step in achieving adequate bioavailability. Several approaches have been explored and utilized for improving the permeability profiles of these compounds. The approaches include traditional methods such as prodrugs, permeation enhancers, ion-pairing, etc., as well as relatively modern approaches such as nanoencapsulation and nanosizing. The most recent approaches include a combination/hybridization of one or more traditional approaches to improve drug permeability. While some of these approaches have been extremely successful, i.e. drug products utilizing the approach have progressed through the USFDA approval for marketing; others require further investigation to be applicable. This article discusses the commonly studied approaches for improving the permeability of BCS Class III compounds