IAP Textbook of Pediatrics (2 Volumes) A Parthasarathy, Panna Choudhury, RK Agarwal, Naveen C Thacker
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Pediatric Care in Developing CountriesChapter 1

Chapter Editor: Piyush Gupta
  • 1.1 Importance of Pediatrics: RD Potdar 2
  • 1.2 Attaining Proficiency in Pediatrics: BNS Walia 3
  • 1.3 Pediatric Care in Developing Countries: BNS Walia 5
  • 1.4 Primary Health Care: Yuvaraj Chandra Mathur, Nitin Chandra Mathur 7
  • 1.5 Primary Neonatal Care: Santosh K Bhargava 9
  • 1.6 Management of Primary Health Centers: Piyush Gupta 12
  • 1.7 Training of Medical Graduate as Middle Level Manager: C Thirugnanasambandham, T Arunmozhi 16
21.1 Importance of Pediatrics
RD Potdar
Till nearly 50 years back, Pediatrics used to be considered as subsidiary of internal medicine in India and other developing countries. It was but natural that many internists while treating children as small adults, realised that children form a unique, definitive and a fairly large segment of human population. Some of them started studying the health and diseases of children exclusively and in depth and established that Pediatrics was a science and a subject by itself.
Undergraduate students of Medicine must clearly understand the attributes, significance, importance and the necessity of the subject of Pediatrics before they embark on Pediatrics itself, merely as an examination subject. Whether they aspire to become specialists in Pediatrics or its subspecialities or otherwise, knowledge of Pediatrics is essential for every medical student because nearly 42 percent of our population is below 18 years and every physician is bound to face children in his/her medical career as frequently, if not more often than adults.
It is necessary to know the special situation of Pediatrics as a subject because of the following reasons:
 
 
Age Group
Pediatrics, unlike the other subjects includes a wide spectrum of age groups. Each of these age groups have their own physiological, pharmacological, pathological and therapeutic characteristics which need to be remembered while handling respective age groups in clinical situations. The age groups are: (1) fetal period including embryogenesis, (2) perinatal period, (3) prematurity, (4) natal period, (5) neonatal period, (6) infancy, (7) toddler group, (8) preschool, (9) school—primary, middle and high, and (10) adolescence.
The pattern of health norms, presentation of diseases, common causes of diseases as well as dosage and tolerance of drugs differ at these ages. Hence, age becomes a very important consideration in treating a child.
 
Presenting Features
In most pediatric patients, symptoms are not directly brought out like those in the adults. History is always second hand coming from the caregiver more often than the child itself.
Many symptoms get converted into presenting features which are a series of common symptoms representing different organ affections or problems as under:
Crying: It is the most common presenting feature of many conditions such as pain, hunger, thirst, wetting, fear, anxiety, local hurt, etc.
Vomiting: It may be a presenting feature of any system malfunction apart from or in addition to gastrointestinal disease.
 
Paucity of Signs
One may not be able to elicit all classical signs that can be elicited in adults. In Pediatrics, clinicians have to use comprehensive findings of history, examination, investigations and natural history and course of the disease to arrive at a specific diagnosis.
 
Growth and Development
A child is a constantly growing and developing organism making it highly susceptible and vulnerable to various invasive, diagnostic and therapeutic actions. This makes the responsibility of the clinician towards the child far greater than that for the adult. Child is always the passive recipient of treatment and hardly has any choice taking any decision concerning itself.
 
Early Diagnosis and Early Intervention
These have tremendous rewards and importance in children as compared to an adult, e.g. TB meningitis suspected and diagnosed at an early stage can prevent many a tragic sequelae as compared to an adult where early intervention may not be that cost-effective.
 
Drug Tolerance, Interaction and Toxicity
It is different for different drugs at different ages of a child. Since the dosage is related to the body surface or 3the weight, it is essential that a drug dosage guide should always be referred to by the treating doctor. The drug dosage in adults, is generally, in fixed formulation since there is no extreme variation in all ages of adulthood unlike the pediatric age group.
 
Intergenerational Impact
Studies all over the world are proving that impact of previous generations can manifest in the present generation both as far as genetic and environmental factors are concerned. New vistas have opened in causation, prenatal diagnosis as well as therapy in terms of genetic engineering and gene therapy.
 
Pediatric Specialties
Even as the science of Pediatrics has come to stay on its own, further subspecialties are continuously being developed. Neonatology and Pediatric Hemato-Oncology as pediatric superspecialties have already been accepted for DM degree which is a postgraduate qualification. Other specialties are also increasingly developing.
It may be, therefore, said that Pediatrics, the science related to children has come of age in 2009 with adolescents forming integral part of Pediatrics, and its importance in India where most young population of coming century in world will form the major segment.
Pediatrics thus needs a constant attention from all medical aspirant students.
1.2 Attaining Proficiency in Pediatrics
BNS Walia
The time required for mastery of the art of treatment of sick children is not proportional to the size of the child vs the adult human. In fact, it is longer and more arduous. Physical, physiologic and metabolic growth which is taking place from birth to maturity as an adult makes the task as difficult as learning to shoot at a moving target, which is more difficult than shooting at a sitting duck! Learning the fundamentals of ‘growth’ are therefore a prerequisite key to understanding several aspects of pediatrics.
Diseases occur in humans and humans are already nine months old on the day of birth! Therefore knowledge of embryology and prenatal development not only helps to understand the genesis of congenital malformations, but also guides regarding vulnerable periods in the evolution of a fetus, which may affect its entire life span.
Osler had said that “a physician is as good as his pathology”. Knowledge of underlying pathology is important to understand the symptoms observed in a disease process and help to understand its evolution.
A sound knowledge of pharmacology helps one to choose the right drug in the right dose. Medicines are the main armamentarium of a physician. He must be aware of what is available, but he must also find out more about their indications, contraindications, side effects, interactions and dosages before he uses any. This applies especially to uncommonly used drug.
Amongst the common drugs, about which a doctor is expected to be well informed, suffice it to say that you need not burden yourself with the names and details of all the brands of a molecule available in the market. Select some reliable brands and stick to them. It has been well said that drugs are like friends, which must be chosen wisely and once trusted, kept close to ones bosom.
The basic sciences enable you to understand the why and how of clinical phenomena and therefore must form the core foundations for your clinical progress. The foundation must be deeper, the higher the structure you wish to construct upon it.
The clinical years are the most interesting period of medical studies. Learn first of all how to take a good clinical history. A well recorded history should not only provide clues to diagnosis and differential diagnosis but also how the patient has responded to the treatments offered so far as well as how advanced the condition is and what the prognosis might be. This must be followed by a complete and thorough examination of the patient howsoever minor the complaint that brings him to you. Many a time you may be able to detect a corroborative sign or another disease, which is unrelated with the presenting symptoms.4
Though the method of systemic examination of a child is in no way different from that of an adult, the order of examination should begin from least discomforting aspects. Also several differences exist in the interpretation of physical signs when seen in a child as compared to an adult e.g. tremors in a newborn, brisk tendon reflexes in a child, extensor plantar response, presence of bronchial breathing in interscapular region or even presence of palpable liver in childhood! You must be aware of these differences and every book on physical examination of the child emphasizes these.
A special effort must be made to learn—some special aspects of physical examination in pediatrics. These include examination of newborn, assessment of gestational age of a neonate and toddler, neurological examination of a neonate, developmental assessment, assessment of growth and sexual development. Identification of signs of nutritional deficiency and ability to conduct neurological examination of a preschool child also require special attention.
Whereas theoretical knowledge is best obtained as described above, clinical skills are acquired by seeing someone perform the clinical examination. Excellent audio and video recordings are now available to practice clinical skills, after seeing these videos. It is important that some one should watch you while you are performing the developmental examination of a child or maturity rating of a newborn infant. Both of you should point out any faults of the partner and if necessary settle your doubt by asking the advice of a person senior to you. Later on practice case presentations to each other and correct each other on history taking, clinical skills. Make a provisional diagnosis and be able to justify it on the basis of history and clinical sign. It is essential to write down a provisional diagnosis or the next best possibility, so that if you are proved wrong, you can go back to the case and reexamine it to see what you had missed to do, which resulted in a diagnostic error. Do not be depressed if you are proved wrong. Only the persons, who do not commit to a diagnosis, never make a mistake. Clinical pediatrics is not like mathematics. There is a lot of intelligent guess work involved depending upon family, occupational history, epidemiologic conditions and prevalence rates of different diseases in a country. But at all times remember that an uncommon manifestation of a common disease is more likely to be the cause of a difficult diagnostic riddle than a rare disease. When faced with a difficult diagnosis sit down with a list of possibilities which can be considered in the differential diagnosis. Score out those that have features that do not fit and start investigating for those conditions, for which the clinical possibility exists. Arriving at a diagnosis should not be like searching for a needle in a haystack but on the other hand, it can be compared to a concerted pursuit of a crime investigator who is gathering evidence against suspects, to whom the needle of suspicion points.
Inspite of learning all that is said above; your training will be still far from complete. The ability to interpret findings on otoscopy and fundoscopy may have to be learnt by visits to the special clinics of department of ENT and Ophthalmology. A week spent in the department of dermatology will familiarize you with the common dermatological problems seen in pediatrics. Similarly, one requires interactions with a child psychiatrist to understand identification and management of behavior disorders which may masquerade with somatic symptoms.
Cardiopulmonary resuscitation should be learnt on a mannequin before you enter a clinical ward. Who knows you may be required to resuscitate a baby on your first night duty, because none else is available!
Competence and confidence in performing procedures is acquired only by doing the procedures. The more you do, the more proficient you become. There is no place for complacency in dealing with sick children. If you do not know how to do a procedure competently, refer the patient to someone who can. If you mess up the life or limb of a child, remember, there is COPRA waiting to sting you!
Basic science related to the disease conditions you are being taught in clinical pediatrics must be revised at the same time. For instance study of diseases of thyroid should start with embryology and anatomy of thyroid gland, the biochemistry related to synthesis of thyroxin and proceed with clinical manifestations of thyroid deficit or excess. This will enable you to understand why and how certain clinical features of the disease manifest. Information on developmental testing will enable you to pick up children who are slow in their development. Read about the growth parameters at the relevant age and about procedures of bone and sexual maturity rating. Next assess your patient. Make a diagnosis and write down the suspected cause for the abnormality. Read about what tests are best for establishing the diagnosis and for repeated evaluation. Now look at treatment options. Talk to parents of the child on how to use the medicines and what response to expect. Explain why medicines must be continued for life time in a dose that 5may vary depending upon patient's response. Inform parents when to suspect side effects of drugs and when to come for follow up to evaluate that the medicines prescribed are acting and there are no adverse side effects. This is just an example of how medicine should be studied and practiced to obtain a clear idea of what needs to be done and its scientific basis. Studied in this way a proper understanding of medicine is obtained and once understood, it is retained for a long time. The above described method may appear to be too time consuming, but infact, each aspect reinforces the other and the whole exercise becomes enjoyable when you understand its why and how.
When bored or tired pick up any of the numerous atlases available on different subjects or Caffee's book on Pediatric Radiology. Several websites also have excellent picture collections. Look at the pictures and try to store these images in your memory bank. You will be surprised at your own memory which will download a picture several years later and provide you a diagnosis.
Even a life time is not enough to attain mastery over entire field of pediatrics but if you can master the diagnosis and treatment of about 50 clinical conditions, you will be known and respected amongst your colleagues as a competent pediatrician. Surely that is not asking for too much. Each one of you has the potential to achieve that status, provided you focus, continue efforts to improve your skills and have the humility to learn from anyone who knows more than you.
Watch the bedside manners of your seniors who are popular with patients. Note how they approach the patient and the way they interact with parents. When social competence combines with clinical competence, nothing can come between you and success. A friendly helpful and sympathetic attitude is essential at all times for building good relationships that last. Never exploit the misery of a patient who is already in distress. Remember always that a patient's best interest must be first and foremost in your mind.
What you learn at the medical school is a minuscule of the vast ocean of knowledge. You mainly learn to acquire knowledge and some practical skills, which will form the foundation of your future career. What you build on it depends on the inputs of hard work, methodically carried out over span of a life time. A life time is too a short period to master even one specialty or sometimes even one medical disease, but if the quest is continuous, you will enjoy the journey, whatever be the distance you cover.
1.3 Pediatric Care in Developing Countries
BNS Walia
Most of the developing countries suffer from the twin scourges of large populations, with vast numbers living in dire poverty and subhuman living conditions. More than half of the population lives below the breadline, which leads to nutritional deficits. Frequent episodes of infectious diseases further sap away the already poor nutritional status.
Adding to these widely prevalent disadvantages are the complexities of living in deep interiors of countryside, where means of transport are either scarce or nonexistent, health centers are miles away and health service providers are either unskilled or not available at all. These people live on the edge, where ruthless nature and state of neglect takes a heavy toll on the weak and the vulnerable, i.e. women and children. Modern medical care is a distant dream and mere survival is a boon from the Gods.
How and why the situation has been allowed to deteriorate to this extent, is an uncomfortable question. The answer lies in the wrong policies pursued by the government of most of the developing countries, with few exceptions. Over the last few decades, these policies have led to a grave imbalance in the allocation of funds for health projects, so that urban health has been given precedence over health of rural populations which constitute 75–80 percent of toal population of a country. Hospitals have been preferred to dispensaries and maternal and child health (MCH) centers; superspecialty hospitals devoted to cardiology and neurology have been given priority over general hospitals, production of 6doctors have been given precedence over availability of paramedics. This imbalance in the disbursement of scant resources has resulted in a situation, where the interests of many have been sacrificed for the sake of the few. Thus, a vast number of people get no medical care. Hospitals, and dispensaries have been starved of supplies. Doctors and their overproduction have culminated in a situation where doctors have to join the queue of educated unemployed, whereas the country is facing grave shortage of nurses, physiotherapists, speech therapists, audiologists, radiographers and laboratory technicians.
A young doctor who begins a career in medicine has to be aware of these shortcomings in the system into which he has stepped, so as to be able to chart his way to be able to accomplish his life's mission in a meaningful way. The first few years of his professional life are to be spent in a rural dispensary or a health center, where leading a health team is going to be his most important task. It is quite likely, that he will discover that his 5 years at the medical college did not prepare him to effectively cope with his responsibilities. The first lesson that he learns is that he has to learn a lot and that this learning shall continue throughout life. He also feels, that his team-mates also, either do not know how to do what is expected of them or are not motivated to do it. Setting standards, and training each member of the team to fulfill his role, meeting the standards expected, is his next important task. Knowing the epidemiologic profile of the geographic area where he is located, helps him to set his priorities correctly and equip himself with medicines and supplies for geographic pathology pertaining to that area. Having ensured himself of a constant supply line of medicines and other articles needed, he has the wherewithal to get started. However, his success is determined by the response that he gets from the populace and its local leaders.
Illiterate, ignorant of the miracles which modern medicine can perform, suspicious of new experiments to be conducted by strangers and misguided by the indigenous quacks whose vested interests, threatened by the availability of effective medical care to population where the quacks hold a monopoly, the villager is often confused as to where to seek medical relief, even if he is convinced of its greater effectiveness. There are several hurdles to cross before he can reach a primary health center. These include: inability of women folk to travel alone; (none to care for children and animal stock left behind while the family is away), loss of a day's earnings; lack of means of transport; and finally the cursory and callous behavior of health workers, who are generally overworked and steeped in their own professional and domestic worries connected with rural living.
The prescriptions obtained after much effort are often not purchased because the poor patient cannot afford them or they are not locally available. Compliance with a full course of treatment is often neglected because instructions are not clearly given or understood and relief of presenting symptoms is mistaken as cure. This often leads to disastrous results in diseases like pulmonary tuberculosis, where bacteria are liable of becoming resistant to commonly used drugs. Supervision of therapy by domicilliary visits of health staff, is often lacking as numerous vertical programs functioning in the health services encourage an attitude amongst workers of doing their bit for their own program and ignoring the other multiple problems being faced by the patient. Thus, a leprosy worker will not take a malaria slide or look at a conjunctivitis eye, because his target is leprosy eradication. The same is true for workers engaged in blindness control, reproductive health or malaria eradication. Whereas most of the world is depending on the single window approach for numerous public services, we are going on opening new windows, serviced by “one disease specialists” who fail to relate with their clients, and thus fail to win their confidence. It is often forgotten that advice on promotive health care programs, e.g. family welfare which forms a predominant part of primary health care, can only be accepted by a woman from a health worker who has helped her to recover from her last episode of dysentery or assisted her last delivery, and not from a stranger, who is chasing her for his personal targets. The recent change in the objectives of the family welfare program to reproductive health program, is indeed a welcome step and is expected to divert the attention of workers from achievements of targets to quality services, to be provided to their clients.
Imparting health education should be an important task of every health worker. He must try to impart some messages related to the problems the patients are facing, at every encounter. This is the only way to counter the scepticism rooted in age-old beliefs in witchcraft and supernatural powers. All traditional beliefs may not be harmful and some indeed may be beneficial to the patient. Unnecessary confrontation of views should be avoided.7
Patients are often brought late to the hospital, and in a critical condition. Their patience as well as their financial resources get exhausted. Promptness in attending to the patient, politeness in dealings, and an attitude of concern and care by the staff is essential. Our patients believe us to be “Gods”, and not mere “Docs” as compared to our co-professionals in developed countries. We must try to live up to the expectations of the people, by showing compassion, and concern, in our dealings and competence in our jobs, to deserve that appellation.
1.4 Primary Health Care
Yuvaraj Chandra Mathur, Nitin Chandra Mathur
All countries of the world are concerned about the problem of primary health care (PHC) for their people. This concern includes such aspects as how to provide it, how to achieve coverage for all of the people, how to provide primary health care of some quality, how to make the maximum use of the country's and community's existing resources, both personnel, equipment, and supplies, and how to link up primary health care at the local community level with secondary and tertiary health resources.
It is for these reasons that the international conference on primary health care was held by the World Health Organization at Alma-Ata in 1978.
 
Definition
Primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country's health system of which it is the nucleus.
 
Content
Primary health care addresses the main health problem in the community, providing promotive, preventive curative and rehabilitative services accordingly. Since these services reflect and evolve from the economic conditions and social values of the country and its communities, they will vary by country and community, but will include at least: promotion of proper nutrition and an adequate supply of safe water, basic sanitation, maternal and child care, including family planning, immunization against the major infectious diseases, prevention and control of locally endemic diseases, education concerning prevailing health problems and the methods of preventing and controlling them, and appropriate treatment for common diseases and injuries.
 
General Principles
  1. PHC should be shaped around the lifestyles of the people to be served.
  2. PHC should be an integral part of the National Health Care System and other services, in particular supplies, supervision, referral and technical, and it should be designed to support the needs at the peripheral level.
  3. PHC activities should be fully integrated with the activities of the other sectors involved in community development (agriculture, education, public works, housing, communications).
  4. The local population should be actively involved in planning health care, so that it suits their needs and priorities. Decisions on what are the community needs requiring solution should be based upon a continuing dialogue between the people and the services.
  5. The health care offered should make use of the available community resources, especially those which have hitherto remained untapped, and should remain within the limits of the funds available.
  6. PHC should use an integrated approach of preventive, promotive, curative, and rehabilitative services for individual, family, and community. The balance among these services should vary according to community needs and may well change over time.
  7. The majority of health interventions should take place in or as near as possible to the patient's home and be carried out by the worker most simply (but adequately) trained to give the treatment in question.8
 
Who Provides Primary Health Care?
Primary health care is usually delivered by community health workers. These are public health workers, usually from the local villages which they serve. They may be full time or part time, they are usually paid. The PHC worker needs to understand and be knowledgeable about the major health problems and needs in his or her community. For primary health care of women, infants, and children, the traditional birth attendant (TBA) has been the person providing primary health care in the villages.
 
Training of Primary Health Care Workers
In order to provide safe basic PHC, one of the early steps required is to define the roles, duties, and functions, the PHC worker is expected to carryout this “job description” for the community health worker then needs to form the basis, for the content of the training program for the PHC worker. This also means that the workers/trainers of the PHC need to be prepared in the appropriate content expected of the PHC staff.
Not only appropriate teaching/training of the PHC staff is essential, careful supervision of the PHC staff is also essential on the job. Responsibility for their supervision needs to be clearly delineated. The supervisors need to be familiar with the job description of the PHC staff, and with the content necessary to supervise them, as well as methods of supervision.
In a similar fashion, there needs to be a job description of traditional birth attendants (TBAs). Courses for TBAs need to contain content to enable them to provide good safe basic prenatal, labor and delivery, and postpartum care for the mother. They need to be able to teach and carry out principles of safe hygiene, and health education for mother and baby. They need to be taught the principles and content of safe care of the newborn, of observation of the infant, and of breastfeeding, and carefully timed supplementary food and weaning. They need to be trained in family planning education, and in well child supervision of the infants and children.
Besides, all PHC staff need to be well-trained in the content of prenatal, intrapartum, postpartum, family planning, and child health care.
 
Role of Family Members, Especially the Mother
Family members, especially the mother, are often the main providers of health care for the family. It is the mother who raises and cares for the children, as well as other family members. It is the mother who usually cooks the food and feeds the family. It is she who observes the condition of children, and who notices and attempts to treat illness in the children. This means that women of the family need to have a good working knowledge of health care, including hygiene, feeding, family planning, and how to follow the child's development and recognize the signs of early illness. Health education as well as general education of women is essential. Women's organizations can play an important role in this matter.
 
The Risk Approach
PHC workers need to be taught and be able to utilize the risk approach. This consists of the ability to follow carefully and observe pregnant women, infants, and children, for symptoms/signs/risk factors which might lead to suspect the presence of a potential health problem requiring special care and referral. The concept of high-risk at a simple basic level needs to be taught to PHC workers. Risk factors recognizable by the PHC worker need to be included in the training of PHC staff. Patients suspected of being potentially at high-risk need to be observed and followed more carefully. Arrangements for quick referral of high-risk patients are essential.
 
Linkages to Secondary and Tertiary Care, Referral System, and Transport
Patients suspected of high-risk need to be referred to a resource available to the community, able to provide special diagnostic treatment, and management service and care, especially a health center or local/district hospital. A referral system needs to be established so that easy, smooth, quick and efficient referrals may be made through a prearranged system. Quick safe transport is an important aspect of such a referral system.
 
Indicators of Care and Outcome
As with any activity in public health practice, evaluation of results is essential for primary health care. Record keeping is essential. The use of home-based mother health records is being tested. The development of a system and of indicators is an important aspect. Basic indicators such as accessibility to health care, births attended by a trained attendant, access to safe drinking water, level of immunization, contraceptive prevalence are frequently utilized to evaluate outcome of PHC.
91.5 Primary Neonatal Care
Santosh K Bhargava
 
Primary Neonatal Care
The sustained decline in infant mortality rate, caused largely by a decrease in post-neonatal period mortality has focussed attention to neonatal mortality and newborn care. If the national goals in child health care are to be achieved then it is essential to improve neonatal care at all the three levels namely primary, secondary and tertiary level. The primary neonatal care deserves highest priority as even today more than 75 percent of births occur at home in both urban and rural community and are attended by trained or untrained birth attendants. Primary care is intended for all parturient mothers and their offsprings irrespective of rural or urban community, institutional, hospital or home delivery for successful outcome of pregnancies. To achieve this and the birth of a healthy newborn it is necessary to care and improve essential prenatal, intranatal, and postnatal care to an expectant mother and neonatal care at birth subsequently.
 
Antenatal Care
The most crucial period for a parturient mother and her fetus is the antenatal period because it is during this time inappropriate or inadequate care may result in problems to both. All pregnant women should have access to antenatal care by trained health professionals. It should include assessment of maternal health, including weight, height, midarm circumference, nutritional assessment, obstetric history and obstetric examination for intranatal risk, follow-up for pregnancy complications such as anemia, hypertension, urinary infection, etc. and assessment for fetal growth. Figure 1.5.1 provides a plan for antenatal care. In our limited resources it is essential to categorize a pregnancy at low or high-risk because a timely referral of a high-risk pregnancy for appropriate care will prevent adverse outcome. Simple information such as bad obstetric history, maternal weight less than 45 kg, height less than 140 cm, birth interval of less than 2 years between two successive pregnancies, pregnancy complications, etc. are indicators of high-risk mothers.
 
Intranatal Care
Safe and clean delivery remains the main objective of good intranatal care. The community must be made aware and encouraged to use safe delivery kit (Table 1.5.1) and delivery by trained birth attendant.
zoom view
Figure 1.5.1: Delivery of perinatal care at primary level
10
TABLE 1.5.1   Birth attendant's kit of safe delivery and newborn care
• Soap
• Plastic sheet
• Cotton and gauze pads
• Thread or ligature
• Razor blade
• Mucus suction trap (may be disposable)
• Spring balance (reusable)
• Measuring tape (reusable, fiber glass)
Hand washing with soap, use of sterile thread and blade, facilities for oropharyngeal suction and warmth at birth are key components of ensuring safe birth.
 
Postnatal Care
A postnatal mother needs to be looked after not only for postdelivery complications such as bleeding and infections but also for initiating and maintaining successful breastfeeding. She must be informed about harmful traditional practices for maternal and newborn care and advised on routine newborn care.
 
Neonatal Care
All newborns irrespective of place of birth, person conducting the birth, whether preterm, term or post-term, normal or low birth weight, apparently well or sick need care for their survival and well-being. This care is a newborn's primary need as prior to birth it is well-protected in safe, sterile and suitably warm in utero environment. The primary care is thus intended to support it to establish successfully its respiration, temperature, nutrition and provide safe environment. In our country almost two-thirds of births occur at home and the remaining at hospital or health care facility. Thus, a newborn is to be cared at home by traditional birth attendants or family and at varying levels of health care by medical professionals who themselves may or may not have been suitably trained.
 
Domiciliary Care
The domiciliary care of a newborn is usually determined by the family tradition, grandmother or any elderly lady in the house. The family practices are usually steeped in tradition, cultural and religious practices. It is therefore necessary to be aware of these practices, their sensitivity to the family to provide appropriate beneficial advice and warning against harmful practices (Table 1.5.2). The advice for home care should be simple and acceptable to family. This should include provision of clean birthing place, delivery by trained birth attendant, use of safe delivery methods and the mother and the newborn to be nursed in warm, clean, well-lighted rooms.
TABLE 1.5.2   Some harmful traditional practices of newborn care
Harmful Practices
Umbilical cord
  • Cord cutting
  • Cord tying
  • Cord application
  • Sickle- or knife-shaped instruments, bamboo spike
  • Thread, cloth, bamboo shred
  • Ghee, turmeric, cow dung, ash
Resuscitation
Slapping, ringing bell, blowing air across mouth, roasting placenta, etc.
Cleaning oropharynx Bath
Finger, cloth Immediately or within few hours of birth
Prelacteal feeds
Honey, jaggery, glucose, janam ghutti
Time to first feed
Delayed from 6–48 hours or more
Breast milk
Discarding colostrum
Eyes, ear, nose
Kajal and oil application
The basic features and components of primary newborn care have been well-defined and accepted for delivery of newborn care at primary level as a package comprising of care at birth, in the immediate neonatal period and subsequently. This package is known and described as essential newborn care (Table 1.5.3). It aims to assist the newborn in establishment of cardiorespiratory effort, prevention of hypothermia and maintenance of body temperature, a physical clinical examination for identification of at risk infant, congenital malformation; early initiation and maintenance of successful breastfeeding and referral of a high-risk or sick newborns for appropriate care to higher level of care.
 
Care at Birth
The birth of a newborn should always occur in a clean environment. The room temperature should be suitably warm. The newborn should be received in a prewarm clean cloth and dried immediately preferably under a radiant heat source and kept warm.11
TABLE 1.5.3   Essential newborn care
• Care at Birth
  • Warmth
  • Initiation and Maintenance of adequate respiratory effort
  • Prevention of Infection
  • Referral for appropriate care
• Care During Immediate and Early Neonatal Period
  • Warmth
  • Early Breastfeeding
  • Prevention of Infection
  • Early diagnosis, appropriate care and referral of a sick newborn
• Care in Late Neonatal Period and Beyond
  • Follow-up
  • Intervention
The time to first cry and breath should be recorded. Most of the newborn cry immediately at birth. Those who fail to cry may need resuscitation.
There are several methods to assess the cardio-respiratory effort of the newborn but the most commonly used method is the Apgar score. The Apgar score consists of giving a score of 0, 1 and 2 to color, heart rate, reflex irritability, muscle tone, respirations at 1, 5 and 10 minutes of birth. A score of 7 or more is considered normal and lower score indicates the need to resuscitate the infant as described elsewhere. However, at peripheral level and for primary care health professional such as traditional birth attendant the time to first cry and whether it is lusty, feeble or poorly sustained and the color are reasonably good indicators to reflect newborn's condition at birth.
A clinical examination at the earliest opportunity after birth is mandatory for all newborns. This is aimed to identify an infant whether he/she is normal or at risk and for determining appropriate level of neonatal care. It is ideal to measure an infant by recording birth weight or by surrogate to birth weight such as midarm circumference by using measuring tape or bangle. A newborn is at a very high-risk of acquiring infection and susceptible to adverse effects of cold or hot environment resulting in hypothermia or fever. It is therefore critical to ensure asepsis and suitable environmental temperature of 26–28°C for protection of the newborn.
 
Care in Immediate Neonatal Period
 
Warmth
A newborn continues to remain susceptible to hypothermia and hence it is necessary to provide warmth to him by radiant heat source such as infant warmers, lighted bulb or other suitable means such as nursing of the mother and the infant in same bed. A heat source should never come in direct contact with the infant or very close to him as this may cause burn or hyperthermia. The child should be appropriately clothed.
 
Early and Sustained Breast Milk Feeding
All newborns should be put to mother's breast as soon as possible after the birth. Early and sustained breast milk feeding is vital for a newborn's survival not only in the immediate neonatal period but also in later months. It is constant suckling of the breast by the infant which results in successful breastfeeding. In case it is not possible for an infant to directly breastfeed, the breast milk should be expressed and the infant fed the same by cup and spoon. Feeding of a newborn with artificial milk feeds endangers it to preventable morbidity and mortality.
 
Prevention of Infection
A newborn is at a very high-risk of acquiring infections from surroundings and/or by people visiting or handling him. It is therefore necessary to wash hands with soap and water before handling the newborn, avoid unnecessary handling by person other than mother or visiting of the newborn by relatives and friends. All newborn must be exclusively breastfed and water, prelacteal feeds such as honey, ghutis, gripe water or unnecessary medication by mouth must be prohibited. The dangers of such practices must be explained to family and mother.
 
Early Diagnosis, Appropriate Care for a High-risk or Sick Newborn
A good history and clinical examination will help in identifying almost all at risk and sick newborns. Birth weight, gestational age, cry at birth, color, movement, activity, body temperature, abdominal distention, tachypnea, refusal or decrease in feeds are dependable signs or symptoms for an early diagnosis. Infants with birth weight less than 2 kg, preterm irrespective of birth 12weight, feeble, ill-sustained or excessive crying, poor color and decreased activity warrant careful observation and need for appropriate or higher level of supervised medical care preferably in a health care facility.
 
Immunization
It is preferrable to immunize the newborn at birth or within two weeks with oral polio and BCG vaccination. Hepatitis B vaccine may be administered in high-risk infants or where the family is able to afford it.
 
Care in Late Neonatal Period and Beyond
The care of the newborn does not end with the discharge from the health care facility or postnatal follow-up of the mother. All infants should be advised adequately on need to follow-up in well baby/immunization clinics for nutritional advice, growth assessment, immunization and for an early diagnosis of developmental delay or disability for appropriate optimal care.
 
BIBLIOGRAPHY
  1. Bhargava SK. Recent Trends in Neonatal Health and Care in India-International Workshop—Improving Health of the Newborn Infant in Developing countries. Kathmandu-Nepal, 1997; 7–10.
  1. Health Information of India 1994.
  1. National child survival and safe motherhood program, integrated clinical skills course for physicians, MCH division, Ministry of Health and Family Welfare, 1993.
  1. National Health Policy, Govt. of India, Ministry of Health and Family Welfare, 1985.
  1. National Neonatology Forum, Proceedings of National Workshop on traditional practices of neonatal care in India, 1991.
 
1.6 Management of Primary Health Centers
Piyush Gupta
The basic aim of the Primary Health Center is to provide primary health care to the people it serves.
 
WHAT IS PRIMARY HEALTH CARE?
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.
Thus the doctor at a Primary Health Center (PHC) has a different role to play. He/she not only delivers the health care but manages the center in totality, trains and leads the team, involves with the community, gets to know the local people, geography and epidemiology of diseases, devises strategy, and coordinates with other managers and stakeholders (both in public and private domains) under the jurisdiction of the PHC.
 
Steps in the Management of Primary Health Care
  1. Assessment of the situation
  2. Selection of priorities
  3. Defining objectives and deciding possible strategies to accomplish them
  4. Involving community
  5. Mobilization of resources
  6. Selection and training of personnel
  7. Identification and supply of essential drugs and equipment
  8. Patient management
  9. Monitoring and supervision of the progress of work
  10. Team management
 
Assessment of the Situation
Health situation in the PHC area should be reviewed with reference to health profile of the people. Availability of local resources should be estimated. Details of other demographic and cultural characteristics of the population in the catchments of the PHC should be obtained. Before hand knowledge of the following factors is generally valuable in planning out of health facility: demography (age and sex distribution, spread of education, average income and economic stratification, religion and caste groups, cultural beliefs and taboos, attitudes towards health, expectations from the proposed health facility and identification of influential as well as 13functional community leaders), health profile (prevailing disease pattern, number of people with disability or handicap, proportion of expectant mothers, infants and young children; age-related death rates, food habits, other health practices, the level of sanitation and hygiene in the community), available resources (the state of agricultural development and irrigation facilities in the area, income stratification, availability of food and sources of potable water, existing health facilities in the area and their utilization, presence and number of available traditional faith healers, traditional birth attendants, practitioners of indigenous systems of medicine, and information regarding organized voluntary agencies or establishments such as village panchayat, health clubs, youth or women's clubs and other voluntary non governmental bodies), and the catchment area (geographic terrain, climate, roads and other means of communication).
 
Selection of Priorities
There may be several compelling health problems necessitating attention in the territory. With the meager health resources generally made available through government agencies for primary health care, every health need of the community cannot be satisfied. It is necessary to be selective. The health issues and the target group of people who merit preferential attention should be recognized and looked after first. Most people seek prompt relief from pain and affliction. Provision should be made for emergency treatment of life threatening conditions. It is more realistic and expedient to try to prevent large number of deaths due to vaccine preventable diseases by immunization than using enormous money to extend the life of a few terminally-sick cancer patients. Cost effective health interventions should receive precedence in planning in relation to those illnesses which though common are hard to prevent or manage.
 
Defining Objectives and Deciding Strategies
The next step is to identify the objectives proposed to be achieved through the health care activities. It is not always necessary to formulate idealistic health objectives. It is more important to be rational and set objectives, which are feasible and attainable within a reasonable time, with the given resources. The objectives should also be pertinent to the country's national health policy and needs. It should be possible to quantify the results of health interventions so that their cost-benefit or cost-effectiveness can be evaluated.
An objective may be achieved by several possible alternate strategies. As a general principle, relatively inexpensive and flexible strategies should be adopted for the management of prevalent common health problems. After carefully reviewing various alternate strategies, their advantages, disadvantages, cost-effectiveness, scientific soundness and cultural acceptability, decision should be made about the activities that should actually be undertaken in accordance with the declared national health policy. The decisions should be technically sound and correct. Possible constraints and obstacles in implementing these activities should be carefully looked into. Adequate prior planning should be done by interaction between the community, members of the health team and the administrative officers.
 
Community Involvement in Primary Health Care
Active participation of community in health care is vital to make health services readily accessible to the people and for better utilization of the PHC. This approach relies on creating increasing awareness among local people about health and health related activities, so that they can commit themselves and have stakes in the success of health activities. People should be actively mobilized to take more interest in development of health services in their area by explaining the purpose of health activity and describing an action plan. Individuals who can assume leadership role are identified. A health committee should be formed from among these influential community leaders to analyze health needs of people and to plan and execute health projects. The committee should interact with health professionals to find locally feasible solutions to the identified problems. The Committee should assess and mobilize resources and assign responsibility for achieving objectives.
 
Mobilization of Resources
Money, personnel and time are the three most important resources that need proper mobilization at a PHC. There should be adequate working space at the health post for members of the health team to operate from a base. Means of communication with the referral centers should also be easily available. A critical minimum amount of resources is needed to maintain the quality of health 14services at an effective level. The resources can be mobilized, either from the government, community, non-government-voluntary agencies or recognized international agencies. It is advisable to rely only on those funding agencies, who assure help on a longterm basis and who create a permanent infrastructure, so that the projects aided by them can become self reliant in the long run.
 
Selecting and Training Personnel
It is almost impossible for a developing country to employ fully trained graduate physicians for all aspects of primary health care. At a PHC, you will need to delegate some of the simpler health tasks to the paramedical workers. Increasing dependence on other categories of personnel with limited on the job training in specific areas of work becomes necessary. Preferably, they should be drawn from as well as chosen by the community they are expected to serve. It does not matter even if they have a lower academic background. These paramedical workers will have to be increasingly employed for assisting the busy and overworked physician for routine and simpler health related tasks. The latter will, then be able to devote more of his time for complex health chores, administration and planning. It is necessary to supervise the work of these specially trained health workers and retrain them periodically for the expected job requirements. Physician should provide technical guidance and support to these workers. The training can be extended to the practitioners of indigenous or traditional systems of medicine, traditional birth attendants, local priest, faith healer or exorcist in the village who performs witchcraft, branding or other rituals; and even the quacks.
 
Identification and Supply of Essential Drugs and Equipment
Essential medicines (those that satisfy the priority health care needs of the population) should be made available at the PHC. Selection of these drugs also depends on local health needs and health services. Ensure adequate and timely supplies of drugs, and immunizing agents. You should be aware of the sources of supply of drugs and procedure for ordering these. The requirements of drugs should be estimated for at least a quarter of the year. The drugs are best stored in a cool-dry place away from direct sunlight. Vaccines should be stored in refrigerator and electricity supply should be ensured. Drugs should be arranged by their generic names in shelves in alphabetical order or according to the therapeutic class (their usage or indications) but not according to the manufacturer or suppliers. Drugs with a recent date of expiry should be used early. Record of all drugs should be kept in a stock book. Drugs should be issued by the storekeeper to the dispenser against issue vouchers and an entry should always be made in the stock book and stock card. Only the minimum essential quantity of drugs required for use on that day or week should be issued at a time, to prevent excessive wasteful use and to minimize the possibility of pilferage.
Medical, surgical equipment, furniture, stationery and other consumable and nonconsumable stores are also essential resources for primary health care posts. Non- expendable stores such as furniture, weighing scales, bedpans, screens, surgical equipment, microscopes and motor vehicles if properly handled, are not easily damaged and can be kept in use for several years. These should be maintained in working order by regular and timely repairs. Drugs, food, paper, syringes, laboratory reagents, kerosene, petroleum, candles, match boxes, torch cells, cotton wool and surgical dressings etc. are actually expended and are called expendable stores. Architecturally, the space within the building should be so arranged, that it facilitates smooth and orderly work, and does not cause inconvenience or obstruct the movement of staff or the patients. A to and fro flow of patients or a common entrance and exit are not conducive to good working arrangement. Records and paper work are essential and unavoidable in a primary health care setting. Stock books and ledgers have to be maintained and general correspondence attended. Periodic report of work is to be submitted to the higher authorities. Poorly maintained and disorganized records books indicate poor management, inefficient patient care, inadequate supervision, mishandling and wasteful use of resources. Stationery and printed forms should be available for outpatient registration, treatment, referral laboratory and X-ray requisition, growth monitoring, immunization and follow up of special diseases such as tuberculosis and leprosy. If the primary health care post has some maternity or general beds, inpatient admission forms, record forms and discharge summary will also be needed.
Health care forms should be designed for easy and effective use. Paper should be used economically, but 15there should be enough space for writing the data. A badly printed form may be used badly, making if difficult to retrieve useful information.
 
Patient Management
Disease management is a priority as it relieves distress of the patient and develops confidence. A delay in initiation of medical care raises the tensions and temper. First Aid should be provided promptly. If a patient requires referral, arrangement for a transfer should be made, transport arranged and a summary of treatment received by the patient should be provided. Emergencies should be given priority. Outpatients should be seen during a fixed time. Other services, which are not run on daily basis, should be clearly advertised. A paramedical worker or a physician should be the first person of contact at the primary health center.
 
Monitoring the Progress of Work
The leader of the health team is expected to set targets for different members of the health team. He should define the tasks to be accomplished within an agreed schedule of time.
The efficiency of different workers may vary and certain essential inputs for optimal functioning may not be available at the appropriate time. To achieve the best results, you should periodically review the progress of all work at specified intervals. You should judge the pace of the work by relating it to the earlier agreed job schedules, reports of their achievements and site visits for personal observations and discussion with the staff. Periodic monitoring helps in recognizing obstacles or unforeseen difficulties in accomplishing the desired objectives. Monitoring is useful in good management but it should be minimal, flexible and timely.
 
Leading the Health Team
Because of the nature of his training, education and status, the primary health center doctor has to assume the role of a natural leader of the PHC team. All personnel working in the PHC constitutes the health team. As a team leader, you should be able to induce colleagues and teammates to work to the best of their capacity, and motivate them. The team leader should be able to achieve perfect coordination and cooperation with all members of the team, so that the efficiency and output of the health team are high and the work is interesting, satisfying and rewarding.
The leader of the health team should realize that the health team consists of individuals, who have feelings, personal interest, anxieties, stresses, conflicts, likes and dislikes, just as other people. People like to be useful and important. Their emotional needs are better satisfied, if they are given the responsibility and authority to carry out the jobs assigned to them. Their efficiency and work output improves, if their working conditions are congenial, peaceful and relaxed with the least tensions and conflicts. The efficiency of a worker declines if he or she remains preoccupied with personal needs, such as lack of adequate lodging close to the place of work, long hours of work, want of personal security, financial worries, inadequate facility for children's education, poor health or perfunctory personal medical care. It is distressing to them if their salaries are not paid in time. Monetary incentive by itself is not adequate for motivating a health worker to do his work more conscientiously. Monetary reward should be judiciously combined with recognition and approbation for his good work.
The leader should be competent in his own technical work, so that his team mates respect him for his knowledge and skills. He should zealously guard his own credibility for fairness, impartiality, honesty and integrity. The leader should be easily approachable, so that the team members can reach him and seek his help and guidance for solution of their personal, technical and official administrative problem. The leader should always appear to be disciplined and well organized in his thought and work. Delegation of responsibility and authority to the health team is equally important in the PHC.
Health team is like a chain: One weak link in the chain breaks the entire chain. A good leader identifies the weak links by constant supervision at regular intervals. He then reinforces them by appropriate measures such as technical guidance, administrative support and corrective retraining. Regular supervisory control helps the leader to discover other constraints such as non-availability or delay in supplies of such needed items.16
1.7 Training of Medical Graduate as Middle Level Manager
C Thirugnanasambandham, T Arunmozhi
The World Health Organization, at Alma-Ata conference on 12th September, 1978, declared that ‘Health’, a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, is a ‘fundamental human right’. There is also an increased realization, backed by scientific evidence, that neither the individual nor the nation can achieve optimal health until we tackle what are commonly known determinants of health-broadly associated with and arising out of physical, social, economic, cultural and political environment. The national and state governments are committed to the achievement of ‘Health for All’, as early as possible through the primary health care approach. That these efforts have had substantial success can be seen from some of the indices like reduction in crude birth rate (CBR) from 40.8 (1951) to 25.8 (2002); halving the infant mortality rate from 146 per thousand live births (1951) to 60 (2001); reduction in crude death rate from 25 (1951) to 8.5 (2002); addition of 31 years to life expectancy from 32 to 64 (2000); and reduction in total fertility rate from 6.0 (1951) to 3.0 (2000). In spite of these successes, the unfinished task for achievement is still high as can be seen from the sociodemographic goals set for the 11th Five Year Plan. Currently India is committed to become a developed nation by the year 2020, which calls for very substantial improvement in health, education, economic development and other areas. A revised strategy for the achievement of these goals have also been formulated and consists of provision of integrated service delivery for reproductive and child health care; decentralized planning and program implementation; convergence of service delivery at village level and empowering women to function as change agents in addition to being consumers of health care services; removal of gender inequalities, and special attention to removing inequity in health care by focusing services to underserved areas like urban slums and hilly and tribal areas and disadvantaged groups like women, female children and adolescents; diverse health care providers; collaboration with Non- Governmental Organizations (NGOs); intensified information, education and communication activities; intersectoral coordination and providing for older population. In addition, the strategy provides for social inputs like increasing literacy and raising age of marriage. In general, the program will continue to be community and maternal and child health (MCH) based.
 
Primary Health Care
The health infrastructure for the delivery of services in health and family welfare consists of the primary health care system. Presently, one primary health centre (PHC) caters to about 30,000 population (20,000 in hilly and tribal areas), one subcentre to about 5000 population (3000 in hilly and tribal areas). In addition, there is one community health centre (CHC) with 30 beds for every 3 PHCs. Both the Taluk and District headquarters hospitals are being equipped and staffed to provide for referral services.
 
Epidemiological Transition
Technological advances in medical and allied sciences have brought down the mortality rate to the targeted level, but the morbidity burden on the society continues to remain high. Both communicable and non communicable diseases rank almost equally in contributing to the high level of morbidity. An additional challenge is the wide disparity in health status between states, within the state and between social groups.
While the disease burden remains unchanged, the pattern has been changing. It is now certain that the health challenges for the next few decades will consist of communicable diseases like HIV/AIDS, drug resistant malaria, tuberculosis, diarrhea and acute respiratory infection among children. The second challenge concerns non communicable diseases like the upsurge of cancer and cardiovascular diseases and other life-style related diseases such as diabetes, high blood pressure, mental depression and suicide and accidents. Increase in tobacco consumption is a cause for added concern. The spread of HIV/AIDS has the potential to offset the hard gains achieved in child survival and life-expectancy. Widespread malnutrition, poverty and illiteracy, as well 17as the generally low status of women impede equitable health development in the country.
Significant changes have taken place in the health scenario in the country since independence.
  1. The predominantly clinical approach in solving health problems has given rise to a mix of curative, preventive, promotive and rehabilitative approach.
  2. A huge infrastructure has been created in the rural areas for delivery of health care and family welfare services. The workload of the medical officers, custodian of health in their areas, has very much increased and consists of integrated curative, preventive and promotive service delivery. Over and above, are the essential management functions in terms of planning, coordination, supervision, training and others.
  3. Renewed emphasis on community involvement, through the recently introduced Panchayati Raj system, in planning and implementing various programs resulting in a need to readjust responsibility and authority and changes in the working of the bureaucracy.
  4. Integration of a number of vertical programs into the rural health services.
  5. The realization that national/state governments working through health sector, by themselves can never achieve the health and demographic goals set. The private sector, NGOs and sectors other than health, like education, industry, social welfare, rural development and civic society can and should play a critical role in health development. Partnerships with all sectors of society and at all levels are imperative if we are to bridge the equity gap in health.
  6. Major shift from the clinic-catered approach to one of a suitable mix of clinic and outreach services.
  7. The total expenditure on the health system has been increasing every year, but has remained static at about 0.9% of the Gross National Product (GNP) over the past two decades. The current level of expenditure is inadequate to bring about reduction in infant mortality rates envisaged under the eleventh plan and reach the millennium development goals. The government has planned to increase the expenditure to 2–3% of GDP by the year 2010 and it is hoped it will materialize.
The above shifts have resulted in major changes in the roles and functions of the middle level managers of health delivery system, particularly of medical officers from that of a pure clinician to include public health practice, communication and health management.
 
Health Services Management
A neglected area so far is that of health services management. The effectiveness and efficiency of the health care delivery system cannot improve significantly, unless sound administration or management practices are adopted to improve the system. It has been the assumption till recently that persons trained in medicine or public health automatically qualify to become managers. Only in the last few years, it has been recognized that this assumption needs change and good managers need sound training in principles and practice of health management or administration.
Administration or management could be defined as a process by which, the potentials of men, money and materials are synthesized and synchronized for the achievement of well-defined goals. It is a way to structure and direct human groups function cooperatively to achieve predetermined goals. Generally, administrative process involves: (i) technical functions, (ii) political functions, and (iii) conflict resolution functions.
Technical functions are best indicated by the well-known seven letters namely POSDCoRB: P for planning, O for organizing, S for staffing, D for directing, Co for coordinating, R for reporting and B for budgeting. Political function is not to be conceived as partisan function of politics, it is concerned with making of policies and structuring of power relationship in an organization. Conflict resolution process aims at resolving conflicts amongst individuals, organizations and between individual and organization goals.
The middle level functionaries in health system should possess sound knowledge and skills in the process of planning, coordination, supervision, training, monitoring and evaluation, communication, community participation and management of subsystems like office management, logistics, budgeting, vehicle management, etc.
 
Planning
A plan is predetermined course of action, it involves the intelligent use of resources and working out the broad outline of things that need to be done and the methods for doing them. The middle level managers are concerned with operational level planning. They are concerned with area planning, area being determined by geographic 18jurisdiction of workers and also governed by those of panchayats and panchayat unions.
The essential steps of planning include collecting baseline information, setting objectives, deciding on courses of actions and programming. Monitoring and evaluation is an integral part of planning. The planning cycle consisting of: planning, implementation, monitoring, replanning with repeat, contributing to a greater progress. However, it will also call for increased managerial skills on the part of medical officers.
Collection of baseline data is a prelude to community diagnosis which helps to define community health problems, their severity, place of occurrence, etc. The process involves decision on information to be gathered, framing and administration of questionnaire, data analysis and report writing. Maximum use has to be made of existing sources of information, restricting household/community surveys to a bare minimum. Once the problems are identified, various options to solve these have to be considered and the ones that are technically feasible, cost-effective, administratively feasible and politically acceptable are chosen.
A problem usually encountered at this level is the need to strike a balance between what community perceives as their felt needs, epidemiologically determined needs of the area and nationally determined priority needs. The medical officer will have to feed all necessary information at this stage to the community and of which they are not aware of. It has been the experience that the community will be able to make sound decisions irrespective of illiteracy, when once they have the information to base the decisions upon. This way, an agreed level of needs with priorities could be reached.
Planning process should also ensure that consumer representatives are involved in the planning process at every stage. Involvement of community through leaders, teachers, students and others in the information gathering process is highly rewarding as it helps to conserve time and energy and arouses the perceptual curiosity of the people and successful implementation of programs decided upon.
Detailed programming for each activity is also part of planning. Programming calls for decision of the agencies involved, manpower, roles of agencies and workers, training, coordination, supervision, logistics, budget, etc. Finally, program developed for separate activities are synthesized into a complete plan.
The middle level manager should possess not only knowledge about planning, but also skills in the planning process.
 
Coordination
Health delivery system consists of a number of workers belonging to different disciplines. Usually, even for achievement of a single goal, work is divided among people, resulting in need to secure coordination or teamwork. Health administration at all levels are faced with bringing about two types of coordination-intradepartmental and interdepartmental.
Within the present setup, even intradepartmental coordination is not an easy task to achieve. Integration of a number of vertical programs into the PHC system resulting in pooling of workers belonging to various agencies and changes in their job descriptions and patterns of work make coordination difficult. A number of factors like status, beliefs, leadership, clarity of functions act as major blocks to coordination. The manager should know various coordinating measures and which combination to use under particular circumstances. The measures available to him include hierarchial control, organizational charts, manuals, reports, staff conferences, supervision, training, consultation, etc.
There will be major factors that inhibit interdepartmental cooperation. These should be identified and solved. Naming a nodal agency for coordination, nodal officers at various levels, clear definition of roles of agencies, training, coordinating mechanisms are important measures to bring about coordination. Coordination should be in all phases of planning, implementation and evaluation.
Good coordination also involves getting the right things done, in the right place, at the right time, in the right way and by the right people.
 
Supervision
A major function of medical officers, at intermediate levels is supervision. It is an educational process in which the supervisor takes responsibility for helping the supervisee develop himself and become more competent in discharging his duties. Supervision aims at goal achievement, work facilitation and building human relations. Staff usually look to the manager for a standard of leadership. Thus, the way in which the managers 19conduct themselves, manage a program and its people will affect how the staff work. It will also influence the thinking and behavior of future managers. One has to lead by example for success.
There are a number of supervisory methods, about which supervisor should be familiar with. These include individual conferences, staff meetings, in work situations, evaluations, etc.
Authority and leadership are concepts which influence supervisory style, i.e. the way a manager behaves when trying to influence the behavior of someone else. Authority is the right to command and is vested in the supervisor by the organization. Leadership is a process of influence. Supervisory style will fall at some point in a continuum between authority and leadership. The mix to be adopted will depend upon the forces in the supervision and situation.
Appraisal of supervisions should form a basis for supervision. Apart from ascertaining the quantitative achievement of those supervised, the supervisor should know what traits he is looking for in the supervision, viz., knowledge, quality of performance, ability to learn, initiative, cooperative attitude, commonsense, etc.
Feedback to staff on their performance is rarely carried out despite its importance. Clear and direct feedback induces certainty, solves problems, builds trust, strengthens relationships and improves work.
 
Communication
Medical officers, to be effective, must be able communicators. The communication skills has to extend to various levels. At the first level, being manager, he/she should be skilled in various methods of official communication. He/she should encourage vertical communications, both from top to bottom and from bottom to top and also horizontal communication between workers at various levels. Two-way communication should be encouraged as a rule, since this leads to better understanding and reduces gaps in communication. As a supervisor, he/ she has to be a good listener. Instructions issued orally or in writing should be clear and unambiguous.
In dealing with communication with community the emphasis should be on empowerment of people. People do take responsibility for their own health, their family's health and the community's health, provided they are given adequate information and technical support.
The communication strategy should be to use a combined approach of mass media, group and individual approach. Audiovisual aids can help communication provided they are relevant and used effectively. Village-based communication should make use of established channels of communication in the village and of indigenous media. Training of village leaders, individual and group meetings should be strengthened. Efforts should be made to utilize workers of health-related developmental agencies having contact at the grass root level.
Training in communication methods and media and evaluation of their effectiveness should be an integral part of training.
 
Teamwork
One of the managerial functions of medical officers is to promote teamwork. By sharing skills and knowledge as a team, people can work more effectively than an individual. Teams can work better when members feel accepted and trust one another, goals are set and tasks defined, roles are clarified, members listen, communicate and participate, conflicts are resolved equitably, leadership is shared and members are mutually supportive. Incentives for team commitment go beyond salaries. People are also driven by their pride in producing excellence.
 
Training
The goal of training is to provide staff with knowledge and skills they do not have and as such an assessment of training needs will be the first and useful step, and managers, employees and clients should be involved. The training curriculum will depend on the assessment. The next step is to identify good trainers from within and outside since a training program is only as-good as the trainer. Other inputs that need attention are development of lesson plans, procurement of training materials, place of training, proper mix of theory and practice, training evaluation and feedback.
Looking holistically, the medical officers are concerned with human resources development, for which training is a tool. Apart from the staff of the health sector, training has to be imparted to community representatives, elected representatives of the civic society and others. Under these circumstances, focus should be on team training which will contribute to teamwork.
 
Building Partnership
It is now widely recognized that we must face new challenges in health that arise out of lack of attention to 20factors influencing health like poverty, illiteracy, nutrition, population, globalization, gender inequalities, pollution and many others. This calls for new forms of action and the challenge is to unlock the potential for health promotion inherent in many health related sectors, societies, local communities, local bodies and families. Health should be the responsibility of all. The primary health care system should therefore focus on building partnerships with all sectors at that level and involve them in health planning and implementation.
 
Community Involvement
Involvement of the community both as individuals and collectively, in the process of decision- making for health and health development is the essence of community involvement. They should be responsible for health needs identification, prioritization of identified needs, preparation of action plans, monitoring and evaluation. Community involvement helps in improving coverage, reduction in inequity and promotion of self-reliance.
Management of community involvement in health requires both knowledge and skills on the part of medical officer. The medical officer should be prepared to work with the people rather than for the people. Success of community involvement, depends upon a number of factors. First is political commitment to transfer responsibility to people. Second is a high degree of bureaucratic commitment to translate the policies into action. Thirdly, the role of the agencies shift to one of directing, supporting and facilitating the process of community involvement in health. Fourthly, the district health organization needs to be reoriented to provide the necessary support. Finally, action is required to decentralize authority and responsibility to the lower levels of PHCs and community.
Involvement of women in health care delivery is crucial as they are the key to primary health care and general welfare of the communities in all developing countries and hence community involvement should pay special attention to participation by women.
 
Monitoring and Evaluation
Monitoring and evaluation is an important management activity. It is an integral part of the program plan and must be built into it. It is an effective tool for testing program promises, planning and improving the program performance.
Monitoring generally refers to the process of checking the status of the program by comparing the actual implementation of the activities against work plan, including the time frame.
On the other hand, evaluation is directed at measuring progress towards the achievement of objectives and the impact of the program. Evaluation is linked to program planning and implementation cycle and assists the program management in making midcourse corrections in the program.
The monitoring system should be designed to provide disaggregated data to reflect the health condition of the disadvantaged groups, so as to enable to mount more focused responses to them. This will contribute to promote equity in health.
To sum up, effective discharge of managerial functions are critical to the success of all our health and family welfare programs. Managers have to see that both the organization and program goals are achieved. No organization can function without competent managers and, indeed, in their absence organizations are often paralyzed or chaotic.
Building up competencies of the medical officers in the planning process, program implementation, supportive supervision, training of health care providers, building partnerships, provision of leadership to health team, promote social action for health, making the system responsive to the health care needs of the population, monitoring and evaluation and many others is therefore vital. Those competencies are in addition to those related to making them effective clinicians and public health program implements.
 
XI FIVE YEAR PLAN
 
Monitorial Socioeconomic Targets
 
Income and Poverty
  • Accelerate growth rate of GDP from 8 to 10% and then maintain at 10% in the 12th Plan in order to double per capita income by 2016–17.
  • Increase agricultural GDP growth rate to 4% per year to ensure a broader spread of benefits.
  • Create 70 million new work opportunities.
  • Reduce educated unemployment to below 5%.
  • Raise real wage rate of unskilled workers by 20 percent.
  • Reduce the head count ratio of consumption poverty by 10 percentage points.21
 
Education
  • Reduce dropout rates of children from elementary school from 52.2% in 2003–04 to 20% by 2011–12.
  • Develop minimum standards of educational attainment in elementary school, and by regular testing monitor effectiveness of education to ensure quality.
  • Increase literacy rate for persons of age 7 years or more to 85%.
  • Lower gender gap in literacy to 10 percentage points.
  • Increase the percentage of each cohort going to higher education from the present 10 to 15% by the end of the 11th Plan.
 
Health
  • Reduce infant mortality rate (IMR) to 28 and maternal mortality ratio (MMR) to 1 per 1000 live births.
  • Reduce Total Fertility Rate to 2.1.
  • Provide clean drinking water for all by 2009 and ensure that there are no slip-backs by the end of the 11th Plan.
  • Reduce malnutrition among children of age group 0–3 to half its present level.
  • Reduce anemia among women and girls by 50% by the end of the 11th Plan.
 
Women and Children
  • Raise the sex ratio for age group 0–6 to 935 by 2011–12 and to 950 by 2016–17.
  • Ensure that at least 33 percent of the direct and indirect beneficiaries of all government schemes are women and girl children.
  • Ensure that all children enjoy a safe childhood, without any compulsion to work.
 
Infrastructure
  • Ensure electricity connection to all villages and BPL households by 2009 and round-the-clock -power by the end of the Plan.
  • Ensure all-weather road connection to all habitation with population 1000 and above (500 in hilly and tribal areas) by 2009, and ensure coverage of all significant habitation by 2015.
  • Connect every village by telephone by November 2007 and provide broadband connectivity to all villages by 2012.
  • Provide homestead sites to all by 2012 and step up the pace of house construction for rural poor to cover all the poor by 2016–17.
 
Environment
  • Increase forest and tree cover by 5 percentage points.
  • Attain WHO standards of air quality in all major cities by 2011–12.
  • Treat all urban waste water by 2011–12 to clean river waters.
  • Increase energy efficiency by 20 percentage points by 2016–17.
 
MDG-THEN AND NOW
 
India's MDG 2005 Report Released
On February 13, 2006, the Union Ministry of Statistics and Program Implementation released India's first Millennium Development Goals country report for the year 2005.
The Millennium Declaration adopted by the General Assembly of the United Nations in September 2000 committed member countries to achieving eight Millennium Development Goals (MDGs) within a specified timeframe. The 2005 report on the MDGs gives an indication of the current status of progress achieved in the country.
 
MDG 1: Eradicate Extreme Poverty and Hunger
India's target: Reduce the proportion of people below the poverty line to 18.75% by 2015.
Status: As on 1999–2000, the poverty headcount ratio stood at 26.1%. The share of the poorest quintile in national consumption is 10.1% for the rural sector and 7.9% for the urban sector. Prevalence of underweight children is in the order of 47%.
 
MDG 2: Achieve Universal Primary Education
India's target: Increase the primary school enrolment rate to 100%, with no dropouts, by 2015.
Status: Dropout rate for primary education during 2002–03 was 34.89%. The gross enrolment ratio at primary schools was near 100% for boys and 93% for girls. The literacy rate (seven years and above) in 2000–01 was 65.4%.
 
MDG 3: Promote Gender Equality and Empower Women
India's target: There should be gender parity in the number of boys and girls enrolled in schools by 2015.22
Status: Female-male proportion in primary education is 78:100, and 63:100 in secondary education (2000–01).
 
MDG 4: Reduce Child Mortality
India's target: Under-five mortality rate (U5MR) must be reduced to 42 for 1,000 live births by 2015.
Status: U5MR was 98 per 1,000 live births in 1998–2002. Infant mortality rate was 60 per 1,000 live births (2003). Proportion of one-year-old children immunized against measles was 58.5% (2002–03).
 
MDG 5: Improve Maternal health
India's target: Reduce the Maternal Mortality Rate (MMR) to 109 per 100,000 live births by 2015.
Status: MMR for 1998 was 407. The proportion of births attended by skilled health personnel was 39.8% in 2002–03.
 
MDG 6: Combat HIV/AIDS, Malaria and other Diseases
Status: The prevalence rate for HIV/AIDS increased from 0.74 per 1,000 pregnant women in 2002 to 0.86 in 2003. This trend needs to be reversed in order to achieve MDG 6. The prevalence and death rate associated with malaria is consistently dropping. The death rate associated with tuberculosis came down from 67 deaths per 100,000 population in 1990 to 33 per 100,000 population in 2003. The proportion of TB patients successfully treated rose from 81% in 1996 to 86% in 2003.
 
MDG 7: Ensure Environmental Sustainability
Status: In 2003, the total land area covered by forests was 20.64%. Reserved and protected forests together accounted for 19% of total land area. Energy use declined from around 36 kilogram oil equivalent in 1991–92 to about 32 kilogram oil equivalent in 2003–04.
The proportion of people without sustainable access to safe drinking water and sanitation is to be halved by 2015. India is on track to achieving this target, says the report.
 
Goal 8: Develop a Global Partnership for Development
According to the report, developed countries must provide development assistance to developing countries. The report says the financial support needed to achieve targets under this goal for less developed countries and smaller countries falls short of what developed countries pledged. It notes, however, that actual disbursements of overseas development assistance in recent years have shown a reversal of the declining trend that lasted for almost a decade since the early 1990s.
In one of the targets under this goal—to make available the benefits of new technologies in cooperation with the private sector—India has made considerable progress:
  • Overall tele-density increased from 0.67% in 1991 to 9.4% in June 2005.
  • Use of personal computers increased from 5.4 million PCs in 2001 to 14.5 million in 2005.
  • There are 5.3 million Internet subscribers, as on March 2005 (2.3 Internet users per 100 population).