Introduction

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, beyond questions of funding shortages, we need to examine
whether the public health system may be misdirecting its efforts, or be poorly
designed. If so, it may also face problems in responding to the countrys
growing burden of non-communicable diseases. Most analyses have focused on
issues related to the provision of medical services, or on specific issues such as
immunization. We focus on understanding gaps in the performance of the basic
functions that an effective public health system must fulfil, in which preventive
and promotive activities play an important role.

U N D E R S TAN D I N G AN D P R O M O T I N G H E ALT H
personal potential and may be more aligned with ideas from humanism.
Drawing on humanist ideas, health might also be considered as selfactualization, which links with the idea of empowerment, a concept discussed in
more detail later in this book. Health might
enable the process of self- actualization or the attainment of health might
constitute self actualization. Either way, research appears to show that this is an
important idea that has implications for health and, specifically, healthpromoting behaviours (Acton & Malathum, 2008). Seedhouse (2001) describes
health as the foundations for achievement. In keeping with the position of this
chapter Seed house starts from the point of acknowledging that health is a
complex and contested concept. Seed house views health as the means by which
we achieve our potential, both as individuals and as groups. Seedhouse (1986:
61) therefore describes a persons optimum state of health as being equivalent
to the set of conditions that enable a person to work to fulfil her realistic chosen
and biological potentials.
This perspective also broadens understandings of health beyond the absence of
disease or abnormality as understood using a medical model (this will be
discussed in more detail later in the chapter). Someone may be, for example,

encountering disease or be disabled and still lay claim to health, thus

challenging assumptions of a normality of health.
As Blaxter (1990: 35) argues health is not, in the minds of most people, a
unitary concept. It is multidimensional, and it is quite possible to have good
health in one respect, but bad in another.
Health can also be conceived of in a number of other ways. Health may be
regarded as a value (Downie & Macnaughton, 2001) and, while most people
would argue that good health is of value too, the degree to which people will
strive for, or prioritize, health will, of course, vary according to individual
circumstances. Health is also viewed both as a right and as a responsibility. The
Constitution of the World Health Organization of 1946 first held up health as a
human right in the statement the enjoyment of the highest attainable standard
of health is one of the fundamental rights of every human being (cited in WHO,
2008a: 5).
Article 25 of the Universal Declaration of Human Rights of 1948 references
health in relation to the right to an adequate standard of living and many of the
other articles are indirectly related to the right to health. The right to health
was again recognized as a human right in the 1966 International Covenant on
Economic, Social and Cultural Rights (WHO, 2008a: 5). Viewing health as a
right can create tension, because with this comes a sense of responsibility for
health that in turn generates debate as to who has responsibility for health the
individual or the state?

Definitions of health
Health has been called an abstract concept that people can find difficult to
define.

Nonetheless different attempts have been made. One of the most frequently
referenced definitions of health in the last few decades is the classic one offered
by the World Health Organization.
Health is defined as a state of complete physical, mental and social well- being
and not merely the absence of disease and infirmity (WHO, 1948 cited in
WHO, 2006).
One of the strengths of this definition is its all- encompassing breadth. It moves
away from the notion that being healthy is simply about not being ill. In this
sense it has a more positive, holistic view about what health is.
However, the WHO definition, has also been criticized on many counts, for
example, as being unattainable and idealistic (see Lucas and Lloyd, 2005).
According to this definition, is it possible for anyone ever actually to be
healthy? In addition there are other dimensions of health that are not considered
in this definition such as sexual, emotional and spiritual health (Ewles and
Simnett, 2003) Health can be viewed positively or negatively. Tones and Green
(2004)refer to this as dichotomous differences in approaches to defining health.
On the one hand there are positive approaches to defining health (health as wellbeing or as an asset) and on the other hand there are more negative definitions
of health those that are illness or disease oriented. When health is viewed in a
negative way, then definitions will tend to focus on health as absence of disease.
When health is viewed in a more positive way definitions tend to be broader and
take into account concepts such well- being.
The World Health Organization definition outlined earlier is an example of a
more positive Definition and marks a shift in understanding away from a more
narrow, medical and negative view of health.
Well- being is another rather slippery concept and is also difficult to define
(Chronin de Chavez et al., 2005). There is a lack of consensus as to what wellbeing is, although generally theoretical understandings converge around the
three major aspects of physical, social and psychological well- being. Like the
notion of health, this makes it difficult to investigate, as it means different
things to different people.
However, drawing on the concept of well- being to understand health is
important. Laverack (2004) offers a useful way of thinking further about the
concept of well- being. He separates well- being into three different types

physical, social and mental. Physical well- being is concerned with healthy
functioning, fitness and performance capacity, social well- being is concerned
with issues such as involvement in community and inter- personal relationships
as well as employability and mental well- being which involves a range of
factors including self- esteem and the ability to cope and adapt. The concept of
wellbeing varies between disciplinary perspectives; however, it is receiving
increasing attention and it is generally argued that it offers a broader
understanding of health than those drawing on a more scientific, medically
dominated position (Chronin de Chavez et al., 2005). A further concept that is
arguably related to how health may be perceived is quality of life. For example,
functional perspectives may assume that increased health automatically results
in increased quality of life (Lee and McCormick, 2004).
Definitions of health can also focus on different aspects of health.
Some are idealistic, as in the WHO definition offered earlier. Some definitions
have a more functional view of health, where it is seen as the ability to be able
to do things and get on with life. Other definitions centre on the idea of health
as a commodity. For example
Aggleton (1990) argues that health is something that can be bought (by
investment in private health care) or sold (through health food shops), given (by
medical intervention) or lost (through disease or injury). The parallels with
contemporary consumerism are evident in this type of definition.
Other types of definitions draw on the idea that health is about being able to
cope and adapt to different circumstances and achieve.

Public health systems are conceptually distinct from medical services.

They have as a key goal reducing a populations exposure to disease for
example through assuring food safety and other health regulations, vector
control, and health education. These services are largely invisible to the public
typically, the public only becomes aware of the need for them when a problem
develops (e.g., an epidemic occurs).
1. Yet unlike most personal medical services, these services produce public
goods, and are of high priority for assuring good health outcomes. When
public health systems falter people pay a high price in illness, debility and
death, and if full-fledged outbreaks occur the economic costs can be very large:
for example, the WHO (1999) estimates that the 1994 plague epidemic in Surat
resulted in losses totaling $1.7 billion. Until recently, there were few tools for
studying public health systems. A framework for analyzing public health
systems as a whole has emerged from efforts to upgrade the US public health
system, based on the Essential Public Health Functions (EPHFs).
2. This framework is beginning to be used in other countries, developed and
developing.
3. Broadly, these core functions pertain to assuring health situation
monitoring, disease surveillance; health promotion; public health regulations;
community partnerships; development of policies and planning; access to and
quality of services; human resource development; and reducing the impact of
emergencies on health. Note that the emphasis is on functions, governance and
organizational structures need to be examined separately. We examine the
functioning of Indias public health system, and illustrate the strengths and
weaknesses of the organizational context in which its component parts have to
work. We use questionnaires based on the EPHF framework, designed for
assessing the public health system in the US and Latin America,
4. which we modified for India. This paper presents the data collected from
federal-level respondents. To provide a conceptual background for interpreting
the results of our study, we begin with a brief discussion of the roles that public
sector health agencies have to play in a public health system, and the roles of a
central health agency in a large federated union of states such as India. This is
followed by a brief description of the constitutional mandate and organizational
structure of the central health ministry in India. In the concluding section, we
note that policy priorities have overlooked some fundamental public health

functions, that the system has deep management flaws which hinder effective
use of resources, and that it needs to do much more to collaborate with subnational levels of government, as well as with other public and private agents
and the communities it serves. The results throw light on why the system is
ineffective despite the considerable human and institutional resources at its
disposal, and why in the absence of some systemic reform it is likely to prove
difficult to improve the functioning of a specific service or program in isolation.

The Role of Public Sector Health Agencies in Assuring Public Health Public
health outcomes are influenced by a wide range of factors, many of them
outside the direct ambit of public sector health agencies. Thus to assure good
health outcomes, health agencies have to engage continuously with a wide range
of actors through advocacy, coordination, and monitoring and oversight. This
includes building, inter alia:
intra-sectoral coordination between different actors in the public health
agencies (e.g., to promote adequate flows of information and support, and to
ensure consistency in policy and practice across programs, levels and
jurisdictions);
coordination with local governments who often have primary responsibility
for implementing public health regulations, and for many aspects of
environmental sanitation;
intersectoral coordination with other public agencies whose work impinges on
health outcomes, for example school health or appropriate drainage in irrigation
systems
coordination with the private sector, especially with private health practitioners
at least for disease surveillance and supplying standardized care for diseases
such as TB and STDs; and
continuous partnership with communities, to build public demand for better
health outcomes, raise awareness of the need to monitor local programs and
policies, and alter personal health behaviours. Depending on their level, health
agencies have somewhat different roles to play. In a large federated union of
states such as India or the United States, the central government health agencys
role has relatively little to do with direct service provision. Their role is to
facilitate the systems overall functioning through stewardship, advocacy, and
support to sub-national levels who are more directly involved in service
provision.

BOHRE COMMITTEE
The Health Survey and Development Committee, popularly known as the Bhore
Committee was set by the Government of India in 1943 with Sir Joseph Bhore
as Chairman to survey the then existing position regarding the health conditions
and health organisation in the country and to make recommendations for future
development. The Committee which had among its members some of the
pioneers of public health, met regularly for two years and submitted in 1946 its
famous report which runs in to four volumes.
The Committee put forward, for the first time, comprehensive proposals for the
development of a national programme of health services for the country. The
Committee observed: "if the nation's health is to be built, the health programme
should be developed on a foundation of preventive health work and that such
activities should proceed side by side with those concerned with the treatment
of patients". Some of the important recommendations of the Bhore Committee
were:

1.Integration of preventive and curative services of all administrative levels.

2. Development of Primary Health Centres in 2 stages :

a. Short-term measure one primary health centre as suggested for a population

of 40,000. Each PHC was to be manned by 2 doctors, one nurse, four public
healthnurses, four midwives, four trained dais, two sanitary inspectors, two
health assistants, one pharmacist and fifteen other class IV employees.
Secondary health centrewas also envisaged to provide support to PHC, and to
coordinate and supervise their functioning.

b. A long-term programme (also called the 3 million plan) of setting up primary

health units with 75 bedded hospitals for each 10,000 to 20,000 population

and secondary units with 650 bedded hospital, again regionalised around
district hospitals with 2500 beds.

3. Major changes in medical education which includes 3 - month training in

preventive and social medicine to prepare social physicians.