Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Reviews
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2936 - 2946

Models Of Health Care Development For Disease Free India

NAIK G L* DESHPANDE S R

* Hassan Institute of Medical Sciences, Hassan Email:gaya3doc@yahoo.com Address: #45, Govt Doctors Quarters, HIMS campus, Hassan Telephone: +91-9480158773

Correspondence Address :
Dr Srinivas Ramachandra Deshpande
MALABAR MEDICAL COLLEGE, MODAKALLUR, CALICUT, INDIA
Email:sriradesh1971@yahoo.com
URL: www.aimdda.org
Address: Dr Srinivas R Deshpande, #45, Govt Doctors Quarters, HIMS campus, Hassan Telephone: +91-9480158750

Abstract

Providing healthcare and disease prevention to India’s billion plus population has always been challenging in the face of limited resources, the socialistic mindset, pluralistic systems of health, misgovernance and socioeconomic disparities. The Government of India needs to understand its limitations with respect to health entrepreneurship. India needs to repeat its successful privatization saga with respect to medical care, health infrastructure provisioning and maintenance and uplift its masses or else, its ambitious rural and urban health schemes will collapse and national health empowerment agendas will remain unfulfilled.

Keywords

: national urban health mission, national rural health mission, accredited social health activist, health entrepreneurship

How to cite this article :

NAIK G L DESHPANDE S R. MODELS OF HEALTH CARE DEVELOPMENT FOR DISEASE FREE INDIA. Journal of Clinical and Diagnostic Research [serial online] 2010 August [cited: 2019 Oct 23 ]; 4:2936-2946. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2010&month=August&volume=4&issue=4&page=2936-2946&id=863


Introduction
A sixth of the world’s population lives in India (1), of which 70% suffers from the vagaries of rural health diseases and infirmities. The health responsibility of rural India is one of the main the health responsibilities of this nation and the state cannot afford to abdicate its responsibilities (2). Since sixty years of its independent existence, Indian ministries on their part are striving for the attainment of better health goals through the massive National Health Care delivery system (1), (2).

Unserviced vacuums in health service provision in rural areas of India are said to be usurped by non-allopathic fee-for-service practitioners from a variety of systems of medicine (ISM) like Ayurveda, Unani ,Homeopathy and Siddha. Many "nonqualified" doctors in practice—people with no medical training of any sort, called compounders, are also illicitly, the unsolicited part of the Indian health system(1),(2),(3).Such unfortunate plurality of medical thoughts and illicit practices are said to have further accentuated the disease burdens due to differences in approach to the health management and have increased poverty due to out of pocket payments(1),(2),(3).Illicit therapeutic misadventures by quacks, absence of action against quacks by the medical and dental councils, mismanaged health situations by cross practitioners, misgovernance of public facilities and the overt commercialization of the medical education and practice have destroyed the credibility of the Indian health system (4),(5).This paper attempts to identify some deficiencies in the Indian health system and invites the health planners of India to explore some models for health care development in India.

Problems Of The Health System
The overburdened Indian health system (4) has always been plagued by serious resource shortfalls and the underdevelopment of the infrastructure (5).This has led to deficient health care for a majority of India and the system has been accused of red tape-ism, indifference, incompetence and gross inefficiency (5),(6) Resource crunch is accentuated by non-priority spends on plural systems of medicine and such parallel spends decrease the emphasis on the main health scourges endemic in the community (3),(5). Sincere efforts are needed to provide universal health care for the health impoverished citizens of India, with smarter, newer models of health caring and also an attempt to improvise the existing health schemes for a disease free India has to be made (3),(5),(6).

The fundamental flaw of the disordered Indian health system has been an absolute lack of financial accountability (3),(5),(6).Also, working in isolation, modern telecommunication networking and the use of intelligent tools like computers, or internet and communication technology tools is poor, in spite of India being an Information technology superpower (7). So, this vast infrastructure is able to cater to only 20% of the population, while 80% of the health care inadequacies are salvaged by the private sector (6),(7).The cream of profits seem to go the private sector, while difficult to handle cases, or defeated health challenges get abandoned and referred to government hospitals (3),(5),(6).

In the light of India’s evergreen health problems, India and its health planners (8) have been frequently on the road of planning for health, but have reached nowhere, thanks to the lax attitude in the implementation of health care programmes in the government ministries. There is a propensity for corruption at all levels and third world health care systems (9),(10) have breeded corruption to the core and greasing the palms of the health staff in charge in the nursing, paramedical or medical departments to get their routine health care rights is the Indian norm. Government staffs in general, are accused of fleecing the clients of the health system for private gain (9),(10).The impact of this is the accentuation of the out of pocket (OOP) payment resultant poverty, which has accentuated societal poverty and disparities (10).

An Independent Commission on Health in India (11), set up by the Voluntary Health Association of India, which submitted its report to the Indian Prime Minister in 1997, had pointed out that Indian public health services `are in an advanced stage of decay’. A survey conducted by the National Council of Applied Economic Research (12) in 1992 revealed that, among the poor, the expenditure incurred to meet the medical needs is the second most important cause of rural indebtedness. These surveys (11),(12) too drew a bleak picture – hospitalized Indians, on an average, spend 58% of their total annual income; over 40% of hospitalised Indians borrow heavily or sell their assets to cover expenses; over 25% of hospitalised Indians fall below the poverty line because of hospital expenses (11),(12).

Neglect of Rural Health: Rural India is suffering from a long - standing health care problem. Studies have shown that only one trained health care provider, including a doctor with any degree, is available per every 16 villages (13).Although more than 70% of its population lives in India’s rural areas, only 20% of the total hospital beds are located there. The health workers have not been attracted to rural areas due to socio-cultural and infrastructural deficiencies in such areas. Recently, a rural conscription of health workers including fresh MBBS doctors has been proposed as a remedy to India’s rural ills (14). However, one has to realize that government’s efforts alone are insufficient in any society which aims for the universal optimum utilization of health resources (15).A course called BRMS( Bachelor of Rural Medicine) has been proposed by the government (11),(12) (15).

Apparently India suffers from problems which are common in most developing societies-unfortunately, government efforts in education ,employment and delivery of health services seem to breed corruption (15) Also, the government efforts at times, lack community support, staff motivation, are drowned in casteism, corruption, illiteracy and other social ills [ 15]. The Government of India definitely needs help in improving its health standards by increased education, community participation and socioeconomic reformation. (11), (12) (15).

Defective Health System Design And Mismanagement
Some features of the present health system model seem to suffer from some critical defects in design, but there are also many defects in implementation (16).As a result, health mismanagement occurs and leads to a continuum of individual level health crises and community level health catastrophes (15),(16). Adhoc-ism rules administrative cadres and bureaucracy stifles advances in management, research and system rectification (16).There seems to be no built- in health alarm system for epidemics or pandemics. There seems to be no efficient epidemic appraisal system and always, temporary solutions are attempted for every epidemic. Memories of epidemics are temporary within the system and the learning curve is long every time due to a short administrative memory mechanism (16).No attempt to look for and screen or attempt futuristic health forecasting seems to be in place, or it is not given adequate importance (16).No mechanism seems to exist for fire fighting and damage limitation and every time a panic predominates the performance. The Indian health system seems to suffer from shortages in money, materials, memory, manpower, mechanisms and management skills (16).

Failure To Promote Career Interests Of The Health Professionals
Scientific education, especially in medical courses, is seen as an emancipator of one’s own socioeconomic and religious problems (17) and hence, endows mobility to these professionals apart from increased societal worthiness and these professionals are keen to settle down where they perceive that greater worthiness exists (17). Ultimately, health professionals are seen to settle where they gain a profitable permanent source (s) of income (s), as do intellectuals of the IT category or the like. Similarly, talented Professors and Clinicians of repute may look for greener pastures (17) than serving for the government.

At the governmental level, services by doctors in villages do not get rewarded, and, disillusionment can set in rapidly as encouragement does not come from most rural communities at times (17)Rural areas don’t inspire young doctors on much counts-poor hospital attendance, poor quality of diagnostic or research material and poor incomes and educational advancement (17).Investing in social studies on the wants of the health professionals could do miracles –for the governments world wide and align the health professional career graph with societal health concerns (17).This would also prevent brain drain and preserve the health professionals as the health guardians of their own societies (17).

Societal Failure To Support The Health Professionals
Presently, not many health staff want to serve or stay in villages and unremunerative areas voluntarily (18).Attempts to invite or maintain talented doctors in villages have failed. Governmental attempts to help doctors and paramedics to settle down in villages and refashion them as family health practitioners or support them to settle down are surprisingly invisible (18), (19), (20).

Indian health system-Strong on Planning and Weak on Implementation
India has vast tracts of land where not even an educated person exists, let alone a doctor. (19),(20). Experts have faulted the implementation system of the health planning in our country-as India has always been found to be weak on the implementation side, though it has been strong on planning (19). No wonder, thus, the health performance in India has been persistently poor. Siphoning of funds allotted to the health sector occurs at all levels (19),(20). The poor too prefer the private providers and the governmental effort is almost going waste (3),(19),(20). The quality of health services provided in the government sector has always been poor and health workers who are associated with the government, are inaccessible, and have been often accused of absenteeism (20).

Since the Indian independence, at the cost of the tax payer, India has laboured to create a vast public health infrastructure of Sub-centres, Public Health Centres (PHCs) and Community Health Centers (CHCs) (21).There is also a large cadre of health care providers (Auxiliary Nurse Midwives, Male Health workers, Lady Health Visitors and Male Health Assistants). Paradoxically, much of this robust infrastructure is put to use by only a handful minority due to fundamental flaws in Health care planning and financing and faulty focii in implementation (21).

The Rural Mission: The National Rural health Mission: (22)
To address these concerns, India has created the National Rural Health Mission (NRHM) to carry out the necessary architectural correction in the basic rural health care delivery system. The National Rural Health Mission was launched in April 2005 and the duration of NRHM will be from 2005 to 2012 (22).The total allocation of funds for The Departments of Health and Family Welfare has been hiked ,nearly 10 times i.e.,from Rs. 8,420 crores to Rs. 90,103 crores in the budget proposals for the year 2007 - 08.The goal is to improve the availability of and access to quality health care in rural areas, especially the poor, women and children. 22The nation has pledged to increase public spending on health to at least 2 - 3 % of the Gross Domestic Product (GDP) with a focus on primary health care. The Mission aims to provide accessible, affordable and accountable quality health services, even to the poorest households in the remotest rural regions. The difficult areas with unsatisfactory health indicators were classified as special focus areas to ensure the greatest attention where needed (23).

Villages As Health Communities, schools as health transformation centre’s:
The thrust is on establishing a fully functional, community owned, decentralized health delivery system, with inter sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health like water, sanitation, education, nutrition and social and gender equality (22). It also aims at mainstreaming the Indian systems of medicine to facilitate health care (22) .The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into the district health system and operationalizing community health centers into functional hospitals which meet Indian Public Health Standards in each block of the country (22),(23).

Accredited Social Health Activists
The NRHM members are expected to cover all the villages in India’s (18),(19),(20) states through approximately 2.5 lakh village - based “Accredited Social Health Activists” (ASHA) who would act as a link between the health centers and the villagers (22).One resident ASHA will be raised from every village, who would be trained to advise village populations about Sanitation, Hygiene, Contraception and Immunization, to provide Primary Medical Care for Diarrhoea, Minor Injuries, and Fevers; and to escort patients to Medical Centers (22),(23). ASHA would also be expected to deliver direct observed short course therapy for tuberculosis and oral rehydration, to give folic acid tablets and chloroquine to malaria patients and to alert the authorities about unusual outbreaks (24).ASHA will receive performance – based compensation for promoting universal immunization, referral and escort services, for Reproductive and Child Health programmmes of the Indian government, for the construction of house - hold toilets and for other health care delivery programs (24).

The selection criteria for ASHA would be “women, residents of the concerned village, of 25 – 45 years of age, formal education up to the 8th grade, to be selected out of a panel by the village health and action committee of the village council” (22),(23),(24),(25). The norm would be 1 per 1000 population, but this norm may be changed for different areas. There would be no pay or honorarium, but they will be given a compensation for various health services provided. They will be given a kit of suitable drugs (22). They would be guided by existing Anganwadi Workers and Auxiliary Nurse Midwife s(ANMs), one of the main agents for increasing the utilization of health and family welfare services in India. In 4 years, 2.5 lakh ASHAs are proposed to be deployed (22),(23),(24),(25).

A Critical Reading Of The NRHM Proposals
NRHM aims at the empowerment of a community based semi-educated woman into the nitty-grittys of the medical profession and to enable her to treat anaemia, tuberculosis, malaria and other complex communicable diseases (25),(26). The lady is not required to have a fundamental knowledge of science and is used for complex disease management. This flaw in the system will be the main reason for the failure of this scheme. While strengthening the public health systems is a laudable idea, the non use of ICT will be a drawback (25).ASHA’s economic status being poor, the roles vested in her (ASHA) seem to be numerous and such heaping of responsibilities looks like a sure recipe for failure (26).Further, the scheme proposes-Mainstreaming of the Alternative Indian systems of Medicine, which should ideally happen at medical college levels, where Indian systems of Medicine can be integrated into modern medicine and respect has to be brought to such systems by inculcating a research attitude and mindset here.25

Neither the Medical Council of India nor the other professional councils seem to endorse the idea of mainstreaming the Indian systems of medicine (25). Also, the basic medical sciences are poorly taught to the Indian Medical professionals. The proper use of the medical laboratory has to be taught to them. Improved management skills mean improved training and open thinking –which can be difficult in bureaucracy ridden health ministries. Evidence based planning may be too much for ground level workers and may not work. Social participation or the emphasis on participatory medicine needs a high level of community involvement, quite an unseen Indian phenomena with regards to health (25),(26),(27).

The National Urban Health Mission (NUHM) (28)
Urban areas in India constitute about 30 percent of the population and 11% of this is in the Indian cities. The National Urban Health Mission (NUHM) is proposed to meet the health needs of the urban poor, particularly the slum dwellers, by making essential primary health care services available to them (28).This will be done by investing in high – caliber health professionals, appropriate technology through public – private partnership and health insurance for the urban poor. By recognizing the seriousness of the problem, urban health will be taken up as a thrust area for the Eleventh Five Year Plan (28).

Focus On The Urban Have Nots
The NUHM would cover all the cities with a population of more than 100,000 (28). It would cover slum dwellers and other marginalized urban dwellers like rickshaw pullers, street vendors, railway and bus station coolies, homeless people, street children and construction site workers who may be in slums or on the sites (28). The existing Urban Health Posts and Urban Family Welfare Centres would continue under the NUHM. All the existing human resources will then be suitably reorganized and rationalized. These centres will also be considered for up-gradation. The intersectoral coordination mechanism and convergence will be planned between the Jawaharlal Nehru National Urban Renewal Mission which is in charge of the socio-economic reformation of the urban areas and the National Urban Health Mission (28).

Partnership is needed with the community for a more proactive involvement in the planning, implementation and monitoring of health systems (28).An e-health grid encompassing governmental partnerships with NGOs, charitable hospitals and other stakeholders will be desirable. The nation could envisage a two – tier system of risk pooling: (i) women’s health committees to fulfill the urgent hard – cash needs for treatments; and (ii) an efficient Health Insurance Scheme and an efficient microfinance scheme involving the rural banks and post offices for enabling the urban poor to meet their urgent medical treatment needs (28)

The Challenges Before The National Health Missions
It is clearly a gigantic task to bring about major changes in outcomes by simultaneous action on a wide range of determinants of health. The NRHM (31) has identified communitization, flexible financing, innovations in human resource management, monitoring against Indian public health standards and building capacities at all levels as the principal approaches to ensure quality service delivery, the efficient utilization of scarce resources and most of all, to ensure service guarantees to local households(28),(29),(30).

Some social scientists have commented that health mission advisors may have suffered from massive blind spots 31about the well established principles of public health practice when they developed their vision of the rural health services (31). For instance, developing facilities for education and the training of Managerial Physicians who have the epidemiological, managerial, social and political competence to provide leadership in the administration of the health services in the country, ought to have found a key place in the in the Mission Document. The same argument holds good for the urban health mission (31).Ultimately, the success of both the missions will depend on the ability to galvanize the State Governments into action and to pursuing innovation and provide flexibility in all spheres of public health action (31). Ensuring the availability of fully trained and equipped resident health functionaries at all levels and large scale financing under initiatives like the Janani Suraksha Yojana for institutional deliveries are a few priorities for action (31). Partnerships with non governmental providers to strengthen pubic health delivery are also an important need, given the distribution of Specialist doctors in India (31).While India has 30,000 MBBS graduates graduating every year, the entire rural health system for more than 750 million people never has around 26,000 doctors. There is an urgent need to shift the decentralization of functions to hospital units/health centres and local bodies (31).

Health Services Prioritization & Other Solutions
Dr Mahal of the Harvard School of Public Health, (32),(33) asserts, “India needs to prioritize interventions and targets”. A range of low cost solutions include peer education, access to condoms, use of anti-retroviral drugs, life style modification and better hygienic practices (32),(33) .

Recruiting and retaining physicians to serve in rural areas is a difficult challenge due to the expectations and attitudes of the medical graduates and post graduates. Incentives to prospective health workers would be more effective in the form of packages and cuts as in Kerala(32),(33) . India needs to improve the way it plans for, educates and employs doctors, nurses and support staff, who make up the health workforce and provide them with better working conditions(32),(33) .

Social scientists have stressed that community participation will alone emancipate the people from health infirmities (32),(33) . But the reality remains, that Indians have been poor acceptors of government provided health services and have relied on their own resources and out of pocket payments for self health maintenance and servicing (34). The governments should respect the public mandate in favour of private leadership in health caring, in spite of the fragmented nature of the private health sector. The government alone seems incapable, unable and inefficient in providing access to basic health care for all and needs support from the community, non-governmental organizations and donor groups and the private sector has a big role to play in health entrepreneurship (32),(33),(34) .As in other sectors of human development, the private capital alone can provide newer research products and hence, is desirable (34).

The Kerala Model Of Health Co-Operatives (35) be Expanded:
The state –of- the- art Cooperative hospitals in this state, currently under cooperative regulations, are prospering and are making their presence felt. The Kerala cooperative movement in the hospital industry has been successful even before the advent of the economic liberalization in the 1990s (35).The results of community domination in health caring are evident in this model of health caring and the resultant human development indices in the state of Kerala are better than anywhere else in the country (35),(36).

In rural Kerala, umpteen numbers of hospitals have sprung up and the migration of doctors from neighboring states to Kerala to equip those hospitals is seen (36),(37).This model is a superb example of what the private capital raised from community share holding can do, even in a communist thought dominated state-and is worth emulation (35),(36),(37). State support to such ventures at every village and subdivision level will nurture the growth of hospitals; clinics, even in rural areas and also improve the competitive spirit between the hospitals (36),(37).

Proposed Reforms: Change The Defeatist Mindset
To make improvements in the delivery of health services, at least three reforms are urgently required (38). First, it is time to accept the fact that the government has at best limited capability to deliver health services and that a radical shift in strategy that gives the poor greater opportunity to choose between the private and public providers is needed (38). It is necessary to realize that the government has failed to provide health services since the past decades and has to engage institutions which have expertise than itself. At the same time, we have to understand that the government has constitutional mandates to look after its millions of poor and has to provide accountability to the tax payer’s money which has been spent on the public health centres (38),(39),(40).

It means that the government has to move towards a different health services model (40) this model cannot be the age old government does everything model-i.e. the selection of the staff, management and the nitty gritty of running the public health centres;(40) and budgeting at state and central levels; by bureaucrats who know very little about health, or by clerks who are even less equipped (40),(41),(42).So, health governance has to shift to health management than the present model. The government instead can think of the public –private partnership route to health for all (40). Indians have been excellent entrepreneurs and many health entrepreneurs do exist. India has recently witnessed the work of Sam Pitroda (the father of India’s communication revolution)(43) and his vision-to provide telecom services to the nation. Today, more mobiles ring in the rural areas than in the urban areas and this is the magic of the private capital, clear-cut governmental policy guidelines, public sector competition and efficient commoditization. As a result, today, India is second to none, in certain sectors like computing and telephony, because of the far reaching reforms and clear-cut policies for private competition.

The telecommunications sector and the economic reforms have enriched the country (43),(44). Norms were built in the Insurance sector, banking, industries, as well as in telecommunications and slowly, the government disengaged itself from being a major services provider (45), (46), (47). This set in competition and encouraged the growth of business houses. Today, every one of every class has access to mobile, as well as cable Television and insurance and banks have ATM machines 24x7. 46, 47 A similar revolution was not attempted in health care servicing and hence, we still languish with our ancestral diseases and nurse health infrastructural infirmities (47). Fifteen years before today, all this growth was non existent. But the health situation fifteen years before and today is almost the same despite rapid the progress in Medicine and Pharmacology (46),(47).

Health Provisioning As A Business
There has been a wave of health sector reforms around the world, which commonly include the decentralization of public health services (Andreano, 1996). Experiments with decentralization have been underway since the late 1970s (Conn et al., 1996; Gilson and Mills, 1995; Leighton, 1996); (46),(47) more than 25 countries in Africa were implementing some sort of decentralization in the early 1990s (Adamolekun, 1991); (46),(47) In fact, it is good to envision the growth of major health care providers, to visualize chains of hospitals run by these health satraps and to encourage them to take over the government’s health responsibilities (46),(47). The governance has to ensure some proper policies-for health care privatization, to decorruptionise the approvals process and to encourage health care firms with good public confidence (47).While private health entrepreneurs work their way to decent profits and maintain public confidence, they can be even be trusted to run health infrastructures which are presently owned by the government on nominal profits or on a no-loss- no- profit basis (47).

Even a build- own -operate and transfer models have not been experimented as has been successfully done in the National Highways Authorities of India. 46-48 It is essential to recognize Indian entrepreneurial skills and to go forward in promoting health entrepreneurship. No amount of government investment will yield fruit unless you give back health responsibilities to the hands of the people (46),(47),(48). The best way of implementing the Alma Ata declaration of Health for All, is to complement the existing socialistic model of primary health caring for free (49). This phenomenon of self health management may in fact be better than the present indifferent approach (46),(47),(48).

Allow Private Hospitals To Exist, prosper, But Not Profiteer:
Certain non profiteering norms and strict norms about organ donation and a strong ethics management team are a prerequisite to the privatization of networks (46),(47),(48),(50). The presence of health insurance has not bettered the health services delivery in Western nations like the USA (49),(51).and the insurance sector has been more of an exploiter of peoples and has made the system costlier. It has also made the system more instrument and procedure oriented than comfortable. Some form of Insurance in the health sector which is managed by the government as government sector health insurance, will be useful for the poor(49).

Limited Effective Privatisation Is Better Than Half Hearted Government Service: (51)
If private care can be better, it can be preferred even by the masses. Efficient governments do not provide half hearted services. If health care services are good in the private or in the public domain, people, even poor are ready to pay (51). The government has to fill the pockets of the poor to pay for the services than engage white elephants to do simple health caring. (51), (53). The government should liberalize investments in the health care sector, while setting the best practice norms which are acceptable world wide(51),(52).Till the privatization of highway ownership, Indians did not taste the true benefits of efficient road transport; today, we envy some of our roadways(52). A similar attempt can be done in health services also. But unfettered commercialization without protection norms for the poor and a judicial system for health care improprieties, it is doubtful whether health sector liberalization will help (52),(53). It may turn into rampant commercialization, misuse in favour of the rich, may widen health disparities, be in the strong holds of health insurance mafia and may lead to health ghettoisation of the health impoverished. Enough safeguards have to be built forehand, even before health sector reformation (51),(53).

Let There Be Competition
A competion model of health caring is needed (54).Today, in the health sector, we don’t have a competition to the best of the health services menu, especially by the corporate hospitals. The best experts in private health caring concentrate on the best hospitals and not on the poor infrastructure and the indifferent government sector. Hence, even medical research has languished (54).

Allow To Take Over Norms And Policies For Small Hospitals, Clinics And Research Establishments In Health
Proper research policies will be needed to be framed by the government of India. An efficient grading system is needed and health professions are to be graded as per their skill sets. The hospitals, clinics, health care establishments, research labs, laboratory services, colleges of health sciences, universities of health sciences, etc, all need to be graded on a national scale and online access to such data must be available (54),(55). Also, it has to be networked or linked to international non profit health networks.
Use New Technologies: Since much of the data used and generated by health providers has a spatial dimension, geographic information system (GIS) is particularly useful to health professionals and administrators in planning and day-to-day health services management (Colledge et al., 1996) (63).Despite tremendous potential of GIS, the health sector in India has not fully explored it. Indian Planning commission has to apply such innovative technologies to map epidemics and rectify infirmities (63).

Majority of the health departments and research organizations need to adequately invest on GIS technology.GIS is a vital tool in strengthening the whole process of epidemiological surveillance information management and analysis (63).GIS provides excellent means for visualising and analyzing epidemiological data, revealing trends, dependencies and inter-relationships that would be more difficult to discover in tabular formats. Public health resources, specific diseases and other health events can be mapped in relation to their surrounding environment and existing health and social infrastructures. Such information when mapped together creates a powerful tool for monitoring and management of diseases and public health programmes (63).

Emergency Care
This can be best accomplished by providing the poor, cash transfers or Medical care coupons for services, for out-patient care and government aided and run insurance for in-patient care (57).The government should invest in public facilities, only in hard to reach regions and places where private health service providers may not emerge (57).It is rational to think of health as an industry. India need not despise quality health services oriented profit making, but at the same time health service providers should abhor profiteering in services (57), (58).

Secondly, the government must introduce at least two-year long training courses in allopathic pharmacology and diagnostics for the existing Indian systems of medicine practitioners, as outlined in the National Health Policy, 2002, (59) which envisages a role for paramedics, nurse practitioners and barefoot doctors elsewhere (59).Finally, there is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. Bachelor of Dentistry (BDS) doctors should be used in providing rural health services (59) after 1 year training in Medicine, Surgery and Family Medicine.

The Indian Medical Council headed by board of governors and the health ministry perhaps needs to relax its medical college norms without diluting the quality of medical standards and the government needs to make salaries competitive to adequately staff the existing colleges and to open new ones (60). The government has taken certain steps already, with respect to the relaxation of land area requirements and is encouraging the vertical growth of medical infrastructures (60).It should go the full way and encourage bigger multi-millionaire industrialists to directly take part in the medical services and the education industry (60). A social service component of 50% free cases, concessional cases or the credit system can be built in to take the masses along. Private mega-hospitals for public caring can be successful if humane individuals and Non-governmental organizations encourage the paradigm shift from public caring to private managed public caring (60). The total number of medical colleges (allopathy, ayurveda, homeopathy, unani, dental, nursing and pharmacy) put together, stood at 2092 in 2005-06 (61).This was a sharp increase from just 817 medical colleges in 2004-05.Without maintaining quality, if such unfettered crass commercialization of health education continues, it will degrade the standards of medical education and this has to be guarded against (61).

Many reasons exist for the availability of poor health resources in the villages and slums of India. The significant reasons are the unnecessary governmentalisation of medical resources and the mismanagement of public health provisioning (61).Public health education can remain with the government. More emphasis should be on the privatisation of public health than on the scarcity of manpower (62), (63),(64),(65).. Manpower scarcity will automatically be improved as the market takes over (62). India needs to repeat its privatisation saga with respect to medical care and health infrastructure provisioning and maintainance, but with a greater degree of compassion and this can ensure some safeguards before allowing full fledged competition (63),(64),(65).

Summary
National Health Missions may be considered as a paradigm shift in the way that healthcare delivery is to be executed, but India needs to introduce a managed competition concept and trigger the private management of health services. Healthy competition can be introduced between the governments and non –government sectors and the Government of India can do the magic again in the health sector, with respect to the telecom, transportation, television and insurance sectors. A lot more work is to be done in order to improve the quality of healthcare of the poor and disadvantaged, through multi-skilling and multi-tasking, multi-sectoral coordination and multi-agency management. However, today, the focus of the national health missions should be a healthy growth of an efficient convergence technology backed e-health network of hospitals and clinics with professional managerial approach. Such an e-health grid alone can help solve the health inequities problem and accomplish equitable distribution of health resources.

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JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com