Distinction between Public health, Community Health, Social Medicine and Community Medicine

First and foremost, among these four terms the words ‘Health’ and ‘Medicine’ used should be distinguished. We define health as “a complete state of physical, mental, social and (newly added) spiritual well-being not merely absence of disease or injury” and medicine as “the science or practice of the diagnosis, treatment, and prevention of disease”. Thus, these two words separate the meaning of ‘public health’ and ‘community health’ with ‘social medicine’ and ‘community medicine’. 

Public health means the science and art to prevent diseases, to promote health and prolong life of the people through an organized effort for sanitation of environment, education of the individual in personal hygiene, control of communicable diseases, organization medical and nursing facilities for early diagnosis and preventive treatment of disease, development of social machinery to ensure everyone a standard of living adequate for the maintenance of health; so organizing these benefits as to enable every citizen to realize his/her birthright of health and longevity.- CEA Winslow, 1920. In a sense, Public Health is both a body of knowledge and also a means to apply that knowledge.

Community health, a field of public health, is a discipline that concerns itself with the study and betterment of the health characteristics of biological communities. While the term community can be broadly defined, community health tends to focus on geographic areas rather than people with shared characteristics. In some instance, it is used as a synonym for ‘environmental health’.

‘Social Medicine’ is a product of France, Germany, Belgium and other European countries. Firmly based in the medical profession, it reflected a concern with the role of social factors in the etiology of disease, which can be known as “social pathology” and the need for government action in the areas of disease prevention and medical care. It tells human is not only a biological animal, but also a social being, and disease has social causes, social consequences, and social therapy. So it stands on two pillars- medicine and sociology.

‘Community medicine’ became prevalent in the United States as a substitute for ‘social medicine’, since the latter term sounds too much like “socialism”. It is a newcomer which has borrowed heavily from the concepts, approaches, and methods of public health, preventive medicine and social medicine. It is a practice which focuses on health of the community as a whole. As of date, there is still confusion and conflict about the roles, tasks and professional identities in the service as well as the academic worlds of community medicine.

But directly or indirectly, these terms deals with the health of the people as a whole, identifying various causes and risk factors for health related problems and taking actions for solving them. Also, they carry major implications for public health policy. All need the strong foundation of epidemiology and biostatistics.

Nepal Health Sector Program, Implementation Plan, 2004-2009

NHSP-IP (2004-2009) was particularly in achieving the health component of the Millennium Development Goals as set out in HMG’s Poverty Reduction Strategy Paper, Nepal’s 10th Five Year Plan, and its fiscal framework.

The NHSP-IP (2004-2009) was a sector-wide program focused on performance results and health policy reform implemented under sector-wide approach (SWAP) with an agreed set of program performance indicators and policy reform milestones for the program duration. It was the operational guideline for implementing the outputs of the Health Sector Reform Strategy during its first five years. It presented a roadmap for this implementation. It ran from July 2004 - July 2009. This covered the remaining period of the Tenth Five-Year Plan (2002-2007) and took into account its Medium Term Expenditure Framework. It includes MDG and poverty reduction.

NHSP-IP re-emphasized the objectives of Tenth Five Year Plan (2002-2007) which was to operationalize the Second long-term health plan. They are as follows:

• Making essential health care services (EHCS) available to all people
• Establishing decentralized health system to encourage peoples’ participation
• Establishing Public-private –NGO partnership in the delivery of health care services, 
• Improving the quality of healthcare through the total quality management of human, financial and physical resources

This program also aims to further decrease fertility rate, provide quality health services and bring effectiveness and efficiency in the healthcare.

NHSP-IP sets out three Programme Outputs to strengthen the health service delivery:

1. Prioritized Essential Health Care Services: The priority elements of Essential Health Care Service costed, allocated the necessary resources and implemented. Clear systems in place to ensure that the poor and vulnerable have priority for access 
2. Decentralized Management of Health Facilities: Local bodies responsible and capable of managing health facilities in a participative, accountable and transparent way with effective support from the MoH and its sector partners. 
3. Role for the Public Private Partnership: The role of the private sector and NGOs in the delivery of health services recognized and developed with participative representation at all levels which ensure consumers get access to cost-effective high-quality services that offer value for money.                                                                                                                                                                                                              Five Sector Management Outputs                             
4. Sector Management: Co-ordinated and consistent Sector Management (planning, programming, budgeting, financing and performance management) in place within the MoH supported by the EDPs, to support decentralized service delivery with the involvement of the NGO and private sectors.
5. Financing and Resource Allocation: Sustainable development of health financing and resource allocation across the whole sector including alternative financing schemes in place.
6. Management of Physical Assets: Structure and systems established and resources allocated within the MoH for the effective management of physical assets and procurement, distribution and rational use of drugs, supplies and equipment.
7. Human Resource Development: Clear and effective Human Resource Development policies, planning
8. Integrated Management Information System and Quality Assurance Policy: Comprehensive and integrated management information system for the whole health sector designed and functional at all levels.

Thus, there are a total eight Health Sector Programme Outputs.

Similarities and Differences between Sociology and Anthropology

Similarities:

• Both sociology and anthropology are social sciences so subject matter and fundamental base is society 
• They are twin sisters ( Krober) 
• Both sciences are focused on social actions, activities, behavior and social life of the human being 
• Both sciences apply similar approaches, methods, and techniques to study the society and apply an empirical approach to the study 
• Both sciences apply interview, observation, and questionnaire for the study of the society 
• Sociology is focused on society and anthropology to the origin, evolution, and development of the human being which are interconnected to each other. 
• Findings of sociology contribute to anthropology and vice versa. 

Differences:

• Sociology is the study of society, social interaction and social relationship whereas anthropology is astudy of the origin, evolution, and development of the human being 
• Anthropology is most focused to cultural aspects where as sociology to society as a whole 
• Anthropology is more focused to social unit as family, institutions etc whereas sociology to social behaviour, interaction and their effects in life 
• Anthropological studies are mostly based on fieldwork, observation, comparisons, and interview so they apply holistic methods but sociological studies are based on survey, interview, questionnaire and literature reviews.
• Anthropological studies are also linked to the laboratory investigations where society is the laboratory for sociological study. 

National Health Policy, 1991

Main deficiencies in previous health services:

• Basic Health requirements of the rural population were not addressed. 
• Weaknesses in the implementation of plans and programmes. 
• Poor supervision, monitoring, and evaluation of the programmes. 
• Centralization of the resources. 
• Posts sanctioned for district level health organizations were not fulfilled 

Regarding health services delivery, there is one hospital for 168 thousand persons and one doctor for 92 thousand persons in the rural areas. Likewise, only one hospital bed is available for nearly 4 thousand persons. There is only one Health post for 24 thousand rural persons, which indicates the inadequacy of PHC services at the rural level.

Thus, the National Health Policy 1991 aims at:

• Extending the primary health care system to the rural population through health infrastructure development, 
• Community participation 
• Multi-sectoral coordination 
• Mobilizing local resources and decentralized planning and management 
• Reducing infant and child mortality has been a priority 

Rationale

• To improve in the present health conditions of the Nepalese people 
• To fulfill the commitment of the elected government in the health sector 
• Necessary to have a new health policy 

Targets of the National Health Policy, 1991

By the year 2000 AD., the following targets are as follows:

1. The infant mortality rate to be reduced to 50 per thousand from the present 107 per thousand. 
2. The mortality rate of children below 5 years to be reduced to 70 per thousand from the present 197 per thousand. 
3. The total fertility rate to be reduced to 4 from the present 5.8. 
4. The maternal mortality rate to be reduced to'4 per thousand from the present 8.5 per thousand. 
5. The average life expectancy to be raised to 65 years from the present 53 years. 

Proposed Programmes:
1. Preventive Health Services
2. Promotive Health Services
3. Curative Health Services
4. Basic Primary Health Services
5. Community Involvement
6. Organizations and Management

• Integration of Hospital and Public Health 
• Technical and administrative supervision 
• Hospitals were classified 
• Health information system developed 
• Logistic improvement 

7. Developments and Management of Health Manpower
8. Private, Non-government and Inter Sectoral Coordination
9. Ayurved and Other Traditional Health Systems.
10. Drug Supply
11. Resource Mobilization in Health Services
12. Health Research
13. Regionalization and Decentralization
14. Blood Transfusion Services
15. Miscellaneous

Second Long Term Health Plan

A first Long Term Health Plan (1975 – 1990) was formulated with a calendar of operations for the Fifth, Sixth and Seventh Five Year Plans. The main emphasis was the provision of comprehensive basic health services to the majority of the rural population. In the past, plans were not guided by a long-term vision. GoN Ministry of Health has felt the need of having a perspective health plan for the coming 20 years. Preparation of Second Long-Term Health Plan (SLTHP) is an attempt to fill this gap.

SLTHP (1997-2017) was prepared with a participatory approach following a rigorous exercise of information collection, analysis, discussion, dissemination of findings and conclusions in different occasions and settings. Emphasis was given to ensure wider participation from all sectors - the public the private and NGO sectors including the key donor partners working in health and related field. The plan has spelled out the need for redirecting resources from high-cost, low-impact interventions to the low-cost high-impact essential health care services (EHCS), while improving effectiveness and efficiency

Perspective of the Health Plan:

1. Build upon the National Health Policy and guide health sector development in response to changing trends in the society
2. Improve the health status of the population particularly those whose health needs often are not met: 

• the most vulnerable groups, 
• women and children, 
• the rural population, 
• the poor, 
• The underprivileged and the marginalized

   3. Address disparities in health status, assuring equitable access to quality healthcare services with full community participation and gender sensitivity

  4. To provide technically competent and socially responsible health personnel in appropriate number for quality health care throughout the country, particularly in under-served areas

    5.  To improve inter and intrasectoral co-ordination

    6. To provide necessary support for effective decentralization of healthcare

Uses of SLTLP:

• As a resource document to guide GON in funding and to avail donor assistance in areas of greatest need
• To avoid duplication
• To assure effective use of public, private, NGO, community and donor resources

Targets for the period of the Second Long Term Health Plan 

By the end of the Second Long Term Health Plan, the following targets will be achieved: 

1. Infant Mortality Rate will be reduced to 34.4 per thousand live births from its present level of 74.7. 
2. Under-five mortality rate will be reduced to 62.5 per thousand from its present level of 118; 
3. Total Fertility rate will be reduced to 3.05 from its present level of 4.58; 
4. Life expectancy in years will be increased to 68.7 from its present level of 56.1; 
5. Crude birth rate will be reduced to 26.6 per thousand from its present level of 35.4; 
6. Crude death rate will be reduced to 6 per thousand from its present level of 11.5; 
7. Maternal Mortality Ratio will be reduced to 250 per hundred thousand births from its present level of 475; 
8. Contraceptive Prevalence Rate will be increased to 58.2 percent from its present level of 30.1; 
9. Percentage of deliveries attended by trained personnel will be increased to 95% from its present level of 31.5; 
10. Percentage of newborns weighing less than 2500 grams will be reduced to 12 percent; 
11. Essential Health Care Services at the District will be available to 90 percent of the population living within 30 minutes travel time.