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Public Health 101

Primary health care, OneHealth, health systems & social determinants
ImpactMojo Workshop Series • Health Equity & Delivery in South Asia
75-90 Minutes

Workshop overview

Target Audience: Health workers, development practitioners, policy makers, NGO staff, and public health students working in South Asian contexts

Prerequisites: Basic understanding of health issues helpful but not required

Materials Needed: Notebooks, calculators for health statistics, access to health databases

Learning objectives

By the end of this workshop, participants will be able to:

Part 1: Public health fundamentals - beyond individual medicine

20 minutes

The public health impact

20th Century Achievement: In the United States, life expectancy rose by more than 30 years over the 20th century, and the CDC attributes 25 of those years to public health advances

Top Contributors: The CDC's ten great public health achievements include vaccination, control of infectious diseases, safer workplaces and safer food (MMWR, 1999)

In India: Life expectancy at birth rose from 49.7 years in 1970-75 to 70.3 years in 2019-23 (Registrar General of India, SRS Abridged Life Tables 2019-23)

Key Insight: Population-level interventions often have greater impact than individual medical care

Defining public health

What is public health?

Classic Definition (Acheson Report, 1988, adapting Winslow, 1920): "The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society"

Core Functions:

  • Assessment: Monitor health status, investigate health problems
  • Policy Development: Inform and educate, mobilize partnerships
  • Assurance: Enforce laws, ensure competent workforce, evaluate services

Public Health vs. Medical Care:

  • Focus: Populations vs. individuals
  • Approach: Prevention vs. treatment
  • Setting: Communities vs. hospitals/clinics
  • Timeframe: Long-term vs. immediate

Primary health care: The foundation

Alma-Ata Declaration (1978) - "Health for All"

Core Principles of Primary Health Care:

  1. Equity: Health care as a human right, reducing disparities
  2. Community Participation: People involved in planning and implementation
  3. Intersectoral Action: Health outcomes depend on multiple sectors
  4. Appropriate Technology: Evidence-based, affordable, acceptable
  5. Prevention Focus: Emphasis on preventing disease and promoting health

Essential Services: Maternal/child health, immunization, nutrition, safe water, sanitation, treatment of common diseases, essential medicines

Social determinants of health

Living conditions

Housing quality, overcrowding, access to clean water, sanitation, neighborhood safety

Working conditions

Employment status, job security, workplace safety, income level, occupational hazards

Education

Literacy, health knowledge, life skills, educational opportunities, early childhood development

Food security

Access to nutritious food, food safety, agricultural practices, market systems

Social environment

Social support, discrimination, gender roles, caste systems, community cohesion

Policy environment

Health policies, social protection, governance quality, corruption levels

Exercise: Health determinants analysis (12 minutes)

Case Study: High rates of tuberculosis in urban slums

Context: A slum area in Mumbai has TB incidence of 400 per 100,000 people (national estimate: 187 per 100,000 in 2024, WHO Global TB Report 2025)

Population: 50,000 people, mostly migrants, working in informal sector

Conditions: Overcrowded housing (8-10 people per room), poor ventilation, limited water access, open drains

Analysis Framework (Work in groups of 3-4):

Social Determinant How it Contributes to TB Intervention Opportunities
Housing/Living Conditions
Economic Factors
Social Factors
Health System Access

Discussion Questions:

  1. Which determinants would you prioritize for intervention? Why?
  2. How would you involve the community in designing solutions?
  3. What sectors beyond health would need to be involved?

Share-out: Groups present one key insight about addressing TB through social determinants (5 minutes)

Part 2: Health systems - building blocks for better health

20 minutes

WHO Health Systems Framework: A health system consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health.

Six building blocks of health systems

Building Block Key Components Indian Context Challenges Success Examples
Service Delivery Availability, accessibility, quality, safety Rural access gaps, quality variation ASHA program, telemedicine
Health Workforce Availability, competency, responsiveness Shortage, maldistribution, skill gaps AIIMS expansion, nursing colleges
Health Information Data collection, analysis, dissemination Data quality, integration challenges Health ID, digital health records
Medical Technologies Medicines, vaccines, equipment Supply chain issues, quality control Generic drugs, Jan Aushadhi
Financing Revenue raising, pooling, purchasing High out-of-pocket spending Ayushman Bharat, state insurance
Leadership/Governance Policy, regulation, accountability Coordination across levels National Health Mission structure

India's health system architecture

Three-tier system structure

Primary Level:

  • Sub-centers: 1 per 5,000 population (ANM-based)
  • Primary Health Centers (PHCs): 1 per 30,000 population
  • Community Health Centers (CHCs): 1 per 120,000 population

Secondary Level:

  • District Hospitals: 100-300 beds, specialist services
  • Sub-divisional Hospitals: Intermediate care

Tertiary Level:

  • Medical Colleges: Teaching hospitals with super-specialty care
  • AIIMS/PGI: Apex institutions for complex cases

Current Gaps: Shortfalls in PHCs, CHCs and doctors at PHCs against population norms (see the Ministry of Health's Rural Health Statistics for current figures)

Health system performance - key indicators

India's health system dashboard (latest available data)

Access:
• 90.6% births in institutions (NFHS-6, 2023-24)
• 82.6% full immunization (NFHS-6)
• 91.3% skilled birth attendance (NFHS-6)
Quality:
• High antibiotic overuse
• 54% of births in private facilities are by caesarean section, against 17% in public ones (NFHS-6)
Efficiency:
• Government health spending at 1.43% of GDP (NHA 2022-23)
• 43.4% of health spending paid out of pocket (NHA 2022-23)
Equity:
• Under-5 mortality 33 rural vs 20 urban (SRS 2023)
• Nearly 3x maternal mortality: EAG states and Assam 116 vs southern states 41 (SRS 2022-24)
• Wealth-based disparities in all indicators

System strengthening exercise (12 minutes)

Scenario: You are designing a health system strengthening intervention for a district with poor health outcomes

District Profile:

  • Population: 2 million (70% rural)
  • Infant Mortality Rate: 45 per 1,000 (national average: 25, SRS 2023)
  • Maternal Mortality Ratio: 150 per 100,000 live births (national average: 87, SRS 2022-24)
  • Only 60% institutional deliveries
  • 40% children underweight
  • Health infrastructure: 80% of required facilities exist but many understaffed

System Analysis (Work in pairs):

  1. Identify (3 min): Which building blocks seem weakest based on the data?
  2. Prioritize (3 min): If you could strengthen only 2 building blocks, which would you choose? Why?
  3. Design (4 min): Outline specific interventions for your chosen building blocks
  4. Integration (2 min): How would you ensure your interventions work together?

Quick Presentations: 1 minute per pair to share top priority and rationale

Part 3: OneHealth - connecting human, animal, and environmental health

15 minutes

OneHealth approach

Core Principle: Human health, animal health, and environmental health are interconnected

Human Health
Animal Health
Environmental Health

Optimal health outcomes require collaboration across all three sectors

Why OneHealth matters - evidence from South Asia

Zoonotic disease burden

The Statistics:

  • 75% of emerging infectious diseases are zoonotic (animal origin)
  • 60% of existing human infectious diseases are zoonotic
  • 5 new diseases emerge annually, most from animal-human interface

South Asian Examples:

  • Nipah Virus (Kerala, Bangladesh): Fruit bats → humans, directly or through contaminated date palm sap; pigs were the intermediate host in Malaysia (1998-99)
  • Avian Influenza: Poultry → humans, multiple outbreaks
  • Rabies: About 5,700 deaths a year in India by an ICMR-NIE estimate published in 2024, down from about 20,000 two decades earlier (WHO India)
  • Japanese Encephalitis: Pigs as amplifying hosts
  • COVID-19: Likely animal origin, pandemic impact

Environmental health connections

Environmental Factor Health Impact South Asian Context OneHealth Response
Air Pollution Respiratory disease, cardiovascular disease Delhi, Dhaka among most polluted cities Integrated monitoring, multi-sectoral action
Water Quality Diarrheal diseases, cholera, typhoid Groundwater contamination, poor sanitation Watershed management, WASH programs
Food Safety Foodborne illness, antimicrobial resistance Informal food systems, antibiotic overuse Farm-to-plate surveillance systems
Climate Change Vector-borne diseases, heat stress Expanding dengue/malaria range Climate-health adaptation planning
Deforestation Emerging diseases, biodiversity loss Human encroachment into wildlife habitat Conservation with health co-benefits

Antimicrobial resistance - a OneHealth crisis

AMR: The silent pandemic

The Challenge: Overuse and misuse of antibiotics in humans, animals, and agriculture creates drug-resistant pathogens

India's AMR Burden:

  • About 58,000 newborn deaths a year from resistant sepsis (Laxminarayan and others, Lancet Infectious Diseases, 2013 estimate)
  • Antibiotics widely sold without prescription
  • High resistance rates in common pathogens (E. coli, Klebsiella)
  • Agricultural antibiotic use only partly regulated (colistin banned for food-producing animals, poultry, aqua farming and animal feed supplements by a Health Ministry notification of July 2019)

OneHealth Solutions:

  • Surveillance: Integrated monitoring across human, animal, environmental sectors
  • Stewardship: Appropriate use guidelines for all sectors
  • Infection Prevention: Hygiene, vaccination, biosecurity measures
  • Research: New drugs, diagnostics, alternatives to antibiotics

OneHealth planning exercise (8 minutes)

Scenario: Outbreak of unknown febrile illness in a rural district bordering forest area

Initial Information:

  • 50 cases over 2 weeks, mostly in villages near forest edge
  • Symptoms: High fever, headache, muscle pain
  • Recent deforestation for agricultural expansion
  • Local reports of increased wildlife-human interaction
  • Some patients also have sick livestock

OneHealth Investigation Plan (Work in groups of 3-4):

  1. Human Health (2 min): What human health data and samples do you need?
  2. Animal Health (2 min): What animal investigation is needed?
  3. Environmental Assessment (2 min): What environmental factors should be examined?
  4. Integration (2 min): How would you coordinate across sectors?

Share-out: Each group shares one key insight about OneHealth investigation approach

Part 4: Health equity and delivery challenges

15 minutes

Understanding health inequities

Biomedical model

  • Focus: Disease, pathology, individual treatment
  • Solutions: Medical interventions, technology, drugs
  • Success metric: Clinical outcomes, survival rates
  • Limitation: Ignores social context and root causes

Health inequities in South Asia

Persistent health disparities

Wealth-based Inequities (India NFHS-5):

  • Child mortality: higher in the poorest than the richest quintile
  • Skilled birth attendance: lower in the poorest quintile
  • Full immunization: lower in the poorest quintile

Caste-based Disparities:

  • Scheduled caste/tribe women have higher maternal mortality
  • Lower access to quality health services
  • Higher rates of malnutrition in children

Gender Inequities:

  • Son preference affecting female survival
  • Lower healthcare seeking for women and girls
  • Higher malnutrition rates among women

Geographic Disparities:

  • Rural-urban gaps in all health indicators
  • Interstate variations: Kerala vs Bihar, Assam
  • Remote areas with limited health facility access

Delivery challenges and innovation

Health system innovations

Digital Health:

  • Telemedicine: eSanjeevani platform for remote consultations
  • Health Records: Ayushman Bharat Health Account (ABHA)
  • Decision Support: AI-based screening and diagnosis tools

Community Health Workers:

  • ASHA Program: 1M+ workers providing doorstep services
  • Skill Upgrading: Training for non-communicable diseases
  • Performance-based Incentives: Results-linked payments

Financial Protection:

  • Ayushman Bharat PM-JAY: About 55 crore people in 12.37 crore families (the bottom 40%) covered for up to ₹5 lakh per family per year, extended to everyone aged 70 and above from October 2024 (PIB, 2025)
  • State Schemes: Additional coverage by progressive states
  • Challenges: Provider network, quality assurance

Equity-focused intervention design (10 minutes)

Challenge: Design a public health intervention to reduce maternal mortality in a high-burden district

Context:

  • Maternal Mortality Rate: 200 per 100,000 (state average: 130)
  • Only 60% institutional deliveries
  • High proportion of tribal population (40%)
  • Limited transport, rough terrain
  • Cultural preferences for traditional birth attendants

Design Framework (Individual then pair discussion):

  1. Root Cause Analysis: Why is maternal mortality high in this context?
  2. Equity Lens: Which women face the greatest barriers?
  3. Multi-level Intervention: What would you do at individual, community, and system levels?
  4. Community Engagement: How would you involve tribal communities in design and implementation?
  5. Measurement: How would you track progress on equity as well as overall rates?

Key Question: How does your intervention address both immediate medical needs and underlying social determinants?

Summary

Public health is about creating conditions in which everyone can be healthy. That means looking past individual behaviour to the social, economic and environmental factors that shape health.

Resources for continued learning

Global Public Health:

Indian Health System:

OneHealth Resources:

Health Equity:

Next Steps in ImpactMojo:

This handout is part of the ImpactMojo 101 Knowledge Series
Licensed under CC BY-NC-ND 4.0 • Free to use with attribution • www.impactmojo.in

For the complete Public Health 101 course with detailed health system analysis, epidemiology modules, and program planning tools, visit the ImpactMojo platform.