WOMEN HEALTH CARE

Brajesh Malaviya

Division of Endocrinology

Central Drug Research Institute, Lucknow (India)

Females have been bestowed by the nature with important role of procreation and mammals have evolved vivi-parity as nature’s best experimental modal for better survival of their limited number of off springs as compared to other phyla. Menstruation an inherent physiological Function generally starts some time after girl’s tenth birthday during the phase of development known as puberty. The years follow before it without ova being produced.  Puberty in female child is a period of intense hormonal activity during which certain subtle changes take place in her body, as an adaptation to perform an essential biological function of child bearing. The female hormones viz. estrogens and progestogens in harmony with other factors. Perform functions to maintain homeostasis for better health. However, in the ageing certain changes occur which trigger many functional changes which affect woman’s health, such that the quality of life is affected. As a girl becomes a women, a women also has to pass through a phase of menopause.

          The terms menarche menstruation and menopause, are derived from the root men (-sem), related to an event taking place every four weeks and menopause is defined as permanent cessation of menstruation   

Resulting from the loss of ovarian follicular activity. It is generally recognized as having occurred after twelve consecutive months of amenorrhea (absence of menstruation) for which there are no other obvious pathological factors. As a matter of fact primates including human females have to undergo this phase in their lives and as the ovaries cease cease to function many symptoms manifest which change the life cycle and adjust accordingly is what Ayurved has emphasized. However, with change in life patterns and awareness towards certain undesirable/unpleasant effects viz Alzheimers, cardiovascular effects and osteoporotic changes could appear and incidence of life threatening breast carcinoma is increased, which hitherto have either remained unnoticed, or went untreated or used to be treated by self medication.

          In contrast to age at menarche the age at menopause appears to be independent of environmental factors, educational background, or physical state. Although age menarche varied from 11-17 years in various geographical areas and 14.3 years being the average age, the age of menopause was less variable. The number of pregnancies also hed no influence on the menopausal symptoms to set in. However, married women were found to have higher age at menopause that spinsters (49.8 versus 47.8) years and stimulation of female sexual organs through regular sexual contact was considered to be the causative factor for higher age at menopause. Physical build-up also seems to have no effect on age at menopause. These are all expected since menopause is dependent on the ovarian follicular activity which although had millions of primitive eggs at birth which get exhausted through follicular atresia during each month, an activity even continuing during prolonged comatose state.

          Since the pattern of setting of menopause is practically identical, it seems likely that no major ethnic differences exist so for as the age at menopause is concerned. With increased longevity during the past century the expected life-span of women has increased dramatically form 50 years to over 80 years hence on an average women would spend as many years under menopause as under menopause as under fertile reproductive phase and effective therapeutic management of menopausal phase would be a cornerstone in strategies for preserving or improving women health. From the standpoint of pharmaceutical industry, it is an opportunity to be exploited for development of such products which may alleviate the unpleasant symptoms of menopause besides evolving therapeutic strategies for life threatening increases in incidence of breast and endometrial carcinoma.

            The main organ functions that get affected during menopause are nervous system, cardiovascular system and bone architecture. The main hormonal element which is implicated in menopause is estrogen and it is long been appreciated that estradiol is a potent neurotrophic and neuroprotective factor during embryonic and development. Its role in sexual differentiation during embryogenesis was studied in early twentieth century. However, soon it was realized that estrogens exert profound protective action on adult brain in both human and animal models. Studies provided physiological and molecular basis for the myths that estrogens influence the aspects of memory, cognition and mood in healthy young and menopausal women. There are also indications that estrogens appear to delay the onset of and slow the decline in cognitive functions associated with neurogenerative diseases such as Alzheimer’s or Parkinson’s disease.

          It is well established that estrogen plays a pivotal role in female development, growth and reproduction. During sex differentiation in females the wolffian duct the progenitor of male reproductive duct system degenerates thus allowing the mullerian duct system to differentiate into female genital tract.

          The incidence of cardiovascular disease differs significantly between the two sexes. The incidence of atherosclerotic diseases is low in pre-menopausal women and rises in menopausal women. Important role that estrogens play in development of atherosclerosis was established in mid fifties of the last century when administration of estrogens in animals tends to inhibit the development of atherosclerosis other wise produced by high cholesterol diet. Recent data suggest that direct actions of estrogens on blood vessels, besides it’s effect on circulating lipid levels, contribute significantly to cardiovascular protective effects of estrogens.

          One of the most distinctive effects of estrogens on the skeleton is inhibition of longitudinal and radial bone growth. It is a common observation that the growth in height is halted as a child attains menarche (similarly when a boy attains puberty). Due to malformed ovaries eunuchs are generally taller than their normal siblings. This inhibition of bone elongation is because of direct effect sex hormones on the chondrogenesis in the growth plate.

          Bone density is measured by either single photon absorptiometry (SPA) or quantitative tomography (QCT). Due to technicality of the instruments involved SPA measures cortical bone density in the appendages i.e. hand and foot (fore and hind limbs) and QCT measures bone density in spine. Besides many other biochemical markers of bone’s physiological functioning and bone formation increase in incidence of fracture is an alarming attribute of oseoporosis. A high incidence of radiolucency if found in routine X’ray films of the spine in menopausal women.

          Bone consists of cells and an intercellular matrix of organic and inorganic substances. The organic matter is made up of collagen, orosomucoid and resistant proteins. The collagen is similar to that found in many other connective tissues. The mucoid is a protein mucopolysachharide complex containing chondroitin sulfate and is less soluble in hot water.

          The inorganic matter is responsible for the rigidity of bone and constitutes about two thirds of the bone weight. It is mainly composed of calcium as phosphate (about 85%); and corbonate (10%) and small amounts of calcium fluoride and magnesium fluoride. The radiolucency is a function of amount of these minerals in bones. During adult hood, there is an intricate balance between bone forming cells (osteoblasts) and bone resorbing cells (osteoclasts) which gets altered during advancingage, thus resulting in loss of fragility in bones. The decreased in protein matrix permits demineralization vis-à-vis decalcification, chemical moieties of these degradation products have been utilized as biochemical diagnostic markers of the degree of osteoporotic progress. This resulting softening of bone, now can not sustain the weight sheer associated with body movements and thus making an individual more susceptible to fracture. While fractures other than spine or hip can be managed with ambulatory and/or surgical manipulations, the one in spine often results in compression of softened vertebral body and intervertebral disc. A principal symptom is mainly persistent pain which may be crippling. Such fractures may produce pressure on spinal root and sciatica.

          Bone mineral density (BMD) or index (BMI) are now days most talked about terms which have made general public more-aware of osteoporosis. Otherwise osteoporosis is a normal ageing phenomenon both in females and males. Since androgenic hormone i.e. testosterone in males and female hormones i.e estrogens and 

Progestogens both decline with advancing age,the resultant development of bone fragility

Or osteoporosis is so amalgamated that hormones deficiency is implicitly correlated with development of osteoporosis. in contrast to men there is a large amount of data relating

To bone mass in females.  Alternatively muscle weakness is an important clinical problem in old age, thus contributing functional limitation for daily activities and related problems such as an increased risk for falls.

Ordinary radiological investigations at time fail to detect such fractures and effected

Persons tend to adopt bending posture and need a stick support for normal movement,

Vertebral fractures are well recognized consequence of menopausal bone loss and are most common osteoporotic fractures. All vertebral fractures whether symptomatic or radiographically identified are associated with increased mortality and morbidity including back pain and decreased activity with consequent increased days of best rest.

Vertebral fractures are serious and irreversible outcome of osteoporosis and are predicative indicator of future susceptibility to fractures unless otherwise treated because

Osteoporosis is actually a quickly progressing disease.

Quality of life issues are particularly important when considering management of menopause .Promotion of healthy lifestyle including dietary advice, encouragement and

Counseling regarding physical activity are the palliative measures which should be considered.

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Health sector Reforms in Andhra Pradesh

    A review on Health sector reforms in India   The health sector reforms in India were started way back in 1970s .The Govt. of India identifies the need HSR and stated in the eighth five year plan. The Eighth Five Year Plan (1992-1997) was the first plan document to state the need for re-structuring of economic management systems, following the macro developments of the 1990s. During this period in the health sector, the concept of free medical care was revoked and people were required to pay, even if partially, for the health services (1). The Ninth Five Year Plan (1997-2002) emphasized the need to review the response of the public, voluntary and private sector health care providers as well as the population themselves to the changing health scenario, to reorganize health services to bring about greater efficiency and effectiveness and to introduce health system reforms to enable the population to obtain optimum care at affordable cost The Ninth Plan sought to increase the involvement of voluntary, private organizations and self-help groups in the provision of health care and ensure inter-sectoral coordination in implementation of health programmes and health-related activities as well as enable the Panchayati Raj Institutions (PRI) in planning and monitoring of health programmes at the local level so as to bring about greater responsiveness to health needs of the people and greater accountability; to promote inter-sectoral coordination and utilise local and community resources for health care(2) .The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary and tertiary level(3).                         Politics influence health systems in significant manner. The goals, priorities, and the strategies, variations in the commitment are largely decided through the political contingencies. There are competing demands on the health systems. The evolution of the health systems is largely shaped by the culture, history, and norms. Client satisfaction is very high. As per NFHS-2 data, an overwhelming majority of clients are satisfied by the services delivered by the public systems. May be the expectations are low or may be our people are so courteous. But on the hand, we have the report from Transparent International, ranked the health system in India is the most corrupt system (4)   The Government has taken several steps for improving the public health care institutions and Strengthening the primary health care infrastructure. However, the situation is compounded by severe resource constraints – financial, technical and human power related, which has resulted in policy makers as well as programme managers at differing levels being faced with difficult choices. In such a situation, attempts are being made through various reform initiatives to ensure that the health needs of the people are met One of the major reform initiatives underway is the Secondary Health System Strengthening Project funded by the World Bank in seven states (Andhra Pradesh, Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). The projects include strengthening FRUs/CHCs and district hospitals so as to improve the availability of emergency care services to patients, to reduce overcrowding at district and tertiary care hospitals, construction works, procurement of equipment, increased availability of ambulances, drugs; improvement in quality of services following skill up gradation training in clinical management, changes in attitudes and behavior of health care providers; reduction in mismatches in health personnel / infrastructure; improvement in hospital waste management, disease surveillance and response system. It is essential to assess both progress and problems in implementation of the reforms in each state and to appropriately modify the content and pace of implementation. Such an overview and analysis of all related issues is necessary to provide evidence to policy makers and other stakeholders in terms of the various dimensions and impact of health sector reform.(5) In the Indian Constitution, health is a state responsibility. During Adjustment, many state governments in India had recourse to Health Systems Development Project loans from the World Bank for carrying out health sector reforms (HSR), of which one of the key policies has been to raise public spending on health care from the abysmally low levels seen up to then. The Health Systems Development Project seeks to develop strategic management capacity; strengthen performance, accountability, and efficiency; and build implementation capacity. Further, it seeks to improve clinical service quality by renovating and expanding district, sub district, and community hospitals and improving access to services. In all seven reforming states, around 15% of the total project cost is borne by the state governments. All the project documents note the low levels of funding for secondary hospitals in the reforming states. This is attributed to the small share of overall public spending allotted to health, the limited portion of total health spending going to hospitals, and, within this, a skewed distribution of funds in favour of the tertiary hospitals. After analysis of the problems of the health sector, the governments of the reforming states have agreed-using terminology ranging from “assurances” to “commitments”-to several undertakings. These are: (i) to enhance the overall size of the health budget; (ii) to redress imbalances in public expenditure between secondary and tertiary care levels; (iii) to safeguard the operations and maintenance components of current expenditure allocations for the secondary health-care sector; (iv) to charge user fees for selected services; and (v) to address workforce issues. The Health Systems Development Project initiated in the seven states recognizes the need for enhanced public spending on health and identifies it as the foremost policy reform to be pursued. Nevertheless, such assurances and conditions have not succeeded in enhancing health sector budgets in states implementing HSR. Worse, HSR has not been able to arrest the decline in the share of health spending within total government spending. The Indian system is especially complicated, as the larger tax resources are controlled by the central government but the major responsibility for health-care spending is bestowed on the states (6).Andhra Pradesh is the first state to go with the HSR.               Health sector reforms in Andhra Pradesh   The state of Andhra Pradesh was formed on 1st November, 1956 under the States’ reorganization scheme. It is the fifth largest State with an area of 2, 76, 754 sq. km, accounting for 8.4 % of India’s territory and also the fifth most populous state with a Population of 75 crores. The state has varied physiographic features ranging from high hills, undulating plains to a coastal deltaic environment. Administratively, Andhra Pradesh is divided into 23 districts, 79 revenue divisions, 1123 mandals, about 27000 villages and 264 towns. AP’s economy grew at 7.2% during 2006-07 — the fourth consecutive year of 6% plus growth. The latest poverty headcount ratio stands at 16%, compared to 23% for India . the third-highest credit rating among the major Indian states; the third best investment climate in the country; and the fourth-lowest corruption level among Indian states Andhra Pradesh was the first Indian state to receive a multi-sector Bank operation – the Andhra Pradesh Economic Restructuring Program for US$ 550 million in 1997 – aimed at helping the state accelerate policy and institutional reforms across a wide range of sectors under a common fiscal framework. It is also the only Indian state where the Bank has disbursed three budget support operations – the First Andhra Pradesh Economic Reform Loan (APERL-1) in March 2002, the Second APERL in February 2004, and the Third APERL in January 2007 – that sought to support the state’s development program.(12) Within AP there are regional, social and gender disparities. Health outcomes are worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% of population), especially those living in underserved areas in North tribal and South drought prone districts, and for women. Effective delivery of quality basic health services is hampered by demand and supply side issues, including poor health infrastructure and staffing.(15)     The reform history in health sector in the State can be traced to Andhra Pradesh First Referral Health System Project, one of the first World Bank aided health system projects in the country. This project, launched in 1995 had been implemented by AP Vaidya Vidhana Parishad (APVVP). Agencies like World Bank and DFID are supporting the reform process in the State. The Bank supported the AP Economic Restructuring Project which included improvement of primary health care as one of the component.(7) The priority reforms focus on improved access to quality and responsive health services, strengthened governance and management in health sector, improved institutional mechanisms for community participation and systems for accountability; and strengthened financial management systems.(15)  The government of Andhra Pradesh [GoAP 1999] Vision 2020 document identifies a seven-point set of priorities for health sector reform: providing universal access to primary healthcare; encouraging private investment in tertiary healthcare; focusing on specific programmes to promote family planning; focusing on improving health levels in disadvantaged groups and backward regions; ensuring a strong prevention focus; enhancing the performance of the public health system; and formulating a state information education and communication (IEC) programme to broadcast information on preventive healthcare.(13) The Government of Andhra Pradesh is embarking on a major health sector reforms to improve health care delivery in the State. D.F.I.D. has expressed its willingness to support these initiatives with a grant of 100 Million pounds over the next five years (2006-2011). The reform initiative will include measures to improve the effectiveness and accountability of public health services, measures to focus on community centric preventive healthcare system and enhance access to quality healthcare for the poorer sections of the population(14) DFID will provide up to GBP40 million health sector budget support to the DoHMFW, GoAP, over 3 years 2007 – 2010. The sector support will build synergy with National Rural Health Mission (NRHM) which is a health sector reform program of the central government for decentralisation, pro-poor focus, strengthening service delivery(15)     The health sector support will be provided over three years (2007-08 – 2009- 10). It aims at increased use of quality health services, especially by the poorest people and in underserved areas.(16) The main outputs will be: a) Improved access to quality and responsive services, especially in remote and interior areas; b) Governance and management of health sector strengthened; c) Institutional mechanisms for community participation and systems for accountability in functioning; and Financial management systems strengthened and improved public expenditure on health.   The performance of health services would be measured against(17)

* greater effectiveness and improved outcomes of existing programs;

* improved efficiency in the allocation of resources;

* greater access and equity; and

* consumer satisfacfion

Reforms underway in health sector   The major reforms underway are classified under these categories and the activities are noted below and we will look each of them in detail  (I) Reorganization and restructuring of existing government health care system

• Establishment of Andhra Pradesh Vaidya Vidhana Parishad
• Strengthening of referral institutions and fixing of service norms
• Improvement in drug supplies
• Formation of Andhra Pradesh Health, Medical & Housing Infrastructure Development Corporation (APHM&HIDC)
• Strengthening of PHCs as 24-hour MCH centers
• Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres

(II) Changes in health system organisation, delivery and Management

• Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals
• Provision of free travel bus passes to pregnant women for antenatal check ups
• Public Private Partnership

(III) Changes in financing methods

• Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme)
• User fees

(IV) Reforms related to human resources

• Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department

(V) Involving community in health service delivery and Provision

• Women Health Volunteers Scheme

(VI) Reforms to quality of care

• Performance indicators for grading the PHCs
• Performance rating of secondary hospitals

    1.Reorganization and restructuring of existing government health care system   A)Andhra Pradesh Vaidya Vidhana Parishad   AP, has created the Andhra Pradesh Vaidya Vidhana Parishad (APVVP) by enacting an Act in the Legislative Assembly in 1986(8) This was done with the objective to lay greater emphasis on development of both preventive as well as curative health care  and to strengthen necessary linkages at appropriate levels to ensure comprehensive medical and health care services. APVVP has undertaken World Bank assisted Andhra Pradesh First Referral Health Systems Project (APFRHSP) in 1994 for a period of seven years. This has been one of the major projects undertaken by APVVP. The objectives of the project included improvement of efficiency in the allocation and use of health resources through policy and institutional developments and enhanced performance of health system by improving the quality, effectiveness and coverage of health services at the first referral level.   B)Strengthening of referral institutions and fixing of service norms   basic service norms for various categories of hospitals under the administrative control of APVVP have been fixed thereby creating a hierarchy of hospitals according to services and facilities. This system of service norms and referral linkages had been developed with a view to optimise utilisation of resources, avoid duplication and wastage of resources, regulate patient flow and reduce cost of treatment by reduction of patient burden at tertiary hospitals. the district hospital has been prescribed to provide services in eleven specialties for which 9 civil surgeon specialists, 18-20 civil assistant surgeons, 54-84 paramedical staff and other supporting staff have been Posted. C)Improvement in drug supplies To ensure regular supply of drugs at all times and in all situations, a system of three sources of drug supply has been put in place for the hospitals under APVVP: (a) centralised drug procurement system under which the institution has been allotted drugs worth a particular amount based on bed strength (Rs 2000 per bed per quarter); (b) an emergency provision for drugs (Rs 100 per bed per month) has been made to every institution from where emergency procurement of drugs is made; (c) drugs which are in short supply and for which regular rate contract suppliers are not available have been stocked at the office of District Coordinators of Health Service. Under the APFRHSP, const-ruction and repair of 160 hospitals including 81 CHCs, 58 area hospitals and 21 district hospitals had been undertaken.(10)         D)Formation of Andhra Pradesh Health, Medical & Housing Infrastructure Development Corporation (APHM&HIDC)   a separate corporation has been set up in 1987 exclusively for developing housing and other infrastructure for medical and paramedical staff and constructing sub centers, PHCs, hospitals, dispensaries, clinics and other health care centers One of the major projects undertaken by APHM&HIDC has been the World Bank assisted India Population Project-VIII launched for improving the medical care facilities in urban slums in 74 municipalities.   E)Strengthening of PHCs as 24-hour MCH centers   In a move to make available maternal and child health care at all times, 470 PHCs in backward districts have been designated as round the clock Mother and Child Health Centre (earlier called women health centres). One staff nurse, one ANM and three support staff have been appointed in each centre on contractual basis. Staff nurses have been trained to conduct normal deliveries and refer emergency cases. Additional facilities like telephone and vehicle have been provided to the PHCs in order to assist communication and transport for referral of emergency cases. Provision has been made to conduct fortnightly specialist clinics of gynaecology and paediatrics in these centres to detect high risk pregnancies and neonates for referral to FRUs.   F)Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres   The State Government has decided to establish 108, CEmONC centres spread across every district so that pregnant mothers requiring emergency care do not have to travel more than 40-50 kms to receive specialist care. Training of MBBS doctors in anaesthesia, neonatal care and blood transfusion is also planned to support this scheme.   2)Changes in health system organisation, delivery and Management A)Formation of Hospital Advisory Committee/ Hospital Development Societies for all PHCs and FRUs/ teaching hospitals   Hospital Development Societies have been constituted in all tertiary hospitals under the control of Directorate of Medical Education.(18) and after implementing NRHM rogi kalyam samithi at every PHC were formed to ensure the adequate participation of local institution,with an aim to improve effective and efficient services with allowed flexible financial powers. These societies are examples for decentralization . Activities of the society include maintenance of the hospital (including sanitation & water supply, electricity, building & civil works and equipment), purchase of drugs & medicine supplies and equipment. The government has set norms and limits for undertaking these works which are to be adhered to by the Society. The ‘system works’, observed an Unicef team which assessed the impact of RKS towards the end of 2000. The system, however, is not without any lacunae. For, it was pointed out that “overall control of the local RKS bodies remain in the hands of the collector and if he is not interested in health care then the whole thing might just drift(13)   B)Provision of free travel bus passes to pregnant women for antenatal check ups(19)   The Government of Andhra Pradesh has started an innovative scheme in order to enable pregnant women in rural areas to avail antenatal check ups at the nearest PHC/area hospital or FRU. It has tied up with the State Road and Transport Corporation to issue free transportation bus tickets pass to be utilised for three visits. The ANM issues the bus passes to the pregnant women on her house visits.       C)Public Private Partnership(20)   *         Management of Urban Health Centers by NGOs   Under the World Bank assisted Andhra Pradesh Urban Slum Health Care Project (APUSHCP), 192 urban health centers (UHCs) have been established in 74 municipal towns in 21 districts covering 1848 slums. After withdrawal of support by the World Bank, the project has been funded by the state government since 2002. The outcomes of the project show marked improvement in ANC coverage, institutional deliveries, post natal care and immunisation in the slum population.   *         108 emergency services                           Govt. has tied up with satyam computers to provide emergency transportation which proved to a most successful programme and many states are following the same like Gujarath. The objective of 108 Ambulances is to save people in life emergency . One ambulance is given for three mandals. Each ambulance fitted with equipment worth Rs.17 lakhs renders its services in life emergencies, road and fire accidents (22)   *         Rajiv arogya sree    The innovative Govt. insurance scheme to serve people of  poor from the serious ailments now attracting the nation as this programme succeeded. this scheme provides financial support to families of BPL upto 2 lakhs per anum for treating serious ailments. it is proposed to cover the entire state by 2nd October 2008 with the govt. paying the insurance premium for all the beneficiaries .an amount of rs.450 crores are provided to implement the scheme during 2008-09. (21)       3)Changes in financing methods   A)Sukhibhava Scheme(23)   Under the Scheme, a cash assistance of Rs.300 (Rs 200 towards transportation charges and Rs 100 for food and incidental expenses) is paid to pregnant women belonging to below poverty line families who come to government hospitals/APVVP hospitals/ teaching hospitals/PHCs/CHCs for delivery serv-ices. This assistance is payable only to those women with no living children or with one living child.   B)User fees:-   If user fees are charged their main use may lie in optimization of expenditure patterns and better allocation between facilities and within facilities(24). Reddy and Vandemoortele (1996), based on a comprehensive review of user financing of basic social services carried out for UNICEF, point to three other discouraging features of user fees: (1) user financing can result in a sharp reduction in the utilization of services, particularly among the poor; (2) gender biases, seasonal variations and regional economic disparities can aggravate the effects of user financing on equity; (3) user financing  quires adequate capacities, effective decentralisation and continued government support; and (4) user financing can undermine political support for the goal of universal coverage of basic social services. In 2001, the Commission on Macroeconomics and Health (2001) also reached a similar conclusion that user fees end up excluding the poor from essential healthservices, in 2005, the Millennium Project’s recent Report to the UN Secretary General (2005) titled “Investing in Development – A Practical Plan to Achieve the Millennium Development Goals” also forcefully argues for abandoning user fees. The health sector in India has acquired a notorious reputation for inefficiency and corruption at all levels. There is little accountability in both the public and private sectors. Quality standards are practically non-existent as are performance measures and honest reporting. A recent report on human resources for health brought out by Harvard University’s Global Equity Initiative (2004) argues that it is people – health workers alone – who can produce an effective health system and deliver good ealth.(25) 4)Reforms related to human resources Integration and responsibilities of functionaries for planning, implementation and monitoring of programmes of HM & FW department At district level, District Health Coordination Committee (DHCC) has been constituted to ensure proper planning, implementation and monitoring of all programmes/activities of HM&FW Department in the district.  The Committee has been entrusted with the primary responsibility of planning, finalizing, implementing and monitoring the District Health Action Plans and institutionwise health plans in a participatory manner including all concerned officials, other concerned departments and NGOs.   5)Involving community in health service delivery and Provision  

• Women Health Volunteers Scheme

  One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist – ‘ASHA’ or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system. Following are the key components of ASHA(26) A woman, usually a daughter-in-law of a house who has studied upto 7th class and preferably from SC/ST community has been selected as WHV by the Gram Panchayat Health Committee. The selected WHV has been given one month training in health care aspects of pregnancy, antenatal, delivery, post natal and new born care, immunisation, diarrhoea, acute respiratory infections, first-aid and treatment of minor ailments. The training has been provided at Telugu Mahila Pranganams for three weeks and one week field level training at PHCs. Academy of Nursing Studies has been designated as the nodal agency for providing training to WHVs.   6)Reforms to quality of care   A)Performance indicators for grading the PHCs   One of the components of World Bank assisted AP Economic Restructuring Project is improvement of primary health care. In order to improve the quality of primary health care services, a system of performance rating has been developed to rate PHCs and CHCs. The grading has been accorded A to C in descending order   B)Performance rating of secondary hospitals   A performance rating system for secondary hospitals under APVVP has been  introduced. The indicators related to general services (outpatients, inpatients, bed occupancy), emergency services (emergency-OP, emergency-IP, emergency major operations, emergency minor operations), clinical services (major/minor operations, tubectomy, deliveries) and diagnostic services (X-ray, ECG, lab tests and USG) have been developed for the purpose. Normative targets for each type of hospital (district hospital, area hospital, community health center) have been fixed against which the performance is measured and rating assigned. Highest grading is A while lowest grading is C.(27)   Conclusion:-   Introduction of user charges and subcontracting of services to the private sector are the main elements of health sector reforms. The health sector reforms are only a part of drastic reforms in other major sectors undertaken as a part of Andhra Pradesh Economic Restructuring Project (APERP) and the overall impact on the health conditions of people and their access to medical care depend more on the changes proposed outside the health sector. For instance, while exempting the white ration card holders i.e. the poor from the user charges in the government hospitals, it proposes to drastically reduce the number of white card holders to half in the state. The net affect would be to reduce the percent of population eligible for free treatment.(29)   On the other hand the success of 108 EMRI services and overwhelming response from Rajiv Arogya sree scheme are the examples for HSR success. Just like every thing has gots its own pros and cons HSR should be done in such a way where the need exist and according to necessities .   Referances:- (Note:-most part of the article was taken from ref.no 28 otherwise reference specified)

1. (Government of India, Eighth Five Year Plan, (1992-1997) Planning Commission, New Delhi.)
2. (Government of India, Ninth Five Year Plan, (1997- 2002) Planning Commission, New Delhi )
3. ( Government of India, Tenth Five Year Plan (2002-2007) Planning Commission, New Delhi)
4. ( D. Agarwal Health Sector Reforms: Relevance in India, Indian Journal of Community Medicine Vol. 31, No. 4, October-December, 2006)
5. Health Sector Reforms in India, Initiatives from Nine States
6. ( http://www.idrc.ca/en/ev-118491-201-1-DO_TOPIC.html.The international development research centre)
7. http://www.worldbank.org.in
8.  (The Andhra Pradesh Vaidya Vidhana Parishad Act 1986 (Act No. 29 of 1986 with Amendaments upto 31.03.1989
9. Dr. MCR Human Resource Development Institute of Andhra Pradesh (Undated). “Andhra Pradesh Vaidya Vidhana Parishad Departmental Manual”
10. 6http://www.aponline.gov.in/apportal/departments/ departments.asp?dep=16&org=98
11. GoAP (2006), Response to Questionnaire on Health Sector Reforms from MOHFW, GoI.
12. http://www.worldbank.org.in/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/INDIAEXTN/0,,contentMDK:20970681~pagePK:141137~piPK:141127~theSitePK:295584,00.html#Ongoing_projects
13. Grish kumar,promoting PPP in health services,EPW commentary,july19,2002
14.  (G.O.Ms.No.130, HEALTH MEDICAL AND FAMILY WELFARE (K2) DEPARTMENT. Dated the 24th April, 2006)
15.  ANDHRA PRADESH HEALTH SECTOR REFORM PROGRAMME (APHSRP) Terms of reference for Technical Cooperation (TC) to DoHMFW, GoAP
16.  PRESS INFORMATION BUREAU GOVERNMENT OF INDIA, HEALTHCARE PROJECT IN AP FUNDED BY DFID, New Delhi, March 5, 2008)
17. http://lnweb90.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/0CFD6217A8A5BDA2852567F5005D32BD
18.  G.O.Ms.No.403, dated Sept 7th 1998
19.  GoAP (2006), Response to Questionnaire on Health Sector Reforms from MOHFW, GoI.
20. Power Point Presentation of Govt of AP at the 2nd Regional Workshop on Health Sector Reforms: Experiences of Select States at Hyderabad, 14-15th February 2005 and ECTA Working paper 2002/61 Public-Private Partnership: Operational Framework used in Andhra Pradesh and Assam
21. http://www.scribd.com/doc/2208678/AP-Budget-Speech
22.  http://pibhyd.ap.nic.in/er27070702.pdf
23.  Dept. of Health Medical Family Welfare, GoAP (undated), “Sukhibhava (Improvement of Institutional Delivery Services Scheme): Implementation Guidelines to PHC/Hospital
24.  http://mohfw.nic.in/NRHM/Documents/CRM_report_full_report_version.pdf
25.   (A.K.Shiv Kumar,,Budgeting for health ,some considerations) Economic and Political Weekly April 2, 2005
26.  http://mohfw.nic.in/NRHM/asha.htm#abt
27. http://health.ap.nic.in/apvvp/apvvp_stat.html
28.  (http://www.whoindia.org/linkfiles/health_sector_reform_hsr_vol_ii_-_andhra_pradesh.pdf)
29.  (Impact Of Health Sector Reforms On Hospital Services In Andhra Pradesh – A Study Of Trends In The Structures Of Provision And Utilisation Pattern)(centre for economic and social studies) (http://www.cess.ac.in/cesshome/research6b.html)

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Pregnancy and Postpartum Depression, Women’s Health Dr. McCarthy explains what happens to a womans body during pregnancy and after child birth and the effects this can have on a womans hormones, health, stress and wellness. Dr. Peter McCarthy, CTN Peter is the Chief Executive Officer and Wellness Director of Life Energy Holistic Partners, Inc. He is a Nationally Board Certified Traditional Naturopath and is a member of the Advisory Committee of the American Naturopathic Certification Board …

Help answer the question about women health clinic

a.)The folate supplementation prevents pernicious anemia, which increases the risk of spina bifida
b)The folate supplementation is needed to ensure a large store that can be utilized by the growing fetus
c.)As long as supplementation begins the day pregnancy is confirmed, there is no risk of defects
d.) The neural tube develops early on in pregnancy, oftentimes before most women realize they are pregnant

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6 yrs experience in public health working with Govt. of Andhra pradesh of INDIA