Health care delivery system in India

Health care delivery system in IndiaFramework Introduction Evolution of health care services in India Role of different committeesOrganizational structure in IndiaHealth care delivery system in IndiaGaps in structure Finance allocationIntegrated approach of health care delivery Contribution by NGOsChallengesIntroduction Older concept Health care means patient care Objective - freedom from the disease through hospital system.

WHO As an integrated care containing promotive, preventive and curative elements that bear the longitudinal association with an individual, extending from womb to tomb, and continuing in the state of health as well as disease.

Service offered by all health disciplines

Inter-sectoral coordination and community participation Responsibility of providing health care expanded well beyond health sector.

Evolution of health care services in IndiaChristian Era civilization started in Indus Valley Environmental sanitation, houses with drainage 1400 B.C. Ayurveda and Siddha systemDeveloped a comprehensive concept of healthPost vedic teaching of buddhism and JainismRahula Sankirtyana developed hospital system.Moghul empire Arabic system of medicine (Unani)British Gov British nationals, armed forces, civil servants.Role of different committees1946 Bhore Committee (Health survey and development committee)Integration of preventive and curative servicesDevelopment of PHC 3 months training in PSM

1962 Mudaliar committee (Health survey and planning committee)Strengthening of PHC and district hospital Regional organization

1963 Chaddah committeeBasic health workersFamily planning health assistant

Role of different committees cont.1965 Mukerji committeeSeparate staff for the family planning programme

1967 Jungalwala committeeIntegration of health servicesElimination of private practice by Gov. doctor

1973 Kartar singhCommittee on multipurpose worker ANM replaced by female health workerBasic health worker replaced by male health worker Lady health worker designated as female health supervisor.

Organizational structure in IndiaHealth system has 3 main linksCentral, state and local or peripheral.

India is a Union of 28 states and 7 territories.

Health is the responsibility of state.

Central responsibility Policy makingGuidingAssistingEvaluatingCoordinating the work of state health ministries.

At the centre Official organ

The union ministry of health and family welfareHeaded by Cabinet minister

Minister of stateDeputy health minister

The union ministry of health and family welfareThe directorate general of health services.The central council of health and family welfare.The union health ministry

Department of healthDepartment of family welfare

Department of health Secretary to the Gov. of India (Executive head)Joint secretary

Administrative staffDirectorate general of health services

Subordinate officer

Department of family welfareWas created in 1966Headed by the secretary to the government of India.

SecretaryAdditional secretaryCommissionerOne joint secretaryDirectorate general of health services - Principal advisor in both medical and public health matter.DGHSAdditional Director General of health servicesTeam of deputiesAdministrative staffDirectorates - three main units

General administrationPublic healthMedical care and hospitalThe central council of health and family welfareChairman Union health ministerMembers State health ministers

Function To consider and recommend board outlines of policy in regards to matters of healthTo make proposals for legislation in fields of medical and public health matters and to lay down.To make recommendations to the central government regarding the health.To established any organization with appropriate functions for promoting and maintain cooperation between central and state health administrations.

At the state levelThe state health administration was started in the year 1919.

The state list which become the responsibility of the state includedProvision of medical care Preventive health servicesPiligrim within the state

State - management sector

Directorate of health and family welfare servicesState ministry of healthState ministry of health and family welfareHeaded - Cabinet minister and deputy minister. (Political head)Responsibility - formulating policiesMonitoring the implementation of these policies and programmes.

State health directorate and family welfarePrinciple advisor in matters relating to medicine and public healthAssisted by joint director, regional joint director and assistant directors.

At the district levelPrincipal unit of administration in India

District health organization identifies and provide the needs of expanding rural health and family welfare programme

Within each district again, there are 6 types of administrative areas

No uniform model of district health organization

RuralUrbanPanchayatsVillagesCommunity Development BlocksCorporationsMunicipal BoardsTown area committeesTahsil (Taluka)DistrictSub-divisionPanchayati Raj 3 tier structure of rural local self government Linking the village to the districtPanchayat Raj

Panchayat Panchayat Samiti Zilla Parishad

Gram Sabha Gram Panchayat

Health care delivery system in IndiaAt the block levelObjective - to provide primary health care to all the sections of the society. 80% of the population is scattered in villages20% of rural population have health care facilities

CentrePlain areaHilly / Tribal / Difficult areaCommunity health centre1,20,00080,000Primary health centre30,00020,000Sub-centre5,0003,000

Community health CentresEstablished and maintained by the State Government under MNP/BMS programme.

As per minimum norms, a CHC is required to be manned by four Medical Specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.

It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities.

It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.

As on March, 2011, there are 4,809 CHCs functioning in the country.

Primary health Centres First contact point between village community and the Medical Officer.

To provide an integrated curative and preventive health care with emphasis on preventive and promotive aspects of health care.

Established and maintained by the State Governments under the MNP/ BMS Programme.

Manned by a Medical Officer supported by 14 paramedical and other staff.

NRHM - two additional Staff Nurses at PHCs (contractual).

It acts as a referral unit for 6 Sub Centres and has 4 - 6 beds for patients.

There were 23,887 PHCs functioning in the country as on March 2011.

Sub-CentreMost peripheral and first contact point between the primary health care system and the community.

Manned by at least one ANM / Female Health Worker and one Male Health Worker.

Under NRHM, one additional second ANM on contract basis.

Provide services in relation to maternal and child health, family welfare, nutrition, immunization and control of communicable diseases. Provided with basic drugs for minor ailments.

Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-Centres 148,124 Sub Centres functioning in the country as on March 2011.Rural health infrastructure: Norms and level of achievements (All India)S. No.IndicatorNational NormsPresent AvgCoverage1Rural Population (2011) (Provisional) covered byGeneralTribal/Hilly/DesertSub Centre500030005624Primary Health Centre (PHC)300002000034876Community Health Centre (CHC)120000800001732352Number of Sub Centres per PHC663Number of PHCs per CHC454Rural Population (2011) (Provisional) covered by a:HW (F) (at Sub Centres and PHCs)500030004008HW (M) (At Sub Centres)50003000159555Ratio of HA (M) at PHCs to HW (M) at Sub Centres1:61:36Ratio of HA (F) at PHCs to HW (F) at Sub Centres and PHCs1:61:13VillageAccredited Social Health Activist (ASHA) for 1000 population

Chosen by and accountable to the panchayat

Act as the interface between the community and the public health system.

Honorary volunteer, receiving performance-based compensation

Facilitate preparation and implementation of the Village Health Plan

The other persons areIndigenous daisAnganwadi workers

Progress over the years

Progress of Sub Centres, which is the most peripheral contact point between the Primary Health Care System and the community, is a prerequisite for the overall progress of the entire system.

Percentage of PHCs functioning in Government buildings has increased significantly from 78% in 2005 to 86.7% in 2011

The % of CHCs in Govt. buildings has increased from 90% in 2005 to 95.3% in 2011Urban health care delivery system in IndiaThe government of India has identified Urban Health as one of the thrust area in the tenth Five Year Plan, National population policy 2000, National Health Policy 2002 and second phase of RCH program

The central government health scheme (1954)objective of providing comprehensive medical health care facilities to the central government employees and their family members.

Urban Family Welfare centerslaunched during the first five year plan. At present 1083 centers are functioning and providing outreach services, primary health services, MCH services and distribution of contraceptives.Urban health postUrban Revamping Scheme introduced following the recommendations of the Krishnan Committee in 1983.

To provide services through setting up of health posts mainly in slum area.

4 type of health post were set up depending on the allotted population.Type A less than 5000 populationType B between 5000 to 10000 populationType C between 10000 to 25000 populationsType D between 25000 to 50000 populations Only Type D health post has a Medical officer.

Services provided by these posts are outreach of RCH services, first and referral services and distribution of contraceptives.Health care delivery services in DelhiWell established infrastructure for its people

One of the highest bed capacity (2.14 beds/1000 persons).

Public Health expenditure consistently remained above 6 per cent .

Delhis per capita expenditure on health is Rs. 685.

However, there is multiplicity of agencies operating their health care outlets in different areas or for defined subset of populations in different areas like Delhi Government, MCD, NDMC, CGHS, DGHS, ESI and Army etc.

Primary health care level Delhi has wide network of 969 dispensaries.

Secondary and tertiary health care level there are 706 hospitals including 505 registered nursing homes with 33711 beds. There are 118 hospitals in the government sector in Delhi.Health care delivery system in MumbaiMumbai has a vast supply of public and private health care services. The services range from the super specialty, tertiary-level care hospitals to the general practitioners.

The Central Government has its own dispensaries, which are available only for their employees.

ESIS - health care services that include hospitals and dispensaries which cater to employees in the organized sector.

The various government organisations, such as ports, railways and defence, have their own health care services for their employees.

The Municipal Corporation of Greater Mumbai (MCGM) provides major facilities in the public sector along with the State Government.

Health care delivery system in Mumbai contThe Department is divided into zonal set-ups for administrative purposes.

There are five such zones, which cover 23 Wards The Deputy Municipal Commissioner handles each zone.

Each Ward has a separate Ward Office and the Ward Medical Health Officer (MHO) heads the Public Health Department in that Ward.

Family welfare and maternal child health programmes are under the supervision of Officer- Maternal Child Health & Family Welfare at F/South Ward.

Peripheral hospitals linked to four super specialty hospitals. Health posts and dispensaries linked to peripheral hospitals in their respective WardsPrivate health sectorIndia - dominance of Private sector.

In a NSS survey in 2001-02, 13 lakhs practitioners were working in private sector.

Accounts 80% of the total facility in the country.

88% of the towns have a medical facility compared to 24% in rural areas with 90% of the facilities manned by sole practitioners.

The private sector has 75% of specialists and 85% of the technology in their facilities.

The private sector accounts for 49% beds and an occupancy ratio of 44% whereas the occupancy rate is 62% in the public sector.

AYUSH

Old acceptance in the communities in India

Form the first line of treatment in case of common ailments in most of the places

Ayurveda is the most ancient medical system with an impressive record of safety and efficacy.

Mainstreaming AYUSH to strengthen the Public Health System at all levels.

AYUSH facilities had been co-located with 208 District Hospitals (36%), 910 Community Health Centres (23%) and 3883 Primary Health Centres in the country .

Gap in structure

The availability of manpower is the important prerequisite for the efficient functioning of the Rural Health servicesShortfall in the manpower at PHC and Sub centre is shown as on march 2011

Even out of the sanctioned posts, a significant percentage of posts are vacant at all the levels.

Shortfall of specialist at CHCs as compared to requirement for existing infrastructure as on March 2011, Overall 63.9% specialists at the CHCs

The current position of specialists manpower at CHCs reveal that as on March 2011, Overall 39.5% of the sanctioned posts of specialists at CHCs were vacant.

Finance allocationHealth Expenditure in India 200405Health Expenditure in India 2008-09Type of ExpenditureDistribution of totalHealth Expenditure (%)Share of GDP (%)Distribution of totalHealth Expenditure (%)Share of GDP (%)Public Expenditure19.670.84271.1Private Expenditure78.053.32723.0External Flow2.280.1020.1Total Health Expenditure1004.251004.1Integrated approach of health care deliveryDemands coordinated efforts of all sectors such as Agriculture, Irrigation, Animal Husbandry, Education, Social and Women's Welfare, Housing and Public Works, Communication, Rural Development, Cooperatives, Industries, Panchayats and Voluntary Organizations, etc.

ICDS integrated child development scheme Supplementary nutrition for children of less than 6 years of age, pregnant mother, lactating mother.Nutrition and health education to women of reproductive age groupMonthly health and nutrition day at anganwadiDrinking water and toilet facility in anganwadi centre (rural development ministry)

Agriculture, irrigation and engineering: Growing more food locally - cereals, pulses, vegetables, fruits etc. Identifying water resources for drinking and other purposes Providing seeds for kitchen garden and community gardenEducating the people for composting

Integrated approach of health care delivery contAnimal Husbandry: Immunizing domestic animals and catties against rabies etc.Preventing zoonotic diseases

Education: Health education covering nutrition, personal hygiene and environmental sanitation; Education about various health problems in the community and their prevention and control;Population education, advantages of small family Providing first-aid and treatment of minor ailments and the knowledge of local health resources.

Social and Women's Welfare: Mobilizing women, mahila mandals, mother's club etc. for propagation of health, nutrition practices, special nutrition programmes for vulnerable groups, maintenance and use of water resources; proper disposal of excreta, composting, kitchen garden etc. Educating mothers on maternal and child care

Contribution by NGOsProviding services like relief to the blind, the disabled and disadvantaged and helping the government in mother and child health care, including family planning programmes.Greater roles for the NGOs was seen to ensure Health for All through the primary health care approach. Government of India started granting financial aids to NGOs for various schemesContracting in government hires individuals on a temporary basis to provide servicesContracting out government pays outside individuals to manage specific functionSubsidies government gives funds to privet groups to provide specific services.Leasing or rental government offers the use of its facilities to a privet organization.Privatization government gives or sells a public health facility to a privet group.Challenges Prices of services in private sectorEarning commission from diagnostic laboratoriesFinancial protection against medical expenditure Non availability of medical, nursing and paramedical staffInadequate and weak drug control infrastructureinadequate drug testing facilityExtremely high drug costNo clear urban health care delivery model

References:GOI. Twelfth five year plan (2012-2017) social sector, Volume III. Planning commission government of India.p1- 47MOHFW. Rural health care system in India-the structure and current scenario. Rural health statistics 2011.GOI. MOHFW. National rural health mission. [online]. [cited 2012 Dec 27]. Available from: http://www.mohfw.nic.in/NRHM.htm Indian Public Health Standards (IPHS) guideline for community health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94GOI. Financing and delivery of health care services in India. MOHFW 2005; 1-320Park K. Park's Textbook of Preventive and Social Medicine. 21st ed. Prem Nagar, Jabalpur, (M.P.), India: M/s Banarsidas Bhanot; 2011