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Health Care Delivery System in

India

Dr Archana Paliwal

Assistant Professor

Department of Community

Medicine MGH, Jaipur

Introduction

�Health is…..……..a state of complete Physical, Mentaland Social well being and not merely anabsence of disease or infirmity….…..which allows a person tolive a socio-economically productive life.

�Illness is…..…a state in which a person’ s physical,emotional, intellectual, social orspiritual functioning is diminished or impaired.

Cont….

�Health care is...…….multitude of services rendered to individuals or communities by the agents ofhealth services or professional for thepurpose of

�Promoting

�Restoring and

�Maintaining health

�Embraces all the goods and servicesdesigned for “prevention, promotionand rehabilitation interventions” includes Medical Care

Health Care provider�A person or organization that provides servicesand/or health care personnel….

….to deliver proper health care in a systematic wayto any individual in need of health careservices.

�Could be a government…or…

�….the health care industry,

�….a health care equipment company,�….an institution such as a hospital or laboratory.

�Health care professionals may include physicians,dentists, and other support staff.

Cont….

Health services

�Permanent countrywide system of

estabilished institutions with the objective of…

�….coping with the various health needs and

demands of population…

�…thereby provide health care to individuals and

community with preventive and curative activities

�….utilizing health care workers

Cont…

System�Includes… concepts ( e.g health and diseases)

�Ideas(e.g equity)

�Objects(e.g hospitals, health centres)�Persons (health care workers viz. physician,nurses)

�Together these forms a systeminteracting with each other, supporting andcontrolling each other

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Components of healthcare delivery

system

1. Structure of health system

� Aspects of the design of health services that influences the

way in which they are delivered Includes….

� Number and type of personnel and staff

� Way of these personnel organized to work

� Nature and extend of facility and equipment

� Range of services offered

� System of management and amenities

� Financing

� Enumeration and determination of the eligible population for

these services

� Governance and decision making

Cont…

2. Process of health care delivery

�Consists of two parts�Behavior of professionals

� Recognition of the problem i.e diagnosis

� Diagnostic procedure

� Recommendation of treatment or management

� Appropiate follow up

�Participation of people

� Utilization of services

� Understanding the recommendations

� Satisfaction with the services

� Participation in decision making

Cont…

3. Outcomes of health care

�Aspects of health that results from interventions provided by the

health system

4. Flow of patients in health care system

�Varies from country to country

�India harbors a multistage (three tier) system, where majority of

health care is delivered by community health care worker

�Indian system is more cost effective if health workers are skilled

and effectively supervised

�Such system could one of the reason to reduced cost of health

care in developing countries

Input Health Care Services Health Care System Output

Health status Or

Health

Problem

Resources

Changes InHealth Status

PublicPrivate

Voluntary

indigenous

Curative Preventive

Promotive

Model of Health CareDelivery System Alma-Ata international conference

� In 1977, World Health Assembly decided to launch a

movement called “Health for all by 2000”

� Fundamental principle of this concept was equity, an equal

health status for all the people in all countries

� This is to be ensured by equitable distribution of health

resources

� In 1978, the note of “Health for all” was reaffirmed and

marked as the major social goal for every country.

� It was stated in the declaration that the best way to achieve

HFA is by providing primary health care……especially to vast

size of underserved rural and urban poor

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Alma-Ata conference, 19781. Public Health Sector:

a) Primary Health Centreb) Hospitals/ health centersc) Health insurance schemesd) Other Agencies

2. Private Sectora) Private hospitals, polyclinics, Nursing homes,

dispensaries.b) General Practitioners & clinics

3. Indigenous system of Medicine4. Voluntary Health Agencies5. National Health Program etc.

Levels of health care

�Primary Health care

�Provided at the community level

�PHC & their SC

�Secondary health care

�Provided at CHC & DH etc.

�Tertiary health care

�Provided at hospitals

Tertiary health

care

Rural Health care system in India

Community Health Centre (CHC)

A 30 bedded Hospital/ Referral unit for 4 no. of PHCs with

specialized Health Services

Primary Health Centre (PHC)

A Referral unit for 4-6 Subcentres; 4-6 bedded manned with a

Medical Officer in-charge and 14 subordinate paramedical staff

no. of PHCs with specialized Health Services

Sub Centre (SC)

Most peripheral contact point of community with Primary Health

Care system; manned with one MPW(M) and MPW(F)

Rural Health care system in India

�The health care infrastructure in rural areas hasbeen developed as a three tier system and is

based on the above population norms.

Health Facility Population Norms

Plain Area Hilly/Tribal/Difficult

Area

Sub-Centre 5000 3000

Primary Health Centre 30,000 20,000

Community Health Centre 1,20,000 80,000

Primary health care in India

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Introduction

� In 1977, GoI launched Rural Health Scheme based on the

principle of “placing people’s health in people’s hand”

� Subsequently in the international conference of Alma-

Ata(1978)the goal of “Health for all” by 2000 through

primary health care approach was set.

� Keeping in view WHO “Health for all” by 2000 GoI

formulated National health policy 2002

� More recently GoI formulated NRHM and Indian Public

Health Standards (IPHS) in this regards

� In order to provide quality care in the public health agencies

of health care delivery IPHS are being prescribed.

� These standards provides basic promotive , preventive and

curative primary health care to the community and……

…….achieve and maintain an acceptable quality of care

� These standards would help monitor and improve

functioning of the health care delivery system

Primary health care�Primary Health Care as defined by the World Health

Organization (WHO) in 1978 is…

�Essential health care; based on�practical,

�scientifically sound, and�socially acceptable method and technology….

� …….made universally accessible to individuals and families of the community through their fullparticipation….

……at a cost that community and country can afford to maintain every stage of their development inthe spirit of self determination.

�

Cont…

Definition

�Primary health care is essential health

care made universally accessible to

individuals and acceptable to them through

their full participation and at a cost the

community and country can afford

Elements of primary health care

1. Education about prevailing health conditions and methods

to prevent and control them

2. Promotion of food supply and proper nutrition

3. Adequate water supply and basic sanitation

4. Maternal and child health care with family planning

5. Immunization against major infectious diseases

6. Prevention and control of locally endemic diseases

7. Appropriate treatment of common diseases and injuries

8. Provision of essential drugs

Principles of primary health care

Equitable distribution

Community participation

Intersectoral coordination

Appropriate technology

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Cont.…

� It is the first level of contact with the health system to promote

health, prevent illness, care for common illnesses, and

manage ongoing health problems.

� Primary Health Care involves concerted effort to provide

rural population of developing countries with least bare

minimum of health services.

� Some services are also provided in community and hospitals

� Primary Health Care is different in each community dependingupon:

– Needs of the residents;

– Availability of health care providers;

– The communities geographic location; &

– Proximity to other health care services in the area.

Sub Center

� The most peripheral and first contact point between the

primary health care system and the community.

� The Ministry of Health & Family Welfare is providing 100%

Central assistance

� They are established on the basis of

� One SC for every 5,000 pop in general and…

� One SC for every 3,000 pop in hilly, tribal and backward areas

� Each Sub-Centre is manned by one Male and one female Health

Worker.

� One Lady Health Worker(LHV) is entrusted with

the task of supervision of six Sub-Centers.

Cont….

�Sub Centre are assigned tasks relating tointerpersonal communication

…..in order to bring about behavioralchange and provide services in relation to….

�Maternal and child health,

�Family welfare,

�Nutrition,

�Immunization,�Diarrhea control and

�Control of communicable diseases programmes.

�The sub centre are provided with basic drugsfor minor ailments.

Primary Health Center

�PHC is the first contact point between villagecommunity and the Medical Officer.

�The PHCs were envisaged to providean integrated curative and preventive healthcare to the rural population with emphasis onpreventive and promotive aspects of health care.

�The PHCs are established and maintained

by the State Governments.

�At present, a PHC is manned by a Medical Officersupported by 14 paramedical and other staff.

Cont….

� It acts as a referral unit for 6 SubCentres.

� It has 4 - 6 beds for patients.

�The activities of PHC involve curative, preventive,primitive and Family Welfare Services.

�National Health Plan (1983) proposedreorganization of PHCs on the basis of….

�One PHC for every…..30,000 pop in Rural areas

�One PHC for every…..50,000 pop in Urban areas

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PHC Pakyong Functions of PHCs

�Medical care

�Health programmes

�MCH care and family planning

�Health education and training

�Referral services

�Safe water supply and basic sanitation

�Prevention and control of locally endemic diseases

�Collection and reporting of vital events

�Basic laboratory services

At PHC level:Medical Officer : 1

Pharmacist : 1

Nurse Mid-wife : 1Health Worker (female)/ANM : 1 BlockExtension Educator : 1Health Assistant (Male) : 1Health Assistant (Female) : 1U.D.C (Upper Division clerk) : 1L.D.C (Lower Division Clerk) : 1Lab. Technician : 1

Driver : 1

�

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� Class IV : 4Total : 15

Health Worker (Female)/ ANM : 1

: 1Health Worker (Male) Voluntary Worker : 1

� At the Sub Centre level :�

�

�

�

� Total : 3

SECONDARY CARE LEVEL

• More complex problems dealt with

• In India, This kind of care provided in DH & CHC

• Serve as first refferal level

Community Health Center (CHC)

� These were established by upgrading the primary health centers

� CHCs are being established and maintained by the State Government.

� eachcommunity health center should cover a population of

80000 to 1.2 lakh

� It is manned by four medical specialists i.e.

Physician, Gynecologist and Pediatricia and……supported by

paramedical and other staff.

Surgeon,

� 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.

Functions of CHCs

�Care of Routine and Emergency Cases in Surgery

� Dressings, I&D, and surgery for Hernia, Hydrocele,

Appendicitis etc.

� Emergencies like Intestinal Obstruction, Haemorrhage, etc.

� Other management including nasal packing, tracheostomy,

foreign body removal etc.

� Fracture reduction and putting splints/plaster cast.

� Conducting daily OPD.

�Care of Routine and Emergency Cases in Medicine

� Daily OPD

� Handling all the emergency and routine cases

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Cont…

� Maternal Health

� Minimum 4 ANC check ups including Registration &

associated services

� 1st visit: Within 12 weeks—preferably as soon as

pregnancy

� 2nd visit: Between 14 and 26 weeks

� 3rd visit: Between 28 and 34 weeks

� 4th visit: Between 36 weeks and term

� 24 hr delivery services including normal and assisted

delivery and cesarean section

� Managing labour using Partograph.

� Minimum 48 hours of stay after delivery, 3-7 days stay

post delivery for managing Complications

Cont….

�Newborn Care and Child Health

� Essential Newborn Care and Resuscitation

� Counseling on Infant and young child feeding

� Routine and emergency care of sick children

� Full Immunization of infants and children against VPDs

� Management of Malnutrition cases.

� Family Planning

� Counseling, provision of Contraceptives, NSV,

Laparoscopic Sterilization Services and their follow up.

� Safe Abortion Services

Cont….

�All National Health Programmes delivered throughCHCs

�School health services

�Others

�Blood storage facility

�Essential laboratory services

�Referral (transport) services

�Maternal Death review (MDR)

Existing Clinical manpower

1. General Surgeon 1

2. Physician 1

3. Obstetrician/ Gynecologist 1

4 Pediatrician 1

Proposed Clinical Man power:

�1. Anesthetist

�2. Eye surgeon

�3. Public health programme manager, also

designated as Block Surveillance officer

� Nurse- Mid wife 7+2

� Dresser 1

� Pharmacist/ Compounder 1

� Lab technician 1

� Radiographer 1

� Ward boy/ nursing orderly 2

� Sweepers / Chownkidar 3

� OPD attendant

� Data Entry Operator 5

� OT attendant

� Registration Clerk

At District level

�There are 640 ( year 2011 census) districtsin India. Within each district, there are 6

types of administrative areas.

1. Sub –division

2. Tehsils ( Talukas )

3. Community Development Blocks

4. Municipalities and Corporations

5. Villages and

6. Panchayats

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A part from the primary health centers, the present organization of health services of the Government sector consist of :

� Rural Hospitals

� Sub-Divisional/ Tehsil/ Taluka hospitals

� District hospitals

� Specialist hospitals

� Teaching institutions

(a) Rural hospitals:

It is now proposed to upgrade the rural dispensaries (allopathic/ traditional system of medicine) to primary health centers.

At present a good no. of PHCs are located at tehsil/ sub-division/ taluka head quarters which also have hospitals.

Such PHCs may be shifted to the interior rural areas. It is proposed to

convert the sub divisional hospitals to sub-divisional health centers so as to cover a population of 5 lakhs.

The current opinion is that the hospital should take an active part

in providing health services to the community.

There are proposals to convert the district hospital into district

health centre. District hospitals are of 200 bed strength but may

be raised upto 300 depending upon the population

Hospitals provide curative services to

people.It consist of curative staff only as they

have doctors, compounders, nurses etc.

�Hospitals have not any special attachment

area and the patients can be drawn from any

part of the country.

TERTIARY CARE LEVEL

Teaching Hospital:-Teaching hospital is a

hospital to which a college is attached

for medical/ nursing/ dental/ pharmacy/

education. The main objective of these

hospitals is teaching based on research and

the provision of health care is secondary eg.

AIIMS New Delhi, PGMERI Chandigarh. Etc.

Specialist hospitals:

Specialist hospitals are hospitals providing medical care and nursing care primarily for only one discipline or a specific disease or

condition of one system.

In other words, these hospitals concentrate on a particular aspect or organ of the body and provides medical and nursing care in

that field

Health Care Delivery System in India

� India is a union of 29 states and 7 union territories.

�States are largely independent in matters relating tothe delivery of health care to the people.

�Each state has developed its own system ofhealth care delivery, independent of theCentral Government.

�The Central Government’s responsibilitymainly of policy making , planning ,

consistsguiding,

assisting, evaluating and coordinating the work ofthe State Health Ministries.

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Health System in India

The health system in India has 3 main links

At the central level

�The official “organs” of health system atnational level are

Ministry of Health and

Family Welfare

Organization Structure Functions of MoHFWUnion list

�International health relations and administration of port

quarintine

�Administration of Central Institutes

�Promotion of research

�Regulation and development of medical, pharmaceutical, dental

and nursing professions

�Establishment and maintenance of drug standards

�Census collection and publication of other statistical data

�Coordination with states

cont….

Concurrent List:

� Prevention of Communicable disease

� Prevention of food adulteration

� Control of drug and poison

� Vital statistics

� Labour welfare

� Economic and social planning

� Poulation control and family planning

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Directorate General of

Health Services

Organization chart Functions of Directorate General of Health

services

General functions

� Surveys

� Planning

� Coordination

� Programming and appraisal of all health matters

Specific function

� International health relations and quarantine of all majorports in country and international airport.

� Control of drug standards

� Maintain medical store depots

� Administration of post graduate training programmes

� Administration of certain medical colleges in India

� Conducting medical research through Indian

Medical Research ( ICMR )

Council of

� Central Government Health Schemes.

� Implementation of national health programmes

� Preparation of health education material for

creating health awareness through Health

Education Bureau

� Collection, compilation, analysis, evaluation and

dissemination of information

� National Medical Library

Central Council of health

Organization chart

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Functions

�To consider and recommend broad outlinesof policy related to matters concerning healthlike environment hygiene, nutrition andhealth education.

�To make proposals for legislation relatingto medical and public health matters.

�To make recommendations to theCentral Government regarding distribution ofgrants-in- aid.

State LevelHealth Services

� Out patient services -Patients who don’t require

hospitalization can receive health care in a clinic. An out

patient setting is designed to be convenient and easily accessible

to the patient.

� Clinics – Clinics involve a department in a hospital where patients

not requiring hospitalization, receive medical care.

� Institutions – Hospitals – Hospital have been the major

agency

of health care system.

� In broad sense the health services should be

a. Comprehensive

b. Accessible

c. Acceptable

d. Provide scope of community participation and….

e. Available at an affordable cost by country and commuity

Thank you