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Health Care Delivery in India

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Healthcare Systems in India
Healthcare provide by 5 major sectors in India
1. Public Health Sector
• Primary health care- PHC’s and sub-centres
• Secondary and Tertiary health care – CHC’s, Rural hospitals, district hospitals, speciality hospitals and teaching hospitals
• Health insurance schemes providing healthcare – ESI, CGHS
• Other agencies: defence services, railways
2. Private sector
• Private hospitals, nursing homes, polyclinics etc.
• General practitioners
3. Indigenous systems of medicine
• Ayurveda, Unani, Homeopathy etc.
4. Voluntary health agencies
5. National health programs

Primary Health Care in India
• Srivastava committee report (1975)
• Based on the above, GOI launched a Rural Health Scheme, a three tier system of health care delivery
• 1978- Alma Ata International conference set the goal ‘an acceptable level of Health for All by 2000 using primary care approach’
• Bound by above, NH Policy was approved in 1983
– Setting goals for 1985, 1900 and 1995.
• Another NH Policy in 2000
• National Population Policy in 2002 and
• National Rural Health Mission (NRHM), 2005
– with formulations of Indian Public Health Standards (IPHS)

Primary Health Care in India
Village Level
Following schemes are in operation
1. Village Health Guides Scheme
2. Training of local dais
3. ICDS scheme
4. ASHA scheme
5. These workers at the village level, are volunteers from the community itself
• Thereby placing the people’s health in people’s own hands and accomplishing community participation in health care
• They are not full time government functionaries
• They are trained to form the first contact between the villagers and the government health infrastructure
• Hence they are free to continue their vocation and just need to take out time for the community health work
• They are paid an honorarium for this work

Village Health Guide (VHG)
• The scheme was introduced on 2nd October, 1977 (under Rural Health Scheme)
• The scheme was not launched in states which already had alternative systems
– Kerala
– Karnataka
– Tamil Nadu
– Arunachal Pradesh
– Jammu and Kashmir
• The VHG were mostly women and the GOI decided to replace all male VHG’s with women VHG
• The VHG was chosen by the community in which they were to work
• The guidelines for their selection were:
– Permanent member of the local community
– Should be able to read and write and min. education up to VI std.
– Should be acceptable to all sections of the community
– Should be able to spare at least 2 – 3 hours every day for community health work

• After selection, short training in primary health care for 200 hours and stipend of ₹ 200 per month during training
• After completion of training they receive:
– Working manual
– Kit of simple medicines
• (both modern and traditional medicine system in vogue locally)
• Duties assigned to health guides
– Treatment of simple ailments, and REFER in time if required
– First aid
– Mother and child health
– Family planning
– Health education and
– Sanitation
• They were paid an honorarium or ₹ 50 per month (revised time to time) and medicines worth ₹ 600 per annum
• Once trained, another VHG was not to be trained from the same village, before three years, as it involves expenditure
• The target was to achieve one VHG for each village or 1000 rural population
• The VHG scheme has now been discontinued by the GOI
• The community health work is now delivered by ASHA, AWW and trained dai

Local Dais
• A program has been undertaken under the Rural Health Scheme to train all categories of traditional birth attendants (dais) to in obstetrical skills and improve their knowledge in elementary concepts of MCH and sterilization
• Training for 30 working days
• Each dai is paid a stipend of 200 during the training
• Training given at PHC/ SC/ MCH centre
– 2 days in a week, trained in the centre
– Remaining 4 days, accompanies the HW (F) to villages
– During training, required to conduct at least 2 deliveries under the supervision of HW (F), ANM or HA (F)
– Main emphasis is on ASEPSIS during home delivery
• After completion of training each dai receives:
– Delivery kit and
– A certificate
• Also expected to propagate small family norm
• National target is to train one local dai in each village

Anganwadi Worker (AWW)
• Under I.C.D.S. Scheme
• One AWW for a population of 400 – 800
• Appx 100 AWW in each ICDS project
• AWW is selected from the community which she is to serve
– Trained for 4 months
– In various aspects of:
• Health
• Nutrition and
• Child development
– Honorarium of 1500 per month
Services include:
– Health check up
– Growth chart monitoring
– Immunization
– Supplementary nutrition
– Health education
– Non formal pre school education
– Referral
• Nursing mother
• Pregnant women
• Women in reproductive age
• Children below 6 yr. of age
• Adolescent girls

Accredited Social Health Activist (ASHA)
• Cadre created under NRHM
• Must be a woman
– Resident of the village
– Married/ widow/ divorced
– Preferred age group 25 to 45 yr.
– Formal education up to VIII std.
– Good communication skills
– Leadership qualities
• Undergoes training for knowledge and a drug-kit to deliver first-contact healthcare
• Also in-service periodic training
• Will receive performance-based incentives for
– promoting universal immunization,
– referral and escort services for Reproductive & Child Health (RCH) and other health programmes,
– Construction of household toilets.
• Norm of selection is 1 ASHA for 1000 population
– Relaxed in hilly/tribal/desert areas to: 1 ASHA per habitation
– Works in liaison with:
– Women's committees (like self-help groups or women's health committees),
– village Health & Sanitation Committee of the Gram Panchayat,
– ANMs and
– Anganwadi workers

• The peripheral outpost of the health delivery system in
– Rural areas
– One s/c for 5,000 population
– One for every 3,000 population in hilly, tribal and backward areas
• Services: All primary health care services
– Immunization
– Antenatal, natal and postnatal care
– Prevention of malnutrition
– Family planning and counselling
– Medicines for minor ailments
• Diarrhoea
• Fever
• Worm infestation etc.
– Implementation of several national health and FW programs
• Staff at a sub-centre:
– One ANM (Auxiliary Nurse Midwife) who is the Female Health Worker
– One Multipurpose Worker (Male) who is the Male Health Worker
– One voluntary health worker as a helper to ANM
• Employed as and when needed
• Two Health Assistants located at the PHC supervise six sub-centres under the PHC
They are supervised by
– One Lady Health Visitor (LHV) who is the Health Assistant (female)
– One Health Assistant (male)

• GOI provides the funds for:
– Salary of ANM
– Salary of LHV
– Rent of sub-centre (if located in a rented building)
– Drugs, equipment and kits
– Contingency money for ANM which includes the stipend for the helper if employed
– State government pays for the:
– Salary of the Male Health Worker

Primary Health Centre (PHC)
• One for every 30,000 population
• One for every 20,000 population in hilly, tribal and backward areas
– 25,020 PHC’s established (as in March, 2014)

• Functions of PHC: all 8 essential elements of Primary health care
– Medical care
– MCH including FP
– Safe water supply and basic sanitation
– Prevention and control of locally endemic diseases
– Collection and reporting of vital statistics
– Health education
– National Health Programs- as relevant
– Referral services
– Training of health guides, health workers, local dais and HA’s
– Basic laboratory services
• It is proposed to equip the PHC with facilities for selected surgical procedures
– Vasectomy
– Tubectomy
– Minor surgical procedures
• ROME program: (Reorientation of Medical Education)
– Three primary health centres have been attached to each medical colleges
– Purpose is to reorient the ME towards the needs of the country and community care

Staff at PHC
• Total 15
– One medical officer
– One pharmacist
– One staff Nurse k/a Nurse – Midwife
– One Health worker (F)
– One Health Educator
– Two Health Assistants – one male and one female
– Two clerks
– One laboratory technician
– One driver
– Four class-IV workers
– Recommended to increase under IPHS
• Six beds per PHC are recommended

Secondary and Tertiary Healthcare in Public Health Sector

Community Health Centre (CHC)
• Established by upgrading PHC’s
• One CHC covers a population of 80,000 to 1.20 lakhs
– 30 beds
– X – ray facility
– Laboratory facilities
• Staff:
– 4 Specialists in
• Surgery
• Medicine
• Obstetrics and gynaecology and
• Paediatrics
– One Community Health Officer
• Selected from supervisory category of staff at PHC and district level
• Should have minimum of 7 years of experience in rural health programs
• Some states have not accepted CHO – and opted for a second medical officer instead
• The specialists at CHC can refer patient to:
– Sub – divisional hospital
– District hospital
– OR if necessary, then directly to
– State level hospital
– Nearest Medical College Hospital

Staff at CHC
Clinical manpower
General Surgeon 1
Physician 1
Obstetrician/ Gynaecologist 1
Paediatrician 1
Support manpower
Nurse – Midwife 7 + 2 (one ANM and one PHN under NRHM)
Dresser (certified by Red Cross/ St. Johns ambulance) 1
Pharmacist 1
Lab technician 1
Radiographer 1
Ophthalmic assistant 0 – 1 (can be employed on contractual basis)
Ward boy/ nursing orderly 2
Sweepers 3
OPD attendant
Statistical assistant/ Data entry operator 5
OT attendant
Registration clerk
Total essential 21 – 22 + 2

• Rural hospital
• Sub- divisional hospital (tehsil/ taluk hospital)
– Proposed to convert these hospitals into
• ‘sub – divisional Health Centre’
• Population covered 5,00,000
• Epidemiological wing to attached to each centre
• District hospitals
– Proposed to convert these into
• District health centre
• One CMO + 3 deputy CMO’s

Difference between a hospital and a health centre
1. Hospital provides only curative services. Health centre provides preventive, promotive and curative- integrated services
2. Hospital has no catchment area. Health centre is responsible for a definite area
3. The hospital team consist of only curative staff. The health team of a centre has an optimal mix of medical and paramedical workers.

• Specialist hospitals and
• Teaching institutions

Health Insurance schemes providing healthcare

– 1948
– Principle of contribution by the employer and employee
– Covers employees with wages ≤ ₹15,000 per month
– Provides medical care in cash and kind
• Sickness
• Maternity
• Employment injury
• Pension for dependents on death due to employment injury
– For Central Government employees
– Introduced in 1954
– Principle of cooperative effort by the employee and the employer
– Facilities provided:
• OPD care through a network of dispensaries
• Supply of necessary drugs
• Laboratory and X-ray investigations
• Domiciliary visits
• Hospitalization services at government and recognized private hospitals
• Specialist consultation
• Paediatric services including immunization
• Antenatal, natal and postnatal services
• Emergency treatment
• Supply of optical dental aids at reasonable rate and
• Family welfare services

Other Agencies
• Defence Medical Services
– Defence services have their own organization for medical care to defence personnel
– Armed Forces Medical Services
– Services are
– integrated and
– Comprehensive

• Health Care of Railway Employees
– Comprehensive
• Railway hospitals
• Health units
• Clinics
– Environmental sanitation supervised by Health Inspectors
– Health check ups
• At entry
• Yearly intervals
– MCH and school health services
• Lady medical officers
• Health visitors
• Midwives provide
– Specialist services at divisional hospitals

Agencies other than the Public Health Sector
• Private Agencies
– Provide a large share of health services
– Mainly curative services
– Mainly congregate in urban areas
– Available to those who can pay
• Indigenous Systems of Medicine
– Ayurveda, Siddha, Homoeopathy etc.
– Provide the bulk of medical care to the rural people
– A central council of Indian Medicine established in1971
• To prescribe minimum standards of education in Indian medicine

• Voluntary Health Agencies