1www.drjayeshpatidar.blogspot.comHEALTH CARE DELIVERY SYSTEM IN INDIA:Introduction:India is a union of 28 states and 7 union territories. States are largely independent inmatters relating to the delivery of health care to the people. Each state has developed its ownsystem of health care delivery, independent of the Central Government.The Central Government responsibility consists mainly of policy making, planning, guiding,assisting, evaluating and coordinating the work of the State Health Ministries. The health systemin India has 3 main links1. Central2. State and3. Local or peripheral(1) At the centralThe official “organs” of the health system at the national level consist of1. Ministry of Health and Family Welfare2. The Directorate General of Health Services3. The Central Council of Health and Family Welfare1. Union Ministry of Health and Family Welfare.Organization PatternCabinet Minister↓Department of Health Department of Family Welfare↓ ↓Joint Secretary Additional Secretary↓ ↓Deputy Secretary Commissioner↓ ↓Administrative staff Joint Secretary↓Administrative staff
2www.drjayeshpatidar.blogspot.comFunctions:(1) Union list1. International health relations and administration of port quarantine2. Administration of Central Institutes such as All India Institute of Hygiene andPublic Health, Kolkata.3. Promotion of research through research centers4. Regulation and development of medical, pharmaceutical, dental and nursingProfessions5. Establishment and maintenance of drug standards6. Census and collection and publication of other statistical data7. Immigration and emigration8. Regulation of labor in the working of mines and oil fields9. Coordination with states and with other ministries for promotion of health(2) Concurrent listThe functions listed under the concurrent list are the responsibility of both the union and stategovernments.1. Prevention and extension of communicable diseases2. Prevention of adulteration of food stuffs3. Control of drugs and poisons4. Vital statistics5. Labor welfare6. Ports other than major7. Economic and social planning8. Population control and Family Planning9. Preparation of health education material for creating health awareness throughCentral Health Education Bureau.10. Collection, compilation, analysis, evaluation and dissemination of informationThrough the Central Bureau of Health Intelligence11. National Medical Library
3www.drjayeshpatidar.blogspot.com2. Directorate General of Health ServicesOrganization PatternDirectorate General of health services↓Director General of health services↓Additional Director General of health service↓Deputy Directorate General of health services↓Administrative staffFunctions:1. International health relations and quarantine of all major ports in country andInternational airport2. Control of drug standards3. Maintain medical store depots4. Administration of post graduate training programmes5. Administration of certain medical colleges in India6. Conducting medical research through Indian Council of Medical Research7. Central Government Health Schemes.8. Implementation of national health programmes9. Preparation of health education material for creating health awareness through Central HealthEducation Bureau.10. Collection, compilation, analysis, evaluation and dissemination of information through theCentral Bureau of Health Intelligence11. National Medical Library
4www.drjayeshpatidar.blogspot.com3. Central Council of HealthOrganization PatternChairman(Union health Minister)↓Members(State health Minister)Functions1. To consider and recommend broad outlines of policy regard to mattersConcerning health like environment hygiene, nutrition and health education.2. To make proposals for legislation relating to medical and public health matters.3. To make recommendations to the Central Government regarding distribution ofGrants-in-aidII. At the State levelThe health subjects are divided into three groups: federal, concurrent and state. The state list isthe responsibility of the state, including provision of medical care, preventive health services andpilgrimage within the state.State health administrationAt present there are 28 states in India, each state having its own health administrationOrganization Pattern(1) State Ministry of Health & family welfare↓Deputy Minister of Health and Family Welfare↓Health Secretary↓Deputy Secretaries↓Administrative staff
5www.drjayeshpatidar.blogspot.com(2) State Director of health↓Director of Medical Education Director of Health Services↓ ↓Dean of medical college Additional Director of Health Services↓ ↓State nursing superintendent Deputy Director of Health Services↓ ↓Hospital Education Regional Functional↓ ↓ ↓Nsg Superintendent Nsg Officer MCH, TB, Leprosy, Immunization↓ ↓Ward Incharge Senior tutor↓ ↓Nsg Staff Junior tutorFunctions of state health Director:(1) Studies in depth the health problem and needs in the state and plans scheme toSolve them(2) Providing curative &preventive services(3) Provision for control of milk and food sanitation(4) Prevention of any outbreak of communicable diseases(5) Promotion of health education(6) Promotion of health programmes such as school health, family planning,Occupational health(7) Supervision of PHC(8) Establishing training courses for health personnel(9) Co-ordination of all health services with other minister of state such as ministerof education, central health minister &voluntary agency
6www.drjayeshpatidar.blogspot.comIII. At the district levelT here are 593 ( year 2001 ) districts in India. Within each district, there are 6 types ofadministrative areas.1. Sub –division2. Tehsils( Taluks )3. Community Development Blocks4. Municipalities and Corporations5. Villages and6. PanchayatsMost district in India are divided into two or more subdivision, eachincharge of an Assistant Collector or Sub CollectorEach division is again divided into taluks, incharge of a Thasildhar. A talukusually comprises between 200 to 600 villagesThe community development block comprises approximately 100 villagesand about 80000 to 1,20,000 population, in charge of a Block DevelopmentOfficer.Finally, there are the village panchayats, which are institutions of rural localself-government.The urban areas of the district are organized intoTown Area Committees (in areas with population ranging between 5,000 to10,000Municipal Boards (in areas with population rangingbetween 10,000 and2,00,000)Corporations (with population above 2,00,000)The Town Area Committees are like panchayats.They provide sanitaryservices.The Municipal Boards are headed by Chairmen /President, elected bymembers.The functions of Municipal Board:Construction and maintenance of roadsSanitation and drainageStreet lightingWater supplyMaintenance of hospitals and dispensariesEducation andRegistration of births and deaths etcThe Corporations are headed by Mayors, elected by councillors, who are elected fromdifferent wards of the city. The executive agency includes the
7www.drjayeshpatidar.blogspot.comcommissioner, the secretary, the engineer and the health officer.The activities are similar to those of municipalities, on amuch wider scale.Panchayat Raj -The panchayat raj is a 3-tier structure of rural local self-government in India linking the villageto the district.It includesPanchayat (at the village level)Panchayat Samiti( at the block level)Zila Parishad(at the district level)(1) Panchayat (at the village level):The Panchayat Raj at the village level consists ofThe Gram SabhaThe Gram PanchayatThe Gram Sabha:It is the assembly of all the adults of the village, which meets at least twice a year.The gramsabha considers proposals for taxation,and elect members of The Gram Panchayat.The Gram PanchayatIt is the executive organ of the gram sabha and an agency for planning and development at thevillage level. The population covered varies from 5000 to 15000 or more.The members ofpanchayat hold offices for a period of 3to4 years. Every panchayat has an elected president(Sarpanch or Sabhapati or Mukhia), a vice president and panchayat secretary. It covers the civicadministration including sanitation and public health and work for the social and economicdevelopment of the village(2) Panchayat Samiti (at the block level):The block consists of about 100 villages and a population of about 80,000 to 1,20,000. Thepanchayat samiti consists of Sarpanch, MLAs, MPs residing in block area, representative ofwomen, SC, ST and cooperative socities. The primary function ofThe Panchayat Samiti is theexecute the community development programme in the block. The Block development Officerand his staff give technical assistance and guidance in development work.(3) Zila Parishad (at the district level):
8www.drjayeshpatidar.blogspot.comThe Zila Parishad is the agency of rural local self governmen at the district level . The membersof Zila parishad include all heads of panchayat samiti in the district,MPs, MLAs, representativeof SC, ST and women and 2 persons of experience in administration,public life or ruraldevelopment. Its functions and powers vary from state to state.Health care system:(1) At village level(2) At sub center level(3) At PHC level(4) At CHC level(1) At village level:At the village level, elementary services are rendered by(a) Village health guides(b) Local dais(c) Anganwadi workers(d) ASHA(a) Village health guides:Village health guide is a person with an aptitude for social service and is not full time govt.functionary. Village health guides scheme was introduced on 2ndoct. 1977.Guidelines for their selection:(1) They should be permanent resident of the local community, preferably women(2) They should be able to read and write, having minimum formal education atleast up to the VI std.(3) They should be acceptable to all sections of community(4) They should be able spare at least 2 to 3 hours every day for community health work.After selection the health guide undergo a short training in primary health care. Thetraining is arranged in the nearest PHC, subcenter or other suitable place for the duration of 200hours, spread over a period of 3 months. During the training period they receive a stipend of Rs.200 per month.Functions of Village health guides:(1) Provide treatment for common minor ailments(2) First aid during accidents and emergency(3) MCH care(4) Family planning(5) Health education
9www.drjayeshpatidar.blogspot.com(2) Local dais:Most deliveries in rural areas are handled by untrained dais. Th e training for dais given for 30working days. Each dai is paid stipend of Rs. 300 during the training period.The training is givenat PHC,subcenters or MCH center for 2 days in a week and on the remaining four days of theweek they accompany the health worker(female) to the village. During her training each dai isrequired to conduct at least 2 deliveries under the supervision and guidance of health worker(female), ANM,health assistant (female).Functions of dais:(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Referral services(6) Safe water and basic sanitation(7) Nutrition(3) Anganwadi worker:Under the ICDS scheme there is an anganwadi worker for a population of 1000.There are about100 such workers in each ICDS project. The anganwadi worker is selected from the communityand she undergoes training in various aspect of health, nutrition and child development for 4months. She is a part time worker and paid an honorarium of Rs.200-250 per month for theservices.Functions of anganwadi worker:(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Referral services(6) Safe water and basic sanitation(7) Supplementary nutrition(8) Nonformal education of childrenAccredited Social Health Activist (ASHA)One of the key components of the National Rural Health Mission is to provide every village inthe country with a trained female community health activist – ‘ASHA’ or Accredited SocialHealth Activist. Selected from the village itself and accountable to it, the ASHA will be trained to
10www.drjayeshpatidar.blogspot.comwork as an interface between the community and the public health system. Following are thekey components of ASHA:SELECTION OF ASHAThe general norm will be ‘One ASHA per 1000 population’. In tribal, hilly, desert areas thenorm could be relaxed to one ASHA per habitation, dependant on workload etc.The States will also need to work out the district and block-wise coverage/phasing forselection of ASHAs.It is envisaged that the selection and training process of ASHA will be given due attention bythe concerned State to ensure that at least 40 percent of the ASHAs in the State are selected andgiven induction training in the first year as per the norms given in the guidelines. Rest of theASHAs can subsequently be selected and trained during second and third year.Criteria for SelectionASHA must be primarily a woman resident of the village ‘Married/Widow/Divorced’ andpreferably in the age group of 25 to 45 yrs.ASHA should have effective communication skills, leadership qualities and be able to reachout to the community. She should be a literate woman with formal education up to Eighth Class.This may be relaxed only if no suitable person with this qualification is available.Adequate representation from disadvantaged population groups should be ensured to servesuch groups better.Roles and responsibilities of ASHA:ASHA will take steps to create awareness and provide information to the community ondeterminants of health such as nutrition, basic sanitation & hygienic practices, healthy living andworking conditions, information on existing health services and the need for timely utilization ofhealth & family welfare services.She will counsel women on birth preparedness, importance of safe delivery, breast- feedingand complementary feeding, immunization, contraception and prevention of common infectionsincluding Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs) and care ofthe young child.ASHA will mobilize the community and facilitate them in accessing health and health relatedservices available at the village/sub-center/primary health centers, such as Immunization, AnteNatal Check-up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other services beingprovided by the government.
11www.drjayeshpatidar.blogspot.comShe will work with the Village Health & Sanitation Committee of the Gram Panchayat todevelop a comprehensive village health plan.She will arrange escort/accompany pregnant women & children requiring treatment/ admissionto the nearest pre-identified health facility i.e. Primary Health Centre/ Community Health Centre/First Referral Unit (PHC/CHC /FRU).ASHA will provide primary medical care for minor ailments such as diarrhea, fevers, and firstaid for minor injuries. She will be a provider of Directly Observed Treatment Short-course(DOTS) under Revised National Tuberculosis Control Programmed.She will also act as a depot holder for essential provisions being made available to everyhabitation like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine,Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug Kit will be provided toeach ASHA. Contents of the kit will be based on the recommendations of the expert/technicaladvisory group set up by the Government of India.Her role as a provider can be enhanced subsequently. States can explore the possibility ofgraded training to her for providing newborn care and management of a range of commonailments particularly childhood illnesses.She will inform about the births and deaths in her village and any unusualhealth problems/disease outbreaks in the community to the Sub-Centers/Primary Health Centre.She will promote construction of household toilets under Total Sanitation Campaign.Fulfillment of all these roles by ASHA is envisaged through continuous training and up-gradation of her skills, spread over two years or moreComparison of health care delivery system in Rajasthan and Maharashtra:(1) Subcenter:Topics Maharashtra Rajasthan(1) Population covered(2) Functions5000 in general3000 in tribal & hilly areas(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Referral services3600 in general2800 in tribal & hilly areas(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Safe water and basicsanitation(6) Prevention and control oflocally endemic diseases
12www.drjayeshpatidar.blogspot.comDesignation Maharashtra Rajasthan(3) Staffing pattern Health worker female 1Health worker male 1Voluntary worker 1(paid Rs 100 per month asHonorariumHealth worker female 1Health worker male 1ANM 1(2) Primary health center:Designation Maharashtra Rajasthan(1) Population covered(2) Functions(3) Staffing pattern30,000 rural population in plains20,000 population in hilly, tribal(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Referral services(6) Safe water and basic sanitation(7) Prevention and control oflocally endemic diseases(8) Collection and reporting of vitalstatistics(9) National health programmes(10) Training of health guides, healthworkers, local dais and healthassistant(11) Basic laboratory servicesMedical officer 2Pharmacist 1Nurse midwife 1Health worker female 1Block extension educator 1Health assistant (female) 1Health assistant male 1U.D.C 148000 population in plains30000 population in tribal andhilly(1) MCH care(2) Family planning(3) Immunization(4) Education about health(5) Referral services(6) Safe water and basicsanitation(7) Prevention and control oflocally endemic diseases(8) Collection and report inOf vital statistics(9) National healthprogrammes(10) Training of health guides,health workers, localdais and health assistant(11) Basic laboratory servicesMedical officer 1Pharmacist 1Nurse midwife 1Health worker female 1Health worker male 1Block extension educator 1Health assistant (female) 1Health assistant male 1U.D.C 1
13www.drjayeshpatidar.blogspot.comL.D.C 1Driver 1ClassIV 4L.D.C 1Driver 1ClassIV 2(3) Community health center:Designation Maharashtra Rajasthan(1) Population covered(2) Bed capacity(3) Specialty(3) Functions80,000 to 1.20 lakhs30 BedsSurgery, medicine, obstetrics andgynecologist and pediatrics with X-ray andlab facilities.Care of routine and emergencycases in surgeryCare of routine and emergencycases in medicine24 hours delivery servicesincluding normal and assisteddeliveriesEssential and emergency obstetriccare including caesarean sectionsand other Medical interventions.Full range of family planningservices including laparoscopicservicesSafe abortion serviceNewborn careRoutine and emergency care ofchildrenOther management including74,000 to 1.5 lakhs24 BedsSurgery, medicine,obstetrics andgynecologist andpediatrics with X-ray andlab facilities.(1) MCH care(2) Family planning(3) Immunization(4) Education abouthealth(5) Referral services(6) Safe water and basicsanitation(7) Prevention andcontrol of locallyendemic diseases(8) Collection andreport in of vitalstatistics(9) 24 hours deliveryservices includingnormal and assisteddeliveries
14www.drjayeshpatidar.blogspot.com(4) Staffing patternNasalpacking,tracheostomy,foreignbody removal(10) All nationalhealth programmesdelivered throughCHCOther services(a) Blood storagefacility(b) Essential lab.Services(c ) Referral(transport) servicesExisting clinical manpowerGeneral surgeon 1Physician 1Obstetrics/ gynecologist 1Pediatrician 1Proposed clinical manpowerAnesthetics 1Eye surgeon 1Public health programme 1managerExisting support manpowerNurse midwife 9Dresser 1Pharmacist 1Lab. Technician 1Radiographer 1Ophthalmic 1Ward boy 2Sweeper 3Chowkidar 1OPD attendant 1Statistical assistant 1OT attendant 1Registration clerk 1(10) Essential and emergencyobstetric care includingcaesarean sections and otherMedical interventions.(11) Full range of familyplanning services includinglaparoscopic services(12) Safe abortion service(13) Newborn care(14) Routine and emergencycare of children’s.(15) ) All national healthprogrammes delivered throughCHCExisting clinical manpowerGeneral surgeon 1Physician 1Obstetrics/ gynecologist 1Pediatrician 1Proposed clinical manpowerAnesthetic 1Public health programme 1managerExisting support manpowerNurse midwife 12Dresser 1Pharmacist 2Lab. Technician 1Radiographer 1Ophthalmic 1Ward boy 2Sweeper 3Chowkidar 2OPD attendant 1Statistical assistant 1OT attendant 1Registration clerk 2
15www.drjayeshpatidar.blogspot.comJob description of the members of the health team:(1) Medical officer:He is the captain of the health team at the primary health center.He devotes the morning hours attending to patients in the out-door,in the afternoon andsupervises the field work.He visits each subcenter regularly on fixed days and hours and provides guidance,supervision and leadership to the health team.He spends one day in each month organizing staff meetings at PHC to discuss theproblems and review the progress of health activities.He ensures that national health programmes are being implemented in in his areaproperlyThe success of PHC depends largely on the team leadership which the medical officer isable to provide.The medical officer must be a planner, the promoter, the director, the supervisior, thecoordinator as well as the evaluator.(2) Health worker male and female:Under the multipurpose worker scheme, one health worker female and one male are postedto each sub-centers and are expected to cover 5000 of population (3000 in tribal and hilly areas)health worker female limits her activities among 350-500 families.Health worker female:She will register pregnant women from three months of pregnancies onwards.Maintain maternity record, register of antenatal cases, eligible couple register, childrenregister up to date.She will provide care to pregnant women especially registered mother throughout theperiod of pregnancy;Give advice on nutrition to expectant and nursing mothers about storage, preparation anddistribution of food.Immunize pregnant mothers with tetanus toxoid.Conduct about 50% of total deliveries at home.Supervise deliveries conducted by Dais and whenever call in.Spread the message of family planning to the couples; motivate them for family planningindividually and in groups.Distribute conventional contraceptives to the couples.Assess the growth and development of the infant and take necessary action.Records and reports births and deaths in her area.
16www.drjayeshpatidar.blogspot.comTest urine for albumin and sugar and do Hb during her home visit.Arrange and help M.O and health assistant in conducting MCH and family planningclinics at subcenters.Maintain the cleanliness of subcenter.Attend staff meetings at PHC, CD block or both.Health worker male:He will survey all the families in his area and collect all the information about eachvillage/ locality in his area.Identify the cases of communicable diseases and notify the health assistant male and M.OPHC immediately.Educate the community about importance of control and preventive measures againstcommunicable diseases.Assist the village health guide in undertaking the activities under TB programmeproperly.Educate community on the method of liquid and solid waste, home sanitation, advantageand use of sanitary latrines.Assist the health assistant male in the school health programme.Utilize the information from the eligible couple and child register for the family planningprogramme.Spread the message of family planning to the couples; motivate them for family planningindividually and in groups.Distribute conventional contraceptives to the couples.Provide follow-up services to male family planning acceptors.Health assistant male and female:Health assistant male and female will supervise 4 health workers each of the correspondingcategory.Health assistant female:Supervise and guide the health workers in the delivery of health care services to thecommunity.Carry out supervisory home visiting.Guide the health workers (female) in Distribution of conventional contraceptives to thecouples.Visit each of the 4 subcenters at least once in a week on fixed days.
17www.drjayeshpatidar.blogspot.comRespond to urgent calls from the health workers and trained dais and render necessaryhelp.Organize and utilize the mahila mandal, teachers etc., in the family welfare programme.Provide information on the availability of services for MTPs and refer suitable cases tothe approved institution.Supervise the immunization of all pregnant women and children (0-5 years)Collect and compile the the weekly reports of births and deaths occurring in his area.Educate the community regarding the need of registration of vital events. .Health assistant male:Supervise the work of Health worker male during concurrent visit.Check minimum 10% of houses in village.Supervise the spraying of insecticides during local spraying along with the health worker(male).Conduct immunization of all school going children with the help of health worker (male).Supervise the immunization of all children’s (0-5 years).Assist M.O.PHC in organization of family planning camps and drives. .Provide information on the availability of services for MTPs and refer suitable cases tothe approved institution.Ensures follow-up of all cases of vasectomy, tubectomy IUD and other family planningacceptors.Ensure that all the cases of malnutrition infants and young childrens (0-5years) are giventhe necessary treatment and advice and refer serious cases to PHC.Ensure that Iron and folic acid and Vitamin A are distributed to the beneficiaries.Conduct MCH and family planning clinics and carry out educational activities.Organize and conduct training for dais women leaders with the help of health workersCollect and compile the the weekly reports of births and deaths occurring in his area.Educate the community regarding the need of registration of vital events.REFERENCES(1) k. Park, Text book of preventive and social medicine, Bhanot publication, 18thedition, Pageno.674-699.(2) B.T.Basvanthappa, Community health nursing, Jaypee, Publication, 6thedition, Page no.584-605.(3) K.K. Gulani, Community health nursing, Kumar Publication, 3rdedition, Page no.591-593.(4) Dr. Sr. Mary Lucita, Public health and Community Health, Nursing, B.I. publication, 1stedition, Page no.25-34.(5) John M. Cookfair, Nursing care in the community, Mosby, Publication, 2ndedition, Page no.65-81.(6) www.google. com.