Mahila arogya smitee- community based peer education group20-100 households preventive promotive care, risk pooling fund and health insurance
community health nursing
HEALTH CARE DELIVERY
It exists to provide services &
resources for better health.
This system includes
hospital, clinic, health centers,
nursing homes &special health
programmes in school, industries &
MODEL OF HEALTH CARE
MODEL OF HEALTH CARE
HEALTH CARE DELIVERY
1. PUBLIC HEALTH SECTOR :
Primary health care
•Primary health centers
Hospitals health centers
•Community health centers
PUBLIC HEALTH SECTOR…
Health Insurance Schemes
•Employee state insurance
•Central government health schemes
2. PRIVATE SECTOR
Private Hospitals, polyclinics,
nursing homes & dispensaries.
General practitioners & clinics.
3.INDIGENOUS SYSTEM OF
Ayurveda & Siddha
Uninani & Tibbi
4.VOLUNTARY HEALTH AGENCIES
5.NATIONAL HEALTH PROGRAMMES
HEALTH CARE DELIVERY
PUBLIC VHO PRIVATE
Urban hospitals and health centre
Central health services/Health Insurance
Other health services.
URBAN HOSPITALS & HEALTH
• District hospitals and dispensaries.
• Urban family welfare centres.
• Special Hospitals.
• Medical college Hospitals/ Teaching
• Super Specialty Hospitals/ Institutes.
Central health services/Health
• Central Govt: Health scheme
Other health services
RURAL HEALTH SERVICES
Other rural services.(VILLAGE)
HEALTH ADMINISTRATION AT RURAL
LEVEL 3-TIER STRUCTURE
HEALTH CARE DELIVERYHEALTH CARE DELIVERY
SYSTEM - VILLAGESYSTEM - VILLAGE
VILLAGE HEALTH GUIDE
1) Lanuched on 2nd
2)Centrally sponsored under family and
This is in operation in all states except
5 states where alternative health
schemes are in progress.
Village health guideVillage health guide
i) Preferably at least VIII Std. passed
local women.Able to read and write.
ii) Undergoes 200 hours training over
iii) Works for 2-3 hours per day
iv) Paid Rs. 50/- and drugs kit Rs.
600/- per year.
1) Jammu and kasmir
( Rehbar-e- sehat)
2)Arunachal pradesh ( Medics)
3) Tamil nadu ( Mini health
4)Kerala ( strenthing of PHC’s)
• Link between village, community, and
Government health care system.
• Health education.
The union health ministry has decided to
discontinue the centrally sponsored village
health guide scheme from April 1, 2002, in
view of its failure to achieve its objectives.
It follows the report of a three-member
committee of experts headed by the former
director of Indian institute of public
administration, P.K. Umashankar.
Trained Birth attendant (LocalTrained Birth attendant (Local
trained Dais)trained Dais)
i) Training for 30 working days
ii) Provided with delivery kit.
iii) Rs.10/- per delivery & Rs.3/-
per registered child.
Anganwadi workerAnganwadi worker
i) Local woman with VIth Std.
ii) Provides non formal education to
Anganwadi workerAnganwadi worker
• ICDS One anganwadi worker
appointed per 1000 population.
• Part time employee.
• 4 months training.
• Honorarium 1500 per month.
• Mobile anganwadi programme.
• Under NRHM
• 1 for 1000 population.
• Married, widow, divorced, 25-45 years.
• Kerala 31868
RURAL HEALTH SERVICES
• Primary health centre system.
• 3 tier system.
Sub centre 5000 3000
PHC 30000 20000
CHC 1,20,000 80,000
RURAL HEALTH SYSTEM
• 148124 Sub Centres,
• 23887 Primary Health Centres (PHCs)
• 4809 Community Health Centres (CHCs)
As On March, 2011
Most peripheral and first
contact point between the
primary health care system
and the community.
Rural health scheme-1977
Placing people’s health in
Number of Sub Centres existing as on
March 2011increased from 146026 in
2005 to 148124 in 2011.
Chhattisgarh, Haryana, Jammu &
Orissa, Punjab, Rajasthan, Tamil Nadu,
Tripura and Uttarakhand.
One auxiliary nurse midwife (ANM) /
Female Health Worker.
One male health worker.
Under NRHM, there is a provision for
one additional second ANM on contract
One lady health visitor (LHV) is
entrusted with the task of supervision of
Sub-Centres are assigned tasks
relating to interpersonal
communication in order to bring
about behavioral change.
Maternal and child health
Control of communicable diseases
• The Ministry of Health & Family
Welfare is providing 100% Central
assistance to all the Sub-Centres in the
country since April 2002 in the form of
salary of ANMs and LHVs, rent at the
rate of Rs. 3000/- per annum and
contingency at the rate of Rs. 3200/-
per annum, in addition to drugs and
INDIAN PUBLIC HEALTH
STANDARDS FOR SUB-CENTRES
In order to provide quality care in the
Sub-centres, Indian Public Health
Standards (IPHS) are being prescribed to
provide basic primary health care
services to the community and achieve
and maintain an acceptable standard of
quality of care.
IPHS SUB CENTRES
The Indian Public Health Standards
(IPHS) for health Sub-centre lays down
the package of services that the Sub-
centre shall provide, the population
norms for which it would be established,
the human resource, infrastructure,
equipment and supplies that would be
needed to deliver these services with
OBJECTIVES OF THE INDIAN PUBLIC
HEALTH STANDARDS FOR SUB-
To specify the minimum assured (essential)
services that Sub-centre is expected to
provide and the desirable services which the
states/UTs should aspire to provide through
To maintain an acceptable quality of care
for these services.
To facilitate monitoring and
supervision of these facilities
To make the services provided
more accountable and responsive
to people’s needs.
SERVICES TO BE PROVIDED IN A
Sub-centres are expected to
and few curative primary
health care services.
Type A: Shall provide all
services as envisaged for the
Sub-centre except the facilities
for conducting delivery will not
be available here.
Type B: They will provide all
recommended services including facilities
for conducting deliveries at the Sub-
centre itself. This Sub-centre will act as
Maternal and Child Health (MCH)
centre with basic facilities for conducting
deliveries and Newborn Care at the Sub-
Early registration of all pregnancies,
within first trimester (before 12th week
However even if a woman comes late in
her pregnancy for registration, she
should be registered and care given to
her according to gestational age.
Minimum 4 ANC including
1st visit: Within 12 weeks—preferably
as soon as pregnancy is suspected for
registration, history and first antenatal
2nd visit: between 14 and 26 weeks
3rd visit: between 28 and 34 weeks
4th visit: between 36 weeks and term.
Associated services like general
examination such as height, weight,
B.P, anaemia, abdominal
examination, breast examination,
Folic Acid Supplementation (in first
trimester), Iron & Folic Acid
Supplementation from 12 weeks,
injection tetanus toxoid, treatment of
Recording tobacco use by all
Minimum laboratory investigations
like urine test for pregnancy
estimation, urine for albumin and
sugar and linkages with PHC for
other required tests.
Name based tracking of all pregnant
women for assured service delivery.
Identification of high risk pregnancy
Identification and management of
danger signs during pregnancy.
Malaria prophylaxis in malaria
endemic zones for pregnant women as
per the guidelines of NVBDCP.
Provide information about provisions
under current schemes and
programmes like Janani Suraksha
Identify suspected RTI/STI case,
provide counselling, basic management
and referral services.
Counselling & referral for HIV/AIDS.
Name based tracking of missed and
left out ANC cases
Counselling on diet, rest, tobacco
cessation if the antenatal mother is
a smoker or tobacco user,
information about dangers of
exposure to second hand smoke and
minor problems during pregnancy,
advice on institutional deliveries,
Pre-birth preparedness and
complication readiness, danger signs,
clean and safe delivery at home if
called for, postnatal care & hygiene,
nutrition, care of newborn, registration
of birth, initiation of breast feeding,
exclusive breast feeding for 6 months,
demand feeding, supplementary
feeding (weaning and starting semi
solid and solid food) from 6 months
onwards, infant & young child feeding
Promotion of institutional deliveries.
Skilled attendance at home deliveries
when called for.
Appropriate and timely referral of
high risk cases which are beyond her
capacity of management.
ESSENTIAL FOR TYPE B SUB-
Managing labour using Partograph.
Identification and management of
danger signs during labor.
Proficient in identification and basic
fist aid treatment for PPH, Eclampsia,
Sepsis and prompt referral of such
cases as per’Antenatal Care and
Skilled birth Attendance at birth’or
• Minimum 24 hours of stay of
mother and baby after delivery
at Sub-centre. the environment
at the Sub-centre should be
clean and safe for both mother
Initiation of early breast-feeding
within one hour of birth.
Ensure post-natal home visits on 0,3,7
and 42nd day for deliveries at home
and Sub-centre (both for mother &
Ensure 3, 7 and 42nd day visit for
institutional delivery (both for mother
& baby) cases.
In case of Low birth weight baby (less
than 2500 gm), additional visits are to
be made on 14, 21 and 28th days.
During post-natal visit, advice regarding
care of the mother and care and feeding
of the newborn and examination of the
newborn for signs of sickness and
congenital abnormalities as per IMNCI
Guidelines and appropriate referral, if
Counselling on diet & rest,
hygiene,contraception, essential newborn
care, immunization, infant and young
child feeding, STI/RTI and HIV/AIDS.
Name based tracking of missed and left
out PNC cases.
Newborn Care Corner In The Labour
Room to provide Essential Newborn
Counselling on exclusive breast-feeding
for 6 months.
Appropriate and adequate
complementary feeding from 6 months
of age while continuing breastfeeding.
Assess the growth and development of
the infants and under 5 children and
make timely referral.
Full Immunization of all infants and
children against vaccine preventable
diseases as per guidelines of Government
Vitamin A prophylaxis to the children
as per National guidelines.
Prevention and control of childhood
diseases like malnutrition, infections,
ARI, Diarrhea, Fever, Anemia etc.
including IMNCI strategy.
Name based tracking of all infants and
children to ensure full immunization
Identification and follow up, referral
and reporting of Adverse Events
Following Immunization (AEFI).
FAMILY PLANNING AND
• Education, Motivation and counselling
to adopt appropriate Family planning
Provision of contraceptives such a
condoms, oral pills, emergency
contraceptives, Intra uterine
Contraceptive Devices (IuCD) insertions
(wherever the ANM is trained in IuCD
Follow up services to the eligible couples
adopting any family planning methods
SAFE ABORTION SERVICES (MTP)
Counselling and appropriate referral for
safe abortion services (MTP) for those in
Follow up for any complication after
abortion/MTP and appropriate referral
• Provide treatment for minor ailments
including fever, diarrhea, ARI, worm
infestation and First Aid including first aid
to animal bite cases (wound care,
tourniquet (in snake bite) assessment and
• Appropriate and prompt referral.
• Provide treatment as per AYUSH as per
the local need. ANMs and MPW (M) be
trained in basic AYUSH drugs.
• Once a month clinic by the PHC medical
• LHV, HWM and ANM should be
available for providing assistance.
Adolescent Health Care
Education, counselling and referral.
• Prevention and treatment of
• Counselling on harmful effects of
tobacco and its cessation.
School Health Services
• Screening, treatment of minor ailments,
immunization, de-worming, prevention
and management of Vitamin A and
nutritional deficiency anemia and referral
services through fixed day visit of school
by existing ANM/MPW.
• Staff of Sub-centre shall provide
assistance to school health services as a
member of team.
Control of Local Endemic
• Assisting in detection, Control and
reporting of local endemic diseases such
as malaria, kala Azar, Japanese
encephalitis, Filariasis, Dengue etc.
• Assistance in control of epidemic
outbreaks as per programme guidelines.
Disease Surveillance, Integrated
Surveillance Project (IDSP)
• Surveillance about any abnormal increase
in cases of diarrhea/dysentery, fever with
rigors, fever with rash, fever with
jaundice or fever with unconsciousness
and early reporting to concerned PHC as
per IDSP guidelines.
• Immediate reporting of any
cluster/outbreak based on syndromic
• High level of alertness for any unusual
health event, reporting and appropriate
• Weekly submission of report to PHC
in’S’Form as per IDSP guidelines.
Water and Sanitation
• Disinfection of drinking water sources.
Promotion of sanitation including use
of toilets and appropriate garbage
Out reach/Field Services
Village Health and Nutrition Day (VHND)
• VHND should be organised at least once
in a month in each village with the help of
Medical Officer, Health Assistant Female
(LHV) of PHC, HWM, HWF, ASHA,
AWW and their supervisory staff, PRI,
Self Help Groups etc.
• Each Village Health and Nutrition Day
should last for at least four hours of
contact time between ANMs, AWWs,
ASHAs and the beneficiaries.
• Early registration and Antenatal care
for pregnant women – as per standard
treatment protocol for the SBA.
• Immunization and Vitamin A
administration to all under 5 children-
as per immunization schedule.
• Coordination with ICDS programme for
Supplementary nutritional services,
health check up and referral services,
health and nutrition education,
immunization for children below 6 years,
Pregnant & Lactating Mother and
health and nutrition education for all
women in the age group (15 to 45 years)
• Family planning counselling and
distribution of contraceptives.
• Symptomatic care and management of
persons with minor illness referred by
ASHAs/AWWs or coming on their own
Health Communication to mothers,
adolescents and other members of the
community who attend the VHND
session for whatever reason.
Meet with ASHAs and provide
training/support to them as needed.
Registration of births and Deaths.
Symptom based care and counselling
with referral if needed for STI/RTI and
for HIV/AIDS suspected cases.
Disinfection of water sources and
promotion of sanitation including use of
toilets and appropriate garbage
• For skilled attendance at birth- where
the woman has opted or had to go in
for a home delivery.
• Post natal and newborn visits – as per
protocol to check out on disease
incidences reported to Health Worker
or she/he comes across during house
visits especially where there it is a
• Visits to houses of eligible couples who
need contraceptive services, but are not
currently using them e.g. couples with
children less than three years of age,
where women are married and less than
19 years of age, where the family is
Follow up of cases who have
undergone Sterilization and MTP, as per
protocols especially those who can not
come to the facility.
Visits to community based DOTS
providers, leprosy depot holders where
this is needed.
• Visits to support ASHA where further
counselling is needed to persuade a family
to utilize required health services e.g.,
immunization dropouts, antenatal care
dropouts, tb defaulter etc.
• To take blood slides/do RDK test in cases
with fever where malaria is suspected.
These surveys would be done once
annually, preferably in April.
Some of the diseases would require
special surveys- but at all times not
more than one survey per month would
• Surveys would be done with support and
participation of ASHAs, Anganwadi
Workers, community volunteers,
panchayat members and Village Health
Sanitation and Nutrition Committee
Age and sex of all family members.
Assess and list eligible couples and their
unmet needs for contraception.
Identify persons with skin lesions or
other symptoms suspicious of leprosy
and refer: essential in high leprosy
Identify persons with blindness, list and
refer: Identify persons with hearing
impairment/deafness, list and refer.
Annual mass drug administration in
filaria endemic areas.
• Identify persons with disabilities, list
and refer and call for counselling
• Identify and list senior citizens who
need special care and support.
• Identify persons with mental health
problems and Epilepsy; list and refer.
• In high endemicity areas-survey for
fever suspicious of kala- azar, for
epidemic management of malaria, for
detection of fluorosis affected cases etc.
• Ani other obvious disease/disorder; list
COMMUNITY LEVEL INTERACTIONS
• Focus group discussions for
information gathering and health
Health Communication especially as
related to National Health programmes
through attending Village Health
Sanitation and Nutrition Committee
meetings, ASHA local review meetings and
meetings with panchayat
members/sarpanch, Self Help Groups,
women’s groups and other BCC activities.
• Coordinated services with AWWs,
ASHAs, Village Health Sanitation and
Nutrition Committee PRI etc.
National Health Programmes
Communicable Disease Prgramme
National AIDS Control Programme
• Condom promotion & distribution of
condoms to the high risk groups.
Help and guide patients with HIV/AIDS
receiving ART with focus on adherence.
IEC activities to enhance awareness and
preventive measures about STIs and
HIV/AIDS, PPtCt services and HIV-TB
• Linkage with Microscopy Centre for
HIV/STI Counseling, Screening and
referral in type b Sub-centres
(Screening in Districts where the
prevalence of HIV/AIDS is high).
National Vector Borne Disease
• Collection of blood slides of fever
• Rapid Diagnostic tests (RDt) for
diagnosis of Pf malaria in high Pf
• Appropriate anti-malarial treatment.
• Assistance for integrated vector control
activities in relation to Malaria, Filaria,
JE, Dengue, kala-Azar etc. as prevalent
in specific areas. Prevention of breeding
places of vectors Indian Public Health
Standards (IPHS) Guidelines for Sub-
centres 13through IEC and community
• Annual mass drug administration with
single dose of Diethyl carbamazine (DEC)
to all elligible population at risk of
• Promotion of use of insecticidal treated
nets, wherever supplied.
• Record keeping and reporting.
National Leprosy Eradication
Health education to community
regarding signs and symptoms of leprosy,
its complications, curability and
availability of free of cost treatment.
• Referral of suspected cases of leprosy
(person with skin patch, nodule,
thickened skin, impaired sensation in
hands and feet with muscle weakness)
and its complications to PHC
• Provision of subsequent doses of MDT
and follow up of persons under treatment
for leprosy, maintain records and
monitor for regularity and completion of
Revised National Tuberculosis
• Referral of suspected symptomatic
cases to the PHC/Microscopy centre.
• Provision of DOTS at Sub-centre,
proper documentation and follow-up.
Sputum collection centers established
in sub-centre for collection and
transport of sputum samples in rural,
tribal, hilly &difficult areas of the
country where Designated Microscopy
Centres are not available as per the
• National Programme for Control of
Detection of cases of impaired vision in
house to house surveys and their
appropriate referral. the cases with
decreased vision will be noted in the
Spreading awareness regarding eye
problems, early detection of decreased
vision, available treatment and health
care facilities for referral of such cases.
IEC is the major activity to help
identify cases of blindness and refer
suspected cataract cases.
The cataract cases brought to the
Hospital by MPW/ANM/and ASHAS.
Assisting for screening of school
children for diminished vision and
National Programme for Prevention
of Deafness (NPPCD):
Detection of cases of hearing
impairment and deafness during House
to house survey and their appropriate
Awareness regarding ear problems,
early detection of deafness, available
treatment and health care facilities for
referral of such cases.
Education of community especially the
parents of young children regarding
importance of right feeding practices,
early detection of deafness in young
children, common ear problems and
available treatment for hearing
National Mental Health
• Identification and referral of common
mental illnesses for treatment and
follow them up in community.
• IEC activities for prevention and early
detection of mental disorders and
greater participation/role of
Community for primary prevention of
NATIONAL PROGRAMME FOR
PREVENTION AND CONTROL OF
CARDIOVASCULAR DISEASES AND
IEC Activities to promote healthy
lifestyle sensitize the community about
prevention of Cancers, Diabetes, CVD
and Strokes, early detection through
awareness regarding warning signs and
appropriate and prompt referral of
National Iodine Deficiency
Disorders Control Programme:
IEC Activities to promote
Iodized salt by the community.
testing of salt for presence of
Iodine through Salt testing kits by
IN FLUOROSIS AFFECTED
• Identify the persons at risk of
Fluorosis, suffering from Fluorosis and
those having deformities due to
Fluorosis and referral.
• Line listing of reconstructive surgery
cases, rehabilitative intervention
activities and referral services
• Focused behaviour change
communication activities to prevent
National Tobacco Control
Spread awareness and health education
regarding ill effects of tobacco use
especially in pregnant females and Non-
Communicable diseases where tobacco is a
e.g. Cardiovascular disease, Cancers,
chronic lung diseases.
Display of mandatory signage of “No
Smoking” in the Sub-centre.
• Counselling for quitting tobacco.
• Awareness to public that smoking is
banned in public places and sale of
tobacco products is banned to minors (less
than 18 years) as well as within 100 yards
of schools and educational institutions.
• Spread awareness regarding law on smoke
free public places.
Health education on oral health and
hygiene especially to antenatal and
lactating mothers, school and
Providing first aid and referral
services for cases with oral health
Health education on Prevention of
Disability. Identification of Disabled
persons during annual house to house
survey and their appropriate referral.
National Programme for Health
Care of Elderly
• Counseling of Elderly persons and
their family members on healthy
• Referral of sick old persons to PHC.
Promotion of Medicinal Herbs
• Locally available medicinal
herbs/plants should be grown around
the Sub-centre as per the guidelines of
Department of AYUSH.
RECORD OF VITAL EVENTS
Recording and reporting of vital events
including births and deaths,
particularly of mothers and infants to
the health authorities.
Sub-centre A Sub-centre B (MCH
Staff Essential Desirable Essential Desirable
1 +1 2
Staff Nurse (or
ANM, if Staff
Nurse is not
1 (Part-time) 1 (Full-time)
*to be outsourced.
** if number of deliveries at the Sub-centre is 20 or more in a month
• Origin of Primary Health Centre The
concept of primary health centre is not
new to India.
• The Bhore Committee in 1946 gave the
concept of primary health centre as a
basic health unit, to provide as close to
the people as possible, an integrated
curative and preventive health care to
the rural population.
• The central council of health as its first
meeting held in January 1953 had
recommended the establishment of
primary health centers in community
development blocks to provide
comprehensive health care to the rural
• Corner stone.
• PHC is the first contact point between
village community and the Medical
• The PHCs were envisaged to provide an
integrated curative and preventive health
care to the rural population with
emphasis on preventive and promotive
aspects of health care.
The PHCs are established and
maintained by the State Governments
under the Minimum Needs Programme
(MNP)/ Basic Minimum Services
• As per minimum requirement, a PHC is
to be manned by a Medical Officer
supported by 14 paramedical and other
staff. Under NRHM, there is a provision
for two additional Staff Nurses at PHCs
on contract basis. It acts as a referral
unit for 6 Sub Centres.
• It has 4 - 6 beds for patients. The
activities of PHC involve curative,
preventive, promotive and Family
• Some diagnostic services also.
• 23,673 PHCs functioning as on March
2010 in the country.
• At the national level, there is an
increase of 437 PHCs in 2010 as
compared to that existed in 2005.
Significant increase is also observed in
the number of PHCs in the States of
Bihar, Chhattisgarh, Haryana, Jammu
& Kashmir, Karnataka,
Some diagnostic facilities.
FUNCTIONS OF THE PHC
• Its functions cover all the 8 essential
elements of PHC as outlined in Alma
MCH including family planning
Safe water supply and basic sanitation
Prevention and control of local
Collection and reporting of vital
Education about health BCC, IEC.
National health programs
Training of health guides, health
workers, local dais and health
Basic laboratory service
Monitoring and supervision.
Services at the Primary Health Centre
for meeting the IPHS
• Type A PHC: PHC with delivery load
of less than 20 deliveries in a month.
• Type B PHC: PHC with delivery load
of 20 or more deliveries in a month.
• Minimum Requirement Projected
based on the basis of 40 patients per
doctor per day, the expected number of
beneficiaries for maternal and child
health care and family planning about
60% utilization of the available
indoor/observation beds (6 beds).
• If the utilization goes up, the standards
would be further upgraded.
• As regards, manpower, one more
Medical Officer (may be from AYUSH
or a lady doctor) and two more staff
nurses are added to the existing total
staff strength of 15 in the PHC to make
it 24x7 services delivery centre.
Objectives of Indian Public Health
Standards (IPHS) for Primary
Health Centres (PHC)
To provide comprehensive primary health
care to the community through the Primary
To achieve and maintain an acceptable
standard of quality of care.
To make the services more responsive and
sensitive to the needs of the community.
Manpower at PHC
Existing Recommended (IPHS)
Medical Officer 1 2(one AYUSH or LMO)
Pharmacist 1 1
Nurse-midwife (Staff 1 3 (for 24-hour PHCs)
(Nurse) (2 may be contractual)
Health workers (F) 1 1
Health Educator 1 1
Health Asstt. (M&F) 2 2
Clerks 2 2
Laboratory Technician 1 1
Driver 1 Optional/vehicles out-sourced.
Class IV 4 4
Total 15 17/18
Community Health Centres
• CHCs are being established 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 Consultation.
• The National health plan
(1983)proposed reorganization of PHC
on the basis of one PHC for every
30,000 rural population in the plains ,
and one PHC for every 20,000
population in hilly, tribal, backward
areas for more effective coverage.
FUNCTIONS OF CHC
• Providing speciality services
• Giving all preventive and curative
• Caring and supervision of concerned
• Providing consultancy and referral
services to PHCs
• Referring patients to district hospitals
and teaching hospitals.
• Implementation of all national health
programmers with active participation
• Providing reproductive and child health
services including family planning
First Referral Units (FRUs)
An existing facility (district hospital,
sub-divisional hospital, community
health centre etc.) can be declared a
fully operational First Referral Unit
(FRU) only if it is equipped to provide
round-the-clock services for Emergency
Obstetric and New Born Care, in
addition to all emergencies that any
hospital is required to provide.
RURAL FAMILLY WELFARE
• PHC’es of block level
• 1 April 1980
• 1 assistant surgeon and 11 para medical
• April 2002 state govt.
URBAN HEALTH SERVICES
• In India 377 million people live in urban
places, out of which an estimated 97
million people live in urban poverty.
• Rapid urbanization and the significant
growth of urban poor population in
absolute numbers already have new
demands on the available infrastructure
and service delivery mechanisms.
URBAN HEALTH SERVICES…
• The urban poor are a mix of people living in
slums and the homeless.
• Urban poverty is characterized by food
insecurity, varied morbidity pattern, poor
access to drinking water and sanitation,
high costs of living and job insecurity.
• All these aspects affect the health seeking
behavior of the urban poor and in general
SIGNIFICANCE OF URBAN
The World Health Day theme for 2010
“Urbanization and Health”
• The Urban Health Initiative (UHI) is
part of a five-year, four country
initiative supported by the Bill &
Melinda Gates Foundation in Nigeria,
Kenya, Senegal, and India.
UHI India is a consortium of
international, national, nongovernmental,
and community-based organizations
working together to improve the health of
the urban poor, especially in the state of
• UHI is designed to be complementary to
national and state health sector plans and
• The initiative supports the
implementation and scale-up of effective
evidence-based strategies, as well as the
testing of promising innovations.
• Nearly one-third of India’s urban citizens
live in crowded informal settlements or
• UN-HABITAT has estimated that by the
year 2020, India’s total slum population
will cross 200 million people.
What are slums?
Habitations located on disputed as well
as unused government, municipal and
private land and characterized by a
serious lack of basic amenities and
sanitation with dense and overcrowded
• City slums are characterized by poor
access to clean water and adequate
sanitation, the basic requirements for
maintaining good hygiene and robust
• Health-wise, the urban poor are worse
off than their middle- and high-income
counterparts; they also appear to be
worse off than their rural counterparts
• Every year, Indian slums bear witness
to how preventable illnesses cause
thousands of deaths and millions of
hours of forfeited productivity.
• The government is cognizant of the
country’s urban healthcare challenges,
but has thus far found it difficult to
adequately serve the space.
Health Delivery System in Urban
• The government of India appointed the
Krishnan Committee in 1982 to address
the problems of urban health.
• The health post scheme was devised for
urban areas based on the
recommendations of the Krishnan
Committee. Its report specifically outlines
which services have to be provided by the
health post .
• These services have been divided into
outreach, preventive, family planning,
curative, support (referral) services
and reporting and record keeping.
• Outreach services include population
education, motivation for family
planning, and health education. In the
present context, very few outreach
services are being provided to urban
• A municipal corporation covers a
population of above three lakh; there are
three types of municipal councils – (A) 1
lakh population, (B) 40,000 to 1 lakh and
(C) less than 40,000. Primary health
services are provided in urban areas
through health posts.
• There are four types of health posts (A, B,
C and D) according to population size (as
per GoI guidelines).
According to the Krishnan Committee
recommendations, the health post was to
be located ‘in’ slum areas.
The committee had recommended one
voluntary health worker (VHW) per
2,000 population with an honorarium of
• The health post (HP) scheme was
launched in 1983-84. A deputy director
and joint director were assigned to urban
health, but functioned chiefly to promote
family planning goals.
• The scheme is centrally funded, and the
financial provisions at present continue to
be the same as those 15 years before.
Urban Revamping Scheme
• Urban revamping scheme was introduced
following recommendations by Krishnan
committee 1983 .
• To provide primary health care, family
welfare, service delivery outreach and
MCH services in urban areas.
• HEALTH POSTS:
• There are 871 health posts functioning in
10 States and 2 UTs.
Type of health post
Type of health post Population
Type A <5000
Type B 5000-10000
Type C 10000-25000
Type D 25000-50000
If population of the area is more than 50000 then it is to be divided into sectors
of 50000 population and a post is established at each sector.
• Medical care
• MCH and family planning.
• Prevention and control of communicable
• Safe drinking water.
• Environmental sanitation.
• Dietary services.
• A dispensary is an office in a school,
hospital or other organization that
dispenses medications and medical
• In a traditional dispensary set-up a
pharmacist dispenses medication as per
prescription or order form.
• Nurse midwife
• Male health
• Female health
• Male health worker
• Female health
URBAN FAMILY WELFARE CENTRES
• Urban Family Welfare Centers are on ground
since First Five Year Plan to provide family
welfare services in urban areas
• Most of UFWCs are equipped to provide
contraceptive supplies. At present 1083
centers are functioning.
• There are three types of Urban Family Welfare
centers based on the population covered by
Staffing pattern for Urban Family Welfare
NO. UNITS Staffing Pattern
Type I 10000 - 25000 326
ANM -1, FP Field
Type II 25000 - 50000 125
or/LHV -1FP Field
Type III Above 50000 632
ANM - 2, LHV - 1,
FP Field Worker
(Male) - 1 ,
TYPE OF HEALTH POST NO. OF HEALTH POSTS
ALL INDIA HOSPITAL POST PARTUM
• PAP Smear facility at 105 PPC attached to
• Medical Termination of Pregnancy;
• Sterilization (Tubectomy);
• Provision of all types of contraceptives;
• Promote family planning as most important
health intervention for Health of Mother &
• Promote spacing of birth;
• At present 550 centers at district level and
1012 centres at sub-divisional level hospitals
• There are three types of Post Partum Centers
at district level hospitals
Type A : covering Medical
Colleges/Institutions conducting 3000 or more
Obstetric and abortion cases annually
:covering Medical Institutions conducting less
• Satellite hospitals.
• Big dispensaries,
• District hospitals
5 lakhDistrict health centres
One Urban Primary Health Centre
(U-PHC) for every fifty to sixty thousand
One Urban Community Health Centre
(U-CHC) for five to six U-PHCs in big
One Auxiliary Nursing Midwives (ANM)
for 10,000 population.
One Accredited Social Health Activist
ASHA (community link worker) for 200 to
• The scheme will focus on primary health
care needs of the urban poor.
• This Mission will be implemented in 779
cities and towns with more than 50,000
population and cover about
7.75 crore people.
• Urban poor population living in listed and
unlisted slums.• All the other vulnerable
population such as homeless, rag- pickers,
street children, rickshaw pullers, construction
and brick kiln workers, sex workers, any other
temporary migrants.• Public health thrust on
sanitation, clean drinking water and vector
control.• Strengthening public health capacity
of urban local bodies
• To address the health concerns by facilitating
equitable access to available health facilities by
rationalizing and strengthening the capacity of
the existing health care delivery system.•
Partnership with all efforts made for accessing
community buildings under various health
programmes to ensure full utilization of
created infrastructure.• Similarly, the
communitization process draw heavily on the
existing community organizations and self-help
• It aims to synergize the mission with the
existing progammes such as Jawahar Lal
Nehru National Urban Renewal Mission
(JNNURM), Swarn Jayanti Shahri Rozgar
Yojana (SJSRY) and ICDS which have similar
objectives to NUHM.
• Core Strategies• Improving the efficiency of
public health system in the cities by
strengthening, revamping and rationalizing
urban primary health structure• Promotion of
access to improved health care at household
level through community based groups: Mahila
Arogya Samitees (MAS)• Strengthening public
health through preventive and promotive
action• Increased access to health care through
community risk pooling and health insurance
• The interventions
· Reduction in Infant Mortality Rate
· Reduction in Maternal Mortality
· Universal access to reproductive
· Convergence of all health related
• Urban Social Health Activist (USHA)• An Urban
Social Health Activist (USHA) will be posted for
every 200-500 households and provide the
leadership and promote the Mahila Arogya
Samitee.• The USHA on the lines of ASHA,
would preferably be a woman resident of the
slum– married/widow/ divorced, preferably in
the age group of 25 to 45 years.• She would
be chosen through a rigorous community
driven process involving ULB counsellors,
• Urban Social Health Activist (USHA)• The
USHA would actually be the nerve centres for
delivering outreach services in the vicinity of
the door steps of the beneficiaries.• The USHA
may be preferably co-located with the
Anganwadi Centres located in the slums for
optimization of health outcomes.
• Mahila Arogya Samitee (MAS)• The NUHM
proposes the creation of Mahila Arogya
Samitee (MAS) a community based federated
group of around 20 to 100 households,
depending upon the size and concentration of
the slum population, with flexibility for state
level adjustments.• MAS - acts as community
based peer education group, involved in
community monitoring and referral.
• Mahila Arogya Samitee (MAS)• The MAS will
have 5-20 members with an an elected
Chairperson and a Treasurer, supported by an
USHA.• This group would focus on health and
hygiene behaviour change promotion,
facilitating access to identified facilities and
risk pooling.• The MAS will be provided an
annual united grant of Rs 5000 per year.
• Primary Urban Health Centre• The situational
analysis has clearly revealed that most of the
existing primary health facilities, namely the
Urban Health Posts (UHPs) /Urban Family
Welfare Centres (UFWC)/ Dispensaries are
functioning sub- optimally due to problems of
infrastructure, human resources, referrals,
diagnostics, case load, spatial distribution, and
inconvenient working hours.• The NUHM
therefore proposes to strengthen and revamp
• Primary Urban Health Centre• The PUHC may
cater to a slum population between 20000-
30000, with provision for evening OPD,
providing preventive, promotive and non-
domiciliary curative care (including
consultation, basic lab diagnosis and
dispensing)• However, depending on the
spatial distribution of the slum population, the
population covered by a PUHC may vary from
5000 for cities with sparse slum population to
• Rogi Kalyan Samiti and Referrals• Rogi Kalyan
Samiti will be made for promoting local
action.• The provision of health care delivery
with the help of outreach sessions in the
slums would also strengthen the delivery of
health care services.• On the basis of the GIS
map the referrals would also be clearly
defined and communicated to the community
thus facilitating their easy access.
• Rogi Kalyan Samiti and Referrals• Creation of
Sub Centers has not been proposed. Outreach
services will be provided through Female
Health Workers (FHWs)/ANMs headquartered
at the U-PHCs, utilizing community halls, AWC,
etc., as fixed points for these services.•
Secondary and Tertiary level care and referral
services will be provided through public or
empanelled private providers.
• Community health risk pooling• The NUHM
would promote Community health risk
pooling and health insurance as measures for
protecting the poor from impoverishing effect
of out of pocket expenditure.• To promote
community risk pooling mechanism the
members of the MAS would be encouraged to
save money on monthly basis for meeting the
health emergencies.• The group members
themselves would decide the lending norms
• Community health InsuranceTo ensure access
of identified families to quality medical care
Identified urban poor families, for a maximum
of five members• Smart Card/Individual or
Family Health Suraksha Cards to be proof of
eligibility and to avoid duplication with similar
schemesImplementing Agency:• Preferably
ULBs, possibly state for smaller citiesPremium
Financing• Up to a maximum of Rs.600 per
• IT enabled services (ITES) and e-governance•
Studies have highlighted that the private
providers, which provide the majority of them
urban poor access for OPD services, remain
outside the public disease surveillance
network.• This leads to compromised
reporting of diseases and outbreaks in urban
slums thereby adversely affecting timely
intervention by the public authorities.• The
availability of ITES in the urban areas makes it
• Monitoring & Evaluation• The Monitoring and
evaluation framework would be based on
triangulisation of information.• The three
components would be (a) Community Based
Monitoring (b) A web based Urban HMIS for
reporting and feedback and (c) external
• 43. Monitoring & Evaluation• The District/
City Urban Health Society along with the
District/ City Urban Health Mission would
URBAN FAMILY WELFARE
• India, the second most populous country in
the world, has no more than 2.5 per cent of
global land but is the home of 1/6th of the
• 2007, April- 1083.
URBAN HEALTH POSTS
• ABCD RCH
871-(2007) FIRST AID
SUPER SPECIALITY HOSPITALS
• First Phase
Up gradation of 13 existing.
• Second phase
Besides, the government has also
approved setting up of two such
institutions, one each in West
Bengal and Uttar Pradesh.
• The steering committee on health for 12th
Five Year Plan has recommended the Union
government to create four new AIIMS like
institutions (ALIs) over and above the eight
already approved under the Pradhan Mantri
Swasthya Suraksha Yojana (PMSSY).
• Government Medical College, Jhansi, Uttar
Pradesh; Government Medical College, Rewa,
Madhya Pradesh; Government Medical
UttarPradesh; Government Medical College,
Dharbanga, Bihar; Government Medical
College, Kozhikode, Kerala; Vijaynagar
Institute of Medical Sciences, Bellary,
Karnataka and Government Medical College,
• Central government health scheme (CGHS)
Started in 1954
-Mainly for central government employees
& their family members
-Ex. M.P.’s, Judges of supreme
& high court, freedom fighter, Central Govt.
pensioner -Employees of semi
autonomous bodies & semigovt.
• Emergency services
• Free supply of drugs
• Lab & radiological services
• Domiciliary visits
• Specialist consultation at hospital, family
welfare centr level
Urban Health service delivery model
Primary level health