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  2. 2. HEALTH CARE DELIVERY SYSTEM  It exists to provide services & resources for better health.  This system includes hospital, clinic, health centers, nursing homes &special health programmes in school, industries & community.
  4. 4. HEALTH CARE DELIVERY SYSTEM 1. PUBLIC HEALTH SECTOR : Primary health care •Primary health centers •Sub centers Hospitals health centers •Community health centers •Rural hospitals
  5. 5. PUBLIC HEALTH SECTOR… •District hospitals. •Specialty hospitals •Teaching hospitals Health Insurance Schemes •Employee state insurance •Central government health schemes Other Agencies •Defense services •Railways
  6. 6. 2. PRIVATE SECTOR Private Hospitals, polyclinics, nursing homes & dispensaries. General practitioners & clinics. 3.INDIGENOUS SYSTEM OF MEDICINE Ayurveda & Siddha Uninani & Tibbi Homeopathy Unregistered Practitioners
  9. 9. URBAN Urban hospitals and health centre Central health services/Health Insurance Other health services.
  10. 10. URBAN HOSPITALS & HEALTH CENTRES • District hospitals and dispensaries. • Urban family welfare centres. • Special Hospitals. • Medical college Hospitals/ Teaching Hospitals. • Super Specialty Hospitals/ Institutes.
  11. 11. Central health services/Health Insurance • ESI • FPI • Central Govt: Health scheme Other health services •Railway •Military
  12. 12. RURAL HEALTH SERVICES Sub Centre. PHC CHC Other rural services.(VILLAGE)  VHG  TBA  Anganwadi workers  ASHA
  13. 13. HEALTH ADMINISTRATION AT RURAL LEVEL 3-TIER STRUCTURE Primary care Secondary Care Tertiary care
  15. 15. VILLAGE HEALTH GUIDE SCHEME 1) Lanuched on 2nd October 1977 2)Centrally sponsored under family and welfare This is in operation in all states except 5 states where alternative health schemes are in progress.
  16. 16. 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 3 months iii) Works for 2-3 hours per day iv) Paid Rs. 50/- and drugs kit Rs. 600/- per year.
  17. 17. 5 states 1) Jammu and kasmir ( Rehbar-e- sehat) 2)Arunachal pradesh ( Medics) 3) Tamil nadu ( Mini health worker) 4)Kerala ( strenthing of PHC’s) 5)Karnataka(strenthing of PHC’s)
  18. 18. FUNCTIONS • Link between village, community, and Government health care system. • Health education.  Communicable Diseases.  MCH, FW.  First aid.
  19. 19.  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.
  20. 20. Trained Birth attendant (LocalTrained Birth attendant (Local trained Dais)trained Dais) i) Training for 30 working days with certificate. ii) Provided with delivery kit. iii) Rs.10/- per delivery & Rs.3/- per registered child.
  21. 21. Anganwadi workerAnganwadi worker i) Local woman with VIth Std. education ii) Provides non formal education to children
  22. 22. Anganwadi workerAnganwadi worker • ICDS One anganwadi worker appointed per 1000 population. • Part time employee. • 4 months training. • Honorarium 1500 per month. • Mobile anganwadi programme.
  23. 23. ASHA • Under NRHM • 1 for 1000 population. • Married, widow, divorced, 25-45 years. • Kerala 31868
  24. 24. RURAL HEALTH SERVICES • Primary health centre system. • 3 tier system.
  25. 25. NAME OF HEALTH CENTRE PLAINS HILLY/TRI BAL Sub centre 5000 3000 PHC 30000 20000 CHC 1,20,000 80,000
  26. 26. RURAL HEALTH SYSTEM • 148124 Sub Centres, • 23887 Primary Health Centres (PHCs) • 4809 Community Health Centres (CHCs) As On March, 2011
  27. 27. SUB CENTRE  Most peripheral and first contact point between the primary health care system and the community. Rural health scheme-1977 Placing people’s health in people’s hand.
  28. 28. SUB CENTRE Number of Sub Centres existing as on March 2011increased from 146026 in 2005 to 148124 in 2011. Chhattisgarh, Haryana, Jammu & Kashmir,Karnataka, Maharashtra, Orissa, Punjab, Rajasthan, Tamil Nadu, Tripura and Uttarakhand.
  29. 29. 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 basis. One lady health visitor (LHV) is entrusted with the task of supervision of six sub-centres.
  30. 30. Sub-Centres are assigned tasks relating to interpersonal communication in order to bring about behavioral change.
  31. 31. SUB CENTRES… Maternal and child health Family welfare Nutrition Immunization Diarrhoea control Control of communicable diseases programmes.
  32. 32. • 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 equipment kit.
  33. 33. 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.
  34. 34. 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 quality.
  35. 35. OBJECTIVES OF THE INDIAN PUBLIC HEALTH STANDARDS FOR SUB- CENTRE. 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 this facility. To maintain an acceptable quality of care for these services.
  36. 36. CONT… To facilitate monitoring and supervision of these facilities  To make the services provided more accountable and responsive to people’s needs.
  37. 37. SERVICES TO BE PROVIDED IN A SUB-CENTRE Sub-centres are expected to provide promotive,preventive 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.
  38. 38. CONT… 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- centre.
  39. 39. MCH MATERMAL HEALTH  Antenatal care:  Early registration of all pregnancies, within first trimester (before 12th week of Pregnancy). 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.
  40. 40. CONT.. Minimum 4 ANC including Registration 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected for registration, history and first antenatal check-up 2nd visit: between 14 and 26 weeks 3rd visit: between 28 and 34 weeks 4th visit: between 36 weeks and term.
  41. 41.  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 anaemia etc.
  42. 42. Recording tobacco use by all antenatal mothers. Minimum laboratory investigations like urine test for pregnancy confirmation, haemoglobin estimation, urine for albumin and sugar and linkages with PHC for other required tests.
  43. 43. CONT… Name based tracking of all pregnant women for assured service delivery.  Identification of high risk pregnancy cases.  Identification and management of danger signs during pregnancy.  Malaria prophylaxis in malaria endemic zones for pregnant women as per the guidelines of NVBDCP.
  44. 44. Provide information about provisions under current schemes and programmes like Janani Suraksha Yojana.  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
  45. 45.  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,
  46. 46. 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 and contraception.
  47. 47. INTRA-NATAL CARE: Essential  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.
  48. 48. ESSENTIAL FOR TYPE B SUB- CENTRE  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 SBA Guidelines.
  49. 49. CONT… • 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 and baby.
  50. 50. POSTNATAL CARE: 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 & baby). Ensure 3, 7 and 42nd day visit for institutional delivery (both for mother & baby) cases.
  51. 51. POSTNATAL CARE… In case of Low birth weight baby (less than 2500 gm), additional visits are to be made on 14, 21 and 28th days.
  52. 52. CONT… 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 needed.
  53. 53. CONT…  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.
  54. 54. CHILD HEALTH Newborn Care Corner In The Labour Room to provide Essential Newborn Care. Counselling on exclusive breast-feeding for 6 months. Appropriate and adequate complementary feeding from 6 months of age while continuing breastfeeding.
  55. 55. CHILD HEALTH Assess the growth and development of the infants and under 5 children and make timely referral. Immunization Services: Full Immunization of all infants and children against vaccine preventable diseases as per guidelines of Government of India
  56. 56. Cont…. 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.
  57. 57. Cont…  Name based tracking of all infants and children to ensure full immunization coverage.  Identification and follow up, referral and reporting of Adverse Events Following Immunization (AEFI).
  58. 58. FAMILY PLANNING AND CONTRACEPTION • Education, Motivation and counselling to adopt appropriate Family planning methods.
  59. 59. Cont… Provision of contraceptives such a condoms, oral pills, emergency contraceptives, Intra uterine Contraceptive Devices (IuCD) insertions (wherever the ANM is trained in IuCD insertion). Follow up services to the eligible couples adopting any family planning methods (terminal/spacing).
  60. 60. SAFE ABORTION SERVICES (MTP) Counselling and appropriate referral for safe abortion services (MTP) for those in need.  Follow up for any complication after abortion/MTP and appropriate referral if needed.
  61. 61. CURATIVE SERVICES Essential •  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 referral). •  Appropriate and prompt referral.
  62. 62. CURATIVE SERVICES • 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 officer. • LHV, HWM and ANM should be available for providing assistance.
  63. 63. Adolescent Health Care Education, counselling and referral. •  Prevention and treatment of Anemia. •  Counselling on harmful effects of tobacco and its cessation.
  64. 64. 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.
  65. 65. CONT… •  Staff of Sub-centre shall provide assistance to school health services as a member of team.
  66. 66. Control of Local Endemic Diseases • 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.
  67. 67. Disease Surveillance, Integrated Disease 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.
  68. 68. CONT… • Immediate reporting of any cluster/outbreak based on syndromic surveillance. • High level of alertness for any unusual health event, reporting and appropriate action. • Weekly submission of report to PHC in’S’Form as per IDSP guidelines.
  69. 69. Water and Sanitation • Disinfection of drinking water sources.  Promotion of sanitation including use of toilets and appropriate garbage disposal.
  70. 70. 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.
  71. 71. CONT… • Each Village Health and Nutrition Day should last for at least four hours of contact time between ANMs, AWWs, ASHAs and the beneficiaries.
  72. 72. CONT.. • 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.
  73. 73. CONT…. • 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)
  74. 74. CONT… • 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 accord.
  75. 75. CONT.. Health Communication to mothers, adolescents and other members of the community who attend the VHND session for whatever reason.
  76. 76. CONT… Meet with ASHAs and provide training/support to them as needed.  Registration of births and Deaths.
  77. 77. CONT… 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 disposal.
  78. 78. HOME VISITS • For skilled attendance at birth- where the woman has opted or had to go in for a home delivery.
  79. 79. CONT.. • 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 notifiable disease.
  80. 80. CONT.. • 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 complete etc.
  81. 81. CONT..  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.
  82. 82. CONT… • 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.
  83. 83. HOUSE-TO-HOUSE SURVEYS 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 be expected.
  84. 84. CONT… • Surveys would be done with support and participation of ASHAs, Anganwadi Workers, community volunteers, panchayat members and Village Health Sanitation and Nutrition Committee members.
  85. 85. CONT… 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 prevalence blocks.
  86. 86. CONT… Identify persons with blindness, list and refer: Identify persons with hearing impairment/deafness, list and refer. Annual mass drug administration in filaria endemic areas.
  87. 87. CONT… • Identify persons with disabilities, list and refer and call for counselling where needed. • Identify and list senior citizens who need special care and support. • Identify persons with mental health problems and Epilepsy; list and refer.
  88. 88. CONT… • 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 and refer.
  89. 89. COMMUNITY LEVEL INTERACTIONS • Focus group discussions for information gathering and health planning.
  90. 90. CONT… 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.
  91. 91. COORDINATION AND MONITORING • Coordinated services with AWWs, ASHAs, Village Health Sanitation and Nutrition Committee PRI etc.
  92. 92. National Health Programmes Communicable Disease Prgramme National AIDS Control Programme (NACP): Essential • Condom promotion & distribution of condoms to the high risk groups.
  93. 93. CONT… 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 coordination.
  94. 94. CONT…. • Linkage with Microscopy Centre for HIV-TBcoordination. HIV/STI Counseling, Screening and referral in type b Sub-centres (Screening in Districts where the prevalence of HIV/AIDS is high).
  95. 95. National Vector Borne Disease Control Programme (NVBDCP): • Collection of blood slides of fever patients • Rapid Diagnostic tests (RDt) for diagnosis of Pf malaria in high Pf endemic areas. • Appropriate anti-malarial treatment.
  96. 96. CONT… • 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 mobilization.
  97. 97. Cont…. • Annual mass drug administration with single dose of Diethyl carbamazine (DEC) to all elligible population at risk of lymphatic filariasis. • Promotion of use of insecticidal treated nets, wherever supplied. • Record keeping and reporting.
  98. 98. National Leprosy Eradication Programme (NLEP): Health education to community regarding signs and symptoms of leprosy, its complications, curability and availability of free of cost treatment.
  99. 99. Cont… • 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
  100. 100. CONT… • Provision of subsequent doses of MDT and follow up of persons under treatment for leprosy, maintain records and monitor for regularity and completion of treatment.
  101. 101. Revised National Tuberculosis Control Programme (RNTCP): • Referral of suspected symptomatic cases to the PHC/Microscopy centre. • Provision of DOTS at Sub-centre, proper documentation and follow-up.
  102. 102. CONT… 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 RNTCP guidelines.
  103. 103. Non-communicable Disease (NCD) Programmes • National Programme for Control of Blindness (NPCB): 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 blindness register.
  104. 104. CONT… 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.
  105. 105. CONT… The cataract cases brought to the District Hospital by MPW/ANM/and ASHAS. Assisting for screening of school children for diminished vision and referral.
  106. 106. National Programme for Prevention and Control of Deafness (NPPCD):  Detection of cases of hearing impairment and deafness during House to house survey and their appropriate referral.  Awareness regarding ear problems, early detection of deafness, available treatment and health care facilities for referral of such cases.
  107. 107. CONT… 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 impairment/deafness.
  108. 108. National Mental Health Programme: • 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 mental disorders.
  109. 109. NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF CANCER, DIABETES, CARDIOVASCULAR DISEASES AND STROKE 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 suspect cases.
  110. 110. CONT… National Iodine Deficiency Disorders Control Programme: IEC Activities to promote consumption of Iodized salt by the community. testing of salt for presence of Iodine through Salt testing kits by ASHAs.
  111. 111. IN FLUOROSIS AFFECTED (ENDEMIC) AREAS • Identify the persons at risk of Fluorosis, suffering from Fluorosis and those having deformities due to Fluorosis and referral.
  112. 112. CONT… • Line listing of reconstructive surgery cases, rehabilitative intervention activities and referral services • Focused behaviour change communication activities to prevent Fluorosis.
  113. 113. National Tobacco Control Programme: Spread awareness and health education regarding ill effects of tobacco use especially in pregnant females and Non- Communicable diseases where tobacco is a risk factor.
  114. 114. CONT… e.g. Cardiovascular disease, Cancers, chronic lung diseases. Display of mandatory signage of “No Smoking” in the Sub-centre.
  115. 115. CONT… • 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.
  116. 116. CONT… Oral Health: Health education on oral health and hygiene especially to antenatal and lactating mothers, school and adolescent children. Providing first aid and referral services for cases with oral health problems.
  117. 117. CONT…. Disability Prevention: Health education on Prevention of Disability. Identification of Disabled persons during annual house to house survey and their appropriate referral.
  118. 118. National Programme for Health Care of Elderly • Counseling of Elderly persons and their family members on healthy ageing. • Referral of sick old persons to PHC.
  119. 119. Promotion of Medicinal Herbs • Locally available medicinal herbs/plants should be grown around the Sub-centre as per the guidelines of Department of AYUSH.
  120. 120. RECORD OF VITAL EVENTS Essential Recording and reporting of vital events including births and deaths, particularly of mothers and infants to the health authorities.
  121. 121. Type of subcentre Sub-centre A Sub-centre B (MCH Sub- centre) Staff Essential Desirable Essential Desirable ANM/Health Worker (Female) 1 +1 2 Health Worker (Male) 1 1 Staff Nurse (or ANM, if Staff Nurse is not available) 1** Safai- karamchari* 1 (Part-time) 1 (Full-time) *to be outsourced. ** if number of deliveries at the Sub-centre is 20 or more in a month
  122. 122. PHC • 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.
  123. 123. PHC • 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 population.
  124. 124. PHC… • Corner stone. • PHC is the first contact point between village community and the Medical Officer. • 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.
  125. 125. PHC The PHCs are established and maintained by the State Governments under the Minimum Needs Programme (MNP)/ Basic Minimum Services (BMS) Programme
  126. 126. PHC • 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.
  127. 127. PHC • It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive, promotive and Family Welfare. • Some diagnostic services also.
  128. 128. • 23,673 PHCs functioning as on March 2010 in the country.
  129. 129. • 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, Maharashtra,Nagaland, Uttarakhand, Uttar Pradesh.
  130. 130. SET UP PHC 30,000 20,000 4-6 Beds Some diagnostic facilities.
  131. 131. FUNCTIONS OF THE PHC • Its functions cover all the 8 essential elements of PHC as outlined in Alma Ata declaration:
  132. 132. Medical care MCH including family planning Safe water supply and basic sanitation Prevention and control of local endemic diseases Collection and reporting of vital statistics
  133. 133. FUNCTIONS Education about health BCC, IEC. National health programs School health.  Referral services Training of health guides, health workers, local dais and health assistants Basic laboratory service Monitoring and supervision.
  134. 134. IPHS PHC 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.
  135. 135. CONT.. • 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).
  136. 136. CONT… • 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.
  137. 137. Objectives of Indian Public Health Standards (IPHS) for Primary Health Centres (PHC) To provide comprehensive primary health care to the community through the Primary Health Centres.  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.
  138. 138. 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
  139. 139. Community Health Centres (CHCs) • CHCs are being established and maintained by the State Government under MNP/BMS programme.
  140. 140. CHC 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.
  141. 141. CONT… • It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist Consultation.
  142. 142. CONT… • 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.
  143. 143. FUNCTIONS OF CHC • Providing speciality services • Giving all preventive and curative health services. • Caring and supervision of concerned PHCs • Providing consultancy and referral services to PHCs • Referring patients to district hospitals and teaching hospitals.
  144. 144. Cont…. • Implementation of all national health programmers with active participation in them. • Providing reproductive and child health services including family planning services.
  145. 145. Title
  146. 146. 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.
  147. 147. RURAL FAMILLY WELFARE CENTRE • PHC’es of block level • 1 April 1980 • 1 assistant surgeon and 11 para medical staffs • April 2002 state govt.
  148. 148. 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.
  149. 149. 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 the health.
  150. 150. SIGNIFICANCE OF URBAN HEALTH 155 The World Health Day theme for 2010 “Urbanization and Health”
  151. 151. Cont… • 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.
  152. 152. Cont… 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 Uttar Pradesh.
  153. 153. Cont… • UHI is designed to be complementary to national and state health sector plans and goals. • The initiative supports the implementation and scale-up of effective evidence-based strategies, as well as the testing of promising innovations.
  154. 154. SLUMS • Nearly one-third of India’s urban citizens live in crowded informal settlements or slum communities. • UN-HABITAT has estimated that by the year 2020, India’s total slum population will cross 200 million people.
  155. 155. 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 housing conditions.
  156. 156. Cont... • City slums are characterized by poor access to clean water and adequate sanitation, the basic requirements for maintaining good hygiene and robust health.
  157. 157. Cont… • 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
  158. 158. Cont… •  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.
  159. 159. Health Delivery System in Urban Slums • 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 .
  160. 160. Cont… • These services have been divided into outreach, preventive, family planning, curative, support (referral) services and reporting and record keeping.
  161. 161. Cont… • 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 slums.
  162. 162. Cont… • 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).
  163. 163. Cont…. 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 Rs 100.
  164. 164. Cont… • 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.
  165. 165. 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.
  166. 166. 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.
  167. 167. URBAN PHC Organization     Municipality Commissioner Health Officer Dispensary/Hospital Medical officer
  168. 168. Functions • Medical care • MCH and family planning. • Prevention and control of communicable diseases. • Safe drinking water. • Environmental sanitation. • Dietary services.
  169. 169. Dispensary • A dispensary is an office in a school, hospital or other organization that dispenses medications and medical supplies. • In a traditional dispensary set-up a pharmacist dispenses medication as per prescription or order form.
  170. 170. Staff Pattern • MO • Nurse midwife • Male health assistant • Female health assistant • Male health worker • Female health worker •Pharmacist •Lab technician •Store keeper •Watchman •Driver •Cook
  171. 171. 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  each centre. 
  172. 172. Staffing pattern for Urban Family Welfare  Centers TYPE POPULATION COVERED NO. UNITS Staffing Pattern Type I 10000 - 25000 326 ANM -1, FP Field  Worker -1 Type II 25000 - 50000 125 FPExtensionEducat or/LHV -1FP Field  Worker(Male) -1 ANM -1 Type III Above 50000 632 Medical Officer  -1(Pref. Female) ANM - 2, LHV - 1,  FP Field Worker  (Male) - 1 ,  Storekeeper-cum-
  173. 173. Cont. TYPE OF HEALTH POST NO. OF HEALTH POSTS A 65 B 76 C 165 D 565
  174. 174. ALL INDIA HOSPITAL POST PARTUM PROGRAMME • PAP Smear facility at 105 PPC attached to  Medical Colleges; • Medical Termination of Pregnancy; • Sterilization (Tubectomy); • Provision of all types of contraceptives; • Promote family planning as most important  health intervention for Health of Mother &  Child; • Promote spacing of birth;
  175. 175. • At present 550 centers at district level and  1012 centres at sub-divisional level hospitals  are functioning. • 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 Type B  :covering Medical Institutions conducting less 
  176. 176. URBAN HOSPITALS • Satellite hospitals. • Big dispensaries, hospitals. • District hospitals Sub divisional health centres 5 lakhDistrict health centres •NUHM
  177. 177. NUHM   One Urban Primary Health Centre (U-PHC) for every fifty to sixty thousand population.  One Urban Community Health Centre (U-CHC) for five to six U-PHCs in big cities.  One Auxiliary Nursing Midwives (ANM) for 10,000 population.  One Accredited Social Health Activist ASHA (community link worker) for 200 to
  178. 178. NUHM • 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.
  179. 179. • 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
  180. 180. • 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 
  181. 181. • 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.
  182. 182. •  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 
  183. 183. NUHM • The interventions · Reduction in Infant Mortality Rate (IMR) · Reduction in Maternal Mortality Ratio (MMR) · Universal access to reproductive health care · Convergence of all health related interventions.
  184. 184. • 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, 
  185. 185. • 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.
  186. 186. • 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.
  187. 187. • 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.
  188. 188. • 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 
  189. 189. •  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 
  190. 190. • 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.
  191. 191. •  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.
  192. 192. • 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 
  193. 193. • Community health InsuranceTo ensure access  of identified families to quality medical care  forhospitalization/surgeryBeneficiaries•  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 
  194. 194. • 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 
  195. 195. • 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  evaluations • 43. Monitoring & Evaluation• The District/  City Urban Health Society along with the  District/ City Urban Health Mission would 
  196. 196. URBAN FAMILY WELFARE CENTRES • 1950 • 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 world's population. • 2007, April- 1083.
  197. 197. URBAN HEALTH POSTS • ABCD RCH 871-(2007) FIRST AID Contraceptives Other services.
  199. 199. SUPER SPECIALITY HOSPITALS • PMSSY. • First Phase 6 AIMS. Jodhpoor Bhopal Raipur Patna Bhuwaneshwar Rishikesh
  200. 200. Cont.. Up gradation of 13 existing. 960 bedded. 500-Medical college. 300-Speciality/super speciality. 100-ICU/ trauma. 30- PM&Rehab. 30- AYUSH.
  201. 201. Cont.. • Second phase Besides, the government has also approved setting up of two such institutions, one each in West Bengal and Uttar Pradesh.
  202. 202. Cont.. • 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).
  203. 203. THIRD PHASE • Government Medical College, Jhansi, Uttar Pradesh; Government Medical College, Rewa, Madhya Pradesh; Government Medical College, Gorakhpur, UttarPradesh; Government Medical College, Dharbanga, Bihar; Government Medical College, Kozhikode, Kerala; Vijaynagar Institute of Medical Sciences, Bellary, Karnataka and Government Medical College, Muzaffarpur, Bihar.
  204. 204. Urban Areas • Central government health scheme (CGHS)     Started in 1954 • Beneficiaries- -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.  Organizations' -Ex. 
  205. 205. Facilities provided • Emergency services • Free supply of drugs • Lab & radiological services • Domiciliary  visits • Specialist consultation at hospital, family  welfare centr level
  206. 206. Urban Health service delivery model Referral Primary level health  care facility Community level

Editor's Notes

  • Mahila arogya smitee- community based peer education group20-100 households preventive promotive care, risk pooling fund and health insurance
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