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Primary health care
- 1. PRIMARY HEALTH CARE SYSTEM IN INDIA
- 2. Universal Health Coverage India is embarking on an ambitious target of achieving Universal Health Coverage for all during 12th Plan period. Everybody will be entitled for comprehensive health security in the country. It will be obligatory on the part of the State to provide adequate food, appropriate medical care, safe drinking water, proper sanitation, education and health-related information for good health. The State will be responsible or ensuring and guaranteeing UHC for its citizens
- 3. Definition of UHC Ensuring equitable access for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services.
- 5. Primary Health Care primary health care is essential health care based on practical , scientifically sound , socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of its development in spirit of self reliance and self determination ‘Health for all by 2000 AD’ in the International Health Conference, held at Alma-Ata (USSR) during the year 1978
- 7. HISTORY 1946 – BHORE COMMITTEE put forward concept of Primary Health Care. 1974- KARTAR SINGH COMMITTEE -Integrated cadre of MPWs. 1977-GOL COMMITEE launched a based on principle of ‘ placing people’s health in people’s hand.’ (Recommendation of SRIVASTAV COMMITTEE 1975) 1978 – ALMA ATA DECLARATION– Health for All through Primary Health Care.
- 8. HISTORY- Trends Bhore Committee – PHC/ 10- 20,000 population. Mudaliar Committee (1962) – PHC/ 40,000 population. By Fifth Plan (1975-80) – PHC was catering health needs of 1,00,000 population. 1983 - National Health Plan – PHC/ 30,000 in plain areas & per 20,000 in hilly region.
- 10. Structure of Health Care In India
- 11. Principles Of PHC Equitable distribution Community Participation
- 12. Principles Of PHC Intersectoral Co-ordination Appropriate Technology
- 15. Elements Of PHC 1. Appropriate treatment of common diseases and injuries. 2. Maternal and child health care and family planning. 3. Immunization against major infectious diseases. 4. Promotion of food supply and proper nutrition
- 16. Elements Of PHC 5. Education of the people about prevailing health problems and methods of preventing and controlling them. 6. Adequate supply of safe water and basic sanitation. 7. Prevention and control of locally endemic diseases. 8. Provision of essential drugs.
- 18. INDIAN PUBLIC HEALTH STANDARDS The objectives of IPHS for PHCs are: i. To provide comprehensive primary health care to the community through the Primary Health Centres. ii. To achieve and maintain an acceptable standard of quality of care. iii. To make the services more responsive and sensitive to the needs of the community.
- 19. INDIAN PUBLIC HEALTH STANDARDS From Service delivery angle, PHCs may be of two types, depending upon the delivery case load – Type A and Type B. 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
- 20. Staffing Pattern Of PHC
- 21. INDIAN PUBLIC HEALTH STANDARDS 1. Medical Care 1. Essential OPD Services 24 hours emergency services Referral services In-patient services
- 22. INDIAN PUBLIC HEALTH STANDARDS Maternal and child health care including family planning 1. Essential Antenatal Care Intra-natal care Proficient in identification and basic treatrment for PPH, Eclampsia , Sepsis and promt referral Postnatal Care New born Care Care of child Family welfare
- 23. INDIAN PUBLIC HEALTH STANDARDS Promotion of safe drinking water and basic sanitation Prevention of local endemic diseases Carry out various health programs Health promotion Referral services Training
- 24. INDIAN PUBLIC HEALTH STANDARDS Basic labrotory and diagnostic services 1. Essential Routine urine , cbc , stool tests Diagnosis of STI/RTI Sputum testing MPFT UPTGRBS Rapid test for featal contamination of water 2. Desirable Blood Cholestrol ECG
- 25. Essential Drugs In PHC Anti infective agents. 1. Penicillins. 2. Co-Trimoxazole and Cephalosporins 3. Gentamycin, Kanamycin and Amikacin 4. Erythromicin and related group of antibiotics 5. Broad spectrum antibiotics like the tetracyclins and chloramphenicol 6. Anti-TB and Anti-Leprosy Drugs 7. Anti-viral agents like acyclovir, and zidovudin (optional )
- 26. Essential Drugs In PHC 8. The common anti parasitic agents like antimalarial durgs- chloroquine, primaquine, pyremethamine, proguanil, quinine, mefloquine, artemehter, and halofantin 9. Anti amoebics like metronidazole or tinidazole 10. Usual anthelmentics – mebandazole, albendazole, pyrental palmoate, piperazine, levamisole, diethylecarbamazine citrate, ivermectine and praziquantel 11. . Drugs for Gastro intestinal disorders-Common antacids, ulcer healing agents – cimetidine, ranitidine, famotidine, omeprazole. 12. Antispasmodics, prokinetics, anti diarohoeals, and laxatives.
- 27. Essential Drugs In PHC 13. Cardiovascular drugs – Betablockers, quinidine, digoxin, adrenaline. Calcium channel blockers, sodiumnitroiprusside, methyledopa, prazosin, ACE inhibitors. 14. Antianginals – sorbitrate, nicorandil 15. Respiratory system drugs. Antihistamines, corticoteroids, cough syrups. Anti asthmatics – salbutamol, terbutaline, theophylline, aminophylline. 16. Oral hypoglycaemic agents – Glybenclamide, tolbutamide, chlopropamide, metformin, phenformin. Different preparation of insulins. 17. Antithyroid drugs (optional)
- 28. Essential Drugs In PHC Other essential group of drugs are the analgesic and antipyretics, Aspirin, paracetamol, morphine, pentazocine, pethidine, ibuprofen, diclophenac, indomethacin pyroxicam, nemuselide. References: 1. World Health Chronicle 2. National drug formulary – Govt. of India
- 29. Current status Sub Centre: 1 per 5,000 population in general areas and 1 per 3,000 population in difficult/tribal and hilly areas Primary Health Centre: 1 per 30,000 population in general areas and 1 per 20,000 population in difficult/tribal and hilly areas Community Health Centre: 1 per 1,20,000 population in general areas and 1 per 80,000 population in difficult/tribal and hilly areas.
- 30. Current status As per the Rural Health Statistics (RHS) 2018, as on 31.3.2018 the status of public health facilities function in the Country is as under: o 1, 58,417 Sub Centres (SCs), o 25,743 Primary Health Centres (PHCs), o 5,624 Community Health Centres (CHCs), o 1130 Sub-divisional Hospitals (SDHs) & 764 Districts Hospitals (DH) in the country • There is a shortfall of 32900 SCs (18%), 6430 PHCs (22%) and 2188 CHCs (30%) across the country as per the Rural Health Statistics (RHS) 2018. There are 9930 PHCs that are operational as 24X7 facilities as on 30.06.2018.
- 31. References Textbook of social and preventive medicine by Suryakanth Preventive and social medicine by K.Park IPHS – guidelines for primary health center (revised 2012) www.nrhm.gov.in
- 32. THANK YOU
Editor's Notes
- BHORE COMMITTEE 1946: PHC a basic health unit to provide integrated preventive and curative services to rural population.one PHC/10 to 20,000 populations with 6 medical officers and 6 public health nurses and other supporting staff. CENTRAL COUNCIL OF HEALTH: In 1953 ,recommended for establishment of PHCs in community development blocks to provide comprehensive health care to rural population. One PHC is for 1,00,000 population with little or no community involvement. Poorly staffed and equipped, inadequately for covering the population. MUDALIAR COMMITTEE,1962: 1. Strengthening of existing PHCs and 2. One PHC for 40,000 populations. SHRIVASTAV COMMITTEE-1975: Community health care should be provided by health workers who are from the same community after proper training. So that people health is placed in people hands. In 1977, the government of India had launched a Rural Health Mission, based on the principle of “placing the people health in people hands”. NATIONAL HEALTH PLAN: As a signatory to the Alma-Ata declaration , India has proposed reorganization of primary health centres on the basis of one PHC for 30,000 populations in plain areas and 20,000 populations in tribal and hilly areas for more effective coverage
- Population Norms for PHC
- This means that the basic health services which are provided under primary health care must be provided to all the people, irrespective of the cast, creed, community and ability to pay (rich or poor) for it and thus these services must be accessible to all This principle is based on the fact that at present the health care services are concentrated in the towns and cities, (where 25 percent of population live and 75 percent of the budget is spent) to the rich and curative oriented. On the other hand, the needy and vulnerable groups of population like the poor rural and the urban slums (where 75% population live and 25% budget is spent) are neglected and who deserve the services most. This social injustice must be removed and the services must be equally distributed to all the people of the community This consists of active involvement of the people of the community in providing primary health care. This is based upon the fact that achieving universal coverage of primary health care is not possible without the involvement of the local community. Involvement of the community in planning, implementation and maintenance of health services is a very prominent feature. Community participation promotes social awareness and self-reliance of the community. It increases the community acceptance of the primary health care programs and reduces the distance between the providers and the consumers of health care. Advantages of community participation • It is a cost effective method of providing health services. • People begin to view health more objectively. So they are more likely to accept the care. • There will be greater commitment of the people resulting in the success of health care services. • Health awareness becomes an integral part of village life. • Health workers get greater support for their activities. • People become more soft reliant in taking care of their health. • Health care services become more relevant to the health needs of the people. • There is less dependence on the Government. • Quality of the health care improves
- It is also realized that primary health care to the community cannot be provided by health sector alone. It requires the co-ordination of other health related sectors also such as education, communication, fisheries, animal husbandry, food and agricultural department, animal husbandry, social-welfare, public-works, voluntary organizations, etc. (Fig. 34.3). Co-ordination of all these sectors is essential. This requires a strong political action. The co-ordination committees will make policies and implement in a planned way, so as to avoid duplication of the activities. The committee also reviews the activities periodically. This means that the technology of the health care service provided must be ‘appropriate’, i.e. it must be simple, scientifically sound, practically adaptable, culturally acceptable, economically cheaper and operationally convenient (Fig. 34.4). Appropriate technologies that have been developed and introduced in the country are Oral rehydration therapy, immunization programs, nutritional supplementation, DOTS, distribution of disposable delivery kits for domiciliary midwifery services, distribution of IFA tablets, biogas plants for cooking
- PHC includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs
- Essential OPD services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for six days in a week. Time schedule will vary from state to state. Minimum OPD attendance is expected to be 40 patients per doctor per day. In addition to six hours of duty at the PHC, it is desirable that MO PHC shall spend at least two hours per day twice in a week for field duties and monitoring. 24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. These services will be provided primarily by the nursing staff. However, in case of need, Medical Officer may be available to attend to emergencies on call basis. Referral services. In-patient services (6 beds) Essential a) Antenatal care I. Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy). Minimum 4 antenatal check-ups and provision of complete package of services. Suggested schedule for antenatal visits: 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration of pregnancy 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 b) Intra-natal care: (24-hour delivery services both normal and assisted) c) Proficient in identification and basic first aid treatment for PPH, Eclampsia, Sepsis and prompt referral d) Postnatal Care -breast milk initiation -counselling for nutrition -management of hypothermia f) Care of the child -routine management of childhood illness -under 5 clinic referral -immunization Prevention of childhood illness Nutrition Services (coordinated with ICDS) Essential a. Diagnosis of and nutrition advice to malnourished children, pregnant women and others. b. Diagnosis and management of anaemia and vitamin A deficiency. c. Coordination with ICDS.
- Screening of diseases , de worming , immunization , health promotion Water and sanitation Essential Disinfection of water sources and Coordination with Public Health Engineering department for safe water supply. Promotion of sanitation including use of toilets and appropriate garbage disposal Prevention of locally endemic diseases like malaria , kala azr
- AS PER IPHS STANDARDS From Service delivery angle, PHCs may be of two types, depending upon the delivery case load – Type A and Type B. 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
- Essential OPD services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for six days in a week. Time schedule will vary from state to state. Minimum OPD attendance is expected to be 40 patients per doctor per day. In addition to six hours of duty at the PHC, it is desirable that MO PHC shall spend at least two hours per day twice in a week for field duties and monitoring. 24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. These services will be provided primarily by the nursing staff. However, in case of need, Medical Officer may be available to attend to emergencies on call basis. Referral services. In-patient services (6 beds) Essential a) Antenatal care I. Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy). Minimum 4 antenatal check-ups and provision of complete package of services. Suggested schedule for antenatal visits: 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration of pregnancy 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 b) Intra-natal care: (24-hour delivery services both normal and assisted) c) Proficient in identification and basic first aid treatment for PPH, Eclampsia, Sepsis and prompt referral d) Postnatal Care -breast milk initiation -counselling for nutrition -management of hypothermia f) Care of the child -routine management of childhood illness -under 5 clinic referral -immunization Prevention of childhood illness Nutrition Services (coordinated with ICDS) Essential a. Diagnosis of and nutrition advice to malnourished children, pregnant women and others. b. Diagnosis and management of anaemia and vitamin A deficiency. c. Coordination with ICDS.
- Essential OPD services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for six days in a week. Time schedule will vary from state to state. Minimum OPD attendance is expected to be 40 patients per doctor per day. In addition to six hours of duty at the PHC, it is desirable that MO PHC shall spend at least two hours per day twice in a week for field duties and monitoring. 24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. These services will be provided primarily by the nursing staff. However, in case of need, Medical Officer may be available to attend to emergencies on call basis. Referral services. In-patient services (6 beds) Essential a) Antenatal care I. Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy). Minimum 4 antenatal check-ups and provision of complete package of services. Suggested schedule for antenatal visits: 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration of pregnancy 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 b) Intra-natal care: (24-hour delivery services both normal and assisted) c) Proficient in identification and basic first aid treatment for PPH, Eclampsia, Sepsis and prompt referral d) Postnatal Care -breast milk initiation -counselling for nutrition -management of hypothermia f) Care of the child -routine management of childhood illness -under 5 clinic referral -immunization Prevention of childhood illness Nutrition Services (coordinated with ICDS) Essential a. Diagnosis of and nutrition advice to malnourished children, pregnant women and others. b. Diagnosis and management of anaemia and vitamin A deficiency. c. Coordination with ICDS.
- Essential OPD services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for six days in a week. Time schedule will vary from state to state. Minimum OPD attendance is expected to be 40 patients per doctor per day. In addition to six hours of duty at the PHC, it is desirable that MO PHC shall spend at least two hours per day twice in a week for field duties and monitoring. 24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. These services will be provided primarily by the nursing staff. However, in case of need, Medical Officer may be available to attend to emergencies on call basis. Referral services. In-patient services (6 beds) Essential a) Antenatal care I. Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy). Minimum 4 antenatal check-ups and provision of complete package of services. Suggested schedule for antenatal visits: 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration of pregnancy 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 b) Intra-natal care: (24-hour delivery services both normal and assisted) c) Proficient in identification and basic first aid treatment for PPH, Eclampsia, Sepsis and prompt referral d) Postnatal Care -breast milk initiation -counselling for nutrition -management of hypothermia f) Care of the child -routine management of childhood illness -under 5 clinic referral -immunization Prevention of childhood illness Nutrition Services (coordinated with ICDS) Essential a. Diagnosis of and nutrition advice to malnourished children, pregnant women and others. b. Diagnosis and management of anaemia and vitamin A deficiency. c. Coordination with ICDS.
- Essential OPD services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for six days in a week. Time schedule will vary from state to state. Minimum OPD attendance is expected to be 40 patients per doctor per day. In addition to six hours of duty at the PHC, it is desirable that MO PHC shall spend at least two hours per day twice in a week for field duties and monitoring. 24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of the condition of the patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. These services will be provided primarily by the nursing staff. However, in case of need, Medical Officer may be available to attend to emergencies on call basis. Referral services. In-patient services (6 beds) Essential a) Antenatal care I. Early registration of all pregnancies ideally in the first trimester (before 12th week of pregnancy). Minimum 4 antenatal check-ups and provision of complete package of services. Suggested schedule for antenatal visits: 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration of pregnancy 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 b) Intra-natal care: (24-hour delivery services both normal and assisted) c) Proficient in identification and basic first aid treatment for PPH, Eclampsia, Sepsis and prompt referral d) Postnatal Care -breast milk initiation -counselling for nutrition -management of hypothermia f) Care of the child -routine management of childhood illness -under 5 clinic referral -immunization Prevention of childhood illness Nutrition Services (coordinated with ICDS) Essential a. Diagnosis of and nutrition advice to malnourished children, pregnant women and others. b. Diagnosis and management of anaemia and vitamin A deficiency. c. Coordination with ICDS.
- Penicillins. For common type of infectious diseases the best and safest antibiotic is penicillin. But because of the emergence of resistant strains and the fear of hyper sensitivity reactions, the use of penicillin’s had declined well. Infection caused by all gram positive organisms, except penicillinase producing staphylococci are susceptible to penicillin. The availability of semisynthetic and synthetic penicillins are now replacing the simple pencillins. But the fear of hypersensitivity is similar to these agents also. In our set up the group of pencillins that may be made use of in the primary centres are the following: 1. ampicillin 2. Amoxycillin 3. Cloxacillin 4. Methicillin are the next important group of anti bacterial agents which may be made available in the primary centres. These can be used for penicillin resistant cases. I Gentamycin, Kanamycin and Amikacin may be stored to tackle the gram negative organisms. Erythromicin and related group of antibiotics are widely used for pharyngitis, tonsillitis, sinusitis, cellulitis. Etc. They can be used in penicillin contra indicated cases also. The broad spectrum antibiotics like the tetracyclins and chloramphenicol are now a days very rarely used because of their toxicity and such drugs may not be stored for primary centres. The newer variety of Qunolones are now widely used mainly for treating typhoid fever and for managing resistant infections of tuberculosis. The primary centre should have enough quantity of anti-tuberculous drugs and also antileprosy drugs. The common anti tuberculous drugs anti leprotic drugs needed are Rifampincin, INH, Dapsone, Ethambutol, Pyrazinamide, and Clofazimine.