Community health Nursing, Public health nursing, Nursing

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SMCH/HCDS/13: First Referral Units
Quadrant-I
Personal Details
Role Name Affiliation
Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras
Hindu University, Varanasi
Paper Coordinator Prof. Najam Khalique Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Writer Prof. Najam Khalique Department of Community Medicine,
J N Medical College, AMU, Aligarh
Content Reviewer
Dr. Anees Ahmad Associate Professor
Department of Community Medicine,
J N Medical College, AMU, Aligarh
Description of Module
Items Description of Module
Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module name/Title First Referral Units
Module Id SMCH/HCDS/13
Pre-requisites Understanding of organization of health system
Objectives To know about organization and functioning of FRUs.
Keywords Child survival, client satisfaction, first referral units, safe motherhood,

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Introduction
Reduction in maternal mortality rate is the stated goal for National Population Policy, National Health
Policy and Tenth Five Year Plan and is also one of the Millennium Development Goals (MDG) to
which the country is a signatory and has to respond. Maternal mortality in India continues to remain
unacceptably high. Historical evidence at the global level has demonstrated that it is possible to bring
down maternal mortality effectively if a package of obstetric services is provided within reach of the
communities and the families. It is in this context that efforts were initiated in 1992 with the
implementation of the Child Survival and Safe Motherhood (CSSM) Programmewith assistance from
World Bank and UNICEFfor upgrading the existing community health centers and sub-district
hospitals into First Referral Units (FRUs), to be equipped for providing delivery of emergency
obstetric care to pregnant women with complications. Over the years, a number of steps have been
taken under the RCH Programme for facilitating the operationalisation of these FRUs. These have
included funds for operationalising Operation Theatre (OTs) and Labour Rooms (LRs), supply of
equipment kits, supply of drug kits containing emergency obstetric care drugs and funds for hiring of
Anaesthetists from private sector. Drugs and Cosmetics Rules have also been amended to enable
setting up of Blood Storage Units in the institutions designated as First Referral Units (FRUs).
Despite all these efforts, not many FRUs identified by the State Governments have become fully
operational for provision of 24-hours Emergency Obstetric and Child Health care services. The
Maternal Mortality Rate (MMR) at the National level continues to be above 178 per 100,000 live
births. The MMR in many major states particularly those, which are part of the Empowered Action
Group (EAG), is much above the National average. This situation is a major cause of concern and it is
imperative that focused efforts have to be made for making the First Referral Units fully operational,
in case we have to meet the National objective of bringing down the MMR to less than 100. The
guidelines on operationalisation of FRUs have been prepared to assist the states to plan for
operationalising of the FRUs. The guidelines are basically suggestive in nature and the states can take
suitable initiatives while planning for various activities towards operationalisation of these FRUs
identified by them. Funding for these activities will be under RCH-II and would accordingly be
subject to the norms for such funding and details of accountability as would be prescribed under the
RCH-II.
It is hoped that the guidelines will help the States in planning for operationalising the FRUs
for strengthening Emergency Obstetric and Child Health care at the First Referral units.
Operationalisation of First Referral Units (FRUs) is an important component of the Reproductive and
Child Health (RCH) Programme. This effort will go a long way not only in planning and
operationalising of FRUs, but also in ensuring uniform and good quality obstetric services at these
First Referral Units (FRUs).(1)
In view of the foregoing, it is considered imperative that the States look at the existing
facilities and identify clearly their requirements for putting into place fully functional FRUs.To realize
the above objective, an exercise will need to be undertaken for mapping the existing health facilities,
available manpower and other resources for each district. This exercise will facilitate proper
placement of the available resources and at the same time will bring out additional requirements in
terms of training, equipment and infrastructure required for operationalising the identified CHCs/sub-
district hospitals as FRUs. Based on this exercise, it should be possible to draw the district-wise action
plans for operationalising FRUs in a phased manner. Consolidation of the district plans at the state

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level will thus bring out the overall requirements of the State in various areas, like infrastructure,
equipment, manpower and training needs for operationalising FRUs during the Tenth Plan.
Learning Outcomes:
After completion of this module the reader should be able to:
 Define first referral unit.
 Mention requirements of FRU
 understand basis referral system in health care delivery system in India
 Enumerate priorities to be considered while selecting sites for operationalising FRU
services.
 Mention services provided at FRU
 State requirement of human resources at FRU.
 Enumerate equipment kits supplied under CSSM programme
 Mention importance of referral transport
 Understand the importance of functioning financial autonomicity.
 Enumerate components of monitoring of FRU operationalisation.
 Enumerate steps taken by state for proper FRU functioning.
Main Text
1.Definition of First Referral Unit.
An existing facility (district hospital, sub-divisional hospital, Community Health Centre etc. )
can be declared 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.
2.Requirements of a First Referral Unit(1)
• Emergency Obstetric Care including surgical interventions like Caesarean Sections
• New-born Care
• Blood Storage Facility
• 24-hour delivery services including normal and assisted deliveries
• Emergency Care of sick children
• Full range of family planning services including Laproscopic Services
• Safe Abortion Services
• Treatment of STI / RTI
• Essential Laboratory Services
• Referral (transport) Services
It should be noted that there are three critical determinants of a facility being 'declared' as a
FRU: availability of Surgical Interventions, New-born Care and Blood Storage Facility on a 24-
hour basis.

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3.Basic referral system
India have three tier referral of healthcare delivery system from sub centre and PHC at grass root
level to medical college and apex institute at the top.
The Sub-centre(SC) is the most peripheral health institution available to the rural population. It
functions as first contact between community and health care provider. PHC is a referral unit for six
sub-centres. Along with para-medical staff, PHC also has medical officers. Thus PHC function as first
contact between community and doctor.
Community Health Centre(CHC) is the first referral unit( FRU) for four PHCs offering specialist care.
It lies at secondary level on three tier health care delivery system along with Sub-District and district
hospital. At CHC patients get specialised medical care in four medical specialities, viz, Medicine,
surgery, paediatrics, and obstetrics and gynaecology and those cases which are require more specialist
care, are referred to District hospital.(2)
District hospital is an essential component of the district health system and functions as a secondary
level of health care which provides curative, preventive and promotive healthcare services to the
people in the district. Every district is expected to have a district hospital linked with the public
hospitals/health centres down below the district such as Sub-district/Sub-divisional hospitals,
Community Health Centres, Primary Health Centres and Sub-centres.
Medical colleges and Apex Institutes lies at tertiary level of health care delivery system, in which
specialized consultative care is provided usually on referral from primary and secondary medical care.
Specialised Intensive Care Units, advanced diagnostic support services and specialized medical
personnel on the key features of tertiary health care.
4.Points to be considered while selecting sites for opertionalising FRU services
Infrastructure needs
• A minimum bed strength of 20-30.
• A fully functional operation theatre equipped for undertaking procedures including Caesarean
Sections and Laporotomies.
• A fully operational Labour Room.
• An area equipped for New-born Care in the Labour Room and also in the ward.
• A functional laboratory with facilities for all essential investigations.
• Blood storage facility
• 24-hour water supply
• Arrangements for waste disposal
• Regular electricity supply with back-up
• Telephone connection.
• Ambulance
Selection of sites
The objective of ensuring proper selection should be to develop a network of 3-4 facilities in the
district in such a way that these together with the district hospital can ensure that all emergency cases
in the district can access the nearest facility within a maximum travel time of 1 hour.
5. Services Provided at FRU

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 Outdoor Patient (OPD)
 Medical OPD
 Surgical OPD
 Pediatric OPD
 Obstetrics & Gynecology OPD
 Dental Care OPD
 Indoor Facility for above services
 Anesthetic Services
 Neo-Natal Care /Obstetric Care Services
 Investigative Procedures
 Ultrasonography
 X-Ray
 Pathology Services
 Control of Epidemic, Endemic & Communicable Disease Programme
 All the National Programme in CHCs is to be integrated with all the existing Programmes like
Blindness Control, Iodine Deficiency, Integrated Diseases Surveillance Project etc.
 Revised National Tuberculosis Control Programme
 National Vector Born Disease Control Programme
 National Leprosy Elimination Programme (Free Distribution of MDT)
 National Blindness Control Programme - Under this Eye Surgeon is envisaged for a
population of 5 Lacs and diagnoses, treatment of common eye diseases, refraction
services and surgical services including CATARACT SURGERIES by IOL
implantation.
 Iodine Deficiency Disease Control Programme
 IDSP - Integrated Disease Surveillance Project includes diagnosis of Malaria,
Tuberculosis, Typhoid and Tests for detection of fecal contamination of water and
chlorination of water.
 Reproductive and Child Health
 Mother & Child Care
 Universal Immunization Programme for Mother & Child
 Pre, Intra & Post Dilivery Services
 Family Welfare Services including Laparoscopic Service (Male & Female
Sterilization)
 Emergency Services
 Medical Emergencies - Handling of all emergencies in related to National Health
Programmes as per the guidelines like Dengue, Hemorrhagic Fever, Cerebral Malaria
etc.
 24 hour Surgical Emergencies including incision, drainage, and surgery for Hernia,
Hydrosol Appendicitis,Hemorrhoids, Fistula, handling of emergencies like intestinal
Obstruction, Hemorrhage etc.
 24 hours delivery services including normal and assisted deliveries including
essential and emergency obstetric care including surgical interventions like caesarian
sections and essential emergency medical interventions.(3)
 New born care

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 Routine and emergency care of sick children
 Safe Abortion services
 Other medical interventions like Nasal Packing, Tracheotomy, Foreign Body
Removal.
 Medico Legal
 24 hour Ambulance service
6. Human resources:
The community health centre was envisaged to be a fully functional FRU (defined to mean a facility
providing full range of FRU services including C-section, along with facilities for handling other
medical emergencies) and, accordingly, a minimum strength of 4 medical officers (who are either
qualified or especially trained to work as surgeon, obstetrician, physician and pediatrician) was
recommended. Facilities selected for operationalising FRU services should, therefore, aim to provide
a similar or increased strength of medical personnel. In addition, adequate number of nursing staff to
work in Operation Theatre, Labour Room and In-patient wards will also need to be carefully
determined.
Considering the general lack of specialists particularly that of anaesthetists, it is imperative to train the
MBBS doctors in life saving anaesthetic skills for emergency obstetric care. A training programme on
this has been designed for this purpose and a pilot course already implemented.
Provision of other support services like blood storage, Laboratory services, pharmacy services should
be planned primarily on the basis of multi-skilling and re-deployment of available paramedical staff
After selection of the facilities to be operationalised as FRUs and assessment of available manpower
and other resources has been completed, it would be necessary to re-deploy the specialists and other
manpower to the facilities designated as FRUs. The State Government has to steer this process since
the process may also require inter-district redeployment.
7. Equipment kits supplied under CSSM Programme
• Kit-E: Standard Surgical Set-I (instruments)
• FRU Kit-F: CHC Standard Surgical Set-II
• Kit-G: IUD Insertion
• Kit Kit-H: CHC Standard Surgical Set-III
• Kit-I: Normal Delivery Kit
• Kit-J: Standard Surgical Set IV
• Kit-K: Standard Surgical Set-V
• Kit-L: Standard Surgical Set VI
• Kit-M: Equipment for Anaesthesia
• Kit-N: Equipment for Neo-natal Resuscitation
• Kit-O: Equipment for Laboratory Tests and Blood Transfusion
• Kit-P: Materials Kit for Blood Transfusion
8. Referral transport
Since most of the referrals originate from the field, the information on availability of
emergency services at FRUs will have to be effectively disseminated to all villages in the area so that
the population knows where they should reach for getting appropriate emergency care.

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The provision of emergency care has to be supported by (i) appropriate referral transport from the
periphery to the functioning First Referral Units providing emergency services and (ii) also from
FRUs to district/tertiary level institutions. State Government will have to develop administrative
mechanisms to facilitate transportation of patients from the field to the FRU on the one hand and from
the FRU to higher facilities (district hospital and/or tertiary care facility), if required, on the other.
Providing Government procured vehicles should not be seen as the only option for referral
transport/linkage. The option of providing funds to the facility in-charges, together with
administrative and financial powers to make local arrangements is a recommended option
9.Functional/financial autonomy
FRU operationalisation is not just about more equipment and funds; it is about empowering
the facilities to respond to emergencies. Therefore, once an FRU becomes operational, State
Government will have to ensure that there is no disruption in the services due to lack/absence of staff
and/or minor requirement of funds. In other words, State Government will have to formulate
appropriate guidelines for providing some functional and financial autonomy (e.g. retention of user
charges, if any) for the hospitals to enable them to
• Hire locally available specialists and/or paramedical workers from the private/ NGO sector in
case of need
• Make local arrangements for referral transport
• Civil works for operationalizing OTs and Labour rooms undertaken;
• Emergency drugs to be supplied to FRUs
• Different Equipments to be supplied to FRU
• Generate resources locally and
• Out-source non-clinical services.
Past experience indicates that sustained availability of specialists, general duty medical officers and
paramedical staff (and their functional competence) holds the key to the functionality of First Referral
Units. It is important, therefore, that every health facility identified as FRU is carefully assessed and a
district wise priority list is drawn
10. Monitoring of FRU operationalization
 Dissemination findings
 FRU Checklist
 FRU Critical Services
 Monitoring of Skilled Based Trainings in field of anesthesia and surgical procedure.
11. Steps taken by state for proper FRU functioning:
 Civil works for operationalizing OTs and Labour rooms undertaken;
 Emergency drugs were supplied to FRUs
 Different Equipments were supplied to FRU
 Drugs and Cosmetics Act amended to facilitate establishing blood storage units at FRUs;
 Guidelines for blood storage units issued to states;
 Funds for Hiring of private specialists Anesthetists and Gynecologists were made available
 Short training programmes in anesthesia & Obstetric
 Training of ANM/ Staff Nurse in Skilled Birth Attendance and basic obstetric care along with
New born care.

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 Deployment of Skilled manpower and rationalizing HR policies e.g. transfer policies, cadre
reviews etc.
 Enabling environment especially adequate residential facilities.
 Focused strategies for capacity building of identified training institutions for nurses and
ANMs.
 Orientation of all health personnel including medical and para medical and all programme
managers.
 Procurement policies and systems in place.
 Developing an accreditation criteria for regular monitoring of the facility and coordinating in
its smooth co-ordination.
Summary:
Health care delivery in India has been envisaged at three levels namely primary, secondary and
tertiary. The secondary level of health care essentially includes Community Health Centres (CHCs)
and the Sub-district Hospitals, constituting the First Referral Units (FRUs). The CHCs were designed

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to provide referral health care for cases from the Primary Health Centres level and for cases in need of
specialist care approaching the centre directly. CHC is a 30-bedded hospital providing specialist care
in Medicine, Obstetrics and Gynaecology, Surgery, Paediatrics, Dental and AYUSH. These centres
are however fulfilling the tasks entrusted to them only to a limited extent. The launch of the National
Rural Health Mission (NRHM) gives the opportunity to have a fresh look at their functioning.
Inspire of adequate infrastructure at CHC, many times it do not function as a FRU. The main reason
behind this is lack/unavailability of specialist doctors. Government should outsource the specialist
doctors from private/NGO setup, if not recute them. This will make join hand in making a FRU
functional and operational according to sets of guidelines.
References:
1. Govt. Of India(2004) Guidelines For Operationalising First Referral Units, Maternal Health
Division Ministry of Health & Family Welfare, New Delhi.
2. Indian Public Health Standards (IPHS) for Community Health Centre, 2012. Directorate
General of Health Services, Ministry of Health & Family Welfare, Government of India.
3. Govt. Of India, Guidelines for Operationalizing a Primary Health Centre for Providing 24-
Hour Delivery and New born care, Ministry of Health & Family Welfare, New Delhi.