HEALTH CARE DELIVERY
A health care delivery system is the totality of services
offered by all health disciplines.
Traditionally the primary purpose of a health care
system had been to offer care to ill and injured.
For this reason the health care system of the past might
be more accurately described as illness care system
India is union of 28 states and 7 union
Under the constitution of india, the states are largely
independent in matters relating to the delivery of
health care to the people each state, there fore, has
developed its own system of health care delivery,
independent of the central government.
The central responsibility consists mainly of
policy making, planning, guiding, assisting,
evaluating , co coordinating the work of the
state health ministries, so that health services
cover every part of the country and no state
behind fro want of these services.
The health system in india has 3 main links i.e
central, sate and local or peripheral.
1 – AT THE CENTRAL
The official “organs” of the health system at
the national level consist of:
The ministry of health and family welfare;
The directorate general of health services; and
The central council of health and family welfare.
UNION MINISTRY OF HEALTH AND
The union ministry of health and family
welfare is headed by a cabinet minister, a
minister of state and a deputy health minister.
These are political appointments. Currently, the
union health ministry has the following
Department of health and family welfare. the health
department is headed by a secretary to the
government of India as its executive head, assisted by
joint secretaries, deputy secretaries and a large
The department of family welfare was created in 1966
with in the ministry of health and family welfare.
The secretary to the government of India in the
ministry of health and family welfare is in over
all charge of the department of family welfare.
he is assisted by an additional secretary and
commissioner(family welfare), and one joint
AT THE CENTRE
Union ministry of health and family welfare
(minister of state & deputy health minister)
Dept of health Dept of family welfare
Secretary to the Govt.of India Secretary to the Govt.of India
Joint secretaries Additional secretary
Deputy secretary Commissioner
Large administrative staff joint secretary
International health relations and administration of port
Administration of central institutes.
Promotion of research through research centers and other
Regulation & development of medical, pharmaceutical, dental
& nursing professions.
Establishment & maintenance of drug standards.
Census, and collection and publication of other statistical data.
Immigration & emigration.
Regulation of labour in the working of mines and oil fields
Coordination with states & with other ministries for promotion
Prevention of extension of communicable diseases
from one unit to another.
Prevention of adulteration of food stuffs
Control of drugs and poisons
Ports other than major
Economic and social planning, and
Population control and family planning.
Directorate general of health services
Director general of health services
Additional Director general of health services
Team of deputies
large administrative staff
Surveys, planning, coordination, programming and appraisal of
all health matters in the country.
International health relations and quarantine
Control of drug standards.
Medical store depots.
Post graduate training.
Central govt. health scheme.
National health programmes.
Central health education bureau.
National medical library.
DIRECTORATE GENERAL OF
The director general of health services is the
principal adviser to the union government in
both medical and public health matters.
The directorate comprises of three main units,
e.g., medical care and hospitals, public health
and general administration .
The GENERAL functions are surveys,
planning, coordination, programming
and appraisal of all health matters in
International health relations and
quarantine: all the major ports in the
country (kolkata, Visakhapatnam,
Chennai cochin Mumbai, Kandla) and
international air ports (Mumbai-santa
Kolkata-Dum Dum, Chennai-Meenambakkam,
Tiruchirapalli, Delhi-Palam) are directly
controlled by the directorate general of health
Control of drug standards: the drugs control
organization is part of the directorate general of
health services, and is headed by the drugs
. Its primary function is to lay down and enforce
standards and control the manufacture and
distribution of drugs through both central and
state government officers. The drugs act (1940)
vests the central government with the powers to
test the quality of imported drugs.
MEDICAL STORE DEPOTS
The union government runs medical store
depots at Mumbai, Chennai, kolkata,
karnal, Gauhati and Hyderabad.
These depots supply the civil medical
requirements of the central government
and of the various state governments.
These depots also handle supplies from
POST GRADUATE TRAINING
The directorate general of health services is
responsible for the administration of national
institutes, which also provide post graduate
training to different categories of health
Some of these institutes are :-1. the all India
institute of hygiene and public health at kolkata,
2. All India institute of mental health at
Bangalore,3. College of nursing at Delhi,
4.National tuberculosis institute at Bangalore,5.
National institute of at communicable diseases at
Delhi, 6.National institute of health and family
welfare at Delhi,etc
The central directorate is directly in charge of
the following medical colleges in India: the
lady hardinge, the maul Ana Azad and the
medical colleges at Pondicherry, and goa.
besides these, there are many medical colleges
in the country which are guided and supported
by the centre.
Medical research in the country in organized
largely through the Indian council of medical
research, founded in 1911 in New Delhi.
The council plays a significant role in aiding,
promoting and co coordinating scientific research
on human diseases, their causation, prevention
The research work is done through the
councils several permanent research
institutes, research units, field surveys
and a large number of ad-hoc research
enquiries financed by the council.
Tuberculosis Chemotherapy Center at
Chennai, Virus Research Centre at Poona,
National institute of Nutrition at
Hyderabad and Blood group references
centre at Mumbai
CENTRAL GOVERNMENT HEALTH
National Health Programmes:
the various national health
programmes for the eradication of
malaria and for the control of
Tuberculosis, Filarial, Leprosy,
AIDS and other communicable
diseases involve expenditure of
cores of rupees
CENTRAL HEALTH EDUCATION
An outstanding activity of this bureau is the
preparation of education material for creating
Health Awareness among the people.
The bureau offers training courses in health
education to different categories of health
The central bureau of health
intelligence was established in 1961 to
centralize collection, compilation,
analysis, evaluation and dissemination
of all information on health statistics for
the nation as a whole.
It disseminates epidemic intelligence to
states and international bodies.
The bureau has an Epidemiological
Unit, a health Economics unit, a
national morbidity survey unit and a
NATIONAL MEDICAL LIBRARY
The central medical library of the directorate
general health services was declared the
national medical library in 1966.
The aim is to help in the advancement of
medical, health and related sciences by
collection, dissemination and exchange of
Central council of health
Chairman – The union health minister
Members – State health ministers
Central Council of Health
A large number of health subjects fall in the
Concurrent list which calls for continuous
consultation, mutual understanding and
cooperation between the Centre and the states.
To consider and recommend broad outlines of policy
in remedial & preventive care, envt hygiene, nutrition,
HE, trg & research.
To make proposals for legislation in medical & public
health matters for development of the country.
To make recommendations to central govt. on grants-
in-aid and review utilization periodically.
To establish organization for maintaining cooperation
between central and state health administrations.
AT THE STATE LEVEL
. The state list which became the
responsibility of the state includes
provision of medical care, preventive
health services and pilgrimages with in
the state. The position has largely
remained the same, even after the new
constitution of India came into force in
1950.The state is the ultimate authority
responsible for all the health services
operating within its jurisdiction.
STATE MINISTRY OF HEALTH
The state ministry of health is headed by
a minister of health and family welfare
and a deputy minister of Health and
family welfare. In some states, the health
minister is also in charge of other
portfolios. The health secretariat is the
official organ of the state ministry of
health and is headed by a Secretary who
is assisted by deputy Secretaries, Under
Secretaries and a large administrative
STATE HEALTH DIRECTORATE
For a long time, two departments, medical and
public health, were functioning in the nstates;
the heads of these departments were known as
surgeon general and inspector general of Civil
Hospitals and Director of public health
The public health engineering
organizations in most states its part of the
public works department of the state
government. It has been recommended by
experts in the public health that the
public health engineering organization in
every state should be part of the state
health department, and that the Chief
Engineer of public health should have the
status of an additional Director of Health
AT THE DISTRICT LEVEL
The principal unit of administration in India is
the district under a collector. There are 593(year
2001) districts in India. There is no “average”
district that is districts vary widely in area and
population. Within each district again there are 6
types of administrative areas
1. Sub – divisions
2. Tehsils (Talukas)
3. Community Development Blocks
4. Municipalities and Corporations
Most districts in India are divided into
two or more sub divisions, each in charge
of an assistant Collector or sub collector.
Each division is again divided in to tehsils
(talukas), in charge of a Tehsildar .
A tehsil usually comprises between 200 to
600 villages. Since the launching of the
community Development programme in
India in 1952.
The block is a unit of rural planning and
development, and comprises approximately 100
villages and about 80,000 to 1,20,000 population,
in charge of a block development officer. Finally
there are the village panchayats, which are
institutions of rural local self government.
The urban areas of the district are
organized into the following institutions of
1. Town area committees- (in areas with
population ranging between 5,000 and
2. Municipal Boards-(in areas with
population ranging between 10,000 and 2
3. Corporations-(with population above 2
The Town area committees are like panchayats.
They provide sanitary services. The municipal
Boards are headed by a chairman/President,
elected usually by the members. The term of a
Municipal Boards ranges between 3-5 years. The
functions of a municipal board are:
Construction and maintenance of roads,
sanitation and drainage, street lighting, water
supply, maintenance of hospitals and
dispensaries, education registration of births and
The councilors are elected from different wards of
The executive agency includes the Commissioner,
the secretary, the Engineer and the Health
officer. Thee activities are similar to those of the
municipalities, but on a much wider scale.
The Panchayati Raj is a 3-tier
structure of rural local self government in
India, linking the village to the district.
The three institutions are:
1. Panchayat-at the village level
2. Panchayat Samiti- at the block
3. Zila Parishad- at the district
COMMUNITY HEALTH CENTERS
These were established by upgrading the
primary health centers,each community
health center should cover a population of
8000 to 1 lakh with 30 beds and
specialists in surgery
community health officer is selected from
amongst the supervisory category of staff
at phc and district level with minimum of
7 yrs experience in rural health
INDIAN PUBLIC HEALTH
STANDARDS FOR COMMUNITY
Every CHC has to provide following services
which are known as assured services.
This includes incision and drainage and also
Care of routine and emergency cases in medicine
24 hrs delivery services including normal and
Essential and emergency obstetric care including
surgical interventions like caesarian,and other
Safe abortion services,new born care,routine
emergency care of sick children
rural hospitals:-It is now proposed to upgrade
the rural dispensaries to PHC’s.
District hospitals:-There are proposals to convert
the district hospitals to District health center
Health insurance:-There is no universal health
insurance in india.Health insurance I snow
available to industrial workers and their families
Employees state insurance scheme;-It was
introduced by an act of parliament in 1948.The
facilities under the scheme include
-supply of necessary drugs
-lab and x-ray investigations
One of the basic tenants of primary health care is
universal coverage and equitable distribution of
Village health guides
Training of local dais
VILLAGE HEALTH GUIDES-
Village health guide is a person with an
aptitude for social service and is not a full
time government functionary.The village
health guides scheme was introduced on
October 1977with idea of securing peoples
participation in the care of their own
health.The scheme was launched in all
states except some states like
have alternative systems of providing
.THE GUIDELINES FOR THEIR
They should be permanent residents of
local community ,preferably women
They should be able to read and write
having minimum formal education
atleast upto 6th standard
They should be acceptable to all sections
They should be able to spare atleast 2-3
hrs every day for community health
FUNCTIONS OF VILLAGE
On completion of training they receive a
working manual and a kit of simple
medicines belonging to modern and
traditional systems of medicine.
Broadly the duties assigned to health
guides include treatment of simple
ailments and activities in first aid ,mother
and childhealth including family
planning,health education and sanitation.
The health guides are free to attend to
their normal location .
Most deliveries in rural areas are still
handled by untrained dais who are often
the only people immediately available to
women during perinatal period.
An extensive programme has been
undertaken under the rural health
scheme to train all categories of local dais
in the country to improve their knowledge
in the elementary concepts of maternal
and child health and sterilization besides
Under the ICDS scheme there is an anganwadi
worker for a population of 1000.
There are about 100 such workers in each ICDS
ASHA must be the resident of village a
women preferably in the age group of 25-
45 years with formal education upto
eighth class having communication skills
and leadership qualities.
Adequate representation from the
disadvantaged population group should be
ensured to serve such groups better.the
general norm of selection will bwe one
ASHA for 1000 population.
ROLE AND RESPONSIBILITY OF
Asha will take steps to create awareness and
provide information to the community on
determinants of health such as nutrition,basic
sanitation and hygiene practices,healthy living
and working conditions ,information on existing
health services and the need for timely utilization
of health and family welfare services.
She will counsel women on birth preparedness
,importance of safe delivery,breastfeeding and
ASHA will mobilize community and facilitate
them in accessing health and health related
services available., at the
anganwai/subcenter/primary health centers such
as immunization, antenatal checkup, postnatal
check up, supplementary nutrition,sanitation and
other services being provided by the government
She will arrange escort/accompany pregnant
women and children requiring
treatment/admission to the nearest pre identified
health facility ie primary health
center/community health center/first referral
unit.ASHA will provide primary medical care for
minor ailments such as Diarrhoea,fevers,and
first aid for minor injuries.She will be a provider
of directly observed treatment short course
(DOTS)under revised National Tuberculosis
She will also act as depot holder for essential
provisions being made available to every
habitation like oral rehydration therapy.iron folic
acid tablet,oral pills,condoms etc.
ROLE AND INTEGRATION WITH
On health day the women ,adolescent girls and
children from village will be mobilized for
orientation on health related issues such as
importance of nutritious food.
personal hygiene, care during
pregnancy,importance of antenatal check up and
institutional delivery, home remedies, for minor
ailment and importance of immune
Anganwadi workers will inform ANM to
participate and guide organizing the health
days at anganwadi center
Anganwadi and ANM’s will act as resource
persons for training of ASHA
ROLE AND INTEGRATION WITH
ANM will guide ASHA in performing following
She will hold weekly/fortnightly meeting with ASHA
and discuss activities undertaken during
She will guide her in case ASHA had encountered any
problem during the performance of her activity.
Anganwadi and ANM’s will act as resource person for
ANM will participate and guide in organizing health
days at anganwadi center.
ANM will guide ASHA in motivating pregnant women
for taking full course of IFA tablets and TT injections
ANM’s will orient ASHA on the dose schedule and
side effects of oral pill
SUB CENTER LEVEL:
It is the peripheral outpost of the existing
health care delivery system in rural areas .They
are being established on the basis of one sub
center for every 5000 population in general and
one for every 30000 population in hilly, tribal
and backward areas .
Currently a sub center is staffed by one female
health worker known as
Auxiliary nurse midwife-1
One male health worker
One health assistant known as lady health
CONSUMERS PROVIDERS SYSTEM
BEE, ANM, HA
HEALTH CARE DELIVERY SYSTEM
1. PUBLIC HEALTH SECTOR
a) Primary Health Care
Primary health centers
b) Hospitals/Health centers
community health centers
District hospital/health center
c) Health insurances schemes
Employees state insurance
Central Govt. Health scheme
d) Other agencies
2. PRIVATE SECTOR
a) Private hospitals, polyclinics, nursing homes, and
b) General practitioners and clinics
3.INDIGENOUS SYSTEMS OF MEDICINE
Ayurveda and siddha
Unani and tibbi
4. VOLUNTARY HEALTH AGENCIES
5. NATIONAL HEALTH PROGRAMMES
HEALTH CARE IN INDIA
Indigenous or traditional medical practitioners
continue to practice throughout the country.
The two main forms of traditional medicine practiced are
the ayurvedic (meaning science of life) system, which deals
with causes, symptoms, diagnoses, and treatment based on
all aspects of well-being (mental, physical, and spiritual),
and the unani (so-called Galenic medicine) herbal medical
A vaidya is a practitioner of the ayurvedic tradition, and a
hakim (Arabic for a Muslim physician) is a practitioner of
the unani tradition.
These professions are frequently hereditary.
A variety of institutions offer training in indigenous
Only in the late 1970s did official health policy
refer to any form of integration between Western-
oriented medical personnel and indigenous medical
In the early 1990s, there were ninety-eight
ayurvedic colleges and seventeen unani colleges
operating in both the governmental and
Healthcare in India is the responsibility of
constituent states and territories of India.
The Constitution charges every state with "raising
of the level of nutrition and the standard of living of
its people and the improvement of public health as
among its primary duties".
The National Health Policy was endorsed by the
Parliament of India in 1983 and updated in 2002.
Providing healthcare and disease prevention to
India’s growing population of more than a billion
people becomes challenging in the face of increased
competition for resources.
2.47 million people in India are estimated to be HIV
India is one of the four countries worldwide where
polio has not as yet been successfully eradicated and
one third of the world’s tuberculosis cases are in
According to the World Health Organization 900,000
Indians die each year from drinking contaminated water and
breathing in polluted air.
As India grapples with these basic issues, new
challenges are emerging for example there is a rise in
chronic adult diseases such as cardiovascular illnesses and
diabetes as a consequence of changing lifestyles.
India's health care system also
includes entities which are world
The Apollo set of hospitals are
considered amougst Asia's most
Many patients seeking treatment
from even from Pakistan have come
In November 2008, a Pakistani
girl was operated on for heart
Thus, India's health care system
has progressed and is a leader in
South East Asia.
1 Medical professionals
3.3 Water and sanitation
4 Healthcare Infrastructure
5 Central government role
7 Healthcare in urban India
8 Primary services
9 Health Insurance
10 Medical Tourism
11 Rate of growth
1 Medical professionals
In a 2005 World Bank study, World Bank reported that
"a detailed survey of the knowledge of medical practitioners
for treating five common conditions in Delhi found that the
average doctor in a public primary health center has around
a 50-50 chance of recommending a harmful treatment".
Random visits by government inspectors showed that
40% of public sector medical workers were not found at the
Malaria is endemic in India.
On going government of India education about HIV has led to
decreases in the spread of HIV in recent years.
The number of people living with AIDS in India is estimated to be
between 2 and 3 million.
The country has had a sharp decrease in the estimated number of
HIV infections; 2005 reports had claimed that there were 5.2 million
to 5.7 million people afflicted with the virus.
The new figures are supported by the World Health Organization
Half of children in India are underweight,
India contributes to about 5.6 million child deaths
every year, more than half the world's total.
Most Indian women are malnourished. The
average female life expectancy today in India is low
compared to many countries, but it has shown gradual
improvement over the years.
In many families, especially rural ones, the girls and
women face nutritional discrimination within the family,
and are anemic and malnourished.
The maternal mortality in India is the second
highest in the world.
iii) Water and sanitation
Water supply and sanitation in India continue to
be abysmal, despite longstanding efforts by the various
levels of government and communities at improving
The situation is particularly inadequate for sanitation,
since only one of three Indians has access to improved
sanitation facilities (including improved latrines).
As of 2003, it was estimated that only 30% of
India's wastewater was being treated, with the remainder
flowing into rivers or groundwater.
The lack of toilet facilities in many areas also presents a
major health risk; open defecation is widespread even in
urban areas of India, and it was estimated in 2002 by the
World Health Organisation that around 700,000 Indians die
each year from diarrhoea.
No city in India has full-day water supply. Most cities
supply water only a few hours a day. In towns and rural
areas the situation is even worse.
4 Healthcare Infrastructure
According to the Investment Commission of India
the healthcare sector has experienced phenomenal growth
of 12 percent per annum in the last 4 years.
Rising income levels and a growing elderly population
are all factors that are driving this growth.
In addition, changing demographics, disease profiles and
the shift from chronic to lifestyle diseases in the country
has led to increased spending on healthcare delivery .
5 Central government role
Central government efforts at influencing
public health have focused on the five-year plans,
on coordinated planning with the states, and on
sponsoring major health programs.
Government expenditures are jointly shared by
the central and state governments.
Goals and strategies are set through central-
state government consultations of the Central Council
of Health and Family Welfare.
Central government efforts are administered by the
Ministry of Health and Family Welfare, which
provides both administrative and technical services
and manages medical education.
States provide public services and health education
In the mid-1990s, health spending amounted to 6% of GDP, one of
the highest levels among developing nations.
The established per capita spending is around Rs 32000 per year
with the major input from private households (75%).
State governments contribute 15.2%, the central government
5.2%, third-party insurance and employers 3.3%, and municipal
government and foreign donors about 1.3, according to a 1995
World Bank study.
Of these proportions, 58.7% goes toward primary health care
(curative, preventive, and promotive) and 38.8% is spent on
secondary and tertiary inpatient care. The rest goes for nonservice
7 Healthcare in urban India
Behaviors between middle- and upper-class
citizens from the four largest metros in India -
Delhi, Chennai, Kolkata, and Mumbai - appear to
In general, those in Chennai appear to be more
“westernized” in their attitude towards medical
Those in Kolkata appear to have a strong relationship
with their healthcare provider but are generally more
traditional in their attitudes towards medical treatment.
Those in Delhi are most likely to have a positive view
of medical care in India but also tend to be more
traditional in their attitudes towards medical
Finally, those in Mumbai are most likely to have a
negative view on healthcare in India and also appear
to have a weak relationship with their healthcare
8 Primary services
Primary health centers are the cornerstone of the
rural health care system.
By 1991, India had about 22,400 primary health
centers, 11,200 hospitals, and 27,400 clinics.
These facilities are part of a tiered health care system
that funnels more difficult cases into urban hospitals while
attempting to provide routine medical care to the vast
majority in the countryside.
Primary health centers and sub centers rely on trained
paramedics to meet most of their needs.
9 Health Insurance
The majority of the Indian population is unable to
access high quality healthcare provided by private
players as a result of high costs.
Many are now looking towards insurance companies
for providing alternative financing options so that they
too may seek better quality healthcare.
The opportunity remains huge for insurance providers
entering into the Indian healthcare market since75% of
expenditure on healthcare in India is still being met by
10 Medical Tourism
India is becoming a location for medical
tourists seeking health care at lower costs than in
11 Rate of growth
India has approximately 600,000 allopathic doctors
registered to practice medicine.
This number however, is higher than the actual
number practicing because it includes doctors who
have emigrated to other countries as well as doctors
who have died.
India licenses 18,000 new doctors a year.