A presentation on health care delivery system in india
RAJKUMARI AMRIT KAUR COLLEGE OF NURSING,
LAJPAT NAGAR, NEW DELHI -110024.
IN INDIA -
AT VARIOUS LEVELS.
MS. ROHINI SHARMA,
MN (F) STUDENT,
The health of a country is based on the Health services provided to the people of
that specific country. The health services help to meet the health needs of the community
through the use of available knowledge and resources. The health services are delivered
by the “health system”. The India which is a second most populated country, the health
services are delivered to the people and these health services have a specific
administrative and organizational pattern.
The health services are organized to meet the needs of the entire population and
not merely selected group. The health service should cover the full range of preventive,
promotive, curative and rehabilitative services. The best way to provide the care to
underserved rural people and urban poor is to develop effective “primary health care”
with proper referral / delivery system. The health care delivery system depends on
consumers of the health care, providers of the health care, funding resources and factors
like constitutional system, political system and ideologies.
CONCEPTUAL MODELS OF HEALTH CARE DELIVERY SYSTEM :
The basic model of health care delivery is as given by Steven’s System Model based o
the “Von Bertanloffy’s” general system theory and is as follows:
INPUTS HEALTH CARE HEALTH CARE SYSTEM OUTPUTS
HEALTH CURATIVE PUBLIC CHANGES
STATUS/ PREVENTIVE PRIVATE IN
HEALTH PROMOTIVE VOLUNTARY HEALTH
PROBLEM RESTORATIVE INDIGENOUS STATUS
MODEL OF HEALTH CARE SYSTEM
The Inputs are the health status or health problems of the community; they represent the
health needs and demands of the community. Since resources are always limited to meet
the many health needs, priority has to be set.
The health care services are designed to meet the health needs of the community through
the use of available knowledge and resources. The resources must be distributed
according to the needs of the community.
The Health Care System is intended to delivery the health care services. It constitutes the
administrative sector and involves organizational matters.
The final outcome or the output is the changed health status or improved health status of
the community which is expressed in terms of lives saved, death averted, disease
prevented, cases treated, expectation of life prolonged, etc.
The various models are:
1. Public System: Run and funded by the government via the taxes collected from the
masses. E.g. as in Britain.
2. Private System : Services are rendered and charged from the consumers directly or
through insurance system . Health care is considered as any other commodity and
is purchasable. However, it is not very well organized and controlled. E.g. USA.
3. Cooperative / Contributory: Proportionate funding is done by the employers ,
employees and the Government and services are insured. E.g. In CGHS , ESIS.
4. Voluntary System: Non- government, non – profit system established by private
individuals. The financial support comes from voluntary contributions and
bequests (confer right by will). e.g. Cancer Society of India.
HEALTH CARE DELIVERY SYSTEM IN INDIA:
In India, the health care delivery system comprises of all the delivery models in
practice. Health is considered to be a social goal and the constitution adopted by the
Indian Union. The organized efforts of both the central and the state governments are put
in to develop the public system of health delivery in India. The services are rendered by
help of three- tier system of primary health care infrastructure i.e. primary health center,
sub-centers and community health centers in the rural areas and by means of the hospitals
at state and district levels along with the MCH and FW centers, Family Planning Clinics,
maternity homes in the urban areas.
The Health Insurance is restricted to the people working in Factory/ Industries.
Private Insurance system is coming up too. There are a variety of NGO’s which are
voluntary organizations and contribute in furthering the public health in India. The
government has launched various national health programmes for the purpose of
implementing it to get it integrated into the general health care delivery system for the
benefit of the people of the country.
Now, many private hospitals and corporate / contributory hospitals are also coming
up. These are however, costly. Also, stress over indigenous systems of medicine like
Unani, Ayurveda, Homeopathy has started. The referral system from sub-center to PHC,
to community health centre to district and state hospitals is being strengthened now.
Thus, the health care delivery system in India operates in context of socio-economic
and political framework. It is represented as:
Administration and Organization according to sectors of health care delivery:
A. Public health sector:
1. Primary Health Care: Primary health Centers, Sub – centre.
2. Hospitals and Health Centers: Community health centre, Rural Hospitals,
Specialist Hospitals, District hospitals, Teaching hospitals.
3. Health Insurance Schemes: Employees State Insurance scheme, Central
Government Health Scheme.
4. Other Agencies: Defensive, Railways.
B. Private Health sector:
1. Private hospitals, polyclinics, nursing homes and dispensaries.
2. General practitioners and clinics.
C. Indigenous System Medicine:
1. Ayurveda , Siddha
2. Unani and Tibetan.
3. Homeopathy, Yoga.
4. Unregistered Practitioners.
D. Voluntary health Agencies: Indian Red Cross, TB Association of India etc.
E. National Health Programs : NRHM , National Malaria Health Program. Etc.
VARIOUS LEVELS OF HEALTH SERVICES DELIVERY IN INDIA:
The health care services organization and administration in India extends from
national level to the community level. It consists of various levels as:
1. National level or At the Centre.
2. State level.
3. Regional level
4. District level.
5. Subdivision/ Taluka level.
6. Community level / Block Level.
1. National level: It consists of Union Ministry of Health and Family Welfare.
Directorate general of Health Services and Central Council of Health.
Administration and organization: The Union ministry of Health and Family Welfare
has three departments: Department of Health, Department of Family Welfare and
Department of Indian Systems of Medicine and Homeopathy. The executive head of
health and family welfare department is the Health Secretary. He is assisted by the Joint
secretaries, Deputy Secretaries, Additional secretary and commissioner of family welfare.
The department of health is supported by a technical wing, the Directorate
General of Health Services (DGHS), headed by Director General who renders technical
advice on all medical and Public health matters and is involved in monitoring of various
Health Schemes .The directorate functions in 3 units: Medical Care and Hospitals ; Public
health and General administration.
The specific functions according to the Central Government under Union list are:
1. International health relations and quarantine.
2. Control of drug standards.
3. Administration of centrally run institutes.
4. Promotion of research through various centers and bodies.
5. Regulation and development of medical medical, dental, Nursing and
pharmacy as professions.
6. Census, health intelligence publications for statistical data.
7. Immigration and Emigration.
8. Regulation of laborers working in mines and coal fields.
9. Co-ordination with the states and other ministries for promotion of health.
The functions in the concurrent list showing responsibilities shared by central and state
1. Prevention of communicable diseases.
2. Health Programmes e.g. Malaria, Tuberculosis, Leprosy, filaria etc.
3. Prevention of adulteration of food stuffs.
4. Control of drugs and poisons.
5. Vital Statistics.
6. Labour welfare.
7. Economic and social Planning.
8. Ports other than major ports.
9. Population control and family planning.
Directorate General of Health Services is also responsible for Central Health Education
Bureau and the National Medical Library.
Department of Health has following functions:
1. Conducting health and morbidity surveys, organizing the health programmes,
coordination of the activities by the central council for health, consultative committee
of Parliament and statutory bodies.
2. Maintaining the international health relations, all matters related to international
agencies and coordinating the activities is taken up by the DGHS.
3. Administration of all central institutions, training colleges, laboratories and Hospitals.
4. Promotion and maintenance of the appropriate standards of education in nursing,
medical , dental , pharmaceutical and allied health personnels.
5. Promotion of medical and public health research.
6. Legislation like drug and cosmetics act, health intelligence like CBHI (Central Bureau
of Health Intelligence).
7. Maintaining the Central Medical Library.
8. Technical and Financial assistance to the states.
9. Running medical depots under DGHS. Six depots are there under Mumbai, Chennai,
Calcutta , Hyderabad , Kurnool and Guwahati.
10. Establishing total medical care for Central government employees.
11. Negotiations with international and bilateral agencies.
Department of family welfare has following functions:
1. Programme appraisal Coordination and training and Sterilization division.
2. Technical operations, maternal and child health, evaluation and intelligence, mass
education, media, Projects division.
3. On secretariat side, there is Policy division, aided programme division, plan budget,
4. Coordination of the various national health and family welfare programmes with the
5. Monitoring the centrally sponsored health and family welfare programmes and
technical guidance, on – spot checking, maintaining malaria clinics and supervision.
Central Council for health has following functions:
The union minister is the chairman and state health ministers are the members.
Formed under the act of constitution in August 1952.
1. To consider and recommend the broad lines of policy on all matters of health e.g.
Primary health care, medical care, nutrition.
2. Make Proposal for legislation in the field of medical and public health matters.
3. Lay down the patterns of development in the country as a whole.
4. Make recommendations regarding distribution of available grants – in aid.
5. Review periodically the achievements in different areas through utilization of funds
available from grants- in aid.
6. Zonal Health council in Central, Northern, Western, Eastern and Southern zones.
Central family welfare council, population advisory council, cabinet sub-committee ,
Consultative committee , Central coordination committee , coordination committees ,
statutory and advisory bodies are also present.
2. State level: The states are also responsible for the health of the people just like the
centre. The functions of state health department are:
1. Provide adequate medical care through hospitals , dispensaries , health centers both in
Urban and rural areas.
2.Make Proper arrangements for Medical education, research and Nursing education too.
3. Proper Implementation of the National Health Programme.
4. Make provisions for personal and impersonal health services like nutrition , school
health, Industrial health , Family planning, Drugs and food control .
5. Control of food and drug administration.
6. Collection and Dissemination of health information.
7. Promotion of indigenous system of medicine.
8. Setting up of laboratories, provision of family welfare services.
9. Enforcement of the professional standards.
10. Control and supervision of local bodies.
Administration and organization: State ministry is also led by a minister and a Deputy
Minister of Health and family welfare.
One wing is the Health Secretariat headed by Health Secretary and other wing is
the Health Directorate headed by the Director of health services who is the technical
advisor and is assisted by the Deputy and additional Directors. There is also additional
director for the Family Welfare called Commissioner of health and Family Welfare. In
many states medical education has been separated from the services and a separate post
of Director of Medical Education has been created to look after medical, nursing and
other allied health education.
In state of West Bengal, a separate Directorate of Nursing is functioning under
Directorship of IAS officer.
3.Regional level: In states like Bihar , Madhya Pradesh , Uttar Pradesh , Andhra Pradesh
, Karnataka and others, zonal or regional or divisional set ups have been created between
the State Directorate of Health Services and District health administration. Each regional/
zonal organization differs, but they are known as Additional/ Joint /Deputy Directors of
Health Services in different states.
4.District level: The district level structure is the middle level management organization
and it is a link between the State as well as regional structure on one side and peripheral
level structures such as PHC as well as sub centre on the other .It receives the message
from the state and transmits the same to the periphery by suitable modifications to meet
the local needs. It brings out the issues of general, organizational and administrative types
in relation to the management of health services. Private sector hospitals are also present.
Adminstration and organization: The state and union territories are divided in districts
or zilla administered by the District magistrate / Collector. The district population on an
average is 10 to 15 million. At the district level there are present district
hospitals/medical college hospitals to render health care services to the common people.
There are also specialist hospitals at district levels. The superintendent of the district
hospital functions under Chief medical officer of Health as District Medical Officer of
Health (DMO). There are also District Malaria officer , District Health Officer etc. A post
of District Public health Nurse has been created with the inception of Multipurpose health
workers scheme at the District family welfare bureau. Her function is to assist
management of Community health nursing in the district by improving practice and
The zilla parishad also functions at district level in rural areas headed by the
chairman called Adhaksha. The collector is also a member of the parishad but doesn’t
vote. The urban areas are organized into Town area committee, City municipal council/
board / corporations. These are for 5000 to 10,000; 10,000-200,000 and above 200,000
population, respectively. Mayor is the head of Municipal Corporation.
5. Subdivision / Taluka level: The district is divided into two or more sub – divisions,
called Tehsil or Taluk. There is present taluka hospitals, dispensaries, nursing homes and
general / rural hospitals belonging to public sector. There may be general practitioners
and clinics too.
Administration and organization: There is Assistant District health and family Welfare
officer (ADHO). The ADHO is assisted by the Medical Officers of Health and Lady
medical officers and medical officers of general hospitals .These are now being converted
to the Community health Centers (CHC).
6. Community / Block Level: The tehsil consists of definite number of blocks. The
community or block has been seen as 80,000 to 1, 20,000 population and this centre
provides basic speciality services in general medicine , pediatrics, surgery , obstetrics and
gynecology. At present there are 6000 community blocks in the country consisting of
200-600 villages. There is existence of community health centres, Prinary health centres ,
sub centres , general practitioners and workers at the village level.
Administration and Organization: The panchayat samiti functions at block level having
about 100 villages .The chairman of the Panchayat Samiti maintains laision with medical
officer of Community. Sarpanch is the head of the Samiti. Block development officer is
also head of a particular block.
The Community health centre is the first referral unit and has to provide following
services which are known as the assured services :
1. Care of routine and emergency cases in surgery and medicine.
2. 24 hour delivery services.
3. Full range of family planning services.
4. Safe abortion services.
5. Newborn care.
6. Routine and emergency care of sick children.
7. All the National programmes should be delivered through the CHC.
The staff for the community health centre is as follows:
1. Medical Officer and Block Medical Officer (Civil Surgeon) 3
2. Staff Nurse 2
3. Block Health Supervisor 1
4. Community Health Nurse 1
5. Sector Health Nurse 3-5
6. Health Worker (Male/ Female) 6-10
7. Female Nursing Assistant or Male Nursing Assistant 1
8. Pharmacist 1
9. Laboratory Technician 1
10. Ophthalmic assistant 1
11. Radiographer 1
12. Hospital Worker 2
Total : 23-29
The specialist at the CHC may refers the patient directly to State level or district level
hospital or nearest medical college hospital bypassing the taluk or district hospital.
The Primary health Centre came into existence in 1978, following an international
conference at Alma – Ata which gave rise to primary health care. The PHC is for every
30,000 rural population in plains and one PHC for every 20,000 population in hilly ,
tribal and backward areas for effective coverage. As on Sept. 2005 , 23236 PHC’s had
been established in the country. The functions are as:
1. Medical care.
2. MCH including family planning.
3. Safe water supply and basic sanitation.
4. Prevention and control of local endemic diseases.
5. Collection and reporting of vital statistics.
6. National programs as relevant.
7. Referral Services.
8. Training of Health guides, health workers, local dais and health assistants.
9. Basic laboratory services.
10. Education about health.
The types of PHC’s that have been functioning in our country are 24 hours PHC,
Upgraded PHC and new PHC’s.
The staffing pattern at a PHC is as:
1. Medical Officer 1
2. Pharmacist 1
3. Nurse – Midwife 1
4. Health Worker (Female)/ ANM/ VHN 1
5. Health Educator 1
6. Health assistant (MALE) 1
7. Health Assistant (female) 1
8. Upper division Clerk / Store Keeper / Supdt. 1
9. Upper division clerk / Junior Assistant 1
10. Laboratory Technician 1
11. Driver (Subject to availability of Vehicle) 1
12. Class IV workers 4
The subcentre level is the peripheral outpost of the existing health delivery system in
rural areas . They are for every 5000 population in general and for 3000 population in
hilly, tribal and backward areas. On September 30th 2005, 146026 subcentres were
established in our country. The staff is:
1. Health worker (female) 1
2. Health worker (Male)/ HIG IB (Health Inspector IB) 1
3. Voluntary Paid worker (at Rs. 50 /- pm as honorarium) 1
Total : 3
It is proposed to extend the facilities at all sub – centers for IUD insertion , and
simple laboratory investigations like routine examination of urine for albumin and sugar.
The revised norm says that one female health assistant will supervise the worker of 6
health workers (female).
The Village level is the basic root of the health service delivery system. The system at
the village level has:
a. Village health Guides: These are the ones who have an aptitude for social service and
are not full time government employees. They come from the community and serve as
link between community and governmental Infrastructure. They are given 3 months
training for educating the village people and helping the qualified basic health workers
who are in charge of the village health care. The village health guides are selected on
the following basis:
They should be permanent residents of the local community, preferably women.
They should be able to read and write, having minimum formal education at least up
to VI standard.
They should be acceptable to all sections of the community and.
They should be able to spare at least 2-3 hours every day for community health
After the selection, the health guides undergo a short training in primary health care.
The training is arranged in the nearest primary health centre, sub centre or any
suitable.During the training time they receive a stipend of Rs. 200 per month.. Broadly,
the duties assigned to the health guides include treatment of simple ailments and
activities in first aid, mother and child health including family planning, health
education and sanitation..They should be able to spare at least 2 to 3 hours daily for
community work for which they are paid an honorarium of Rs. 50 per month and Rs.
600 per annum. As this requires expenditure, the Government doesn’t train another
Health Guide from the same village, before three years. As of date, there are 3.23 lakh
village guides working in our country.
b. Local Dias/ Birth attendants: They are given one month training to conduct safe
deliveries and help in family planning and immunization programmes. She has to work
under close supervision of FHW, cooperating actively with her.
c. Anganwadi worker: Under ICDS scheme, there is an anganwadi worker for the
population of 1000. There are about 100 such workers in each ICDS project .Up to date
, 5671 ICDS units are working in our country. She is selected from the community and
undergoes training for 4 months. She works part – time with honorarium of Rs. 200-
250 . She conducts health check ups, health education, and non – formal pre-school
education and referral services.
Under NRHM , a cadre of Accredited Social Health Activist (ASHA) has come up who
should be the resident of the village , a woman of age group 25 -45 years with formal
education up to 8 th class having communication skills and leadership qualities .She is
for 1000 population. She shall mobilize the community and facilitate them in assessing
health services available at anganwadi/sub-centre/PHC.
OTHER AGENCIES FOR HEALTH CARE DELIVERY:
1. HEALTH INSURANCE: The insurance is limited only to industrial workers and
their families. The central government employees too have the facility.
a. Employees State Insurance Scheme: The ESI scheme, introduced by an act of
Parliament in 1948 provides for medical care benefits and benefits during sickness,
maternity , employment injury and pension for dependants on the death of
industrial worker because of employment injury.
b. Central Government Health Scheme: To the employees of central government .It
was first introduced in New Delhi in 1954 .The scheme is based on the cooperative
efforts by the employee and the employer to the mutual advantage of both facilities
under this scheme.
2. DEFENSIVE MEDICAL SERVICES: Defensive Services have their own
organization for medical care to defense personnel under the banner “Armed Forces
Medical Services”. The services provided are integrated and comprehensive
embracing preventive, promotive and curative services.
3. HEALTH CARE FOR THE RAILWAY EMPLOYEES: The Railway provides
comprehensive health care services through agency of Railway Hospital , health units
and clinics. Health checks up of employees at the yearly intervals along with the
4. PRIVATE AGENCIES: Many practitioners practice independently or in a private
organization providing curative services. The MCI and the IMA regulate some of the
functions and activities of the large body of private medical practitioners.
5. INDIGENOUS SYSTEMS OF MEDICINE: The indigenous system provides for the
bulk of medical care in rural India. Many ayurvedic dispensaries are being run by the
6. VOLUNTARY HEALTH AGENCIES IN INDIA:
Indian Red cross Society.
Hindu Kusht Nivaran Sangh.
Indian Council for Child Welfare.
Tuberculosis Association of India.
Bharat Sevak Samaj.
Central Social Welfare Board.
Family Planning Association of India.
All India Women Conference.
The India Blind Relief Society.
International Agencies – Rock Feller Foundation Care, WHO, UNICEF.
7. NATIONAL HEALTH PROGAMMES :
National Tuberculosis control Program.
National Malaria Eradication programme
National leprosy Control programme
National family welfare programme.
National small pox eradication programme.
National filarial control programme.
National leprosy control programme.
Applied Nutrition Programme.
National Trachoma control programme.
HEALTH CARE SERVICES:
1. Health promotion
a. Prenatal classes
b. Nutrition counseling
c. Family Planning
d. Stress management
2. Illness prevention
a. Screening programs (Eg. Hypertension, breast cancer)
c. Occupational health and safety measures
d. Mental health counseling
e. AIDS control program.
3. Primary care
a. School health units
b. Routine physical examination
c. Follow up for chronic illnesses (eg – Diabetes, Epilepsy)
a. Radiological procedure ( Eg. CT scans, X ray Studies)
b. Physical examination
c. Laboratory investigations
1. Surgical intervention
2. Laser therapies
3. Pharmacological therapy
1. Cardiovascular programs
2. Sports medicine
3. Mental illness program
ROLE OF NURSE IN HEALTH CARE DELIVERY IN INDIA:
1. Care Provider : Nurse acts as a care provider when working at PHC’s , CHC’s and
Sub – centers at rural level. She also works in hospitals, dispensaries and clinics to
diagnose and give care accordingly. She promotes preventive and promotive health
care to maintain the health.
2. Sensitive Observer: She acts to observe the various administrative and organizational
demands of a particular centre or hospital. She observes shortcomings of any area and
reports any action that needs to be
3. Educator : She can educate VHG, Anganwadi workers for better delivery of care. Se
can also tell tips about administration.
4. Manager: She manages the institution and organizes activities, co-ordinates,
supervises and guides the staff and other faculty under her.
5. Planner: The planning for staff selection, patient care is all set up by the nurse.
6. Organizer: She organizes the staff in the PHC, CHC. She makes the equipments and
7. Controller and evaluator: Evaluating the services of health system and controlling the
staff and their development by education.
8. Administrator: The nurses at administrative positions e.g in Directorate of Nursing
services can provide for better patient care at community level.
So, today we discussed the health care delivery system in India – concept , models
, types of delivery systems , levels of delivery system in India, administration and
organization at various levels and role of the nurse in system.
The structure of health care services and health care delivery system as
provided by the government sector is impressive. There is continuous striving to attain an
adequate delivery system for promotion oh HFA goals and achieve these. The
strengthened health care and its adequate delivery surely ensure the progress and
prosperity of a country. The health which is important needs to be delivered at the
doorstep of the people and made available to them by all means to prevent illness, cure it
, promote health and rehabilitate the patient as and when required.
Qureshi, M. A. “A Comparative Study of the Health Delivery Systems in India and
China”. Health and Population – Perspectives & Issues. June, 1980 .3 (3). Page No.
187 – 203.
Looking at the health care system in India and China one comes to know that
the two being the Asian countries have tried their level best in solving the rural health
problems in their country but with different approaches. Both have been the victims of
the Western style of medicine which has led to the neglect in their traditional methods of
the / systems of medicine in early colonial period.
The western system mainly benefitted the urban population which formed only
20 percent of the population and bypassed the huge rural mass. The rural health scheme
started in India in 1977 yielded results. The community health volunteers are being
accepted by the rural masses. Although the number of difficulties are felt but the
determined effort is being made to provide hygienic and good sanitary conditions and
thus, preventing the occurrence of a number of common diseases. These volunteers
receive short period training, it is best to utilize them for dispensing the preventive advice
and dissemination of family planning services. These also provide a link between the
professional doctors and local people who often fall into the trap of quacks.
China has been able to develop more facilities. The Great Leap Forward and then
Cultural Revolution were when the large number of professional doctors were forced to
go countryside. The barefoot doctors were also present as front line to cope with the
needs of the rural people. In China however this happened at cost of shutting of the
hospitals and medical education institutions. In India, there is a need to strengthen efforts
to integrate the western and traditional styles of system of medicine. This requires more
investment in the research and development in the traditional systems.
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