Health care delivery system

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HEALTH CARE DELIVERY SYSTEM IN INDIA:
Introduction:
India is a union of 28 states and 7 union territories. States are largely independent in
matters relating to the delivery of health care to the people. Each state has developed its own
system of health care delivery, independent of the Central Government.
The Central Government responsibility consists mainly of policy making, planning, guiding,
assisting, evaluating and coordinating the work of the State Health Ministries. The health system
in India has 3 main links
1. Central
2. State and
3. Local or peripheral
(1) At the central
The official “organs” of the health system at the national level consist of
1. Ministry of Health and Family Welfare
2. The Directorate General of Health Services
3. The Central Council of Health and Family Welfare
1. Union Ministry of Health and Family Welfare.
Organization Pattern
Cabinet Minister
↓
Department of Health Department of Family Welfare
↓ ↓
Joint Secretary Additional Secretary
↓ ↓
Deputy Secretary Commissioner
↓ ↓
Administrative staff Joint Secretary
↓
Administrative staff

Functions:
(1) Union list
1. International health relations and administration of port quarantine
2. Administration of Central Institutes such as All India Institute of Hygiene and
Public Health, Kolkata.
3. Promotion of research through research centers
4. Regulation and development of medical, pharmaceutical, dental and nursing
Professions
5. Establishment and maintenance of drug standards
6. Census and collection and publication of other statistical data
7. Immigration and emigration
8. Regulation of labor in the working of mines and oil fields
9. Coordination with states and with other ministries for promotion of health
(2) Concurrent list
The functions listed under the concurrent list are the responsibility of both the union and state
governments.
1. Prevention and extension of communicable diseases
2. Prevention of adulteration of food stuffs
3. Control of drugs and poisons
4. Vital statistics
5. Labor welfare
6. Ports other than major
7. Economic and social planning
8. Population control and Family Planning
9. Preparation of health education material for creating health awareness through
Central Health Education Bureau.
10. Collection, compilation, analysis, evaluation and dissemination of information
Through the Central Bureau of Health Intelligence
11. National Medical Library

2. Directorate General of Health Services
Directorate General of health services
↓
Director General of health services
↓
Additional Director General of health service
↓
Deputy Directorate General of health services
↓
Functions:
1. International health relations and quarantine of all major ports in country and
International airport
2. Control of drug standards
3. Maintain medical store depots
4. Administration of post graduate training programmes
5. Administration of certain medical colleges in India
6. Conducting medical research through Indian Council of Medical Research
7. Central Government Health Schemes.
8. Implementation of national health programmes
9. Preparation of health education material for creating health awareness through Central Health
Education Bureau.
10. Collection, compilation, analysis, evaluation and dissemination of information through the
Central Bureau of Health Intelligence
11. National Medical Library

3. Central Council of Health
Chairman
(Union health Minister)
↓
Members
(State health Minister)
Functions
1. To consider and recommend broad outlines of policy regard to matters
Concerning health like environment hygiene, nutrition and health education.
2. To make proposals for legislation relating to medical and public health matters.
3. To make recommendations to the Central Government regarding distribution of
Grants-in-aid
II. At the State level
The health subjects are divided into three groups: federal, concurrent and state. The state list is
the responsibility of the state, including provision of medical care, preventive health services and
pilgrimage within the state.
State health administration
At present there are 28 states in India, each state having its own health administration
(1) State Ministry of Health & family welfare
↓
Deputy Minister of Health and Family Welfare
↓
Health Secretary
↓
Deputy Secretaries
↓

(2) State Director of health
↓
Director of Medical Education Director of Health Services
↓ ↓
Dean of medical college Additional Director of Health Services
↓ ↓
State nursing superintendent Deputy Director of Health Services
↓ ↓
Hospital Education Regional Functional
↓ ↓ ↓
Nsg Superintendent Nsg Officer MCH, TB, Leprosy, Immunization
↓ ↓
Ward Incharge Senior tutor
↓ ↓
Nsg Staff Junior tutor
Functions of state health Director:
(1) Studies in depth the health problem and needs in the state and plans scheme to
Solve them
(2) Providing curative &preventive services
(3) Provision for control of milk and food sanitation
(4) Prevention of any outbreak of communicable diseases
(5) Promotion of health education
(6) Promotion of health programmes such as school health, family planning,
Occupational health
(7) Supervision of PHC
(8) Establishing training courses for health personnel
(9) Co-ordination of all health services with other minister of state such as minister
of education, central health minister &voluntary agency

III. At the district level
T here are 593 ( year 2001 ) districts in India. Within each district, there are 6 types of
administrative areas.
1. Sub –division
2. Tehsils( Taluks )
3. Community Development Blocks
4. Municipalities and Corporations
5. Villages and
6. Panchayats
Most district in India are divided into two or more subdivision, each
incharge of an Assistant Collector or Sub Collector
Each division is again divided into taluks, incharge of a Thasildhar. A taluk
usually comprises between 200 to 600 villages
The community development block comprises approximately 100 villages
and about 80000 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
Town Area Committees (in areas with population ranging between 5,000 to
10,000
Municipal Boards (in areas with population rangingbetween 10,000 and
2,00,000)
Corporations (with population above 2,00,000)
The Town Area Committees are like panchayats.They provide sanitary
services.
The Municipal Boards are headed by Chairmen /President, elected by
members.
The functions of Municipal Board:
Construction and maintenance of roads
Sanitation and drainage
Street lighting
Water supply
Maintenance of hospitals and dispensaries
Education and
Registration of births and deaths etc
The Corporations are headed by Mayors, elected by councillors, who are elected from
different wards of the city. The executive agency includes the

commissioner, the secretary, the engineer and the health officer.
The activities are similar to those of municipalities, on a
much wider scale.
Panchayat Raj -
The panchayat raj is a 3-tier structure of rural local self-government in India linking the village
to the district.It includes
Panchayat (at the village level)
Panchayat Samiti( at the block level)
Zila Parishad(at the district level)
(1) Panchayat (at the village level):
The Panchayat Raj at the village level consists of
The Gram Sabha
The Gram Panchayat
The Gram Sabha:
It is the assembly of all the adults of the village, which meets at least twice a year.The gram
sabha considers proposals for taxation,and elect members of The Gram Panchayat.
The Gram Panchayat
It is the executive organ of the gram sabha and an agency for planning and development at the
village level. The population covered varies from 5000 to 15000 or more.The members of
panchayat hold offices for a period of 3to4 years. Every panchayat has an elected president
(Sarpanch or Sabhapati or Mukhia), a vice president and panchayat secretary. It covers the civic
administration including sanitation and public health and work for the social and economic
development of the village
(2) Panchayat Samiti (at the block level):
The block consists of about 100 villages and a population of about 80,000 to 1,20,000. The
panchayat samiti consists of Sarpanch, MLAs, MPs residing in block area, representative of
women, SC, ST and cooperative socities. The primary function ofThe Panchayat Samiti is the
execute the community development programme in the block. The Block development Officer
and his staff give technical assistance and guidance in development work.
(3) Zila Parishad (at the district level):

The Zila Parishad is the agency of rural local self governmen at the district level . The members
of Zila parishad include all heads of panchayat samiti in the district,MPs, MLAs, representative
of SC, ST and women and 2 persons of experience in administration,public life or rural
development. Its functions and powers vary from state to state.
Health care system:
(1) At village level
(2) At sub center level
(3) At PHC level
(4) At CHC level
(1) At village level:
At the village level, elementary services are rendered by
(a) Village health guides
(b) Local dais
(c) Anganwadi workers
(d) ASHA
(a) Village health guides:
Village health guide is a person with an aptitude for social service and is not full time govt.
functionary. Village health guides scheme was introduced on 2nd
oct. 1977.
Guidelines for their selection:
(1) They should be permanent resident of the local community, preferably women
(2) They should be able to read and write, having minimum formal education at
least up to the VI std.
(3) They should be acceptable to all sections of community
(4) They should be able spare at least 2 to 3 hours every day for community health work.
After selection the health guide undergo a short training in primary health care. The
training is arranged in the nearest PHC, subcenter or other suitable place for the duration of 200
hours, spread over a period of 3 months. During the training period they receive a stipend of Rs.
200 per month.
Functions of Village health guides:
(1) Provide treatment for common minor ailments
(2) First aid during accidents and emergency
(3) MCH care
(4) Family planning
(5) Health education

(2) Local dais:
Most deliveries in rural areas are handled by untrained dais. Th e training for dais given for 30
working days. Each dai is paid stipend of Rs. 300 during the training period.The training is given
at PHC,subcenters or MCH center for 2 days in a week and on the remaining four days of the
week they accompany the health worker(female) to the village. During her training each dai is
required to conduct at least 2 deliveries under the supervision and guidance of health worker
(female), ANM,health assistant (female).
Functions of dais:
(1) MCH care
(2) Family planning
(3) Immunization
(4) Education about health
(5) Referral services
(6) Safe water and basic sanitation
(7) Nutrition
(3) Anganwadi worker:
Under the ICDS scheme there is an anganwadi worker for a population of 1000.There are about
100 such workers in each ICDS project. The anganwadi worker is selected from the community
and she undergoes training in various aspect of health, nutrition and child development for 4
months. She is a part time worker and paid an honorarium of Rs.200-250 per month for the
services.
Functions of anganwadi worker:
(1) MCH care
(2) Family planning
(3) Immunization
(7) Supplementary nutrition
(8) Nonformal education of children
Accredited Social Health Activist (ASHA)
One of the key components of the National Rural Health Mission is to provide every village in
the country with a trained female community health activist – ‘ASHA’ or Accredited Social
Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to

work as an interface between the community and the public health system. Following are the
key components of ASHA:
SELECTION OF ASHA
The general norm will be ‘One ASHA per 1000 population’. In tribal, hilly, desert areas the
norm could be relaxed to one ASHA per habitation, dependant on workload etc.
The States will also need to work out the district and block-wise coverage/phasing for
selection of ASHAs.
It is envisaged that the selection and training process of ASHA will be given due attention by
the concerned State to ensure that at least 40 percent of the ASHAs in the State are selected and
given induction training in the first year as per the norms given in the guidelines. Rest of the
ASHAs can subsequently be selected and trained during second and third year.
Criteria for Selection
ASHA must be primarily a woman resident of the village ‘Married/Widow/Divorced’ and
preferably in the age group of 25 to 45 yrs.
ASHA should have effective communication skills, leadership qualities and be able to reach
out to the community. She should be a literate woman with formal education up to Eighth Class.
This may be relaxed only if no suitable person with this qualification is available.
Adequate representation from disadvantaged population groups should be ensured to serve
such groups better.
Roles and responsibilities of ASHA:
ASHA will take steps to create awareness and provide information to the community on
determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and
working conditions, information on existing health services and the need for timely utilization of
health & family welfare services.
She will counsel women on birth preparedness, importance of safe delivery, breast- feeding
and complementary feeding, immunization, contraception and prevention of common infections
including Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/STIs) and care of
the young child.
ASHA will mobilize the community and facilitate them in accessing health and health related
services available at the village/sub-center/primary health centers, such as Immunization, Ante
Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS, sanitation and other services being
provided by the government.

She will work with the Village Health & Sanitation Committee of the Gram Panchayat to
develop a comprehensive village health plan.
She will arrange escort/accompany pregnant women & children requiring treatment/ admission
to the nearest pre-identified health facility i.e. Primary Health Centre/ Community Health Centre/
First Referral Unit (PHC/CHC /FRU).
ASHA will provide primary medical care for minor ailments such as diarrhea, fevers, and first
aid for minor injuries. She will be a provider of Directly Observed Treatment Short-course
(DOTS) under Revised National Tuberculosis Control Programmed.
She will also act as a depot holder for essential provisions being made available to every
habitation like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine,
Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug Kit will be provided to
each ASHA. Contents of the kit will be based on the recommendations of the expert/technical
advisory group set up by the Government of India.
Her role as a provider can be enhanced subsequently. States can explore the possibility of
graded training to her for providing newborn care and management of a range of common
ailments particularly childhood illnesses.
She will inform about the births and deaths in her village and any unusual
health problems/disease outbreaks in the community to the Sub-Centers/Primary Health Centre.
She will promote construction of household toilets under Total Sanitation Campaign.
Fulfillment of all these roles by ASHA is envisaged through continuous training and up-
gradation of her skills, spread over two years or more
Comparison of health care delivery system in Rajasthan and Maharashtra:
(1) Subcenter:
Topics Maharashtra Rajasthan
(1) Population covered
(2) Functions
5000 in general
3000 in tribal & hilly areas
(1) MCH care
(2) Family planning
(3) Immunization
3600 in general
2800 in tribal & hilly areas
(1) MCH care
(2) Family planning
(3) Immunization
(5) Safe water and basic
sanitation
(6) Prevention and control of
locally endemic diseases

Designation Maharashtra Rajasthan
(3) Staffing pattern Health worker female 1
Health worker male 1
Voluntary worker 1
(paid Rs 100 per month as
Honorarium
Health worker female 1
ANM 1
(2) Primary health center:
(2) Functions
(3) Staffing pattern
30,000 rural population in plains
20,000 population in hilly, tribal
(1) MCH care
(2) Family planning
(3) Immunization
(8) Collection and reporting of vital
statistics
(9) National health programmes
(10) Training of health guides, health
workers, local dais and health
assistant
(11) Basic laboratory services
Medical officer 2
Pharmacist 1
Nurse midwife 1
Block extension educator 1
Health assistant (female) 1
Health assistant male 1
U.D.C 1
48000 population in plains
30000 population in tribal and
hilly
(1) MCH care
(2) Family planning
(3) Immunization
sanitation
(8) Collection and report in
Of vital statistics
(9) National health
programmes
(10) Training of health guides,
health workers, local
dais and health assistant
(11) Basic laboratory services
Medical officer 1
Pharmacist 1
Nurse midwife 1
Block extension educator 1
Health assistant (female) 1
Health assistant male 1
U.D.C 1

L.D.C 1
Driver 1
ClassIV 4
L.D.C 1
Driver 1
ClassIV 2
(3) Community health center:
(2) Bed capacity
(3) Specialty
(3) Functions
80,000 to 1.20 lakhs
30 Beds
Surgery, medicine, obstetrics and
gynecologist and pediatrics with X-ray and
lab facilities.
Care of routine and emergency
cases in surgery
Care of routine and emergency
cases in medicine
24 hours delivery services
including normal and assisted
deliveries
Essential and emergency obstetric
care including caesarean sections
and other Medical interventions.
Full range of family planning
services including laparoscopic
services
Safe abortion service
Newborn care
Routine and emergency care of
children
Other management including
74,000 to 1.5 lakhs
24 Beds
Surgery, medicine,
obstetrics and
gynecologist and
pediatrics with X-ray and
lab facilities.
(1) MCH care
(2) Family planning
(3) Immunization
(4) Education about
health
sanitation
(7) Prevention and
control of locally
endemic diseases
(8) Collection and
report in of vital
statistics
(9) 24 hours delivery
services including
normal and assisted
deliveries

(4) Staffing pattern
Nasal
packing,tracheostomy,foreign
body removal
(10) All national
health programmes
delivered through
CHC
Other services
(a) Blood storage
facility
(b) Essential lab.
Services
(c ) Referral
(transport) services
Existing clinical manpower
General surgeon 1
Physician 1
Obstetrics/ gynecologist 1
Pediatrician 1
Proposed clinical man
power
Anesthetics 1
Eye surgeon 1
Public health programme 1
manager
Existing support manpower
Nurse midwife 9
Dresser 1
Pharmacist 1
Lab. Technician 1
Radiographer 1
Ophthalmic 1
Ward boy 2
Sweeper 3
Chowkidar 1
OPD attendant 1
Statistical assistant 1
OT attendant 1
Registration clerk 1
(10) Essential and emergency
obstetric care including
caesarean sections and other
Medical interventions.
(11) Full range of family
planning services including
laparoscopic services
(12) Safe abortion service
(13) Newborn care
(14) Routine and emergency
care of children’s.
(15) ) All national health
programmes delivered through
CHC
Existing clinical manpower
General surgeon 1
Physician 1
Obstetrics/ gynecologist 1
Pediatrician 1
Proposed clinical man
power
Anesthetic 1
Public health programme 1
manager
Existing support manpower
Nurse midwife 12
Dresser 1
Pharmacist 2
Lab. Technician 1
Radiographer 1
Ophthalmic 1
Ward boy 2
Sweeper 3
Chowkidar 2
OPD attendant 1
Statistical assistant 1
OT attendant 1
Registration clerk 2

Job description of the members of the health team:
(1) Medical officer:
He is the captain of the health team at the primary health center.
He devotes the morning hours attending to patients in the out-door,in the afternoon and
supervises the field work.
He visits each subcenter regularly on fixed days and hours and provides guidance,
supervision and leadership to the health team.
He spends one day in each month organizing staff meetings at PHC to discuss the
problems and review the progress of health activities.
He ensures that national health programmes are being implemented in in his area
properly
The success of PHC depends largely on the team leadership which the medical officer is
able to provide.
The medical officer must be a planner, the promoter, the director, the supervisior, the
coordinator as well as the evaluator.
(2) Health worker male and female:
Under the multipurpose worker scheme, one health worker female and one male are posted
to each sub-centers and are expected to cover 5000 of population (3000 in tribal and hilly areas)
health worker female limits her activities among 350-500 families.
Health worker female:
She will register pregnant women from three months of pregnancies onwards.
Maintain maternity record, register of antenatal cases, eligible couple register, children
register up to date.
She will provide care to pregnant women especially registered mother throughout the
period of pregnancy;
Give advice on nutrition to expectant and nursing mothers about storage, preparation and
distribution of food.
Immunize pregnant mothers with tetanus toxoid.
Conduct about 50% of total deliveries at home.
Supervise deliveries conducted by Dais and whenever call in.
Spread the message of family planning to the couples; motivate them for family planning
individually and in groups.
Distribute conventional contraceptives to the couples.
Assess the growth and development of the infant and take necessary action.
Records and reports births and deaths in her area.

Test urine for albumin and sugar and do Hb during her home visit.
Arrange and help M.O and health assistant in conducting MCH and family planning
clinics at subcenters.
Maintain the cleanliness of subcenter.
Attend staff meetings at PHC, CD block or both.
Health worker male:
He will survey all the families in his area and collect all the information about each
village/ locality in his area.
Identify the cases of communicable diseases and notify the health assistant male and M.O
PHC immediately.
Educate the community about importance of control and preventive measures against
communicable diseases.
Assist the village health guide in undertaking the activities under TB programme
properly.
Educate community on the method of liquid and solid waste, home sanitation, advantage
and use of sanitary latrines.
Assist the health assistant male in the school health programme.
Utilize the information from the eligible couple and child register for the family planning
programme.
Spread the message of family planning to the couples; motivate them for family planning
individually and in groups.
Distribute conventional contraceptives to the couples.
Provide follow-up services to male family planning acceptors.
Health assistant male and female:
Health assistant male and female will supervise 4 health workers each of the corresponding
category.
Health assistant female:
Supervise and guide the health workers in the delivery of health care services to the
community.
Carry out supervisory home visiting.
Guide the health workers (female) in Distribution of conventional contraceptives to the
couples.
Visit each of the 4 subcenters at least once in a week on fixed days.

Respond to urgent calls from the health workers and trained dais and render necessary
help.
Organize and utilize the mahila mandal, teachers etc., in the family welfare programme.
Provide information on the availability of services for MTPs and refer suitable cases to
the approved institution.
Supervise the immunization of all pregnant women and children (0-5 years)
Collect and compile the the weekly reports of births and deaths occurring in his area.
Educate the community regarding the need of registration of vital events. .
Health assistant male:
Supervise the work of Health worker male during concurrent visit.
Check minimum 10% of houses in village.
Supervise the spraying of insecticides during local spraying along with the health worker
(male).
Conduct immunization of all school going children with the help of health worker (male).
Supervise the immunization of all children’s (0-5 years).
Assist M.O.PHC in organization of family planning camps and drives. .
Provide information on the availability of services for MTPs and refer suitable cases to
the approved institution.
Ensures follow-up of all cases of vasectomy, tubectomy IUD and other family planning
acceptors.
Ensure that all the cases of malnutrition infants and young childrens (0-5years) are given
the necessary treatment and advice and refer serious cases to PHC.
Ensure that Iron and folic acid and Vitamin A are distributed to the beneficiaries.
Conduct MCH and family planning clinics and carry out educational activities.
Organize and conduct training for dais women leaders with the help of health workers
Collect and compile the the weekly reports of births and deaths occurring in his area.
Educate the community regarding the need of registration of vital events.
REFERENCES
(1) k. Park, Text book of preventive and social medicine, Bhanot publication, 18th
edition, Page
no.674-699.
(2) B.T.Basvanthappa, Community health nursing, Jaypee, Publication, 6th
edition, Page no.584-
605.
(3) K.K. Gulani, Community health nursing, Kumar Publication, 3rd
edition, Page no.591-593.
(4) Dr. Sr. Mary Lucita, Public health and Community Health, Nursing, B.I. publication, 1st
edition, Page no.25-34.
(5) John M. Cookfair, Nursing care in the community, Mosby, Publication, 2nd
edition, Page no.
65-81.
(6) www.google. com.

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