In this slide explain about Levels of health care and health care settings.. References taken from: 1. Text book of Community Health Nursing-I written by Lt. Col. KK Gill 2. Text book of Community Health Nursing written by Keshav Swarnkar

1. Levels of Health care and Health care settings
RAJDIP MAJUMDER
TUTOR,
INSTITUTE OF NURSING
BRAINWARE UNIVERSITY

2. INTRODUCTION OF HEALTH CARE
 The dictionary meaning of health care is to protect health, to be concerned
about health or to take care of health.
 GOI is committed to achieve the goal of “Health for all” through primary
health care approach.
 The National Health Policy was reviewed in 2001, to achieve acceptable
standard of health by strengthening the existing infrastructure and
emphasizing the need to strengthen primary health care infrastructure
making basic health services available to the people at grass root level.

3. CHARACTERISTICS
 Should be accessible to all within a specified geographical area taking care of
their social and cultural values.
 Should be appropriate and adequate to satisfy the needs of the people.
 Comprehensive in nature.
 Within the capacity of available resources like money, material and manpower.
 According to the priorities of the needs and policies of the government.

4. PURPOSES
 To reduce the morbidity and mortality rate.
 To improve the basic environmental sanitation.
 To improve nutritional status.
 To increase the life expectancy of individuals.
 To investigate the new emerging health problems and take appropriate
steps to deal with.

5. CONT…
 To develop manpower and other resources.
 To explore the potential of the people toward “Progressive India”
N.B: Health care in India is based on 3 tier system of services provided at
three levels. These are: Primary level, Secondary level, Tertiary level.

6. LEVELS OF HEALTH CARE
1.PRIMARY LEVEL OF HEALTH CARE:
 It is the first level of contact between community and health care providers
at grass root level.
 At this stage many health problems are solved by the people themselves
with some guidance, education and assistance provided by the health team.
 The health agencies that provide primary health care are Subcenters,
Primary health centers.
 These services are comprehensive in nature and provide basic health care
by the team of health professionals.

7. 1.PRIMARY LEVEL OF HEALTH CARE:
 Health professionals includes medical officer, health supervisors,
multipurpose health workers male and fenmale, sanitarian and extension
health education.
 At village level the health guide, Anganwadi worker, Trained Dias and
Accredited social health activists (ASHA) and other leaders are active in
contributing their services at primary level of health care.

9. 2.Secondary Level of Health Care
 As per the policies of primary health care, the primary levels of health care
setting are not equipped with the facilities and manpower to deal all
complex problems.
 So the cases which require secondary level of preventive services, i.e.
diagnostic, curative services and specialists consultation are referred as
secondary level care.
 The secondary level services are provided at Community Health Center,
district hospital, and district health center.

11. 3.Tertiary Level of Health Care
 The health problems which cannot be treated at secondary level care
setting are dealt at tertiary level care setting.
 The tertiary level care is provided at state level, regional level or central
level. Institution include specialist hospitals, medical college hospital and
super specialist hospital.
 These institution serve as referral units for primary and secondary level of
care. In these institutions the latest technology facilities and super
specialists, are available.

12. 3.Tertiary Level of Health Care
 These institutions in addition to provide tertiary level care also serve
as teaching institution. The training and medical education is
provided to the various categories of health workers.
 The planning management and research work is also executed at
this level.

13. HEALTH CARE
SETTING

14. INTRODUCTION OF HEALTH CARE
SETTING
 All the countries to remove the inequalities in the distribution of health are
services and resources and attainment of "Health for all" by 2000 AD. That
means minimum of care must be accessible and affordable to each
individual of the society so as to maintain optimum level of health.
 To meet the global commitment of "HFA" the health care settings are
restructured through primary health care approach to provide universal
comprehensive health care to the people which they can accept and afford.

15. HEALTH CARE SETTING DEPENDS UPON
 FUNDS: Funds are generated by the government through general taxes. . It
is up to the government how much funds available for health care services.
 TECHNICAL MANPOWER: it is the most expensive factor. How much
trained manpower employed by the government, depends upon government
policies and decisions.
 CONSUMER HEALTH CARE: these are the people to whom health care
services are to be provided. The extent and nature of services depends upon
the size., demographic characteristics, health status of the people.

16. CONT…
 OTHER FACTORS: constitutional obligation, political system, health
policies agenda and judiciary obligations.

17. HEALTH CARE SETTING CLASSIFIED AS
A. Public system.
B. Private sector.
C. Voluntary health agencies.
D. National health programs.
E. Indigenous system of medicine.

18. A.Public system
 Public sector is a government sponsored system. It is financed by
public funds generated through taxes. Services are provided to
rural and urban area through Block level, District level, State
level.
BLOCK LEVEL: Organizational structure at block level is
developed under:
1. Village level
2. SC
3. PHC
4. CHC

19. 1.Village level
To provide basic health facilities At village level, there are 4
categories of workers who provided health care to 1000 population
after getting training at SC & PHC under the supervision of
Auxiliary nurse and midwives (ANM) and male health workers.
They are:
a. Village health guide
b. Traditional birth attendants(TBA)/ Trained DAIS
c. Anganwadi worker
d. Accredited social health activist (ASHA)

20. a.Village health guide
Village health guide is a person with an aptitude for social work but
not full time worker, preferably female from the same village. The
guidelines for selection:
 They should be a permanent resident of the village.
 They should be acceptable to the people of the village.
 They should have minimum education up to 8th standard.
 They should be able to spend at least 2-3 hours/ day for
community health work.
 They should have good communication to motivate the people
towards positive health.

21. a.Village health guide
After selection, village health guide is given training for
200 hours over period of 3 months at SC or PHC. During
this training, the village health guide is paid stipend 200/-
per month. On completion of training, working manual and
a kit of simple medicine worth 600/- is given to Village
health guide. Village health guide is paid 50/- month as an
honorarium after the training.
Presently they get 3000/- per month.

22. a.Village health guide
Function:
 Advice on simple health education
 Treatment of minor ailments.
 Sanitation: advice the people about proper disposal of garbage
and construction of latrines.
 Disinfection of water.
 First aid in emergency cases.
 Advise people on family planning
 Mother and child health care.

23. b. Traditional birth attendants(TBA)/ Trained DAIS
 The national objective is to have 1 TBA in each village.
 They have vital role in providing domiciliary midwifery services in
rural areas.
 They are giving training for 30 working days at SC and PHC 2days
in a week and remaining 4 days, they accompany the ANM to the
village.
 TBA are required to conduct 2 deliveries under the guidance and
supervision of female health worker.
 They are paid 300/- during the training.
 She is entitled to receive 10/- delivery provided the case is registered
with SC or PHC.

24. b. Traditional birth attendants(TBA)/ Trained DAIS
FUNCTION:
 Contact every pregnant woman and get her registered.
 Attend every prenatal clinic.
 Ensure immunization of pregnant woman and newborn babies.
 Motivate eligible couple.
 Report about birth and death in the area to the authorities.
 Provide essential newborn care.
 Postnatal care to the delivery cases.

25. c.Anganwadi workers
Under the integrated child development services(ICDS)
scheme, 1 anganwadi worker has been appointed for 1000
population.
She is selected from the local community and undergoes
training for 4 months.
After training she is paid an honorarium of 1500/- per
month. She is part time worker.

26. c.Anganwadi workers
FUNCTION:
Health checkup
Supplementary food
Immunization
Informal education
Takes care of lactating mother, adolescent girls, women of
reproductive age (15-40 years) and children under 6 years.

27. d.ASHA
 The post of ASHA was created under NRHS (National rural health
services) also known as NRHM. There is 1 ASHA for 1000
population. She is selected from the same community.
 She should be married/Divorce or widow between age group of 25-
45 years. Minimum education upto 8th standard.
 She should have good knowledge and art of communication and
leadership qualities.
 She is volunteer worker. No salary paid. She is provided travel
allowance. Dearness allowance, awards and nonmonetary
incentives.

28. d.ASHA
FUNCTION:
 Create awareness and provide instruction to the community about health,
nutrition, personal hygiene and sanitation.
 Counsel the women on safe pregnancy, delivery, breastfeeding and
complementary feeds.
 Adopt small family norms.
 Depot holder for essential medicines like ORS, iron, folic acid, tablets,
chloroquine, oral pills and disposable delivery kit.

29. d.ASHA
FUNCTION:
 Mobilize the community in accessing health services at SC and PHC.
 She will escort pregnant woman requiring treatment.
 Provide primary medical care for minor ailments.
 Inform about births and deaths in the village and outbreak of unusual health
problems to SC and PHC.
 Promote construction of household toilets.

30. 2.Subcenter
 It is the first peripheral health unit between the community and health
services in rural area.
 It covers a population of 5000 in plain and 3000 in hilly area, tribal and
backward area.
 SC is managed by 1 multipurpose female health worker (ANM) and 1
multipurpose male health worker and 1 voluntary worker.

31. 2.Subcenter
FUNCTION:
 Field visit
 MCH care and family welfare services.
 Immunization of pregnant women and children under 1year.
 Training and supervision of Dais.
 IUD insertion.

32. 2.Subcenter
FUNCTION:
 Simple Lab investigation.
 Health education
 Birth and death registration.
 Record maintenance.
 School health services.

33. 2.Subcenter
FUNCTION:
 IEC activities.
 Attending review meeting and submission of reports to PHC MO.
 Involvement in National health program.
 Join health activities with Anganwadi and Balwadi workers.
 Coordinating with other agencies and sectors.

34. 3. Primary health center (PHC)
 PHC is the first contact between the village community and MO.
 It is the 1st structural and functional unit of public health services for
rendering primary health services and health care peripheral area.
 PHC are established and maintained by the state govt. under the minimum
need program.
 A PHC acts as a referral unit for SC and covers a population of 30000 in
plain area and 20000 in hilly, tribal and backward are.

35. RECOMMENTED STAFFING PATTERN OF PHC
 Medical officer -1
 Nurse midwife -1
 Pharmacist -1
 Health worker -1
 Block extension educator -1
 Health assistant (F) LHV -1
 Health assistant (M) -1
 Lab technician -1
 UDC and LDC -2 (1 each)
 Drivers -1
 Class IV employee -4
( TOTAL STAFF-15)

36. FUNCTION OF PHC
 Medical care including referral and laboratory services.
 Control of communicable disease.
 Environmental sanitation with priority for provision of safe water supply
and sanitary disposal of human excreta.
 Maternal and child health services (MCH).
 Family planning

37. FUNCTION OF PHC
 Family planning.
 School health services.
 Health education.
 Collection of vital statistics.
 Implementing the national health programs.
 Training of personnel

38. 4. Community health center (CHC)
 The Community Health Centres (CHCs) constitute the secondary level of
health care, were designed to provide referral as well as specialist health
care to the rural population.
 CHC are maintained by the state government under the minimum need
program.
 Each CHC has 30 sectioned bed. It covers population 1,20,000 in plain and
80,000 in tribal and backward area. It acts as a referral unit for 4 PHC.
 From CHC patients are referred to district hospital/health centers if
required for consultation and treatment.

39. 4. Community health center (CHC)
Specialist services provided at CHC:
 Surgery
 Medicine
 Obstetrics and gynecology
 Pediatrics
 Dental and ENT

40. 4. Community health center (CHC)

41. 4. Community health center (CHC)

42. 4. Community health center (CHC)

43. 4. Community health center (CHC)

44. 4. Community health center (CHC)

45. 4. Community health center (CHC)

46. 4. Community health center (CHC)

47. 4. Community health center (CHC)
FUNCTION:
 Routine and emergency surgery.
 Routine and emergency medical care.
 24 hours delivery services including surgical intervention like CS.
 Essential and emergency obstetric care.
 Newborn care.
 Routine and emergency care of sick children.

48. District, Slate level and medical college hospitals:
The services to the urban community are provided through these hospitals.
These hospitals are also referral units for the rural communities.
Central government hospitals:
They provide general as well as referral services.
Defence hospitals:
These hospitals are financed by central govt and provide services only the
defence employees and their family. Defence have their own medical college,
nursing college and nursing school.

49. Railway hospitals
Managed by central government and provide services to the railway
employees and their family.
Employees state insurance scheme(ESI):
ESI scheme was introduced in India on the principles of contribution by
employer and employee. It was started under the parliament act in 1948 to
provide medical benefits in kind and cash during sickness, employment
injuries, maternal and pension for dependents on the death of worker because
of injury. The act covers employees drawing wages not exceeding 21000/- per
month.

50. Central government health scheme(CGHS)
 It was introduce in 1954 to start at New Delhi to provide comprehensive health care to the
central government employees. Later on, it was extended to other cities not only to the
employees but, to their family member also.
 It was implemented to the autonomous organization employees, member of the parliament,
retired central govt servants, widows receiving family pension, governors and retired
judges.
 The scheme is based on the principle of cooperative effort by the employee and employer
for the mutual advantages.
 The facilities at CGHS are: OPD, supply necessary drugs, lab and x-ray investigation,
referral services, pediatric services, obstetric services, family welfare services, emergency
services, supply of optical and dental services etc.

51. Autonomous institutes:
 Under this category some institutions receive aid from central government
but except few important matters, all other decision are made by the
institutions itself AIIMS, NIMHANS, PGI. These hospitals provide referral
services to the rural and urban communities.

52. B.Public system
 In private sectors, there are speciality hospitals, super specialist hospitals,
medical college hospitals, dispensaries and health clinics.
 The people who can afford heavy expenses are taking the facilities of health
care. But these hospitals provide only curative services. Poor and weeker
section can not take their facilities.
 Mission/ Religious hospitals: this type of hospitals are charitable and run by
trust or mission. They provide medical services foe free of cost or minimum
rate. They present in urban areas but provided care to rural area also through
campus.

53. C.Voluntary health agencies
 These agencies are non-government and non-profit making. They are initiated, established
and administered by private citizens.
 They are financed by voluntary contributions and donations. These agencies are
complimentary to government health agencies.
 The members of the agencies hold meetings, collect funds for its functioning from private
sources.
FUNCTION:
 Supplementing the work of government agencies: Government can not provide complete
health services because of financial restriction.
 Education: Government alone can not cope with health education in India unless
supplemented by voluntary efforts.

54. C.Voluntary health agencies
FUNCTION Cont….:
 Pioneering: Voluntary health agencies are in a position to find out ways and
means of solving problems and getting the solution of doing things in
fruitful way. Family planning program in India is an example of pioneering
by the voluntary agencies.
 Demonstration: By the putting up experimental projects the voluntary health
agencies succeeded in its contribution toward health care services.
 Guarding the work of government agencies: Through their experimental
approach, voluntary health agencies are capable of guarding and criticizing
the work of government agencies.

55. C.Voluntary health agencies
Type of voluntary health agencies:
 Indian red cross society.
 Hind kusht Nivaran Sangh
 Indian Council for Child Welfare
 Tuberculosis Association of India.
 Bharat Sevak Samaj
 Cental Social Welfare Board
 The Kasturba Memorial Funds.
 Family Planning Association of India.
 All India Women’s conference.
 The All India Blind Relief Society
 International Agencies.

56. D.National Health programs
 In addition to various levels of health care setting, the government of india
has put up lots of efforts to deal with various health problem at national
level.
 These problems include communicable and non communicable diseases,
environmental sanitation, nutrition problems and population problems etc.

57. E. Indigenoys system of medicine
 In the last few years lots of efforts have been taken strengthen indigenous
system of medicine in the public sector of health care in both rural and
urban areas.
 These services of indigenous system are provided through OPD,
dispensaries and hospitals.
 This system includes Ayurveda, Yoga and Naturopathy, Unani, Siddha,
Homeopathy (AYUSH)