This document provides an overview of India's public health system and levels of healthcare. It defines key terms like health, referral system, and levels of care. It describes the primary, secondary, and tertiary levels of care and the facilities at each level. It outlines the public health infrastructure including village health posts, subcenters, PHCs, and CHCs. It discusses the roles of frontline workers like ASHAs, ANMs, and dais. It also covers voluntary agencies, national health programs, private healthcare settings, and indigenous systems of medicine in India.

1. REFERRAL SYSTEM
CHN/UNIT 7/ PART -1
GNM

2. TOPICS
• Health
• Health Care
• Levels Of Health Care
• Health Care Setting
• National Health Programmes
• Indigenous System Of Medicine

3. DEFINITION
• WHO defined “Health is a state of complete physical, mental
and social well being and not merely an absence of disease or
infirmity”.
• Multiple services rendered to the individuals , families and
community by the health agency for the purpose of promoting
, preventing, maintaining, monitoring and restoring the health.

4. REFERRAL SYSTEM
“Referral system is defined as a system of transferring
cases which are beyond the technical competence of one
infrastructure to a higher level infrastructure/ institution
having technical competency and all other resources to
provide desired health services”.

5. • The referral system is vertical in nature.
• The cases can be referred from village health post to SC/PHC,
from SC to PHC/CHC and from PHC to CHC/secondary or
tertiary level hospital and from CHC to secondary or tertiary
level hospital.

7. CHARACTERISTICS OF HEALTH CARE
• Should be accessible to all within a specified geographical
area taking care of their social & 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 man power
• According to the priorities of the needs and policies of the
government.

8. PURPOSE OF HEALTH CARE
• To reduce the morbidity and mortality rate
• To improve basic environmental sanitation
• To improve nutritional status
• To investigate new emerging health problems and take
appropriate steps to deal
• To develop manpower and other resources
• To explore the potential of the people toward “Progressive
India”

9. LEVEL OF HEALTH CARE
a) PRIMARY LEVEL OF HEALTH CARE
• It is the first level of contact between community and health
care providers at grass root level
• Health problems solved by people themselves with guidance,
education and assistance by health team
• Health agencies provide basic health care by health team
• Health team include medical officer, health supervisors,
multipurpose health workers( male & female) etc
• Village level has village health guide, anganwadi worker,
trained dais, accredited social activists(ASHA) and other
leaders in social activities

10. Primary level of
health care
PHC for 30000
population
SC level 1:5000
population
Village level for
1000 population
Medical officer – 1
Other members of the health team
Part time voluntary worker-1
MPHW (m)- 1
MPHW(f) ANM -1
Village health guide-1
Trained Birth attendant- 1
Anganwadi worker- 1
ASHA-1

11. b) SECONDARY LEVEL OF HEALTH CARE
• Cases which require secondary level of preventive services
• Diagnostic , curative services, specialist consultations
• Consist of community health center, district hospital and
district health center
c) TERITIARY LEVEL OF HEALTH CARE
• Health problems that cannot be treated at secondary level care
setting
• Care provided at state level , regional level , or central level
• Institutions include: specialist hospitals, medical college
hospital, super specialty hospital.
• Institution serve as teaching institution along with tertiary care
• Planning management and research work also executed at this
level

12. Secondary level of health
care
District hospital
District health and FW center
Community health center
1:120000

16. HEALTH CARE SETTING
• 75% population belong to rural area
• People of rural community lack facilities due to poverty ,
illiteracy and ignorance result high morbidity and mortality in
rural community
• Priority on “Health for all” by 2000AD, focus on minimum
health care accessible and affordable to each individual of
society so as to maintain optimum level of health.
Factors affecting health care setting:
Funds
Technical manpower
Consumers of health care
Others( constitutional obligation, political system , health
policies, agenda and judiciary obligation)

17. • Health setting classified as follows:
HEALTH CARE SETTING
PUBLIC SYSTEM
VOLUNTARY
HEALTH
AGENCIES
NATIONAL
HEALTH
PROGRAMMES
PRIVATE SECTOR
INDIGENOUS
SYSTEM OF
MEDICINE

19. PUBLIC SYSTEM
• It is a government sponsored system
• Financed by public fund generated through taxes
• Services provided to rural and urban area by three tier system
at Block Level , District Level & State Level.
Health services at rural areas
Services provided through infrastructure , developed right
from village to the block level.

20. BLOCK
LEVEL
Village level
Sub center level
PHC level
CHC level

22. BLOCK LEVEL
1. VILLAGE LEVEL
• 4 categories of workers :
Village health guide
Traditional birth attendants(TBA)/ trained dais
Anganwadi workers
Accrediated social health activist(ASHA)
• Provide health care to 1000 population
• Trained under supervision of ANM & MHW at Sub center and
PHCs

23. • VILLAGE HEALTH GUIDE
Person with aptitude for social work not full time worker ,
preferably female from the same village .
Guidelines for selection of VHG:
Should be a permanent resident of village.
Should be acceptable to people of the village
Should have minimum education up to 8th standard
Should be able to spend at least 2-3 hrs/day for field work
Should have good communication to motivate people to
positive health.

24. • VHG training for 200 hours over 3 month period at sub center
/PHCs with a stipend of 200/- per month . After training,
working manual and a kit of sample medicine worth Rs.600/-
and Rs.50/- per month as honorarium after training.
Functions of VHG
 Advice on simple health education
 Treatment of minor ailments
 SANITATION: advice people about waste management and
latrine construction
 Disinfection of water
 First aid in emergencies
 Advice people on family planning
 Mother and child health care

25. TRAINED DAIS
Also known as trained birth attendants(TBA). National
objective of 1 TBA in each village . Vital role of domiciliary
midwifery services in rural areas.
• Trained for 30 days at PHCs /SCs, 2 days in a week and
remaining 4 days accompany ANM to the village.
• Dais conduct delivery under guidance and supervision of
FHW( female health worker)
• Rs.300/- during training. After completion of training ,
provided with delivery kit and certificate and could receive
Rs.10/- per delivery after registering in SCs/PHCs.

26. Functions of TBA:
• Contact every pregnant women and get her registered
• Attend every prenatal clinic
• Ensure immunization of pregnant woman and newborn babies
• Motivate eligible couples
• Report about birth and death in the area to the authorities
• Provide essential newborn care
• Postnatal care to the delivery cases

27. ANGANWADI WORKERS ( AW)
Under ICDS( integrated child development services) scheme , 1
anganwadi worker appointed for 1000 population.
Selected from local community
Trained for 4 months
Honorarium of Rs.1500/- per month
Part time worker
Functions of AW
Health check up
Supplementary food
Immunization
Informal education
Takes care of lactating mother, adolescent girls, women and
reproductive age( 15-40 years) and children under 6 years.

28. ACCREDITED SOCIAL HEALTH ACTIVIST (ASHA)
ASHA post Created under NRHS also known as National rural
health mission(NRHM). 1 ASHA worker for 1000 population .
She is selected from the same community.
Selection of ASHA:
 Should be a Married/divorcee/widow between 25 to 45 years
of age.
 Should have Minimum education of 8th standard
 Should have Good knowledge and art of communication and
leadership qualities.
 Should be a volunteer worker
 She will be provided TA/DA and non monetary incentives.

29. Function of ASHA worker:
Create awareness & provide instruction to community About health,
nutrition , personal hygiene and sanitation.
Adopt small family norms
Counsel women on safe pregnancy, delivery, breast feeding and
complementary food
Promote construction of household latrines
Provide primary medical care for minor ailments
Escort women requiring treatment
Mobilize community in accessing health services at SCs/PHCs
Inform about births and deaths in village & outbreak of unusual
health problems to SCs/PHCs
She is a depot holder for essential medicine like ORS, Iron , Folic
acids, chloroquine, oral pills, disposable delivery kit etc

30. 2. SUBCENTER LEVEL
• The first peripheral health unit between community and
health services in rural area
• Covers 5000/ population in plains and 3000/ population in
hilly areas
• Managed by Multipurpose female health worker(ANM) and 1
multipurpose health worker male and 1 voluntary health
worker part time paid RS.100/- month

31. Functions Of Health Sub center:
• Field visit
• MCH and family welfare services
• Immunization of pregnant women and children under 1 year
• Training and supervision of Dais
• IUD insertion
• Simple lab investigation
• Health education
• Birth and death registration
• Record maintenance
• School health services

32. • Information , education and communication
• Attending review meetings and submission of reports to PHC
medical officer
• Involvement in National health program
• Joined health activities with anganwadi and balwadi workers
• Coordinating with other agencies and sectors

33. 3. PRIMARY HEALTH CENTER LEVEL
• The first point of contact between village community and
medical officer
• First structural and functional unit of public health services for
rendering primary health services and health care in peripheral
area.
• Established and maintained by state government under the
minimum need program
• PHC act as referral unit for 6 sub centers and covers a
population of 30000 in plain and 20000 in hilly , tribal and
backward area

34. Staffing pattern at PHC is:
Medical officer-1
Nurse midwife-1
Health worker female ANM-1
Pharmacist-1
Health educator -1
Health assistant male/health supervisor-1
Health assistant female/LHV- 1
Upper division clerk/storekeeper- 1
Lower division clerk. Junior assistant – 1
Laboratory technician – 1
Driver – 1
Class IV worker – 4
Total – 15
There are 4 -6 beds in some of the PHC.

35. Functions of PHCs:
Medical care
MCH & Family planning services
Prevention and control of communicable disease
Basic laboratory services
Training of health guides, health workers, local dais & health
assistants
School heath services
Collection & reporting of vital statistics
Safe water supply & basic sanitation
Health education
Referral services
Prevention of food adulteration practices

36. 4. COMMUNITY HEALTH CENTERS LEVEL (CHC)
• Maintained by the state government under minimum need
programme
• Each CHC has 30 sanctioned beds
• Covers a population of 120000 in plain and 80000 in hilly,
tribal and backward area
• Its referral unit for 4 PHCs.
• Patients referred to district hospital/health center from a CHC.
• Specialist services at CHC include: Surgery,Medicine,
Obstetrics & Gynecology, Pediatrics, Dental & ENT.

37. Staffing pattern at CHC is:
Medical officer-4
Nurse midwife-7
Dresser-1
Pharmacist-1
Health educator -1
Radiographer -1
Ward boys-2
Sweepers -3
Aya – 1
Laboratory technician – 1
Peon – 1
Dhobi– 1
Mali – 1
Chowkidar - 1
Total – 25

38. Functions of CHCs:
Routine & Emergency medical care
Routine & Emergency Surgery
Routine & Emergency obstetric care
Routine & emergency care of sick children
Newborn care
Essential laboratory services
24 hour delivery services including surgical intervention like
caesarean section
Blood storage facilities
Safe abortion center
Full range of family planning services including laparoscopic
services
All National Health programs
Other emergency measure like tracheostomy, foreign body removal
& nasal packing etc.
Referral services

39. DISTRICT LEVEL, STATE LEVEL & MEDICAL
COLLEGES
• Services to urban community provided through the district
hospital/ medical college
CENTRAL GOVERNMENT HOSPITAL
• Provide general as well as referral services
DEFENCE HOSPITAL
• Hospital financed by central government and provide services
only to defence employees and their family.
• It include medical college , nursing college & nursing school
RAILWAY HOSPITAL
• Hospital financed by central government and provide services
only to Railway employees and their family.

40. EMPLOYEES STATE INSURANCE SCHEME( ESI)
• It was started under parliament Act in 1948
• It was introduced on principal of contribution by employer &
employee.
• It Provide medical benefits in kind and cash during sickness,
employment injury, maternity and pension for dependants on death
of worker because of injury.
• It covers employees drawing wages not exceeding Rs.21000/- per
month.
CENTRAL GOVERNMENT HEALTH SCHEME (CGHS)
• It was introduced in 1954 at New Delhi to provide comprehensive
health care to Central government employees
• It was implemented to autonomous organization employees,
members of the parliament, retired central government servants,
widows receiving family pensions, governors and retired judges.

41. Facilities at CHGS are:
• Outpatient care
• Supply of necessary drugs
• Lab & X-ray investigations
• Domiciliary visits
• Hospitalization at government as well as private hospitals
• Referral services
• Paediatric services
• Obstetric services
• Family welfare services
• Emergency treatment
• Supply of optical and dental aids

42. AUTONOMOUS INSTITUTES:
Institutions receive aid from central government except
few important matters, all other decision made by institution
itself.
• All India institute of medical science(AIIMS),New Delhi
• National Institute Of Mental Health and Neuroscience
(NIMHANS), Bangalore.
• Post graduate Institute(PGI), Chandigarh.

43. PRIVATE SECTOR
It include:
• Specialty hospital
• Super specialty hospital
• Medical college hospitals
• Dispensaries
• Health clinics
People who can afford heavy expenses, poor section of society
could not afford
Provide curative services

44. MISSION/ RELIGIOUS HOSPITALS
Institution are charitable run by trust /mission
Medical services either free of cost/minimum rate
Located in urban areas , reach rural population via camps.

45. Recap…
HEALTH CARE SETTING
PUBLIC SYSTEM
VOLUNTARY
HEALTH
AGENCIES
NATIONAL
HEALTH
PROGRAMMES
PRIVATE SECTOR
INDIGENOUS
SYSTEM OF
MEDICINE

46. VOLUNTARY HEALTH AGENCIES
• Non government , non profit making agencies
• Initiated, established and administered by private citizens
• Members of agencies hold meetings, collect funds for its
functioning from private sectors
Functions of voluntary health agencies are:
Supplementing the work of government agencies
Education
Pioneering
Demonstration
Guarding the work of government agencies
Advancing health legislation

47. Types of voluntary health agencies:
• Indian Red Cross Society
• Hind Kusht Nivaran Sangh
• Indian Council of Child Welfare
• Tuberculosis Association of India
• Bharat Sevak Samaj
• Central Social Welfare Board
• The Kasthurba Memorial Fund
• Family Planning Association of India
• All India Women's Conference
• The All India Blind Relief Society
• Professional Bodies
• International Agencies

48. 1. INDIAN RED CROSS SOCIETY
• Established in 1920
• It has 400 branches all over India
Aim :
• Promotion of health, Prevention of disease and Mitigation of
suffering among the people
Functions of Indian Red Cross Society:
Relief work
Milk and medicine supplies
Armed forces
Maternal and child welfare surfaces
Family planning
Blood bank and first aid

49. 2. HIND KUSHT NIVARAN SANGH
It was established in 1950 with headquarters at New Delhi
and branches all over India. Works in close association with
government and other agencies
Functions :
• It provide financial access to various leprosy homes and
clinics
• It provide health education through publication & posters
• It provide training to medical workers and physiotherapist
• It conduct research and field investigation on leprosy

50. 3. INDIAN COUNCIL FOR CHILD WELFARE
• It was started in 1952 affiliated with international Union for
Child Welfare with branches all over India
• Aim: secure Indian children “helps enabling the children to
develop physically, mentally, socially and spiritually in a
healthy and normal manner and in condition of freedom and
dignity”
4. KASTURBA MEMORIAL FUND
• It was formed in 1944 after death of Kasthurba Gandhi.trust is
engaged in various projects in the country
• Objective: to raise the standard of women, especially in village
through gram sevikas.

51. 5. TUBERCULOSIS ASSOCIATION OF INDIA
• Established in 1939, with branches all over India
• Activities: Organizing TB seal campaign every year to raise
funds, train doctors, health visitors and social workers in anti
tuberculosis work, promotion of consultations and
conferences.
• Institutions under Association are : The New Delhi
tuberculosis center ; The Lady Linlithgow Sanatorium ,
Kasauli ; The King Edward VII Sanatorium, Dharampur ;
Tuberculosis Hospital,Mehrauli .
6. BHARAT SEVAK SAMAJ
• It was formed in 1952, with branches all over India
• Non political, non official organization
• Aim: It help people to achieve health by their own action and
improve sanitation in villages

52. 7. CENTRAL SOCIAL WELFARE BOARD
• It was set up by GOI in 1953
• It is an autonomous organization under general administrative
control of Ministry of Education.
• Functions:
 Surveying the needs and requirement of voluntary welfare
organization in the country
Promoting and setting up of social welfare organization and
institutions
Rendering of financial assistance to deserving existing
organization and institutions

53. 8. FAMILY PLANNING ASSOCIATION OF INDIA
• It was started in 1949 with headquarters in Mumbai, who is
answerable to family planning queries
• It has branches all over India with grant-in-aid from
government
• Hundreds of doctors , health visitors trained in family planning
aspect
• Recommendable work in propagating Family Planning in
India
9. ALL INDIA WOMENS CONFERENCE
• Originated in 1926 with branches all over India.
• Only women's voluntary welfare organization in India
• Branches run MCH clinic, Medical centers, Adult Education
Centers, Milk Centers and Family Planning Clinics

54. 10. ALL INDIA BLIND RELIEF SOCIETY
• Formed in 1946
• It coordinate different organization working for blind
• It organizes relief camps and other means for the relief of the blind
11. PROFESSIONAL BODIES
 Voluntary agencies of men and women qualified in respective
fields and possess registrable qualification
• The Indian Medical Association
• All India Licentiates Association
• All India Dental Association
• Trained Association Of India
 They conduct annual conferences, publish journals, arrange
specific scientific sessions and exhibition, poster , research and set
up standards of professional education
 They also organizes relief camps during natural calamities

55. INTERNATIONAL AGENCIES
• It provide technical and material assistance in planning and
implementation of various health programs.
• Agencies include:
WHO [world health organization]
UNICEF
World Bank
UNPFA[United Nation Population Fund]
USAID[ United State Agency For International Development]
CARE [ Cooperative for Assistance and Relief Everywhere]

56. NATIONAL HEALTH PROGRAMS

57. INDIGENOUS SYSTEM OF MEDICINE[AYUSH]
Treatment via out patient departments, dispensaries and hospital .
Government strengthening activities in Urban And Rural areas