healthcare delivery system in india

Health Care Delivery System in India

Dr Utpal Sharma

Assistant Professor

Department of Community Medicine

SMIMS, Gangtok, Sikkim

Introduction

Health is…..……..a state of complete Physical, Mental and Social well being and not merely an absence of disease or infirmity….

…..which allows a person to live a socio-economically productive life.

Illness is…..

…a state in which a person’ s physical, emotional, intellectual, social or spiritual functioning is diminished or impaired.

Cont….

Health care is...

…….multitude of services rendered to individuals or communities by the agents of health services or professional for the purpose of

Promoting Restoring andMaintaining health

Embraces all the goods and services designed for “prevention, promotion and rehabilitation interventions” includes Medical Care

Health Care providerA person or organization that provides services

and/or health care personnel….  ….to deliver proper health care in a

systematic way to any individual in need of health care services.

Could be a government…or… ….the health care industry, ….a health care equipment company, ….an institution such as a hospital or laboratory.

Health care professionals may include  physicians, dentists, and other support staff.

Cont….

Health services

Permanent countrywide system of estabilished

institutions with the objective of…….coping with the various health needs and

demands of population…

…thereby provide health care to individuals and

community with preventive and curative activities

….utilizing health care workers

Cont…

SystemIncludes… concepts ( e.g health and diseases)Ideas(e.g equity)Objects(e.g hospitals, health centres)Persons (health care workers viz. physician, nurses)

Together these forms a system interacting with each other, supporting and controlling each other

Components of healthcare delivery system

1. Structure of health system

Aspects of the design of health services that influences the way in

which they are delivered Includes….

Number and type of personnel and staff

Way of these personnel organized to work

Nature and extend of facility and equipment

Range of services offered

System of management and amenities

Financing

Enumeration and determination of the eligible population for these

services

Governance and decision making

Cont…

2. Process of health care delivery

Consists of two parts Behavior of professionals

Recognition of the problem i.e diagnosis

Diagnostic procedure

Recommendation of treatment or management

Appropiate follow up

Participation of people Utilization of services

Understanding the recommendations

Satisfaction with the services

Participation in decision making

Cont…

3. Outcomes of health care

Aspects of health that results from interventions provided by the

health system

4. Flow of patients in health care system

Varies from country to country

India harbors a multistage (three tier) system, where majority of

health care is delivered by community health care worker

Indian system is more cost effective if health workers are skilled

and effectively supervised

Such system could one of the reason to reduced cost of health

care in developing countries

Levels of health care

Secondary health care

Primary health care

Primary Health careProvided at the community level

Secondary health careProvided at PHC, CHC, DH etc.

Tertiary health careProvided at hospitals

Tertiary health care

Alma-Ata international conference In 1977, World Health Assembly decided to launch a movement

called “Health for all by 2000”

Fundamental principle of this concept was equity, an equal health

status for all the people in all countries

This is to be ensured by equitable distribution of health resources

In 1978, the note of “Health for all” was reaffirmed and marked as

the major social goal for every country.

It was stated in the declaration that the best way to achieve HFA

is by providing primary health care……

……… especially to vast size of underserved rural

and urban poor

Alma-Ata conference, 1978

Alma-Ata Declarations

A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. - “HEALTH FOR ALL BY 2000”

Primary health care is the key to attaining this target as part of development in the spirit of social justice.

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford.

Alma-Ata DeclarationIt forms an integral part of the country's health

system, and of the overall social and economic development of the community.

It is the first level of contact of individuals, the family and community with the national health system.

All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors.

Primary health carePrimary Health Care as defined by the World Health

Organization (WHO) in 1978 is…

Essential health care; based on practical, scientifically sound, and socially acceptable method and technology….

…….made universally accessible to individuals and families of the community through their full participation….

……at a cost that community and country can afford to maintain every stage of their development in the spirit of self determination.

Cont…

Definition

Primary health care is essential health care made universally accessible to individuals and acceptable to them through their full participation and at a cost the community and country can afford

What is there in Primary Health Care..?????

Primary Health Care includes:

– Primary Care (physicians, midwives & nurses);

– Health promotion, illness prevention;

– Health maintenance & home support;

– Community rehabilitation;

– Pre-hospital emergency medical services… and…

– Coordination and referral to other areas of health care.

Cont.…

It is the first level of contact with the health system to promote

health, prevent illness, care for common illnesses, and manage

ongoing health problems.

Primary Health Care involves concerted effort to provide rural

population of developing countries with least bare minimum of

health services.

Some services are also provided community and hospitals

Primary Health Care is different in each community depending upon: – Needs of the residents;– Availability of health care providers; – The communities geographic location; &– Proximity to other health care services in the area.

Elements of primary health care1. Education about prevailing health conditions and methods

to prevent and control them

2. Promotion of food supply and proper nutrition

3. Adequate water supply and basic sanitation

4. Maternal and child health care with family planning

5. Immunization against major infectious diseases

6. Prevention and control of locally endemic diseases

7. Appropriate treatment of common diseases and injuries

8. Provision of essential drugs

Principles of primary health care

Equitable distribution

Community participation

Intersectoral coordination

Appropriate technology

Health Care Delivery System in India

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’s responsibility consists mainly of policy making , planning , guiding, assisting, evaluating and coordinating the work of the State Health Ministries.

Health System in India

The health system in India has 3 main links

Local or peripheral

State

Central

At the central levelThe official “organs” of health system at

national level are

The Ministry of Health and Family welfare

The directorate general of Health Services

The central council of health and family welfare

Ministry of Health and Family Welfare

Organization Structure

Functions of MoHFW

Union list

International health relations and administration of port quarintine

Administration of Central Institutes

Promotion of research

Regulation and development of medical, pharmaceutical, dental and nursing professions

Establishment and maintenance of drug standards

Census and collection and publication of other statistical data

Coordination with states

cont….

Concurrent List:

Prevention of Communicable disease

Prevention of food adulteration

Control of drug and poison

Vital statistics

Labour welfare

Economic and social planning

Poulation control and family planning

Directorate General of Health Services

Organization chart

Functions of Directorate General of Health services

General functions Surveys Planning Coordination Programming and appraisal of all health matters

Specific function International health relations and quarantine of all major

ports in country and international airport. Control of drug standards Maintain medical store depots Administration of post graduate training programmes

Cont…

Administration of certain medical colleges in India

Conducting medical research through Indian Council of Medical

Research ( ICMR )

Central Government Health Schemes.

Implementation of national health programmes

Preparation of health education material for creating health

awareness through Health Education Bureau

Collection, compilation, analysis, evaluation and dissemination

of information

National Medical Library

Central Council of health

Organization chart

Functions

To consider and recommend broad outlines of policy related to matters concerning health like environment hygiene, nutrition and health education.

To make proposals for legislation relating to medical and public health matters.

To make recommendations to the Central Government regarding distribution of grants-in-aid.

State Level

At District level

There are 593 ( year 2001 census) districts in India. Within each district, there are 6 types of administrative areas.1. Sub –division

2. Tehsils ( Talukas )

3. Community Development Blocks

4. Municipalities and Corporations

5. Villages and

6. Panchayats

Disrtict Level

Districts

Tehsils /Talukas (200-600 villages)

Community Development Blocks (approx 100 Villages & 80,000 -1.2

Lac Pop)

Municipalities & CorporationsMunicipal Board (10,000- 2 Lac

Pop)

Corporations (> 2 lac pop)

Town Area Committee (5,000-

10,000 Pop)

Panchayats

Villages

Health Services Out patient services -Patients who don’t require hospitalization can

receive health care in a clinic. An out patient setting is designed to be

convenient and easily accessible to the patient.

Clinics – Clinics involve a department in a hospital where patients not

requiring hospitalization, receive medical care.

Institutions – Hospitals – Hospital have been the major agency of health

care system.

In broad sense the health services should be

a. Comprehensive

b. Accessible

c. Acceptable

d. Provide scope of community participation and….

e. Available at an affordable cost by country and commuity

Health care systems Intended to delivery healthcare services and represented by five

major sectors different from each other by health technology

1. Public health sector

a. Primary health care Primary health centres Sub centres

b. Hospitals/Health centres Community health centres Rural hospitals District hospitals/health centres Specialist hospitals Teaching hospitals

c. Health insurance schemes Employees State Insurance Central Govt. Health Schemes

d. Other agencies Defense services Railways

Cont…

2. Private sector

a. Private hospitals, polyclinic, nursing homes and dispensaries

b. General practitioners and clinics

3. Indigenous system of medicine

a. Ayurveda and Siddha

b. Unani and Tibbi

c. Homeopathy

d. Unregistered practitioners

4. Voluntary health agencies

5. National health programmes

Primary health care in India

Introduction

In 1977, GoI launched Rural Health Scheme based on the

principle of “placing people’s health in people’s hand”

Subsequently in the international conference of Alma-

Ata(1978)the goal of “Health for all” by 2000 through

primary health care approach was set.

Keeping in view WHO “Health for all” by 2000 GoI

formulated National health policy 2002

Cont….

More recently GoI formulated NRHM and Indian Public

Health Standards (IPHS) in this regards

In order to provide quality care in the public health agencies

of health care delivery IPHS are being prescribed.

These standards provides basic promotive, preventive and

curative primary health care to the community and……

…….achieve and maintain an acceptable quality of care

These standards would help monitor and improve functioning of the health care delivery system

Rural Health care system in India

Primary Health Centre (PHC)A Referral unit for 4-6 Subcentres; 4-6 bedded manned with a Medical Officer in-charge and 14 subordinate paramedical staff

no. of PHCs with specialized Health Services

Community Health Centre (CHC)A 30 bedded Hospital/ Referral unit for 4 no. of PHCs with

specialized Health Services

Sub Centre (SC)Most peripheral contact point of community with Primary Health

Care system; manned with one MPW(M) and MPW(F)

Rural Health care system in India

The health care infrastructure in rural areas has been developed as a three tier system and is based on the above population norms.

Health Facility

Population Norms

Plain Area Hilly/Tribal/Difficult Area

Sub-Centre 5000 3000

Primary Health Centre

30,000 20,000

Community Health Centre

1,20,000 80,000

Sub Center

The most peripheral and first contact point between the primary

health care system and the community.

The Ministry of Health & Family Welfare is providing 100% Central

assistance

They are established on the basis of One SC for every 5,000 pop in general and…

One SC for every 3,000 pop in hilly, tribal and backward areas

Each Sub-Centre is manned by one Male and one female Health

Worker.  

One Lady Health Worker (LHV) is entrusted with the task of

supervision of six Sub-Centers.

Cont….

Sub Centre are assigned tasks relating to interpersonal communication

…..in order to bring about behavioral change and provide services in relation to….

Maternal and child health, Family welfare, Nutrition, Immunization, Diarrhea control and Control of communicable diseases programmes.  

The sub centre are provided with basic drugs for minor ailments.

Primary Health Center

PHC is the first contact point between village community and the Medical Officer.

The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care.

The PHCs are established and maintained by the State Governments.

At present, a PHC is manned by a Medical Officer supported by 14  paramedical and other staff.  

Cont….

It acts as a referral unit for 6 SubCentres. 

  It has 4 - 6 beds for patients.  

The activities of PHC involve curative, preventive, primitive and Family Welfare Services.  

National Health Plan (1983) proposed reorganization of PHCs on the basis of…. One PHC for every…..30,000 pop in Rural areas One PHC for every…..50,000 pop in Urban areas

PHC Pakyong

Functions of PHCsMedical care

Health programmes

MCH care and family planning

Health education and training

Referral services

Safe water supply and basic sanitation

Prevention and control of locally endemic diseases

Collection and reporting of vital events

Basic laboratory services

Staffing of PHCs

Source: IPHS 2012

Community Health Center (CHC) These were established by upgrading the primary health centers

CHCs are being established and maintained by the State Government.

centers,each community health center should cover a population of 8000

to 1.2 lakh

It is manned by four medical specialists i.e. Surgeon,

Physician,  Gynecologist and Pediatrician and….

……supported by paramedical and other staff.  

It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory

facilities.  

It serves as a referral centre for 4 PHCs and also provides facilities for

obstetric care and specialist consultations.

Functions of CHCs

Care of Routine and Emergency Cases in Surgery

Dressings, I&D, and surgery for Hernia, Hydrocele, Appendicitis etc.

Emergencies like Intestinal Obstruction, Haemorrhage, etc.

Other management including nasal packing, tracheostomy, foreign

body removal etc.

Fracture reduction and putting splints/plaster cast.

Conducting daily OPD.

Care of Routine and Emergency Cases in Medicine

Daily OPD Handling all the emergency and routine cases

Cont…

Maternal Health

Minimum 4 ANC check ups including Registration &

associated services

1st visit: Within 12 weeks—preferably as soon as

pregnancy

2nd visit: Between 14 and 26 weeks

3rd visit: Between 28 and 34 weeks

4th visit: Between 36 weeks and term

24 hr delivery services including normal and assisted delivery

and cesarean section

Managing labour using Partograph.

Minimum 48 hours of stay after delivery, 3-7 days stay post

delivery for managing Complications

Cont….

Newborn Care and Child Health

Essential Newborn Care and Resuscitation

Counseling on Infant and young child feeding

Routine and emergency care of sick children

Full Immunization of infants and children against VPDs

Management of Malnutrition cases.

Family Planning

Counseling, provision of Contraceptives, NSV, Laparoscopic

Sterilization Services and their follow up.

Safe Abortion Services

Cont….

All National Health Programmes delivered through CHCs

School health services

Others

Blood storage facilityEssential laboratory services Referral (transport) services

Maternal Death review (MDR)

Staffing of CHCs

Cont…

Cont….

Thank you