health care delivery system

1 www.drjayeshpatidar.blogspot.com

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 ofThe 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:

Designation Maharashtra Rajasthan


(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:

Designation

Maharashtra Rajasthan


(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.

http://www.google/