Health Care Delivery System in India Dr Utpal Sharma Assistant Professor Department of Community Medicine SMIMS, Gangtok, Sikkim
Aug 05, 2015
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