PRESENTED BY - RISHABH KUMAR MBBS 2009 BATCH

HEALTH CARE DELIVERY SYSTEM IN INDIA

CONTENTSINTRODUCTION

EVOLUTION OF HEALTH CARE SERVICES IN INDIA

ROLE OF DIFFERENT COMMITTEES

HEALTH ORGANISATION SYSTEM IN INDIA

GAPS IN STRUCTURE

INTEGRATED APPROACH OF HEALTH CARE DELIVERY CONTRIBUTION BY NGOS &CHALLENGES

INTRODUCTION

INDIA is union of 28 states & 7 union terrorties Older concept – Health care means patient care Objective - freedom from the disease through

hospital system.

DEFINITION WHO – “As an integrated care containing

promotive, preventive and curative elements that bear the longitudinal association with an individual, extending from womb to tomb, and continuing in the state of health as well as disease.”

EVOLUTION OF HEALTH CARE SERVICES IN INDIAChristian Era –

civilization started in Indus

Valley Environmental sanitation,

houses with drainage

1400 B.C. – Ayurveda and Siddha system

Developed a comprehensive

concept of health

Post Vedic – teaching of

Buddhism and Jainism

Rahula Sankirtyana – developed

hospital system

STILL…66 YRS. OF HEALTH SERVICES

Crude Death Rate ↓Crude birth rate ↓Life expectancy ↑S.pox & G. worm EradicatedLeprosy EliminatedIMR ↓Infrastructure – Expanded Polio Eradicated

ROLE OF DIFFERENT commiteescoCOMMITTEESc

1946 – BHORE COMMITTEE (HEALTH SURVEY AND DEVELOPMENT COMMITTEE) Integration of preventive and curative services Development of PHC 3 months training in PSM

1962 – MUDALIAR COMMITTEE (HEALTH SURVEY AND PLANNING COMMITTEE) Strengthening of PHC and district hospital Regional organization

CONT…

1973 – KARTAR SINGH Committee on multipurpose worker ANM replaced by female health worker Basic health worker replaced by male health worker Lady health worker designated as female health

supervisor.

PROBLEMS

EnvironmentEducationEmpowerment

DiseasesCommunicable Non CommunicableNew emerging

FertilityPopulationGrowth rate Total Fertility

NutritionMalnutritionObesity

INDIRECTLY RELATED TO HEALTH

DIRECTLY RELATED TO HEALTH

MODEL OF HEALTH CARE SYSTEM

INPUTS HEALTH CARE SERVICES

HEALTH CARESYSTEM OUTPUTS

Health Status or Health Problems

Resources

CurativePreventivePromotive

PublicPrivate

VoluntaryIndigenous

Changes in Health Status

HEALTH DEMANDS & NEEDS OF THE COMMUNITY

COMPREHENSIVE &COMMUNITY BASED CARE

CONSTITUTES MANAGEMENT

SECTOR & INVOLVES ORGANIZATION

IMPROVED HEALTH STATUS

EXPRESSED IN TERMS OF LIVES,SAVES, DEATH A

VERTED, DISEASES PREVENTED,LIFE EXPECTENCY

INCREASED

HEALTH ORGANISATION IN INDIA

CENTRAL LEVEL

STATE LEVEL

PERIPHERAL LEVEL

AT THE CENTRE LEVEL

MINISTRY OF HEALTH

AND FAMILY

WELFARE

DIRECTORATE GENERAL OF

HEALTH SERVICES

CENTRAL COUNCIL OF HEALTH AND

FAMILY WELFARE

A. THE UNION MINISTRY OF HEALTH AND FAMILY WELFARE

DEPARTMENT OF HEATLH

SECRETARY

JT. SECRETARY

DY. SECRETARY

ADMN. STAFF

DEPARTMENT OF FAMILY WELFARE

SECRETARY

JT. SECRETARY

DY. SECRETARY

OFFICE STAFF

CENTRAL LIST

International Health, Port Health Research Technical & Scientific Education

FUNCTIONS

International health relations; administration of port quarantine

Administration of central institutes

Promotion of research through research centers

Regulation of medical, pharmaceutical, dental and nursing professions

1. UNION LIST

CONT…

Establishment of drug standards

Census and collection & publication of other statistical data

Coordination with other states for promotion of health

Regulating labor in mines and oil mines

Immigration & emigration

2. CONCURRENT LIST

Prevention of extension of communicable diseases from one unit to another

Prevention of adulteration of food

Control drugs and poisons

Population control and family planningEconomic and social planning

Administration of ports other than majorLabor welfare

B. DIRECTORATE GENERAL OF HEALTH SERVICES (DGHS)

Administrative Staff

Team Of Deputies

Additional Director Of Health Services

Principal Adviser To Union Government

ORGANIZATION

DGHSAdditional DGHS

Deputy DGHS

(Medical care)

Office Staff

Deputy DGHS

(Public health)

Office Staff

Deputy DGHS

(Gen. Administrator)

Office Staff

FUNCTIONS OF DIRECTORATE GENERAL OF HEALTH

SurveysPlanningCoordinationProgrammingAppraisal of all health matters

International Health relationsControl of drug standardsMedical store depotsPostgraduate trainingMedical educationMedical researchCGHS, NHP, CHEB etc.

GENERAL FUNCTIONS SPECIFIC FUNCTIONS

THE CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE

The central council of health was set up by the presidential order on 9th August 1952 under article 263 of the constitution of India for promoting coordinated and concerted action between the center and the state for the implementation of all the programmes and measures pirating to the health of the nation.

Chairman The Union Health Minister

Members The State Health Minister

FUNCTION OF CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE1. To consider and recommend broad outlines of

policy in regard to matters of health such as,Provision of remedial and preventive care.Environment Hygiene.Nutrition.Health education and Promotion of facilities for training and research.

Cont..

2. To make proposals for legislation in fields of medical and public health matters and to lay down.

3. To make recommendations to the central government regarding the health.

4. To established any organization with appropriate functions for promoting and maintain cooperation between central and state health administrations

MILE STONES NRHM-2005 NHP-2002 NPP-2000 RCH-1996

UIP-1985 NHP-1983

Alma Ata-1978 (HFA)JugglingPriorities

Small pox eradicated-July 5, 1975

NFPP-1952 India Joins WHO-1948

HSDC-1946

STATE LEVEL OF HEALTH CARE

HISTORY:

This started from year1919, when the states (then known as provinces) obtained autonomy, from the central government, in matters of public health.

THE STATE LIST

The government of India act, 1935 gave further autonomy to the states. The health subjects were divided into three lists under the 7th schedule of the India constitution. They are:

 1 The Union List2 The State List3 The Concurrent List

FUNCTIONS UNDER STATE LIST

Public health sanitations , hospitals and dispensaries

Local government, i.e. the constitutions and powers of municipal corporations, district boards.

Intoxicating liquors that is production, manufacture, possession, transport, purchase and sale of intoxicating liquors.

Cont….

Relief of the disabled and unemployable.

Burials and burial grounds, cremation grounds.

Markets and fairs.

AT THE STATE LEVEL

•STATE MINISTRY OF HEALTH

•STATE HEALTH DIRECTORATE

ORGANIZATION

STATE MINISTRY OF HEALTH AND FAMILY WELFAREHEADED - Cabinet minister and deputy minister. (Political head)

RESPONSIBILITY - formulating policies

Monitoring the implementation of these policies and programmes

Coordination with government of India and other state government.

STATE HEALTH DIRECTORATE AND FAMILY WELFARE

Principle advisor in matters relating to medicine and public health

Assisted by joint director, regional joint director and assistant directors.

AT THE DISTRICT LEVEL

The principal unit of administration in India is the district under a collector.

There are 672 districts in India.

Districts are known as “ZILA”

DISTRICT HEALTH ORGANIZATION

Identifies and provide the needs of expanding rural health and family

welfare programme

Within each district again, there are 6 types of administrative areas

No uniform model of district health organization

ORGANIZATION

Corporations

Panchayats

Villages

Community Development

Blocks

Town Area Committees

Tahsil (Taluka)

District

Sub division

Municipal Boards

Rural Urban

PANCHAYATI RAJ It is a three tier structure of rural local

self government of India linking village to the district

The three institutions are - Panchayat - Panchayat Samiti - Zilla Parishad

Contd

At village level Panchayati Raj consist of:

- Gram Sabha - Gram Panchayat - Nyaya Panchayat Every Panchayat consist of Sarpanch ,

Up Sarpach and a Pachayat secretary whose functions are to cover entire field of civic admindstration including sanitation and public health.

Contd

At Block level Panchayati Raj agency is the Panchayat Samiti consisiting of village sarpachas,MLA’s and MP’s residing in that area , representatitives of women , SC and ST’s and cooperative societies .

At the District level the Zilla Parishad consist of all heads of Panchayat Samitis ,MLA’s and MP’s of the area and two persons of experience in adminstration, public life or rural development.

HEALTH CARE DELIVERY SYSTEM IN INDIAAt the block level Objective - to provide primary health care to all

the sections of the society. 80% of the population is scattered in villages 20% of rural population have health care facilities

Centre Plain area Hilly / Tribal / Difficult area

Community health centre

1,20,000 80,000

Primary health centre

30,000 20,000

Sub-centre 5,000 3,000

COMMUNITY HEALTH CENTRE’S

Established and maintained by the State Government under MNP/BMS programme.

As per minimum norms, a CHC is required to be manned by four Medical Specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.

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

CONT..

It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.

As on Sep 2013, there are 4,833 CHCs functioning in the country.

In Haryana 2013, there are 108 CHCs functioning.

PRIMARY HEALTH CENTRE’S

First contact point between village community and the Medical Officer.

To provide an integrated curative and preventive health care with emphasis on preventive and promotive aspects of health care.

Established and maintained by the State Governments under the MNP/ BMS Programme.

Manned by a Medical Officer supported by 14 paramedical and other staff.

CONT….

NRHM - two additional Staff Nurses at PHCs (contractual).

It acts as a referral unit for 6 Sub Centre’s and has 4 - 6 beds for patients.

There were 24,049 PHCs functioning in the country as on Sep 2013.

In Haryana Sep 2013, there were 425 PHCs functioning.

PRIMARY HEATH CARE

DEFINITION: Essential health care based upon practical and scientifically sound socially acceptable methods and technology made universally accessible to individuals and families in the community at an affordable price.

Contd… Hallmarks of Primary Health Care: -Acceptability -Affordability -Availability -Accessibility Pillars of Primary Health Care: -Equitable distribution -Community participation -Intersectoral Coordination -Appropriate technology

Components of PRIMARY HEALTH CARE- Education of health problems and their control- Locally endemic diseases prevention and control- Essential drugs- Maternity and Child health care- Immunisation - Nutrition and proper food supply- Treatment of common diseases-

Levels of Primary Health care

Primary level: Includes -Village level -Sub centre -PHC Secondary level:First referral unit Includes CHC TERTIARY LEVEL: 2ND referral unit Includes gov hospitals and medical colleges

Village level At village level following schemes are in

operation: - village health guide scheme - training of local dais - ICDS scheme - ASHA scheme

Village Health guide scheme Introduced on 2nd October 1977. Village health guides serve as first contact

between individual and heath system.Criteria of their selection:

-permanent residents -formal education till 6th standard -acceptable to all sections of society

Local dais They are trained traditional birth attendants -Trained for 30 working days -paid a stipend of Rs 300. -Training given at PHC or sub centre for 2 days a week. - Each dai is required to conduct atleast 2 deliveries supervised by ANM of FHW.

Aanganwadi Worker-1 per 1000 population-100 such workers in each ICDS project - She is trained in various aspects of health

nutrion and child development for a period of 4 months

- Salary 1500 per monthBeneficiaries are nursing mothers,pregnant women,adolescent girls and children.

Functions of Aanganwadi Worker

- Health checkup- Maintanence of growth charts- Immunisation- Supplementary nutrition- Heath education- Non formal pre school education- Referral services

ASHA (Accredited Social Health activist) Selection : - Must be the resident of the village -Age between 25 to 45 years -Preferrably a women -Formal education till 8th class -Having communication and leadership skills -Suggested norm 1per 1000.

Functions of ASHA- Create awareness on nutrition,sanitation, Hygiene and healthy environment.- Counsel women on birth preparedness,safe delivery,breast and complementary feeding,immunisation and contraception- Mobilise community to sub centres and PHC - She will work with the village health and sanitation committee.

Contd..- Escort pregnant women and children req treatment to the PHC’s.- Provide primary medical care for minor ailments like diarrhoea and injuries- Provider of DOTS.- Depot holder for ORS,IFA tablets, DDK’s,chlororoquine, OCP’s and condoms.- Inform about the births and deaths in her community.

Role and integration with ANM

- ANM will hold fortnightly meetings with ASHA- She will act as resource person in the training of ASHA- Inform ASHA about date and time of outreach session.- Will participate in organising health days - She would educate ASHA on all her resposibilties and use her in motivating all sections of community on health issues.

Evaluation of ASHA’s work % of newborns weighed and families

counselled % of children with diarrhoea receiving ORS % of deliveries with skilled assistance % of institutional deliveries % of completely immunised children

below 2yrs of age.

Sub centre Peripheral outpost of the health care

delivery in rural areas. 1 per 5000 in plains and per 3000 in hilly

areas. Staff – 3 1 MPW male 1 MPW female 1 volunteer workerNo. of subcentres in India ,152326(2014)

Functions of Sub Centre Antenatal care Intranatal care Child health care Family planning and contraception Counselling for safe abortion Adolescent care School health services

Primary Health Centres First contact point between village

community and Medical Officer. Staff of PHC - 15 - Medical officer – 1 Pharmacist - 1 - Nurse -1 Health worker(f)- 1 - Heath Educator – 1 - Health assistant ( m and f ) -2 - Clerk – 2 lab assistant -1 - driver -1 class 4 - 1

Functions of PHC and medical officer

PHC: - OPD,emergency and referral services -Maternal and child health care -Family planning services -MTP services -prevention/management of RTI/STI. -nutrional services. -school/adolescent health services -National heath programmes.

Contd…- Disease survillience and epidemic control- Collection and reporting vital events- Sanitation promotion- Prompt referral to CHC’s- Training of health workers, birth

attendants , ASHA ,ANM ,Aanganwadi,pharmacist.

- Vasectomy and tubectomy- Basic laboratory services

Community heath centres Each CHC acts as referral centre for 4

PHC’s Staff 30-31 -Physician,General Surgeon- 1 each -Pediatrician,Gynaecologist- 1 each -Nurse- midwife – 9 -pharmacist and lab tech – 1each -radiographer and ophthalmic ass -1 other staff – 15

Suggested population norms

Doctor:1 per 1000 Nurse:3 per 1 doctor Health worker:1 per 5000 & 3000 Health assistant:1 per 30000 & 20000 Pharmacist:1 per10000 Lab technician:1 per 10000 ASHA:1 per 1000 Trained dai:1 per 1000 AWW:1 per 400 & 800

RURAL HEALTH STATISTICS

No. of subcentres : 152326 No. of PHC’s : 25020 No. of CHC’s : 5363 No. of districts : 672 No. of villages : 640867 Rural population : 68.9% CBR : 21.4 (SRS) CDR : 7.0 (SRS) IMR : 40

PHC PROGRESS IN INDIA (2012-13)

Progress made in CHCs during 2005-12

INTEGRATED APPROACH OF HEALTH CARE DELIVERYICDS – integrated child development scheme

Agriculture, irrigation and engineering

Animal Husbandry

Education

Social and Women's Welfare

Urban Family Welfare Centers

Health planning Steps of health planning 1- analysis of heath situation 2- establishment of goals 3- assessment of resources 4- fixing priorities 5- formulating plan 6- programming & implementation 7- monitoring 8- evaluation

BUDGET IN FIVE YEAR PLANSFIRST PLAN (1951-56) • BUDGET: 1,960 Crore HEALTH: 5.9%

SECOND PLAN (1956-61) • BUDGET: 4,672 Crore HEALTH: 5%

THIRD PLAN (1961-66) • BUDGET: 8,576 Crore HEALTH: 4.3%

FOURTH PLAN (1969-74) • BUDGET: 15,778 Crore HEALTH: 7.2%

FIFTH PLAN (1974-79) • BUDGET: 39,322 Crore HEALTH: 8.8%

SIXTH PLAN (1980-85) • BUDGET: 97,500 Crore HEALTH: 1.8%

SEVENTH PLAN (1985-90)• BUDGET: 1,80,000 Crore HEALTH:

1.9%EIGHTH PLAN (1992-97) • BUDGET: 79,8000 Crore HEALTH: 9.5%

NINTH PLAN (1997-2002)• BUDGET:8,59,200 Crore HEALTH:

1.25%TENTH PLAN (2002-07)

• BUDGET: 14,84,131.30Crore HEALTH: 1%

ELEVENTH PLAN (2007-12) • BUDGET: 136,147Crore HEALTH: 1.5%

TWELFTH PLAN (2012-17) • BUDGET ALLOCATED: 90,000 Crore

Twelth five year plan goals IMR - 25

MMR - 100 TFR - 2.1 Under 3 yr malnutrition - 50% reduction Anaemia in 15 to 49 – 28% 0 to 6 child sex ratio - 950 TB- mortality reduction by 50 % Leprosy- zero incidence Malaria - incidence < 1/1000 Filaria – Mf prevalence <1% Dengue – CFR<1% HIV/AIDS – ZERO NEW INFECTIONS Kala Azar - Elimination by 2015

BUDGET SUPPORT

Budget Support for Central Departments in Eleventh Plan (2007–12) and Twelfth Plan (2012–17) Projections (` Crore)

Department ofMoHFW

Eleventh PlanExpenditure (in

Crore)

TwelfthPlan

Outlay( in Crore)

%Increase

Department of Health and Family Welfare

83407 268551 322%

Department of Ayurveda, Yoga &Naturopathy, Unani, Siddha & Homoeopathy (AYUSH)

2994 10044 335%

Department of Health Research 1870 10029 536%

Aids Control 1305 11394 873%

Total MoHFW 89576 300018 335%

HEALTH EXPENDITURE, PUBLIC (% OF GDP) IN INDIA

HEALTH EXPENDITURE, PRIVATE (% OF GDP) IN INDIA

OUT-OF-POCKET HEALTH EXPENDITURE (% OF PRIVATE EXPENDITUTEON HEALTH) IN INDIA

EXTERNAL RESOURCES FOR HEALTH EXPENDITURE (% OF TOTALEXPENDITUTEON HEALTH) IN INDIA

NURSES AND MIDWIVES (/ 1000 PEOPLE) IN INDIA

CONTRIBUTION BY NGOS

Providing services like relief to the blind, the disabled and disadvantaged and helping the government in mother and child health care, including family planning programmes.

Greater roles for the NGOs was seen to ensure Health for All through the primary health care approach.

Government of India started granting financial aids to NGOs for various schemes

Contracting in & out – government hires individuals on a temporary basis to provide services

Privatization

CHALLENGES Prices of services in private sector

Earning commission from diagnostic laboratories

Financial protection against medical expenditure

Non availability of medical, nursing and paramedical staff

Inadequate and weak drug control infrastructure

Inadequate drug testing facility

Extremely high drug cost

No clear urban health care delivery model

CONCLUSION

“The number of students graduating from secondary schools, which can be expressed as “the percent of health schools that are accredited” which can be expressed as “ the reflection of health care of the country” 

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Jaypee publishers : New Delhi. 2008; 38,43, 894- 903 Behind_the_numbers_Medical_cost_trends_for_2011 http://pwchealth.com/cgilocal/hregister.cgi?link=reg/ www.pubmed.com www.google.com

Indian Public Health Standards (IPHS) guideline for community health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94

http://www.newindianexpress.com/magazine/India-has-just-one-doctor-for-every-1700-people/2013

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information.html

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