PRIMARY HEALTH CARE SYSTEM IN INDIA -STRUCTURE & SERVICESDR PRADIP AWATE, ASSISTANT DIRECTOR OF HEALTH SERVICES, MAHARASHTRA

Scheme of Presentation

Concept & Importance of Primary Health Care (PHC)

Brief history of PHC in India Evolution of PHC in India Current structure of PHC Services provided through PHC Issues, Challenges & Opportunities in front of PHC

Concept of PHC

Characteristics of PHC I

1. PHC reflects and evolves from the economicconditions and sociocultural and politicalcharacteristics of the country and its communitiesand

2. PHC is based on the application of the relevantresults of social, biomedical and health servicesresearch and public health experience;

3. PHC addresses the main health problems inthe community, providing promotive,preventive, curative and rehabilitativeservices accordingly;

4. PHC includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

Characteristics of PHC II

6. PHC should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;

7. PHC relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

Characteristics of PHC III

History & Evolution of PHC

‘If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material

and the lowering of human efficiency through malnutrition andpreventable morbidity,

we feel that the result would be so startling that the whole countrywould be aroused and

would not rest until a radical change had been brought about‘(Bhore Committee Report 1946)

सव सु खनः संतु l

सव संतु नरामया ll'Let all be free

from disease/let all be healthy',

History

1946 – put forward concept of Primary Health Care.

1974- Integrated cadre of MPWs.

In 1977, GoI launched a based on principle of ‘ placing people’s health in people’s hand.’ ( Recommendation of

1975) 1978 – – Health for All

through Primary Health Care.

Population Norms for PHC

Bhore Committee – PHC/ 10- 20,000 population.( But ….resources???) Mudaliar Committee (1962) – PHC/ 40,000

population. By Fifth Plan (1975-80) – PHC was catering health

needs of 1,00,000 population. Alma Ata – New philosophy of Primary Health Care 1983- National Health Plan – PHC/ 30,000 in plain

areas & per 20,000 in hilly region.

Number of PHCs

725

5484

23,887

I Five Year Plan V Five Year Plan Mar-11

Current Structure of PHC in India

The Ultimate Goal of PHC

1. Reducing exclusion & social disparities in health. ( Universal Health Coverage Reform)

2. Organizing health services around people’s needs. ( Service delivery reforms)

3. Integrated health in to all sectors ( Public Policy Reforms)

4. Pursuing collaborative models of policy dialogue ( Leadership reform)

5. Increasing stake holder participation

Structure of Health Care In India

District Hospital

RH/SDH/CHC

Primary Health Center

Subcenter

Village

Subcenter

Village Village Village

Subcener

Village Village

Subcenter

Services Provided Through PHC

Octagon of PHC

1. Education of the people about prevailing health problems and methods of preventing and controlling them.

2. Promotion of food supply and proper nutrition. 3. Adequate supply of safe water and basic sanitation. 4. Maternal and child health care and 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.

Octagon of PHC

Health Education

Food Supply & Nutrition

Safe Water & Sanitation

Mother & Child Health

& Family Welfare

Immunization

Prevention & Control of Diseases

Appropriate Treatment of

Common Diseases &

Injuries

Provision of Essential drugs

Spectrum of Primary Health Care

Village Level

• Started in 1977.• Now replaced by ASHA

Village Health Guide

• Started under rural health scheme • Training of local dais for 30 days• Now not preferred.

Training of Local Dais

• Advent with NRHM (per 1000 population) • Imp link between community & health servicesASHA

AWW •Under ICDS•For every 400-800 population

ASHA

–

1. Local resident.2. Preferable Age -25-45 yrs3. Formal education up to 8th class.4. Communication & leadership qualities.5. Adequate representation from disadvantaged

population.6. Ensured to serve such groups better

Role of ASHA

1. Awareness & info to community about determinants of health.

2. Counseling of women3. Mobilization &

facilitation of community to access health care.

4. Work with VHSNC.5. Accompany women &

children in need of health care.

6) T/t minor ailments & DOTS provider.

7) Depot holder of essentialdrugs, ORS, IFA, DDK, Antimalariadrugs, condoms, Oral pills.

8) T/t of childhood illnesses9) Inform about vital events.10) Promote household toilets

under total sanitationcampaign.

Integration of ASHA with AWW & ANM AWW & ANM –

resource person for ASHA.

Organizing Health day.

Mobilizing beneficiaries

Survey of eligible couples & children < 1 yr

Wkly/fortnightly meeting of ASHAs by ANM.

IEC activity Preparation of Village

Health plan

Anganwadi Worker (ICDS)

1. Health check up including maintenance of growth charts.2. Immunization3. Supplementary nutrition4. Health education5. Non formal pre primary education6. Referral services

Nursing & pregnant women Other women (15-45 years) Children below 6 years

Composition of VHSNC

50% members should be women. Every hamlet should have adequate representation

along with representative from weaker sections. 30% representation for Non Government Sectors. Representation to women’s self help group.

Village Health Sanitation & Nutrition Committee (VHSNC) Create awareness about nutritional issues Carry out survey on nutritional status and nutritional deficiencies in the village Identify locally available food stuffs of high nutrient value as well as disseminate

and promote best practices (traditional wisdom) congruent with local culture, capabilities and physical environment through a process of community consultation.

Inclusion of Nutritional needs in the Village Health Planand facilitate its working in improving nutritional status of women and children. .

Monitoring and Supervision of Village Health and Nutrition Day to ensure that it is organized every month in the village with the active participation of the whole village.

Facilitate early detection of malnourished children in the community, tie up referral to the nearest Nutritional Rehabilitation Centre (NRC) as well as follow up for sustained outcome.

Supervise the functioning of Anganwadi Centre (AWC) in the village Act as a grievances redressal forum on health and nutrition issues

Sub center

One per 5000 population in general & one for every 3000 population in hilly region.

As of 2011, total sub centers in our country –1,48,124.

Approved staff – One ANM + One MPW. One Health Assistant (Male) & One Health Assistant

(Female –LHV) –located at PHC HQ are entrusted with supervision of six SCs under PHCs.

Rogi Kalyan Samiti(Patient Welfare Committee)

Simple yet effective management structure

A registered society, acts as a group of trustees for the hospitalsto manage the affairs of the hospital.

It consists of members from1. local Panchayati Raj Institutions (PRIs), 2. NGOs, 3. local elected representatives and 4. officials from Government sector who are responsible for

proper functioning and management of the hospital / Community Health Centre / FRUs.

RKS / HMS is free to prescribe, generate and use the funds with it as per itsbest judgment for smooth functioning and maintaining the quality of services.

Package of Services at Sub Center

Immunization Antenatal, natal & postnatal care Prevention of malnutrition Common Childhood Diseases Family Welfare Services Counseling Elementary drugs for minor ailments Community Needs Assessment Various National Health Programmes

Objectives of IPHS for PHCs

I] To provide comprehensive primary health care to the community through the primary health center.

II] To achieve & maintain an acceptable standard of quality of care.

III]To make the services more responsive & sensitive to the needs of the community.

PRIMARY HEALTH CARE

Preventive

Promotive

Curative

Rehabilitative

IPHS for PHCs

1. Medical Care2. Maternal & child care3. Family planning services4. MTP services 5. Health education &

management of RTI/STI6. Nutrition Services7. Basic lab services8. Selected Surgical

procedures

9. School health Services10. Adolescent health care11. Disease Surveillance &

control programme12. Collection of vital events13. Promotion of sanitation

including use of toilet & appropriate garbage disposal

14. Water quality monitoring15. M & E

Main National Health ProgrammesThrough PHC RNTCP National Programme for blindness (NPCB) National Leprosy Elimination Programme (NLEP) NVBDCP National AIDS Control Programme (NACP) National Program for Prevention & Control of

Cancer, Diabetes, Cardiovascular diseases & Stroke National Program For Health Care of the Elderly

(NPHCE) Programmes for Iodine Deficiency, Tobacco Control

INTEGRATED HEALTH APPROACHContent Activities Ministries/Agencies involved

Focused activities for marginalized population Employment, Food security Tribal Welfare, Social welfare

Food SupplyGrains, Cereal, Tuber, Vegetables and Fruit

productionAgriculture, Animal Husbandry, Fisheries, Social

Welfare

Proper Nutrition Milk and dairy products, meat and fish Animal Husbandry, Dairies - pvt/cooperatives, FDA

Food supply Agricultural Produce Markets Ration Shops PDS

Food quality, safety FDA

ICDS, Women and Child Development Women & Child Welfare

Safe Water

Drinking Water Resources, Sewage drainage and disposal, Water purification, Forest and

Water Conservation, IrrigationWater Supply & Sanitation , PWD, Rural Development,

Public Health Labs

Sanitation Solid waste disposal PWDs, Urban Planning, Environmental

Mother (Women) CareMarriage registration, ANC, PNC, CaCx

detection, family planningPublic Health and Family welfare, Registrar of Vital

events

Child care

Trained Birth Attendant, Institutional delivery, Birth registration, early Breast feeding,

Immunization, treatment of illnesses, early child care

Public Health and Family welfare, FDA, Pharmaceutical and Health device industry, Paediatric clinics/hospitals,

vaccine industry

Communicable Diseases Prevention & Control activities Water Supply & Sanitation, Urban Development, Rural Development, Agriculture, Forest, Animal Husbandry

Challenges In Providing Effective PHC

Challenges ???

Infrastructure for rising population Size & diversity Rapid urbanization Changing demographic profile – Ageing

population Triple burden of diseases Man power crisis Quality care & client satisfaction Quality research in PHC

The woods are lovely, dark & deepBut I have promises to keep…And miles to go before I sleep…!

--- Robert Frost.