HEALTH CARE DELIVERY SYSTEM IN INDIA

Dr Umesh Kawalkar

INDEX
Health care Evolution of health care system in India Hospitals Health insurance sheme Private sectors Voluntary health agencies

Health Care
Multitude of services rendered to individual or communities by the agent of the health services or professional for the purpose of promoting, restoring and maintaining the health It is along with prevention, promotion and rehabilitation care and also includes medical care

Public Health System

A network of public, private, and voluntary entities that contribute to the health and wellbeing of a community.
(Source: WHO World Health Report 2004.)

Components of Health service system

Structure of health system Process of health care delivery Outcomes of health care Flow of patient in health care system

Health care system in India

1) Public health Sector
Primary Health Care
Primary Health Centers Sub Centers

Hospitals/ Health centers

CHC Rural Hospitals District Hospitals Specialist Hospitals Teaching Hospitals

Health insurance Schemes

Central Govt. Health Scheme E.S.I. Scheme

Other Agencies
Defence services Railways

2) Private Sector
Private Hospitals , Nursing Homes G.P. & Dispensaries

3) Indigenous System of Medicine AYUSH 4)Voluntary Health Agencies 5)National Health Programmes

Evolution of Health system In India

Bhore committee constituted in 1943 laid the framework on which the health care was eventually built in the independent India. The health care in India has since moved from bureaucratic government based top down approach to decentralized community based bottom- up system after the Panchayati Raj came into being.

 Srivastava committe (1974) recommended Creation of Village Health Guide (VHG) or community health volunteers based on its recommendation rural health scheme was launched. Rural Health Scheme has principle of Placing peoples health in people hand.

 In 1977, the World Health Assembly at Alma Ata decided to launch an ambitious movement known as, Health for All (HFA) by 2000 AD. As a signatory to HFA strategy, the Government of India frame its own policy in 1983 i.e. National Health Policy

More recently National Rural Mission was lunched

In twelfth five year plan (2012-2017) total government expenditure on health would be increased to 2.5 percent of the gross domestic product (GDP) by 2017, to to allocate adequate resources to achieve the target

Health Care System

The health system in India has 3 main links
1.Central 2.State and 3.Local or peripheral

Central level
Union Ministry of Health and Family Welfare Department of Health & Family Welfare Department of AYUSH Department of Health Research Department of AIDS Control (each of which is headed by a secretary ) .

Directorate General of Health Services(Dte.GHS) is attached office of the Department of Health & Family Welfare and has subordinate at offices spread all over the country. The DGHS renders technical advice on all medical and public health matters and is involved in the implementation of various health services.

State level
Under the State Department of Health and Family Welfare in each State headed by Minister and with a Secretariat under the charge of Secretary/Commissioner (Health and Family Welfare). The State Directorate of Health Services, as the technical wing, is an attached office of the State Department of Health and Family Welfare and is headed by a Director of Health Services The area of medical education which is with the Directorate of Health Services at the State, is known as Directorate of Medical Education and Research. Some states have created the posts of Director (Ayurveda) and Director (Homeopathy)

Regional level Each regional/zonal set-up covers three to five districts and acts under authority delegated by the State Directorate of Health Services. District Level A middle level management organization and it is a link between the State as well as regional structure on one side and the peripheral level structures such as PHC as well as sub-centre on the other side.

RURAL AREAS
Through the network of Community Health workers Sub centers , PHC

Community level
For a successful primary health care programme, effective referral support is to be provided. For this purpose one Community Health Centre (CHC) has been established. Community Health Centre (CHC) has been established for every 80, 000 to 1, 20, 000 population, Provides the basic specialty services in general medicine, pediatrics, surgery, obstetrics and gynecology.

 . At present 4510 CHCs are functioning in the country

Primary Health Centre (PHC)

Cornerstone of rural health services- a first port of call to a qualified doctor of the public sector in rural areas for the sick. The 6th Five year Plan (1983-88) proposed reorganization of PHCs on the basis of one PHC for every 30,000 rural population in the plains and one PHC for every 20,000 population in hilly, tribal and backward areas for more effective coverage.

 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 curative, preventive, Family Welfare Services and promotive aspects of health care. There are 23391 PHCs functioning in the country.

Minimum Requirements at the Primary Health Centre for meeting the IPHS :
Medical care Maternal and Child Health Care including family planning Medical Termination of Pregnancies Management of Reproductive Tract Infections / Sexually Transmitted Infections Nutrition Services (coordinated with ICDS) School Health Adolescent Health Care Promotion of Safe Drinking Water and Basic Sanitation Prevention and control of locally endemic diseases. Disease Surveillance and Control of Epidemics Collection and reporting of vital events

 Education about health National Health Programmes Referral Services Training Basic Laboratory Services Monitoring and Supervision AYUSH services as per local peoples preference Rehabilitation Selected Surgical Procedures Record of Vital Events and Reporting

Duties of Medical Officer, Primary Health Centre

Curative Work Preventive and Promotive Work Training Administrative Work

COMMENTS
Majority of PHC don't have full staff Shortage & misuse of transport vehicle Few no. Female physicians so difficulty in delivering RCH services Majority of MBBS graduate were not ready to work at PHC

Sub-Centre
Most peripheral and first contact point between the primary health care system and the community. provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes Also provides with basic drugs for minor ailments Sub-centre is staffed by one Female Health Worker commonly known as Auxiliary Nurse Midwife (ANM) and one Male Health Worker commonly known as Multi Purpose Worker (Male) Lady Health Visitor (LHV) and one Health Assistant (Male) located at the PHC level are entrusted with the task of supervision

Village Level
Village Health Guide Scheme Trained Local Dais ICDS Scheme ASHA scheme

Village Health Guide Scheme

Started from 2nd Oct 1977 In all states expect (J &K ,Kerala, Karnataka , TN,AP) Come from & chosen by the community in which they work First contact between individual & Health system Guidelines of their selections
Permanent resident of local community Preferably women At least formal education upto VI std Acceptable by all spare 2-3 hr per day for work daily

 VHG undergo short training at PHC for 200 hrs After training completion get working manual & kit of simple medicine Duties
T/t of simple aliments mother and child health care Family planning Health education & Sanitation

Trained Local Dais

Only women immediately available to women during perinatal period Training of dais under rural health scheme To improve their knowledge in elementary concept MCH & sterilization Training for 30 working days During training must have to conduct at least 2 deliveries under supervision of HWF ,ANM, HAF Get certificate with delivery kit Expected to play vital role in propagating small family norm

ICDS SCHEME
Anganwadi worker for the population of 1000 Undergoes training in various aspect of health nutrition, & child development Part time worker & get 1500 Rs per month Services rendered Health checkup of child maintaining growth chart Immunization Non formal preschool education Referral services Beneficiaries are nursing mothers, pregnant women, other women 15-45 yrs, children below 6 yrs & adolescent girls

Accredited Social Health Activists (ASHA)

Provided in each village in the ratio of one per 1000 population.(tribal, hilly, desert areas, the norm could be relaxed)
Primary resident of the village Formal education upto class VIII and The age group 25-45. Selected by the gram Sabha.

she would be entitled for performance based compensation & reasonable efficiency would be able to earn Rs. 1000 per month.

 ASHAs would reinforce community action for universal immunization, safe delivery, newborn care, prevention of water-borne and other communicable diseases, nutrition and sanitation. She will also help the villagers promote preventive health by converging activities of nutrition, education, drinking water, sanitation etc. Work with AWW ASHA will also assist the villagers in referral services for AYUSH/testing HIV/ AIDs, STI, RTI, also preventive, promotive health already with AWW/VHGs etc.

Comments
None of ANM workers found to be performed excellent job (>75% subtask performed well) by the Rangrao etal study in 2003 The stress to achieving the sterilizing targets left little time to attend other duties. ANM have to maintain 13 registers & submit seven reports to PHC LHV should have to support but have more on administrative supervisor than clinically competent provider Lack of physical infrastructure ; equipment & basic amenities No time for house to house visit for newborn ; perinatal care & village health level session

Health Manpower in Rural area

Shortages of doctors at PHC & specialist care also shortage Available public health specialist low Doctors and specialist in position means that it is not always that he/she present at center and performing duty .Absenteeism is very high Large no fresh graduates have no knowledge of simple procedure like immunization , nutritional advice, IV fluids inj., contraception's More urban oriented and heavily dependant on the methods used at tertiary care

URBAN AREAS
Central Govt. Health Scheme started 1954 at Delhi For the medical care facilities to central govt. employees & their family members. Later extended to other major cities URBAN HEALTH SERVICES As one of the thrust area 10 th five year plan; National population policy 200,National health policy 2002; RCH IInd phase URBAN FAMILY WELFARE CENTERS Launched during First five year plan 1083 till functioning providing promotive, preventive, curative activity

HOSPITALS
Govt. hospital mainly to serve urban area Hospitals differs from health centers
Services provided are mostly are curative No catchment area .I.E. No definite area of responsibilities Only curative staff

Apart from PHC, the present organization of health services of the Govt. sector consist Rural Hospital, Sub Divisional Hospital , District Hospitals , Specialist Hospitals & Teaching Hospitals

Health Insurance
Here the basic tenet is that a large group of people are made to share the risk that they may need health care at any point of time, thus creating a risk pool. The funds dedicated for health care are collected through prepayment and managed in such a way as to ensure that the risk of having to pay for health care is borne by all the members of the pool and not by each contributor individually.

ESI Central Govt. Health scheme

Pradhan Mantri Swasthya Surksha Yojana

Approved in March 2006 Objectives of correcting the imbalance between in availability of affordable & reliable tertiary level health care in general and to augment facilities for quality of medical education in underserved area Setting of 6 AIIMS like institutions Upgrading of the medical institutions

Rashtriya Swasthya Bima Yojana

Launched on 15 Aug. 2007 by Prime Ministers Health insurance scheme for BPL families in unorganized sectors

PRIVATE AGENCIES
Very large share of health service Own account enterprises are 80% of the total health facility Most of them congregate in urban areas. Mainly curative services Available for only those who can pay.
Facts in NSS survey
Highly skewed distributions (88% health facilities at Urban & Remaining 22% in rural) Private sectors has 75% specialist & 85% technology Nearly 2/3 of doctors were concerted at urban area Private sectors accounts for 49% of bed 75% of services for dental, mental , ortho, vascular & cancer & 40% of the communicable disease were by private sectors

Alternate systems of health care in India

A large share of health practice in the country based on alternate systems of medicines, These systems are supporting health care in remote areas, for the disadvantaged groups and the poor who cannot afford the increase in health care costs in the country. Government of India has established a separate department of AYUSH under MOHFW

Voluntary Health Agency

Organization that is administered by an autonomous board which holds meeting , collects funds for its support chiefly from private source and expends money whether with or without paid workers in conducting programme dedicated primarily furthering public health by providing health services or health education or by advancing research or legislation for health or by combining these activities

Voluntary Health Agency In India Indian Red Cross Society Hind Kusht Nivarn Sangh Indian Council For Child welfare TB association in India Bharat Sewak Samaj International Agency Rockefellar Foundations FORD Foundations CARE

National Health Programmes

Measures to improve the health of the people 1. Control/eradication of communicable and noncommunicable diseases 2. Improvement of environmental sanitation 3. Raising the standard of nutrition 4. Control of population 5. Improving rural health

References
Park k. Textbook of Preventive and Social Medicine 20 th edition 2009 Bhanot publications p.n. 76-82 Dr J.P. Baride Dr. A.P. Kulkarni.Textbook of community medicine 3rd edition Vora publications 2006, Bhalwar Rajvir . Textbook of Public Health And Community Medicine published by dept of community medicine , AFMC,pune 2009 J Kishors National Health Programmes of India , National policies and Legislation Realted to Health 9 th edition century publiccations