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P.G.Guide : Dr.

Gajanan Velhal
P.G.Student:
Dr amit Gujarathi
Dr. Tushar Nale
WHO Health Definition
Health- It is state of complete physical,
mental & social wellbeing of individual & not
merely absence of disease or infirmity
Non medical dimensions are spiritual,
emotional vocational & political
Positive Health- person who is healthy
physically, mentally & socially is said to be in
state of positive health i.e. highest standard of
health
Health care system in India consist of 3
sectors 1. Public sector
2. Private
3. Informal network of care
providers
Health care defined as multitude of services
rendered to individual or communities by
agents of services for purpose of promoting,
restoring & maintaining of health.
Evolution of health
system in INDIA
Phase I- (1947-1983)- It was based on two
principles 1. None should be denied care for
want of ability to pay 2. It was totally state’s
responsibility to provide health care to the
people
Phase II (1983-2000)- First national health
policy of 1983 articulated the need to encourage
private initiative in health care service delivery
Phase III (post 2000)-
1. Desire to utilize private sector
resources for addressing public health goals
2. Liberalization of
insurance sector to provide health financing
system 3. Redefining
roll of state from being only a provider to a
financier of health services as well
Committees & Commissions
 Bhore committee : Health survey and development Committee (1943-
1946) report submitted.
 Stressed on to provide comprehensive health care package by introducing
PHC
 Short term and long term measure
 Compulsory 3 months training during medical education to prepare social
physician.
 Mudaliar committee(1959-62)Health Survey And Planning Committee
 It had evaluated the measures taken by Bhore committee
 Strengthening of existing PHC’s and Taluka and District hospital as referral
 Chaddah committee(1963) (Surveillance) Stared the survelilance
activity under NMEP by PHC’s staff (1 per 10,000) additional duties like
Vital staitics and FP activity ( Multipurpose worker)
 Mukherjee committee(1965)
• Recommended that there should be sepetare staff to carry out
Family planning activities
• 1966 Establishment of Rural Family planning centers and urban
Family planning centers
 Junglewala committee(1967)
• Integration Of Health Services so named as Committee on
integration of health services.
• There should be unified cadre, Common seniority, Recognition of
extra qualification Equal pay for eqal work and special pay for
special work ,Elimination of private practice by Gov. doctors
 Kartar Singh committee(1973) MPW scheme
Recommendation were :
Auxiliary midwife to Female multipurpose worker
BHW,MSW,Vaccinator to one grope Heal worker Male and Female
Male and Female health assistants
 Srivastav committee(1974-75)
• Medical Education & Support Man-Power
• They have studied the medical education and health care services in
india and formulates he suitable curriculum for medical education
and health care delivery system
Still…62 yrs. of Health Services
Sr. Indicators Rate during Current rate Target by 2000
no 1978 AD
1 CBR 33/1000 MYP 22.8/1000MYP 21/1000 MYP
2 CDR 14/1000 MYP 7.4/1000 MYP 9/1000 MYP
3 IMR 125/1000 Live 53/1000 live 60/1000 MYP
births births
4 MMR 4.5/1000 live 2.54/1000 live 2/1000 Live
births births births
5 Incidence LBW 30% 30% 10%

6 CPR 23% 46.6% 60%


7 Immunization 35% 85% 100%
infants
8 Life 52 Years 64 Years 63 Years
expectancy
Still…62 yrs. of Health Services
Crude Death Rate ↓
Crude birth rate ↓
Life expectancy ↑
IMR ↓
S.pox & G. worm eradicated
Leprosy eliminated
Infrastructure – expanded
Growth rate
Literacy
Sex ratio
Mile stones:
NRHM-2005
NHP-2002
NPP-2000
RCH-1996
UIP-1985
NHP-1983
Alma Ata-1978 (HFA)
Small pox eradicated-July 5, 1975
NFPP-1952
India Joins WHO-1948

HSDC-1946
 Juggling Priorities
 Committees and Commissions
 Single issue addressed by Committee
 Comprehension was missing
 recommendations- reiterations of Bhore Committee.
 Uni-purpose workers later baptized as Multi-purpose.
 Programs worked in complete isolation till 1980 (e.g.
NTCP).
 Fragmented approach to Health.
Administration and
Health team
 Management :can be defined as the universal process of
organizing people and resources efficiently so as to direct
activities toward common goals and objectives.
Health Team : Is group of persons having common Health
goals, to achievement of which each member of team
contributes in accordance with his or her competence and
skills and in coordination with function of other team
Administration: Getting the work done
Indian Administrative
levels
Health administration governed in India at 4
levels
 1) National level(Central level)
 2) State level
3) District level
4) Village level
Administration at central
level
Health administration in India is governed by
the union Ministry of Health and Family
Welfare
The central administration provides co-
ordination and direction to a network of state
health ministries for actual implementation
FUNCTIONS OF UNION
HEALTH MINISTRY
UNION LIST ( Function carried out by only
central government)

1. International health relations &


administration of port quarantine.
2. Administration of central institutes e.g.
NICD, AIIHPH etc.
3. Promotion of research through research
centers & other bodies.
4. Regulation & development of medical, dental,
pharmaceutical & nursing professions.
5. Establishment & maintenance of drug
standards.
6. Census and collection & publication of other
statistical data.
7. Immigration & emigration.
8. Regulation of labour in the working of mines &
oil fields.
9. Co-ordination with states and with other
ministries for promotion of health.
FUNCTIONS OF UNION
HEALTH MINISTRY
CONCURRENT LIST ( joint responcibilty
between central and state governments)
1. Prevention of extension of communicable
diseases from one unit to another.
2. Prevention of adulteration of foodstuffs.
3. Control of drugs & poisons.
4. Vital statistics & registration
5. Labor Welfare( social security and and
insurance)
6. Ports other than major
7. Economic planning.
8. Social planning.
9. Population control
10. Family Planning.
CENTRAL LEVEL 3 Heads
Political
UNION MINISTRY OF Executive
HEALTH & FAMILY Technical
WELFARE

Cabinet Minister
Minister of State
Deputy Health Minister

Dept of Health Dept o f F.W. Dept. of AYUSH


Secretary to Government of India

Joint Secretaries Additional Secretary


Deputy Secretaries 1 Joint Secretary 2 Joint sec
Administrative Staff Commissioner F.W 1 Assistant sec.
ORGANISATION :
DIRECTOR - Principle advisor to union government

assisted by Medical Public Health


matters.

Deputies & other administrative staff.

FUNCTIONS –
FUNCTIONS –
General : Surveys, planning , co-ordination, programming &
appraisal
of health matters.

Specific Function :
1. International health relations & quarantine

2. Control of drug standards

3. Maintenance of Medical Stores depots

4. Administration of all national institutes

5. Medical Education- Lady Harding Medical College, The Maulana

Azad MC, Medical colleges at Pondicherry and Goa.


6. Emergence of medical research Medical
Research – ICMR (1911)
CRC, TRC, Virus Research Centre, Pune, NIV.
7. Implementation of CGHS
8. Implementation of National Health Program
9. Running central health education bureau
10 . Running Central Bureau of Health
intelligence .
11. Running National Medical Library (1966)
Functions of Department of
Health:
Health related activities, including various
immunization campaigns
Control over various health bodies including
National Aids Control Organization (NACO),
National Health Programmes, Medical
Education & Training, and International
Cooperation in relation to health;
 Administers the Hospital Services
Consultancy Corporation
Functions of Department of Family &
Welfare:
Maternal and Child Health Services.
Information, Education and Communication.
Rural Health Services, Non-Governmental
Organizations and Technical Operations.
Policy Formulation, Statistics, Planning,
Autonomous Bodies and Subordinate Offices.
Supply of Contraceptives.
International Assistance for Family Welfare
and Urban Health Services.
Administration and Finance for the
Departments of Health, Family Welfare
Functions of Department of
AYUSH:
Upgrade the educational standards in the
Indian Systems of Medicines and
Homoeopathy colleges in the country;
Strengthen existing research institutions and
ensure a time-bound research programme on
identified diseases for which these systems
have an effective treatment;
Draw up schemes for promotion, cultivation
and regeneration of medicinal plants used in
these systems;
Evolve Pharmacopoeial standards for Indian
Systems of Medicine and Homoeopathy drugs
Central Council of Health and family
welfare
 Set up on 9th August 1952
 For promoting coordinated and concerted action
between the centre and the states in the
implementation of all the programmes and
measures pertaining to the health of the nation.

Chairman - Union Health Minister


Members - Health Ministers of all states and union
territory
Meets once in year
Functions
1) Promoting co-operation between health
organization and at central and state level
2) Formulates broad policy and programme
3) Proposing suitable legislation in public
health matters
4) Recommends appropriate framework for
proper distribution of GRANT-In-AID to
states for health purposes.
5) Reviews work done in last one year
Health Administration at State level
- State list
- Mainly Medical care, preventive health services
and pilgrimages within the state.
State Ministry of Health
Minister of Health and Family Welfare( political )
Secretary ( executive)
Directors of 1) Health and family welfare
2) Medical education and research
(technical)
Assisted by deputy director, additional director and
administrative staff.
Regional level (circle)- Each
regional/zonal set-up covers three to five
districts and acts under authority
delegated by the State Directorate of
Health Service
District: An Administrative unit
Defined Geographical boundary and Population
 Peripheral most Planning unit
 A self contained segment of National Health System
 Middle level management organisation
 Link between state as well as regional structure on one
side and peripheral level structure has CHC, PHC, Sub
centre on other side
District officer with overall control is designated as
CMHO (Chief Medical Health Officers (CMHOs)
Or
DMHO (District Medical and Health
Officer).Technical head
Sub-divisional/Taluka level - At the Taluka
level, health care services are rendered
through the office of Assistant District Health
and Family Welfare Officer (ADHO)
.
Functions of District Health System
Liaison between Field units & Headquarter
• Field reports
• Inspections
• Meetings
Implementation of Policy & Programs
District level planning & Action Plans
Rationale use of Finance & Resources
Communication Management
• Plans/Schedules/Progress/Problems
Control & Monitoring
Health administration at Rural
level 3-tier structure
Primary care

Secondary Care

Tertiary care
Levels of Health Care in
India
Health Care services have 3 levels –
1. Primary
First level of contact, where essential health care is
provided by PHCs and SCs.
2. Secondary
For treatment of complex problems through district
hospital and community health centers.
3. Tertiary
Highly specialized health care through medical
college hospitals, AIMI, Regional Hospitals,
Specialized Hospitals and other Apex institutes.
RURAL HEALTH CARE
SYSTEM
Sub Centre (SC)
Most peripheral contact point between Primary Health Care
System &
Community manned with one MPW(F)/ANM & one MPW(M)

Primary Health Centre (PHC)


A Referral Unit for 6 Sub Centers 4-6 bedded manned with a
Medical
Officer In charge and 14 subordinate paramedical staff

Community Health Centre (CHC)


A 30 bedded Hospital/Referral Unit for 4 PHCs with Specialized
services
At community level

Centre Population Norms


Plain Area Hilly/Tribal/Difficult
Area
Community Health 1,20,000 80,000
Centre
Primary Health 30,000 20,000
Centre
Sub-Centre 5000 3000
Manpower Existing
at PHC Recommended (IPHS)
Medical Officer 1 2(one AYUSH or LMO)
Pharmacist 1 1
Nurse-midwife (Staff 1 3 (for 24-hour PHCs)
(Nurse) (2 may be contractual)
Health workers (F) 1 1
Health Educator 1 1
Health Asstt. (M&F) 2 2
Clerks 2 2
Laboratory Technician 1 1
Driver 1 Optional/vehicles out-sourced.
Class IV 4 4
Total 15 17/18
Title
Health care delivery
system - village
Provided through –
1) Village health guide
i) Preferably VIth Std. passed local women
ii) Undergoes 200 hours training over 3
months
iii) Works for 2-3 hours per day
iv) Paid Rs. 50/- and drugs kit Rs. 600/- per
year. Education
Village health guide
scheme
1) lanuched on 2nd October 1977
2)Centrally sponsored under family and welfare
this is in operation in all states except 5 states where
alternative health schemes are in progress.
3) 5 states are
a) jammu and kasmir ( Rehbar-e- sehat)
b)arunachal pradesh ( Medics)
c) Tamil nadu ( Mini health worker)
d)Kerala ( strenthing og PHC’s)
e) Karnataka(strenthing og PHC’s)
2) Trained Birth attendant (Local trained
Dais)
i) Training for 30 working days with certificate
ii) Provided with delivery kit
iii) Rs.10/- per delivery & Rs.3/- per registered
child
3) Anganwadi worker
i) Local woman with VIth Std. education
ii) Provides non formal education to children
iii) Antenatal services (Nutrition
Urban Areas
Central government health scheme (CGHS)
Started in 1954
Beneficiaries- -Mainly for central government
employees & their family members -Ex. M.P.’s,
Judges of supreme & high court, freedom
fighter, Central Govt. pensioner -Employees
of semi autonomous bodies & semigovt.
Organizations' -Ex. Governors, EX. V.P.’s etc.
Facilities provided

Emergency services
Free supply of drugs
Lab & radiological services
Domiciliary visits
Specialist consultation at hospital, family
welfare centr level
Referral

Primary level health


care facility

Community level

Urban Health service delivery model


Urban Revamping Scheme
Urban revamping scheme was introduced following
recommendations by Krishnan committee 1983 .
To provide primary health care, family welfare, service
delivery outreach and MCH services in urban areas.
HEALTH POSTS:
 There are 871 health posts functioning in 10 States and
2 UTs.
Type of health post

Type of health post Population


Type A <5000
Type B 5000-10000
Type C 10000-25000
Type D 25000-50000

If population of the area is more than 50000 then it is to be divided into sectors
of 50000 population and a post is established at each sector.
Type-wise staff sanctioned :
NAMEOF NO. OF POSTS ADMISSIBLE
THE POST A B C D

Lady Doctor - - - 1
Public - - - 1
Health
Nurse
Nurse Mid- 1 1 2 3-4
wife
Male MPW* - 1 2 3-4
Class IV - - - 1
Comp-cum - - - 1
Clerk
Voluntary - - - 1
Women
Health
Worker*
* At present there is a no new male mpw post is sanctioned
Cont.
TYPE OF HEALTH POST NO. OF HEALTH POSTS
A 65
B 76
C 165
D 565
 URBAN FAMILY WELFARE
CENTRES
Urban Family Welfare Centers are on ground
since First Five Year Plan to provide family
welfare services in urban areas
Most of UFWCs are equipped to provide
contraceptive supplies. At present 1083
centers are functioning.
There are three types of Urban Family Welfare
centers based on the population covered by
each centre.
Staffing pattern for Urban
Family Welfare Centers
TYPE POPULATION NO. UNITS Staffing
COVERED Pattern
Type I 10000 - 25000 326 ANM -1, FP Field
Worker -1
Type II 25000 - 50000 125 FPExtensionEduc
ator/LHV -1FP
Field
Worker(Male) -1
ANM -1
Type III Above 50000 632 Medical Officer
-1(Pref. Female)
ANM - 2, LHV - 1,
FP Field Worker
(Male) - 1 ,
Storekeeper-
cum-clerk -1
ALL INDIA HOSPITAL POST
PARTUM PROGRAMME
PAP Smear facility at 105 PPC attached to Medical
Colleges;
Medical Termination of Pregnancy;
Sterilization (Tubectomy);
Provision of all types of contraceptives;
Promote family planning as most important health
intervention for Health of Mother & Child;
Promote spacing of birth;
Follow up services to acceptors;
Out reach services
At present 550 centers at district level and 1012 centres at
sub-divisional level hospitals are functioning.
There are three types of Post Partum Centers at district level
hospitals Type A : covering Medical Colleges/Institutions
conducting 3000 or more Obstetric and abortion cases
annually Type B :covering Medical Institutions conducting less
than 3000 but 1500 or more cases annually  Type C
:covering Institutions conducting less than 1500 cases
annually.
NRHM
To implement National health policy 2002
Inaugurated on April 12, 2005
Intended for 2005 – 2012
to provide accessible, affordable and
accountable quality health services even to the
poorest households in the remotest rural
regions.

NRHM absorbs Key national programs 1. RCH-II


2. NDCP 3. IDSP 4. Mainstreaming of
AYUSH
Vision
Special Focus on 18 states – with poor public health
indicators these are Uttar Pradesh, Uttaranchal,
Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand,
Orissa, Rajasthan, Himachal Pradesh, Jammu and
Kashmir, Assam, Arunachal Pradesh, Manipur,
Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.
Increase spending on health from 0.9% of GDP in
1999 to 2.3% of GDP
To carry out necessary architectural correction in
basic health care delivery system
To provide service through ASHA in each village
Vision-cont
To strengthen the rural hospitals to meet public health
standards
To integrate national health programs
To mainstream AYUSH
To decentralize village & district level health planning &
management
To define time bound goals
To seek access of rural people to equitable, affordable ,
accountable & effective primary health care.
To provide improved health care service under JSY for
BPL families
Objectives
Provides trained & supported village health activist in
underserved areas as per need
Preparation of health action plans by panchayats as mechanism
for involvement of community
Strengthening PHC/SC/CHC’s as per IPHS guidelines
Institutionalization & substantial strengthening of district level
Management of health
Increase utilization of FRU’s from <20 % to > 75% by 2010
Strengthening of local health traditions related to public health
and PHC
Goals
Reduction in Infant Mortality Rate (IMR) and
Maternal Mortality Ratio (MMR)
Universal access to public health services
Prevention and control of communicable and
non-communicable diseases, including locally
endemic diseases
Access to integrated comprehensive primary
healthcare
Population stabilization, gender and
demographic balance.
Goals- cont.
Revitalize local health traditions and mainstream
AYUSH
Promotion of healthy life styles
Plan of Action
Provision of health activist in each village i.e.
ASHA
Strengthening of Sub centers
Strengthening of PHC’s
Strengthening of CHC’s .
District health plan – District becomes core unit
of planning, budgeting & implementation.
Converging sanitation & hygiene under NRHM
Strengthening disease control programs
PPP for public health goals, including private
sector
New health financing mechanisms
Reorienting Health/ Medical education to
support rural health issues
ROLE OF
PANCHAYATI RAJ
INSTITUTIONS
The 5 pillars of
Democracy

Technocracy
Bureaucracy

Politicians
Bureaucracy

Technocracy

Politicians

Judiciary
People
Judiciary

People (citizen)
Staff at different levels in
PRI
Place Bureaucrat Technocrat Politician Judiciary
1)District C.E.O. D.H.O. Chairman Sessions
(Z.P.) (Z.P.) court

2)Taluka BDO M.S. Civil Panchayat Taluka


Hosp. or Samiti court
M.O.(PHC) Chairman

3)Village Gram HW Sarpanch Gram


Sevak (Male/Female) Panchayat

-On the basis of recommendation or Report from the


Technocrat decision is taken by the Bureaucrat
Place Bureaucrat Technocrat Politician Judiciary
1.Mumbai Assistant M.C. Executive Chairman of Session
Health Public Health Court
Officer Committee
(Public Health)

2. Zones Joint M.C. Deputy President Session


(6 zones) Executive Prabhag Samiti Court
Health Officer

3. Sub-zones Deputy M.C. Asst. Health Members of Session


Officer Public Court
Health
Committee

4. Wards Ward Officer M.O.H. Municipal --


Councillors

5. State Health D.H.S. Health Minister High court


Secretary
A task force would look at the process of
making panchayats central to implementation
of NRHM
States to indicate in their MoUs the
commitment for devolution of funds,
functionaries and programs for health, to PRIs
The District Health Mission
ASHA
Cont-
The Village Health Committee
Rogi Kalyan Samitis for good hospital
management.
Provision of training to members of PRIs.
Making available health related databases to
all stakeholders, including Panchayats at all
levels
Organogram of NRHM
National steering group Mission steering group
Empowered program committee Mission
directorate State health mission
District health mission<--------------->Rogi kalyan samiti
Panchayat (Village Health Committee)
Major Stakeholders
Accredited Social Health Activist (ASHA)
Auxiliary Nurse Midwife and Anganwadi
worker
Panchayati Raj Institutions and NGOs
District Administration
State Governments
Village level
ASHA
accredited social health activist
Female activist given accreditation after 4 phase
training
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.
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.
Qualities
Adequate representation from disadvantaged
population groups should be ensured to serve
such groups better.
Training Strategy

Induction Training
Periodic Trainings
On the job training
District Level
District health plan generated by combining
village health plans
Elements are drinking water, sanitation,
hygiene and nutrition
Strengthen PHC (Primary Health Centers) and
CHC (Community Health Centers)
Higher levels
Integrate vertical health and family welfare at
district, block, state and national levels
Integration of vertical health programs (leprosy,
TB, malarial programs, etc.)
All health facilities and infrastructure built based
on Indian Public Health Standards (IPHS) standards
Rectify manpower shortage, equipment and other
furnishings in health facilities
 Strengthen capacities for data collection,
processing, evaluation and supervision
Timeline for Milestones to
be achieved:
Health provider in each village 2005-08
Upgrading of rural hospitals 2005-07
Build new hospitals 2005-08
District Planning Operational 2005-07
Village Health Plans 2006
Merger of multiple societies into April 05
District/State Mission
Operational PMUs 2005-06
Technical Support 2005-07
Expected out come
IMR reduced to 30/1000 live births by 2012
MMR reduced to 01/1000 live births by 2012
TFR reduced to 2.1by 2012
Malaria mortality reduction rate -50% by 2010
& additional 10 % by 2012
Kala Azar mortality reduction rate -100% by
2010 & sustaining elimination by 2015
Dengue mortality reduction rate -50% by
2010 sustaining it at that level by 2012
Japanese encephalitis mortality reduction rate -50% by 2010
sustaining it at that level by 2012
Cataract operations increasing to 46 lakh per annum till 2012
Leprosy prevalence rate- reduce from 1.8 per 10000 in 2005 to
less than 1 per 10000 thereafter
TB DOT series- maintain 85% cure rate throughout the mission
Upgrading all CHCs to IPHS
Increasing utilization of FRU from bed occupancy by referred
cases of less than 20% to over 75%
Salient features of 11th
five year plan
Need to plan for easy Access of clean drinking water.
Need to take stock of habitation survey on rural water
supply and urgent action plan should be designed and
opertionaliesd .
The position regarding for waste water disposal in
states is harmful and it is need to be addressed
priority in coordination with department of drinking
water and sanitation. ASHA should have a bathroom in
her house which could be taken as a indicator.
A sanitation movement both in interest of social eqity and
prevention of diseases should be taken up as priority. All
sanitation worker should be examined annually .
Replicate use of SHULAB SAUCHALYA.
Introduce environmental sanitation in all school in rural
and urban slum.
To promote health education and awareness in drinking
water .(SWAJAL PROJECT)
Distribution of key micronutrients among anemic mother
and children
Building up of and effective health system to
clearly focus on important outcomes of NHP 2002.
Promotion of high volume care for lower surgical
procedures like cataract surgery
Promotion of yoga and exercise.
Bring a shift from specific project to program
support as in case of RCH II.
Professionalize service delivery by appropriate
measures for increasing number and facility of
medical and nursing college.
Better motivation and periodic traning of
MPW’s and ANM’s
Uniform system of reporting of data by state
and their validation.( introducing NRHM)
Title
Categ Rural Area Total Urban Area Total
ory
Mother’s ASHA’s Rs. Mother’s ASHA’s Rs.
Package Package Package Package
LPS 1400 600 2000 1000 200 1200
HPS 700 - 700 600 - 600