Transcript of Health care delivery system in India. Framework Introduction Evolution of health care services in...
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- Health care delivery system in India
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- Framework Introduction Evolution of health care services in
India Role of different committees Organizational structure in
India Health care delivery system in India Gaps in structure
Finance allocation Integrated approach of health care delivery
Contribution by NGOs Challenges
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- Introduction Older concept Health care means patient care
Objective - freedom from the disease through hospital system. 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. Service offered by all health disciplines
Inter-sectoral coordination and community participation
Responsibility of providing health care expanded well beyond health
sector.
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- Evolution of health care services in India Christian 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. Moghul
empire Arabic system of medicine (Unani) British Gov British
nationals, armed forces, civil servants.
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- Role of different committees 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
1963 Chaddah committee Basic health workers Family planning health
assistant
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- Role of different committees cont. 1965 Mukerji committee
Separate staff for the family planning programme 1967 Jungalwala
committee Integration of health services Elimination of private
practice by Gov. doctor 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.
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- Organizational structure in India Health system has 3 main
links Central, state and local or peripheral. India is a Union of
28 states and 7 territories. Health is the responsibility of state.
Central responsibility Policy making Guiding Assisting Evaluating
Coordinating the work of state health ministries.
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- At the centre Official organ The union ministry of health and
family welfare Headed by Cabinet minister Minister of state Deputy
health minister The union ministry of health and family welfare The
directorate general of health services. The central council of
health and family welfare.
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- The union health ministry Department of healthDepartment of
family welfare Department of health Secretary to the Gov. of India
(Executive head) Joint secretary Administrative staff Directorate
general of health services Subordinate officer
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- Department of family welfare Was created in 1966 Headed by the
secretary to the government of India. Secretary Additional
secretary Commissioner One joint secretary
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- Directorate general of health services - Principal advisor in
both medical and public health matter. DGHS Additional Director
General of health services Team of deputies Administrative staff
Directorates - three main units General administration Public
health Medical care and hospital
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- The central council of health and family welfare Chairman Union
health minister Members State health ministers Function To consider
and recommend board outlines of policy in regards to matters of
health To make proposals for legislation in fields of medical and
public health matters and to lay down. To make recommendations to
the central government regarding the health. To established any
organization with appropriate functions for promoting and maintain
cooperation between central and state health administrations.
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- At the state level The state health administration was started
in the year 1919. The state list which become the responsibility of
the state included Provision of medical care Preventive health
services Piligrim within the state State - management sector
Directorate of health and family welfare services State ministry of
health
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- State ministry of health and family welfare Headed - Cabinet
minister and deputy minister. (Political head) Responsibility -
formulating policies Monitoring the implementation of these
policies and programmes. 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.
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- At the district level Principal unit of administration in India
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
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- RuralUrban Panchayats Villages Community Development Blocks
Corporations Municipal Boards Town area committees Tahsil (Taluka)
District Sub-division
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- Panchayati Raj 3 tier structure of rural local self government
Linking the village to the district Panchayat Raj Panchayat
Panchayat Samiti Zilla Parishad Gram Sabha Gram Panchayat
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- Health care delivery system in India At 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 CentrePlain areaHilly
/ Tribal / Difficult area Community health centre 1,20,00080,000
Primary health centre30,00020,000 Sub-centre5,0003,000
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- Community health Centres 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, Labour Room and Laboratory facilities. It serves as a
referral centre for 4 PHCs and also provides facilities for
obstetric care and specialist consultations. As on March, 2011,
there are 4,809 CHCs functioning in the country.
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- Primary health Centres 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. NRHM - two
additional Staff Nurses at PHCs (contractual). It acts as a
referral unit for 6 Sub Centres and has 4 - 6 beds for patients.
There were 23,887 PHCs functioning in the country as on March
2011.
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- Sub-Centre Most peripheral and first contact point between the
primary health care system and the community. Manned by at least
one ANM / Female Health Worker and one Male Health Worker. Under
NRHM, one additional second ANM on contract basis. Provide services
in relation to maternal and child health, family welfare,
nutrition, immunization and control of communicable diseases.
Provided with basic drugs for minor ailments. Ministry of Health
& Family Welfare is providing 100% Central assistance to all
the Sub-Centres 148,124 Sub Centres functioning in the country as
on March 2011.
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- Rural health infrastructure: Norms and level of achievements
(All India) S. No. IndicatorNational Norms Present Avg Coverage 1
Rural Population (2011) (Provisional) covered by General
Tribal/Hilly /Desert Sub Centre500030005624 Primary Health Centre
(PHC)300002000034876 Community Health Centre (CHC)12000080000173235
2Number of Sub Centres per PHC66 3Number of PHCs per CHC45 4Rural
Population (2011) (Provisional) covered by a: HW (F) (at Sub
Centres and PHCs)500030004008 HW (M) (At Sub Centres)5000300015955
5 Ratio of HA (M) at PHCs to HW (M) at Sub Centres 1:61:3 6Ratio of
HA (F) at PHCs to HW (F) at Sub Centres and PHCs 1:61:13
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- Village Accredited Social Health Activist (ASHA) for 1000
population Chosen by and accountable to the panchayat Act as the
interface between the community and the public health system.
Honorary volunteer, receiving performance-based compensation
Facilitate preparation and implementation of the Village Health
Plan The other persons are Indigenous dais Anganwadi workers
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- Progress over the years Progress of Sub Centres, which is the
most peripheral contact point between the Primary Health Care
System and the community, is a prerequisite for the overall
progress of the entire system.
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- Percentage of PHCs functioning in Government buildings has
increased significantly from 78% in 2005 to 86.7% in 2011
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- The % of CHCs in Govt. buildings has increased from 90% in 2005
to 95.3% in 2011
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- Urban health care delivery system in India The government of
India has identified Urban Health as one of the thrust area in the
tenth Five Year Plan, National population policy 2000, National
Health Policy 2002 and second phase of RCH program The central
government health scheme (1954) objective of providing
comprehensive medical health care facilities to the central
government employees and their family members. Urban Family Welfare
centers launched during the first five year plan. At present 1083
centers are functioning and providing outreach services, primary
health services, MCH services and distribution of
contraceptives.
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- Urban health post Urban Revamping Scheme introduced following
the recommendations of the Krishnan Committee in 1983. To provide
services through setting up of health posts mainly in slum area. 4
type of health post were set up depending on the allotted
population. Type A less than 5000 population Type B between 5000 to
10000 population Type C between 10000 to 25000 populations Type D
between 25000 to 50000 populations Only Type D health post has a
Medical officer. Services provided by these posts are outreach of
RCH services, first and referral services and distribution of
contraceptives.
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- Health care delivery services in Delhi Well established
infrastructure for its people One of the highest bed capacity (2.14
beds/1000 persons). Public Health expenditure consistently remained
above 6 per cent. Delhis per capita expenditure on health is Rs.
685. However, there is multiplicity of agencies operating their
health care outlets in different areas or for defined subset of
populations in different areas like Delhi Government, MCD, NDMC,
CGHS, DGHS, ESI and Army etc. Primary health care level Delhi has
wide network of 969 dispensaries. Secondary and tertiary health
care level there are 706 hospitals including 505 registered nursing
homes with 33711 beds. There are 118 hospitals in the government
sector in Delhi.
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- Health care delivery system in Mumbai Mumbai has a vast supply
of public and private health care services. The services range from
the super specialty, tertiary-level care hospitals to the general
practitioners. The Central Government has its own dispensaries,
which are available only for their employees. ESIS - health care
services that include hospitals and dispensaries which cater to
employees in the organized sector. The various government
organisations, such as ports, railways and defence, have their own
health care services for their employees. The Municipal Corporation
of Greater Mumbai (MCGM) provides major facilities in the public
sector along with the State Government.
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- Health care delivery system in Mumbai cont The Department is
divided into zonal set-ups for administrative purposes. There are
five such zones, which cover 23 Wards The Deputy Municipal
Commissioner handles each zone. Each Ward has a separate Ward
Office and the Ward Medical Health Officer (MHO) heads the Public
Health Department in that Ward. Family welfare and maternal child
health programmes are under the supervision of Officer- Maternal
Child Health & Family Welfare at F/South Ward. Peripheral
hospitals linked to four super specialty hospitals. Health posts
and dispensaries linked to peripheral hospitals in their respective
Wards
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- Private health sector India - dominance of Private sector. In a
NSS survey in 2001-02, 13 lakhs practitioners were working in
private sector. Accounts 80% of the total facility in the country.
88% of the towns have a medical facility compared to 24% in rural
areas with 90% of the facilities manned by sole practitioners. The
private sector has 75% of specialists and 85% of the technology in
their facilities. The private sector accounts for 49% beds and an
occupancy ratio of 44% whereas the occupancy rate is 62% in the
public sector.
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- AYUSH Old acceptance in the communities in India Form the first
line of treatment in case of common ailments in most of the places
Ayurveda is the most ancient medical system with an impressive
record of safety and efficacy. Mainstreaming AYUSH to strengthen
the Public Health System at all levels. AYUSH facilities had been
co-located with 208 District Hospitals (36%), 910 Community Health
Centres (23%) and 3883 Primary Health Centres in the country.
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- Gap in structure The availability of manpower is the important
prerequisite for the efficient functioning of the Rural Health
services Shortfall in the manpower at PHC and Sub centre is shown
as on march 2011
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- Even out of the sanctioned posts, a significant percentage of
posts are vacant at all the levels.
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- Shortfall of specialist at CHCs as compared to requirement for
existing infrastructure as on March 2011, Overall 63.9% specialists
at the CHCs
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- The current position of specialists manpower at CHCs reveal
that as on March 2011, Overall 39.5% of the sanctioned posts of
specialists at CHCs were vacant.
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- Finance allocation Health Expenditure in India 200405 Health
Expenditure in India 2008-09 Type of Expenditure Distribution of
total Health Expenditure (%) Share of GDP (%) Distribution of total
Health Expenditure (%) Share of GDP (%) Public Expenditure
19.670.84271.1 Private Expenditure 78.053.32723.0 External
Flow2.280.1020.1 Total Health Expenditure 1004.251004.1
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- Integrated approach of health care delivery Demands coordinated
efforts of all sectors such as Agriculture, Irrigation, Animal
Husbandry, Education, Social and Women's Welfare, Housing and
Public Works, Communication, Rural Development, Cooperatives,
Industries, Panchayats and Voluntary Organizations, etc. ICDS
integrated child development scheme Supplementary nutrition for
children of less than 6 years of age, pregnant mother, lactating
mother. Nutrition and health education to women of reproductive age
group Monthly health and nutrition day at anganwadi Drinking water
and toilet facility in anganwadi centre (rural development
ministry) Agriculture, irrigation and engineering: Growing more
food locally - cereals, pulses, vegetables, fruits etc. Identifying
water resources for drinking and other purposes Providing seeds for
kitchen garden and community garden Educating the people for
composting
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- Integrated approach of health care delivery cont Animal
Husbandry: Immunizing domestic animals and catties against rabies
etc. Preventing zoonotic diseases Education: Health education
covering nutrition, personal hygiene and environmental sanitation;
Education about various health problems in the community and their
prevention and control; Population education, advantages of small
family Providing first-aid and treatment of minor ailments and the
knowledge of local health resources. Social and Women's Welfare:
Mobilizing women, mahila mandals, mother's club etc. for
propagation of health, nutrition practices, special nutrition
programmes for vulnerable groups, maintenance and use of water
resources; proper disposal of excreta, composting, kitchen garden
etc. Educating mothers on maternal and child care
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- 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 government hires individuals on a temporary basis to
provide services Contracting out government pays outside
individuals to manage specific function Subsidies government gives
funds to privet groups to provide specific services. Leasing or
rental government offers the use of its facilities to a privet
organization. Privatization government gives or sells a public
health facility to a privet group.
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- 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
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- References: GOI. Twelfth five year plan (2012-2017) social
sector, Volume III. Planning commission government of India.p1- 47
MOHFW. Rural health care system in India-the structure and current
scenario. Rural health statistics 2011. GOI. MOHFW. National rural
health mission. [online]. [cited 2012 Dec 27]. Available from:
http://www.mohfw.nic.in/NRHM.htmhttp://www.mohfw.nic.in/NRHM.htm
Indian Public Health Standards (IPHS) guideline for community
health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94 GOI. Financing
and delivery of health care services in India. MOHFW 2005; 1-320
Park K. Park's Textbook of Preventive and Social Medicine. 21st ed.
Prem Nagar, Jabalpur, (M.P.), India: M/s Banarsidas Bhanot;
2011