Health care delivery system in India. Framework Introduction Evolution of health care services in...

Health care delivery system in India

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

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.

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.

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

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.

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.

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.

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

Department of family welfare Was created in 1966 Headed by the secretary to the government of India. Secretary Additional secretary Commissioner One joint secretary

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

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.

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

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.

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

RuralUrban Panchayats Villages Community Development Blocks Corporations Municipal Boards Town area committees Tahsil (Taluka) District Sub-division

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

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

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.

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.

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.

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

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

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.

Percentage of PHCs functioning in Government buildings has increased significantly from 78% in 2005 to 86.7% in 2011

The % of CHCs in Govt. buildings has increased from 90% in 2005 to 95.3% in 2011

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.

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.

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.

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.

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

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.

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.

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

Even out of the sanctioned posts, a significant percentage of posts are vacant at all the levels.

Shortfall of specialist at CHCs as compared to requirement for existing infrastructure as on March 2011, Overall 63.9% specialists at the CHCs

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.

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

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

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

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.

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

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

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