The document describes India's health care delivery system. It discusses the various components of the system including the public sector (comprised of primary health centers, community health centers, hospitals, etc.), private sector, voluntary agencies and indigenous systems. It then focuses on the rural health services component, describing the three-tier structure of primary care, secondary care and tertiary care. Considerable detail is provided about the rural health infrastructure, particularly the sub-center which acts as the most peripheral contact point between the community and primary health services. The roles, services and standards of the sub-center are defined.

3. HEALTH CARE
DELIVERY
SYSTEM
INDIA

4. HEALTH CARE DELIVERY
SYSTEM
 It exists to provide services &
resources for better health.
 This system includes
hospital, clinic, health centers,
nursing homes &special health
programmes in school, industries &
community.

5. MODEL OF HEALTH CARE
DELIVERY SYSTEM
MODEL OF HEALTH CARE
DELIVERY SYSTEM
HEALTH
STATUS/
HEALTH
PROBLEMS
RESOURCES
CURATIVE
PREVENTIE
PROMOTIVE
PUBLIC
PRIVATE
VOLUNTARY
INDIGENOUS
CHANGES
IN
HEALTH
STATUS
INPUTINPUT
HEALTH
CARE
SERVICES
OUT
PUT
HEALTH
CARE
SYSTEM

6. HEALTH CARE DELIVERY
SYSTEM
1. PUBLIC HEALTH SECTOR :
Primary health care
•Primary health centers
•Sub centers
Hospitals health centers
•Community health centers
•Rural hospitals

7. PUBLIC HEALTH SECTOR…
•District hospitals.
•Specialty hospitals
•Teaching hospitals
Health Insurance Schemes
•Employee state insurance
•Central government health schemes
Other Agencies
•Defense services
•Railways

8. 2. PRIVATE SECTOR
Private Hospitals, polyclinics,
nursing homes & dispensaries.
General practitioners & clinics.
3.INDIGENOUS SYSTEM OF
MEDICINE
Ayurveda & Siddha
Uninani & Tibbi
Homeopathy
Unregistered Practitioners

9. 4.VOLUNTARY HEALTH AGENCIES
5.NATIONAL HEALTH PROGRAMMES

10. HEALTH CARE DELIVERY
SYSTEM INDIA
PUBLIC VHO PRIVATE
URBAN
AUTONOMOUS
AYUSH
RURAL
NHP
HOSPITALS
CONSULTATION
MTR
N&IN
HA

11. URBAN
Urban hospitals and health centre
Central health services/Health Insurance
Other health services.

12. URBAN HOSPITALS & HEALTH
CENTRES
• District hospitals and dispensaries.
• Urban family welfare centres.
• Special Hospitals.
• Medical college Hospitals/ Teaching
Hospitals.
• Super Specialty Hospitals/ Institutes.

13. Central health services/Health
Insurance
• ESI
• FPI
• Central Govt: Health scheme
Other health services
•Railway
•Military

14. RURAL HEALTH SERVICES
Sub Centre.
PHC
CHC
Other rural services.(VILLAGE)
 VHG
 TBA
 Anganwadi workers
 ASHA

15. HEALTH ADMINISTRATION AT RURAL
LEVEL 3-TIER STRUCTURE
Primary care
Secondary Care
Tertiary
care

16. HEALTH CARE DELIVERYHEALTH CARE DELIVERY
SYSTEM - VILLAGESYSTEM - VILLAGE

17. 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.

18. Village health guideVillage health guide
i) Preferably at least VIII Std. passed
local women.Able to read and write.
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.

19. 5 states
1) Jammu and kasmir
( Rehbar-e- sehat)
2)Arunachal pradesh ( Medics)
3) Tamil nadu ( Mini health
worker)
4)Kerala ( strenthing of PHC’s)
5)Karnataka(strenthing of
PHC’s)

20. FUNCTIONS
• Link between village, community, and
Government health care system.
• Health education.
 Communicable Diseases.
 MCH, FW.
 First aid.

21.  The union health ministry has decided to
discontinue the centrally sponsored village
health guide scheme from April 1, 2002, in
view of its failure to achieve its objectives.
It follows the report of a three-member
committee of experts headed by the former
director of Indian institute of public
administration, P.K. Umashankar.

22. Trained Birth attendant (LocalTrained Birth attendant (Local
trained Dais)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.

23. Anganwadi workerAnganwadi worker
i) Local woman with VIth Std.
education
ii) Provides non formal education to
children

24. Anganwadi workerAnganwadi worker
• ICDS One anganwadi worker
appointed per 1000 population.
• Part time employee.
• 4 months training.
• Honorarium 1500 per month.
• Mobile anganwadi programme.

25. ASHA
• Under NRHM
• 1 for 1000 population.
• Married, widow, divorced, 25-45 years.
• Kerala 31868

26. RURAL HEALTH SERVICES
• Primary health centre system.
• 3 tier system.

27. NAME OF
HEALTH
CENTRE
PLAINS HILLY/TRI
BAL
Sub centre 5000 3000
PHC 30000 20000
CHC 1,20,000 80,000

28. RURAL HEALTH SYSTEM
• 148124 Sub Centres,
• 23887 Primary Health Centres (PHCs)
• 4809 Community Health Centres (CHCs)
As On March, 2011

30. SUB CENTRE
 Most peripheral and first
contact point between the
primary health care system
and the community.
Rural health scheme-1977
Placing people’s health in
people’s hand.

31. SUB CENTRE
Number of Sub Centres existing as on
March 2011increased from 146026 in
2005 to 148124 in 2011.
Chhattisgarh, Haryana, Jammu &
Kashmir,Karnataka, Maharashtra,
Orissa, Punjab, Rajasthan, Tamil Nadu,
Tripura and Uttarakhand.

32. One auxiliary nurse midwife (ANM) /
Female Health Worker.
 One male health worker.
Under NRHM, there is a provision for
one additional second ANM on contract
basis.
One lady health visitor (LHV) is
entrusted with the task of supervision of
six sub-centres.

33. Sub-Centres are assigned tasks
relating to interpersonal
communication in order to bring
about behavioral change.

34. SUB CENTRES…
Maternal and child health
Family welfare
Nutrition
Immunization
Diarrhoea control
Control of communicable diseases
programmes.

35. • The Ministry of Health & Family
Welfare is providing 100% Central
assistance to all the Sub-Centres in the
country since April 2002 in the form of
salary of ANMs and LHVs, rent at the
rate of Rs. 3000/- per annum and
contingency at the rate of Rs. 3200/-
per annum, in addition to drugs and
equipment kit.

36. INDIAN PUBLIC HEALTH
STANDARDS FOR SUB-CENTRES
In order to provide quality care in the
Sub-centres, Indian Public Health
Standards (IPHS) are being prescribed to
provide basic primary health care
services to the community and achieve
and maintain an acceptable standard of
quality of care.

37. IPHS SUB CENTRES
The Indian Public Health Standards
(IPHS) for health Sub-centre lays down
the package of services that the Sub-
centre shall provide, the population
norms for which it would be established,
the human resource, infrastructure,
equipment and supplies that would be
needed to deliver these services with
quality.

38. OBJECTIVES OF THE INDIAN PUBLIC
HEALTH STANDARDS FOR SUB-
CENTRE.
To specify the minimum assured (essential)
services that Sub-centre is expected to
provide and the desirable services which the
states/UTs should aspire to provide through
this facility.
To maintain an acceptable quality of care
for these services.

39. CONT…
To facilitate monitoring and
supervision of these facilities
 To make the services provided
more accountable and responsive
to people’s needs.

40. SERVICES TO BE PROVIDED IN A
SUB-CENTRE
Sub-centres are expected to
provide promotive,preventive
and few curative primary
health care services.
Type A: Shall provide all
services as envisaged for the
Sub-centre except the facilities
for conducting delivery will not
be available here.

41. CONT…
Type B: They will provide all
recommended services including facilities
for conducting deliveries at the Sub-
centre itself. This Sub-centre will act as
Maternal and Child Health (MCH)
centre with basic facilities for conducting
deliveries and Newborn Care at the Sub-
centre.

43. MCH
MATERMAL HEALTH
 Antenatal care:
 Early registration of all pregnancies,
within first trimester (before 12th week
of Pregnancy).
However even if a woman comes late in
her pregnancy for registration, she
should be registered and care given to
her according to gestational age.

44. CONT..
Minimum 4 ANC including
Registration
1st visit: Within 12 weeks—preferably
as soon as pregnancy is suspected for
registration, history and first antenatal
check-up
2nd visit: between 14 and 26 weeks
3rd visit: between 28 and 34 weeks
4th visit: between 36 weeks and term.

45.  Associated services like general
examination such as height, weight,
B.P, anaemia, abdominal
examination, breast examination,
Folic Acid Supplementation (in first
trimester), Iron & Folic Acid
Supplementation from 12 weeks,
injection tetanus toxoid, treatment of
anaemia etc.

46. Recording tobacco use by all
antenatal mothers.
Minimum laboratory investigations
like urine test for pregnancy
confirmation, haemoglobin
estimation, urine for albumin and
sugar and linkages with PHC for
other required tests.

47. CONT…
Name based tracking of all pregnant
women for assured service delivery.
 Identification of high risk pregnancy
cases.
 Identification and management of
danger signs during pregnancy.
 Malaria prophylaxis in malaria
endemic zones for pregnant women as
per the guidelines of NVBDCP.

48. Provide information about provisions
under current schemes and
programmes like Janani Suraksha
Yojana.
 Identify suspected RTI/STI case,
provide counselling, basic management
and referral services.
 Counselling & referral for HIV/AIDS.
 Name based tracking of missed and
left out ANC cases

49.  Counselling on diet, rest, tobacco
cessation if the antenatal mother is
a smoker or tobacco user,
information about dangers of
exposure to second hand smoke and
minor problems during pregnancy,
advice on institutional deliveries,

50. Pre-birth preparedness and
complication readiness, danger signs,
clean and safe delivery at home if
called for, postnatal care & hygiene,
nutrition, care of newborn, registration
of birth, initiation of breast feeding,
exclusive breast feeding for 6 months,
demand feeding, supplementary
feeding (weaning and starting semi
solid and solid food) from 6 months
onwards, infant & young child feeding
and contraception.

51. INTRA-NATAL CARE:
Essential
 Promotion of institutional deliveries.
 Skilled attendance at home deliveries
when called for.
Appropriate and timely referral of
high risk cases which are beyond her
capacity of management.

52. ESSENTIAL FOR TYPE B SUB-
CENTRE
 Managing labour using Partograph.
 Identification and management of
danger signs during labor.
 Proficient in identification and basic
fist aid treatment for PPH, Eclampsia,
Sepsis and prompt referral of such
cases as per’Antenatal Care and
Skilled birth Attendance at birth’or
SBA Guidelines.

53. CONT…
• Minimum 24 hours of stay of
mother and baby after delivery
at Sub-centre. the environment
at the Sub-centre should be
clean and safe for both mother
and baby.

54. POSTNATAL CARE:
Initiation of early breast-feeding
within one hour of birth.
 Ensure post-natal home visits on 0,3,7
and 42nd day for deliveries at home
and Sub-centre (both for mother &
baby).
Ensure 3, 7 and 42nd day visit for
institutional delivery (both for mother
& baby) cases.

55. POSTNATAL CARE…
In case of Low birth weight baby (less
than 2500 gm), additional visits are to
be made on 14, 21 and 28th days.

56. CONT…
During post-natal visit, advice regarding
care of the mother and care and feeding
of the newborn and examination of the
newborn for signs of sickness and
congenital abnormalities as per IMNCI
Guidelines and appropriate referral, if
needed.

57. CONT…
 Counselling on diet & rest,
hygiene,contraception, essential newborn
care, immunization, infant and young
child feeding, STI/RTI and HIV/AIDS.
 Name based tracking of missed and left
out PNC cases.

58. CHILD HEALTH
Newborn Care Corner In The Labour
Room to provide Essential Newborn
Care.
Counselling on exclusive breast-feeding
for 6 months.
Appropriate and adequate
complementary feeding from 6 months
of age while continuing breastfeeding.

59. CHILD HEALTH
Assess the growth and development of
the infants and under 5 children and
make timely referral.
Immunization Services:
Full Immunization of all infants and
children against vaccine preventable
diseases as per guidelines of Government
of India

60. Cont….
Vitamin A prophylaxis to the children
as per National guidelines.
Prevention and control of childhood
diseases like malnutrition, infections,
ARI, Diarrhea, Fever, Anemia etc.
including IMNCI strategy.

61. Cont…
 Name based tracking of all infants and
children to ensure full immunization
coverage.
 Identification and follow up, referral
and reporting of Adverse Events
Following Immunization (AEFI).

62. FAMILY PLANNING AND
CONTRACEPTION
• Education, Motivation and counselling
to adopt appropriate Family planning
methods.

63. Cont…
Provision of contraceptives such a
condoms, oral pills, emergency
contraceptives, Intra uterine
Contraceptive Devices (IuCD) insertions
(wherever the ANM is trained in IuCD
insertion).
Follow up services to the eligible couples
adopting any family planning methods
(terminal/spacing).

64. SAFE ABORTION SERVICES (MTP)
Counselling and appropriate referral for
safe abortion services (MTP) for those in
need.
 Follow up for any complication after
abortion/MTP and appropriate referral
if needed.

65. CURATIVE SERVICES
Essential
•  Provide treatment for minor ailments
including fever, diarrhea, ARI, worm
infestation and First Aid including first aid
to animal bite cases (wound care,
tourniquet (in snake bite) assessment and
referral).
•  Appropriate and prompt referral.

66. CURATIVE SERVICES
• Provide treatment as per AYUSH as per
the local need. ANMs and MPW (M) be
trained in basic AYUSH drugs.
• Once a month clinic by the PHC medical
officer.
• LHV, HWM and ANM should be
available for providing assistance.

67. Adolescent Health Care
Education, counselling and referral.
•  Prevention and treatment of
Anemia.
•  Counselling on harmful effects of
tobacco and its cessation.

68. School Health Services
• Screening, treatment of minor ailments,
immunization, de-worming, prevention
and management of Vitamin A and
nutritional deficiency anemia and referral
services through fixed day visit of school
by existing ANM/MPW.

69. CONT…
•  Staff of Sub-centre shall provide
assistance to school health services as a
member of team.

70. Control of Local Endemic
Diseases
• Assisting in detection, Control and
reporting of local endemic diseases such
as malaria, kala Azar, Japanese
encephalitis, Filariasis, Dengue etc.
• Assistance in control of epidemic
outbreaks as per programme guidelines.

71. Disease Surveillance, Integrated
Disease
Surveillance Project (IDSP)
• Surveillance about any abnormal increase
in cases of diarrhea/dysentery, fever with
rigors, fever with rash, fever with
jaundice or fever with unconsciousness
and early reporting to concerned PHC as
per IDSP guidelines.

72. CONT…
• Immediate reporting of any
cluster/outbreak based on syndromic
surveillance.
• High level of alertness for any unusual
health event, reporting and appropriate
action.
• Weekly submission of report to PHC
in’S’Form as per IDSP guidelines.

73. Water and Sanitation
• Disinfection of drinking water sources.
 Promotion of sanitation including use
of toilets and appropriate garbage
disposal.

74. Out reach/Field Services
Village Health and Nutrition Day (VHND)
• VHND should be organised at least once
in a month in each village with the help of
Medical Officer, Health Assistant Female
(LHV) of PHC, HWM, HWF, ASHA,
AWW and their supervisory staff, PRI,
Self Help Groups etc.

75. CONT…
• Each Village Health and Nutrition Day
should last for at least four hours of
contact time between ANMs, AWWs,
ASHAs and the beneficiaries.

76. CONT..
• Early registration and Antenatal care
for pregnant women – as per standard
treatment protocol for the SBA.
•  Immunization and Vitamin A
administration to all under 5 children-
as per immunization schedule.

77. CONT….
• Coordination with ICDS programme for
Supplementary nutritional services,
health check up and referral services,
health and nutrition education,
immunization for children below 6 years,
Pregnant & Lactating Mother and
health and nutrition education for all
women in the age group (15 to 45 years)

78. CONT…
• Family planning counselling and
distribution of contraceptives.
• Symptomatic care and management of
persons with minor illness referred by
ASHAs/AWWs or coming on their own
accord.

79. CONT..
Health Communication to mothers,
adolescents and other members of the
community who attend the VHND
session for whatever reason.

80. CONT…
Meet with ASHAs and provide
training/support to them as needed.
 Registration of births and Deaths.

81. CONT…
Symptom based care and counselling
with referral if needed for STI/RTI and
for HIV/AIDS suspected cases.
Disinfection of water sources and
promotion of sanitation including use of
toilets and appropriate garbage
disposal.

82. HOME VISITS
• For skilled attendance at birth- where
the woman has opted or had to go in
for a home delivery.

83. CONT..
• Post natal and newborn visits – as per
protocol to check out on disease
incidences reported to Health Worker
or she/he comes across during house
visits especially where there it is a
notifiable disease.

84. CONT..
• Visits to houses of eligible couples who
need contraceptive services, but are not
currently using them e.g. couples with
children less than three years of age,
where women are married and less than
19 years of age, where the family is
complete etc.

85. CONT..
 Follow up of cases who have
undergone Sterilization and MTP, as per
protocols especially those who can not
come to the facility.
Visits to community based DOTS
providers, leprosy depot holders where
this is needed.

86. CONT…
• Visits to support ASHA where further
counselling is needed to persuade a family
to utilize required health services e.g.,
immunization dropouts, antenatal care
dropouts, tb defaulter etc.
• To take blood slides/do RDK test in cases
with fever where malaria is suspected.

87. HOUSE-TO-HOUSE SURVEYS
These surveys would be done once
annually, preferably in April.
Some of the diseases would require
special surveys- but at all times not
more than one survey per month would
be expected.

88. CONT…
• Surveys would be done with support and
participation of ASHAs, Anganwadi
Workers, community volunteers,
panchayat members and Village Health
Sanitation and Nutrition Committee
members.

89. CONT…
Age and sex of all family members.
 Assess and list eligible couples and their
unmet needs for contraception.
 Identify persons with skin lesions or
other symptoms suspicious of leprosy
and refer: essential in high leprosy
prevalence blocks.

90. CONT…
Identify persons with blindness, list and
refer: Identify persons with hearing
impairment/deafness, list and refer.
Annual mass drug administration in
filaria endemic areas.

91. CONT…
• Identify persons with disabilities, list
and refer and call for counselling
where needed.
• Identify and list senior citizens who
need special care and support.
• Identify persons with mental health
problems and Epilepsy; list and refer.

92. CONT…
• In high endemicity areas-survey for
fever suspicious of kala- azar, for
epidemic management of malaria, for
detection of fluorosis affected cases etc.
• Ani other obvious disease/disorder; list
and refer.

93. COMMUNITY LEVEL INTERACTIONS
• Focus group discussions for
information gathering and health
planning.

94. CONT…
Health Communication especially as
related to National Health programmes
through attending Village Health
Sanitation and Nutrition Committee
meetings, ASHA local review meetings and
meetings with panchayat
members/sarpanch, Self Help Groups,
women’s groups and other BCC activities.

95. COORDINATION AND
MONITORING
• Coordinated services with AWWs,
ASHAs, Village Health Sanitation and
Nutrition Committee PRI etc.

96. National Health Programmes
Communicable Disease Prgramme
National AIDS Control Programme
(NACP):
Essential
• Condom promotion & distribution of
condoms to the high risk groups.

97. CONT…
Help and guide patients with HIV/AIDS
receiving ART with focus on adherence.
IEC activities to enhance awareness and
preventive measures about STIs and
HIV/AIDS, PPtCt services and HIV-TB
coordination.

98. CONT….
• Linkage with Microscopy Centre for
HIV-TBcoordination.
HIV/STI Counseling, Screening and
referral in type b Sub-centres
(Screening in Districts where the
prevalence of HIV/AIDS is high).

99. National Vector Borne Disease
Control
Programme (NVBDCP):
• Collection of blood slides of fever
patients
• Rapid Diagnostic tests (RDt) for
diagnosis of Pf malaria in high Pf
endemic areas.
• Appropriate anti-malarial treatment.

100. CONT…
• Assistance for integrated vector control
activities in relation to Malaria, Filaria,
JE, Dengue, kala-Azar etc. as prevalent
in specific areas. Prevention of breeding
places of vectors Indian Public Health
Standards (IPHS) Guidelines for Sub-
centres 13through IEC and community
mobilization.

101. Cont….
• Annual mass drug administration with
single dose of Diethyl carbamazine (DEC)
to all elligible population at risk of
lymphatic filariasis.
• Promotion of use of insecticidal treated
nets, wherever supplied.
• Record keeping and reporting.

102. National Leprosy Eradication
Programme (NLEP):
Health education to community
regarding signs and symptoms of leprosy,
its complications, curability and
availability of free of cost treatment.

103. Cont…
• Referral of suspected cases of leprosy
(person with skin patch, nodule,
thickened skin, impaired sensation in
hands and feet with muscle weakness)
and its complications to PHC

104. CONT…
• Provision of subsequent doses of MDT
and follow up of persons under treatment
for leprosy, maintain records and
monitor for regularity and completion of
treatment.

105. Revised National Tuberculosis
Control Programme
(RNTCP):
• Referral of suspected symptomatic
cases to the PHC/Microscopy centre.
• Provision of DOTS at Sub-centre,
proper documentation and follow-up.

106. CONT…
Sputum collection centers established
in sub-centre for collection and
transport of sputum samples in rural,
tribal, hilly &difficult areas of the
country where Designated Microscopy
Centres are not available as per the
RNTCP guidelines.

107. Non-communicable Disease
(NCD) Programmes
• National Programme for Control of
Blindness (NPCB):
Detection of cases of impaired vision in
house to house surveys and their
appropriate referral. the cases with
decreased vision will be noted in the
blindness register.

108. CONT…
Spreading awareness regarding eye
problems, early detection of decreased
vision, available treatment and health
care facilities for referral of such cases.
IEC is the major activity to help
identify cases of blindness and refer
suspected cataract cases.

109. CONT…
The cataract cases brought to the
District
Hospital by MPW/ANM/and ASHAS.
Assisting for screening of school
children for diminished vision and
referral.

110. National Programme for Prevention
and Control
of Deafness (NPPCD):
 Detection of cases of hearing
impairment and deafness during House
to house survey and their appropriate
referral.
 Awareness regarding ear problems,
early detection of deafness, available
treatment and health care facilities for
referral of such cases.

111. CONT…
Education of community especially the
parents of young children regarding
importance of right feeding practices,
early detection of deafness in young
children, common ear problems and
available treatment for hearing
impairment/deafness.

112. National Mental Health
Programme:
• Identification and referral of common
mental illnesses for treatment and
follow them up in community.
• IEC activities for prevention and early
detection of mental disorders and
greater participation/role of
Community for primary prevention of
mental disorders.

113. NATIONAL PROGRAMME FOR
PREVENTION AND CONTROL OF
CANCER, DIABETES,
CARDIOVASCULAR DISEASES AND
STROKE
IEC Activities to promote healthy
lifestyle sensitize the community about
prevention of Cancers, Diabetes, CVD
and Strokes, early detection through
awareness regarding warning signs and
appropriate and prompt referral of
suspect cases.

114. CONT…
National Iodine Deficiency
Disorders Control Programme:
IEC Activities to promote
consumption of
Iodized salt by the community.
testing of salt for presence of
Iodine through Salt testing kits by
ASHAs.

115. IN FLUOROSIS AFFECTED
(ENDEMIC) AREAS
• Identify the persons at risk of
Fluorosis, suffering from Fluorosis and
those having deformities due to
Fluorosis and referral.

116. CONT…
• Line listing of reconstructive surgery
cases, rehabilitative intervention
activities and referral services
• Focused behaviour change
communication activities to prevent
Fluorosis.

117. National Tobacco Control
Programme:
Spread awareness and health education
regarding ill effects of tobacco use
especially in pregnant females and Non-
Communicable diseases where tobacco is a
risk factor.

118. CONT…
e.g. Cardiovascular disease, Cancers,
chronic lung diseases.
Display of mandatory signage of “No
Smoking” in the Sub-centre.

119. CONT…
• Counselling for quitting tobacco.
• Awareness to public that smoking is
banned in public places and sale of
tobacco products is banned to minors (less
than 18 years) as well as within 100 yards
of schools and educational institutions.
• Spread awareness regarding law on smoke
free public places.

120. CONT…
Oral Health:
Health education on oral health and
hygiene especially to antenatal and
lactating mothers, school and
adolescent children.
Providing first aid and referral
services for cases with oral health
problems.

121. CONT….
Disability Prevention:
Health education on Prevention of
Disability. Identification of Disabled
persons during annual house to house
survey and their appropriate referral.

122. National Programme for Health
Care of Elderly
• Counseling of Elderly persons and
their family members on healthy
ageing.
• Referral of sick old persons to PHC.

123. Promotion of Medicinal Herbs
• Locally available medicinal
herbs/plants should be grown around
the Sub-centre as per the guidelines of
Department of AYUSH.

124. RECORD OF VITAL EVENTS
Essential
Recording and reporting of vital events
including births and deaths,
particularly of mothers and infants to
the health authorities.

125. Type of
subcentre
Sub-centre A Sub-centre B (MCH
Sub-
centre)
Staff Essential Desirable Essential Desirable
ANM/Health
Worker
(Female)
1 +1 2
Health Worker
(Male)
1 1
Staff Nurse (or
ANM, if Staff
Nurse is not
available)
1**
Safai-
karamchari*
1 (Part-time) 1 (Full-time)
*to be outsourced.
** if number of deliveries at the Sub-centre is 20 or more in a month

126. PHC
• Origin of Primary Health Centre The
concept of primary health centre is not
new to India.
• The Bhore Committee in 1946 gave the
concept of primary health centre as a
basic health unit, to provide as close to
the people as possible, an integrated
curative and preventive health care to
the rural population.

127. PHC
• The central council of health as its first
meeting held in January 1953 had
recommended the establishment of
primary health centers in community
development blocks to provide
comprehensive health care to the rural
population.

128. PHC…
• Corner stone.
• 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 preventive and promotive
aspects of health care.

129. PHC
The PHCs are established and
maintained by the State Governments
under the Minimum Needs Programme
(MNP)/ Basic Minimum Services
(BMS) Programme

130. PHC
• As per minimum requirement, a PHC is
to be manned by a Medical Officer
supported by 14 paramedical and other
staff. Under NRHM, there is a provision
for two additional Staff Nurses at PHCs
on contract basis. It acts as a referral
unit for 6 Sub Centres.

131. PHC
• It has 4 - 6 beds for patients. The
activities of PHC involve curative,
preventive, promotive and Family
Welfare.
• Some diagnostic services also.

132. • 23,673 PHCs functioning as on March
2010 in the country.

133. • At the national level, there is an
increase of 437 PHCs in 2010 as
compared to that existed in 2005.
Significant increase is also observed in
the number of PHCs in the States of
Bihar, Chhattisgarh, Haryana, Jammu
& Kashmir, Karnataka,
Maharashtra,Nagaland, Uttarakhand,
Uttar Pradesh.

134. SET UP
PHC
30,000
20,000
4-6 Beds
Some diagnostic facilities.

135. FUNCTIONS OF THE PHC
• Its functions cover all the 8 essential
elements of PHC as outlined in Alma
Ata declaration:

136. Medical care
MCH including family planning
Safe water supply and basic sanitation
Prevention and control of local
endemic diseases
Collection and reporting of vital
statistics

137. FUNCTIONS
Education about health BCC, IEC.
National health programs
School health.
 Referral services
Training of health guides, health
workers, local dais and health
assistants
Basic laboratory service
Monitoring and supervision.

138. IPHS PHC
Services at the Primary Health Centre
for meeting the IPHS
• Type A PHC: PHC with delivery load
of less than 20 deliveries in a month.
• Type B PHC: PHC with delivery load
of 20 or more deliveries in a month.

139. CONT..
• Minimum Requirement Projected
based on the basis of 40 patients per
doctor per day, the expected number of
beneficiaries for maternal and child
health care and family planning about
60% utilization of the available
indoor/observation beds (6 beds).

140. CONT…
• If the utilization goes up, the standards
would be further upgraded.
• As regards, manpower, one more
Medical Officer (may be from AYUSH
or a lady doctor) and two more staff
nurses are added to the existing total
staff strength of 15 in the PHC to make
it 24x7 services delivery centre.

141. Objectives of Indian Public Health
Standards (IPHS) for Primary
Health Centres (PHC)
To provide comprehensive primary health
care to the community through the Primary
Health Centres.
 To achieve and maintain an acceptable
standard of quality of care.
To make the services more responsive and
sensitive to the needs of the community.

142. Manpower at PHC
Existing 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

143. Community Health Centres
(CHCs)
• CHCs are being established and
maintained by the State Government
under MNP/BMS programme.

144. CHC
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.

145. CONT…
• It serves as a referral centre for 4 PHCs
and also provides facilities for obstetric
care and specialist Consultation.

146. CONT…
• The National health plan
(1983)proposed reorganization of PHC
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, backward
areas for more effective coverage.

147. FUNCTIONS OF CHC
• Providing speciality services
• Giving all preventive and curative
health services.
• Caring and supervision of concerned
PHCs
• Providing consultancy and referral
services to PHCs
• Referring patients to district hospitals
and teaching hospitals.

148. Cont….
• Implementation of all national health
programmers with active participation
in them.
• Providing reproductive and child health
services including family planning
services.

150. Title

151. First Referral Units (FRUs)
An existing facility (district hospital,
sub-divisional hospital, community
health centre etc.) can be declared a
fully operational First Referral Unit
(FRU) only if it is equipped to provide
round-the-clock services for Emergency
Obstetric and New Born Care, in
addition to all emergencies that any
hospital is required to provide.

152. RURAL FAMILLY WELFARE
CENTRE
• PHC’es of block level
• 1 April 1980
• 1 assistant surgeon and 11 para medical
staffs
• April 2002 state govt.

153. URBAN HEALTH SERVICES
• In India 377 million people live in urban
places, out of which an estimated 97
million people live in urban poverty.
• Rapid urbanization and the significant
growth of urban poor population in
absolute numbers already have new
demands on the available infrastructure
and service delivery mechanisms.

154. URBAN HEALTH SERVICES…
• The urban poor are a mix of people living in
slums and the homeless.
• Urban poverty is characterized by food
insecurity, varied morbidity pattern, poor
access to drinking water and sanitation,
high costs of living and job insecurity.
• All these aspects affect the health seeking
behavior of the urban poor and in general
the health.

155. SIGNIFICANCE OF URBAN
HEALTH
155
The World Health Day theme for 2010
“Urbanization and Health”

156. Cont…
• The Urban Health Initiative (UHI) is
part of a five-year, four country
initiative supported by the Bill &
Melinda Gates Foundation in Nigeria,
Kenya, Senegal, and India.

157. Cont…
UHI India is a consortium of
international, national, nongovernmental,
and community-based organizations
working together to improve the health of
the urban poor, especially in the state of
Uttar Pradesh.

158. Cont…
• UHI is designed to be complementary to
national and state health sector plans and
goals.
• The initiative supports the
implementation and scale-up of effective
evidence-based strategies, as well as the
testing of promising innovations.

159. SLUMS
• Nearly one-third of India’s urban citizens
live in crowded informal settlements or
slum communities.
• UN-HABITAT has estimated that by the
year 2020, India’s total slum population
will cross 200 million people.

160. What are slums?
Habitations located on disputed as well
as unused government, municipal and
private land and characterized by a
serious lack of basic amenities and
sanitation with dense and overcrowded
housing conditions.

161. Cont...
• City slums are characterized by poor
access to clean water and adequate
sanitation, the basic requirements for
maintaining good hygiene and robust
health.

162. Cont…
• Health-wise, the urban poor are worse
off than their middle- and high-income
counterparts; they also appear to be
worse off than their rural counterparts

163. Cont…
• Every year, Indian slums bear witness
to how preventable illnesses cause
thousands of deaths and millions of
hours of forfeited productivity.
• The government is cognizant of the
country’s urban healthcare challenges,
but has thus far found it difficult to
adequately serve the space.

164. Health Delivery System in Urban
Slums
• The government of India appointed the
Krishnan Committee in 1982 to address
the problems of urban health.
• The health post scheme was devised for
urban areas based on the
recommendations of the Krishnan
Committee. Its report specifically outlines
which services have to be provided by the
health post .

165. Cont…
• These services have been divided into
outreach, preventive, family planning,
curative, support (referral) services
and reporting and record keeping.

166. Cont…
• Outreach services include population
education, motivation for family
planning, and health education. In the
present context, very few outreach
services are being provided to urban
slums.

167. Cont…
• A municipal corporation covers a
population of above three lakh; there are
three types of municipal councils – (A) 1
lakh population, (B) 40,000 to 1 lakh and
(C) less than 40,000. Primary health
services are provided in urban areas
through health posts.
• There are four types of health posts (A, B,
C and D) according to population size (as
per GoI guidelines).

168. Cont….
According to the Krishnan Committee
recommendations, the health post was to
be located ‘in’ slum areas.
The committee had recommended one
voluntary health worker (VHW) per
2,000 population with an honorarium of
Rs 100.

169. Cont…
• The health post (HP) scheme was
launched in 1983-84. A deputy director
and joint director were assigned to urban
health, but functioned chiefly to promote
family planning goals.
• The scheme is centrally funded, and the
financial provisions at present continue to
be the same as those 15 years before.

170. 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.

171. 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.

172. URBAN PHC
Organization
Municipality
Commissioner
Health Officer
Dispensary/Hospital
Medical officer

173. Functions
• Medical care
• MCH and family planning.
• Prevention and control of communicable
diseases.
• Safe drinking water.
• Environmental sanitation.
• Dietary services.

174. Dispensary
• A dispensary is an office in a school,
hospital or other organization that
dispenses medications and medical
supplies.
• In a traditional dispensary set-up a
pharmacist dispenses medication as per
prescription or order form.

175. Staff Pattern
• MO
• Nurse midwife
• Male health
assistant
• Female health
assistant
• Male health worker
• Female health
worker
•Pharmacist
•Lab technician
•Store keeper
•Watchman
•Driver
•Cook

176. 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.

177. Staffing pattern for Urban Family Welfare
Centers
TYPE
POPULATION
COVERED
NO. UNITS Staffing Pattern
Type I 10000 - 25000 326
ANM -1, FP Field
Worker -1
Type II 25000 - 50000 125
FPExtensionEducat
or/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-

178. Cont.
TYPE OF HEALTH POST NO. OF HEALTH POSTS
A 65
B 76
C 165
D 565

179. 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;

180. • 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

183. URBAN HOSPITALS
• Satellite hospitals.
• Big dispensaries,
hospitals.
• District hospitals
Sub
divisional
health
centres
5 lakhDistrict health centres
•NUHM

184. NUHM
 One Urban Primary Health Centre
(U-PHC) for every fifty to sixty thousand
population.
 One Urban Community Health Centre
(U-CHC) for five to six U-PHCs in big
cities.
 One Auxiliary Nursing Midwives (ANM)
for 10,000 population.
 One Accredited Social Health Activist
ASHA (community link worker) for 200 to

185. NUHM
• The scheme will focus on primary health
care needs of the urban poor.
• This Mission will be implemented in 779
cities and towns with more than 50,000
population and cover about
7.75 crore people.

186. • Urban poor population living in listed and
unlisted slums.• All the other vulnerable
population such as homeless, rag- pickers,
street children, rickshaw pullers, construction
and brick kiln workers, sex workers, any other
temporary migrants.• Public health thrust on
sanitation, clean drinking water and vector
control.• Strengthening public health capacity
of urban local bodies

187. • To address the health concerns by facilitating
equitable access to available health facilities by
rationalizing and strengthening the capacity of
the existing health care delivery system.•
Partnership with all efforts made for accessing
community buildings under various health
programmes to ensure full utilization of
created infrastructure.• Similarly, the
communitization process draw heavily on the
existing community organizations and self-help

188. • It aims to synergize the mission with the
existing progammes such as Jawahar Lal
Nehru National Urban Renewal Mission
(JNNURM), Swarn Jayanti Shahri Rozgar
Yojana (SJSRY) and ICDS which have similar
objectives to NUHM.

189. • Core Strategies• Improving the efficiency of
public health system in the cities by
strengthening, revamping and rationalizing
urban primary health structure• Promotion of
access to improved health care at household
level through community based groups: Mahila
Arogya Samitees (MAS)• Strengthening public
health through preventive and promotive
action• Increased access to health care through
community risk pooling and health insurance

190. NUHM
• The interventions
· Reduction in Infant Mortality Rate
(IMR)
· Reduction in Maternal Mortality
Ratio (MMR)
· Universal access to reproductive
health care
· Convergence of all health related
interventions.

191. • Urban Social Health Activist (USHA)• An Urban
Social Health Activist (USHA) will be posted for
every 200-500 households and provide the
leadership and promote the Mahila Arogya
Samitee.• The USHA on the lines of ASHA,
would preferably be a woman resident of the
slum– married/widow/ divorced, preferably in
the age group of 25 to 45 years.• She would
be chosen through a rigorous community
driven process involving ULB counsellors,

192. • Urban Social Health Activist (USHA)• The
USHA would actually be the nerve centres for
delivering outreach services in the vicinity of
the door steps of the beneficiaries.• The USHA
may be preferably co-located with the
Anganwadi Centres located in the slums for
optimization of health outcomes.

193. • Mahila Arogya Samitee (MAS)• The NUHM
proposes the creation of Mahila Arogya
Samitee (MAS) a community based federated
group of around 20 to 100 households,
depending upon the size and concentration of
the slum population, with flexibility for state
level adjustments.• MAS - acts as community
based peer education group, involved in
community monitoring and referral.

194. • Mahila Arogya Samitee (MAS)• The MAS will
have 5-20 members with an an elected
Chairperson and a Treasurer, supported by an
USHA.• This group would focus on health and
hygiene behaviour change promotion,
facilitating access to identified facilities and
risk pooling.• The MAS will be provided an
annual united grant of Rs 5000 per year.

195. • Primary Urban Health Centre• The situational
analysis has clearly revealed that most of the
existing primary health facilities, namely the
Urban Health Posts (UHPs) /Urban Family
Welfare Centres (UFWC)/ Dispensaries are
functioning sub- optimally due to problems of
infrastructure, human resources, referrals,
diagnostics, case load, spatial distribution, and
inconvenient working hours.• The NUHM
therefore proposes to strengthen and revamp

196. • Primary Urban Health Centre• The PUHC may
cater to a slum population between 20000-
30000, with provision for evening OPD,
providing preventive, promotive and non-
domiciliary curative care (including
consultation, basic lab diagnosis and
dispensing)• However, depending on the
spatial distribution of the slum population, the
population covered by a PUHC may vary from
5000 for cities with sparse slum population to

197. • Rogi Kalyan Samiti and Referrals• Rogi Kalyan
Samiti will be made for promoting local
action.• The provision of health care delivery
with the help of outreach sessions in the
slums would also strengthen the delivery of
health care services.• On the basis of the GIS
map the referrals would also be clearly
defined and communicated to the community
thus facilitating their easy access.

198. • Rogi Kalyan Samiti and Referrals• Creation of
Sub Centers has not been proposed. Outreach
services will be provided through Female
Health Workers (FHWs)/ANMs headquartered
at the U-PHCs, utilizing community halls, AWC,
etc., as fixed points for these services.•
Secondary and Tertiary level care and referral
services will be provided through public or
empanelled private providers.

199. • Community health risk pooling• The NUHM
would promote Community health risk
pooling and health insurance as measures for
protecting the poor from impoverishing effect
of out of pocket expenditure.• To promote
community risk pooling mechanism the
members of the MAS would be encouraged to
save money on monthly basis for meeting the
health emergencies.• The group members
themselves would decide the lending norms

200. • Community health InsuranceTo ensure access
of identified families to quality medical care
forhospitalization/surgeryBeneficiaries•
Identified urban poor families, for a maximum
of five members• Smart Card/Individual or
Family Health Suraksha Cards to be proof of
eligibility and to avoid duplication with similar
schemesImplementing Agency:• Preferably
ULBs, possibly state for smaller citiesPremium
Financing• Up to a maximum of Rs.600 per

201. • IT enabled services (ITES) and e-governance•
Studies have highlighted that the private
providers, which provide the majority of them
urban poor access for OPD services, remain
outside the public disease surveillance
network.• This leads to compromised
reporting of diseases and outbreaks in urban
slums thereby adversely affecting timely
intervention by the public authorities.• The
availability of ITES in the urban areas makes it

202. • Monitoring & Evaluation• The Monitoring and
evaluation framework would be based on
triangulisation of information.• The three
components would be (a) Community Based
Monitoring (b) A web based Urban HMIS for
reporting and feedback and (c) external
evaluations
• 43. Monitoring & Evaluation• The District/
City Urban Health Society along with the
District/ City Urban Health Mission would

203. URBAN FAMILY WELFARE
CENTRES
• 1950
• India, the second most populous country in
the world, has no more than 2.5 per cent of
global land but is the home of 1/6th of the
world's population.
• 2007, April- 1083.

204. URBAN HEALTH POSTS
• ABCD RCH
871-(2007) FIRST AID
Contraceptives
Other services.

205. • SPECIALITY HOSPITALS.
• TEACHING HOSPITALS.
300 ( 2009).

206. SUPER SPECIALITY HOSPITALS
• PMSSY.
• First Phase
6 AIMS.
Jodhpoor
Bhopal
Raipur
Patna
Bhuwaneshwar
Rishikesh

207. Cont..
Up gradation of 13 existing.
960 bedded.
500-Medical college.
300-Speciality/super
speciality.
100-ICU/ trauma.
30- PM&Rehab.
30- AYUSH.

208. Cont..
• Second phase
Besides, the government has also
approved setting up of two such
institutions, one each in West
Bengal and Uttar Pradesh.

209. Cont..
• The steering committee on health for 12th
Five Year Plan has recommended the Union
government to create four new AIIMS like
institutions (ALIs) over and above the eight
already approved under the Pradhan Mantri
Swasthya Suraksha Yojana (PMSSY).

210. THIRD PHASE
• Government Medical College, Jhansi, Uttar
Pradesh; Government Medical College, Rewa,
Madhya Pradesh; Government Medical
College, Gorakhpur,
UttarPradesh; Government Medical College,
Dharbanga, Bihar; Government Medical
College, Kozhikode, Kerala; Vijaynagar
Institute of Medical Sciences, Bellary,
Karnataka and Government Medical College,
Muzaffarpur, Bihar.

211. 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.

212. Facilities provided
• Emergency services
• Free supply of drugs
• Lab & radiological services
• Domiciliary visits
• Specialist consultation at hospital, family
welfare centr level

213. Urban Health service delivery model
Referral
Primary level health
care facility
Community level