health care delivery system in india

1. Health Care Delivery System in
India
Dr Utpal Sharma
Assistant Professor
Department of Community Medicine
SMIMS, Gangtok, Sikkim

2. Introduction
Health is…..
……..a state of complete Physical, Mental
and Social well being and not merely an
absence of disease or infirmity….
…..which allows a person to
live a socio-economically productive life.
Illness is…..
…a state in which a person’ s physical,
emotional, intellectual, social or spiritual
functioning is diminished or impaired.

3. Cont….
Health care is...
…….multitude of services rendered to
individuals or communities by the agents
of health services or professional for the
purpose of
Promoting
Restoring and
Maintaining health
Embraces all the goods and services
designed for “prevention, promotion and
rehabilitation interventions” includes
Medical Care

4. Health Care provider
A person or organization that provides services
and/or health care personnel….
….to deliver proper health care in a systematic
way to any individual in need of health care
services.
Could be a government…or…
….the health care industry,
….a health care equipment company,
….an institution such as a hospital or laboratory.
Health care professionals may include physicians,
dentists, and other support staff.

5. Cont….
Health services
Permanent countrywide system of
estabilished institutions with the objective of…
….coping with the various health needs and
demands of population…
…thereby provide health care to individuals and
community with preventive and curative activities
….utilizing health care workers

6. Cont…
System
Includes… concepts ( e.g health and diseases)
Ideas(e.g equity)
Objects(e.g hospitals, health centres)
Persons (health care workers viz. physician,
nurses)
Together these forms a system interacting
with each other, supporting and controlling
each other

7. Components of healthcare delivery
system

8. 1. Structure of health system
 Aspects of the design of health services that influences the
way in which they are delivered Includes….
 Number and type of personnel and staff
 Way of these personnel organized to work
 Nature and extend of facility and equipment
 Range of services offered
 System of management and amenities
 Financing
 Enumeration and determination of the eligible population for
these services
 Governance and decision making

9. Cont…
2. Process of health care delivery
 Consists of two parts
 Behavior of professionals
 Recognition of the problem i.e diagnosis
 Diagnostic procedure
 Recommendation of treatment or management
 Appropiate follow up
 Participation of people
 Utilization of services
 Understanding the recommendations
 Satisfaction with the services
 Participation in decision making

10. Cont…
3. Outcomes of health care
 Aspects of health that results from interventions provided by the
health system
4. Flow of patients in health care system
 Varies from country to country
 India harbors a multistage (three tier) system, where majority of
health care is delivered by community health care worker
 Indian system is more cost effective if health workers are skilled
and effectively supervised
 Such system could one of the reason to reduced cost of health
care in developing countries

11. Levels of health care
Primary Health care
Provided at the community level
Secondary health care
Provided at PHC, CHC, DH etc.
Tertiary health care
Provided at hospitals
Tertiary health
care

12. Alma-Ata international conference
 In 1977, World Health Assembly decided to launch a
movement called “Health for all by 2000”
 Fundamental principle of this concept was equity, an equal
health status for all the people in all countries
 This is to be ensured by equitable distribution of health
resources
 In 1978, the note of “Health for all” was reaffirmed and
marked as the major social goal for every country.
 It was stated in the declaration that the best way to achieve
HFA is by providing primary health care……
……… especially to vast size of
underserved rural and urban poor

13. Alma-Ata conference, 1978

14. Alma-Ata Declarations
 A main social target of governments, international
organizations and the whole world community in the coming
decades should be the attainment by all peoples of the world
by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life. - “HEALTH
FOR ALL BY 2000”
 Primary health care is the key to attaining this target as part of
development in the spirit of social justice.
 Primary health care is essential health care based on
practical, scientifically sound and socially acceptable methods
and technology, made universally accessible to individuals
and families in the community through their full participation
and at a cost that the community and country can afford.

15. Alma-Ata Declaration
It forms an integral part of the country's health
system, and of the overall social and economic
development of the community.
It is the first level of contact of individuals, the
family and community with the national health
system.
All governments should formulate national policies,
strategies and plans of action to launch and sustain
primary health care as part of a comprehensive
national health system and in coordination with
other sectors.

16. Primary health care
Primary Health Care as defined by the World Health
Organization (WHO) in 1978 is…
Essential health care; based on
practical,
scientifically sound, and
socially acceptable method and technology….
 …….made universally accessible to individuals
and families of the community through their full
participation….
 ……at a cost that community and country can
afford to maintain every stage of their development in
the spirit of self determination.

17. Cont…
Definition
Primary health care is essential health
care made universally accessible to
individuals and acceptable to them
through their full participation and at a cost
the community and country can afford

18. What is there in Primary Health
Care..?????
 Primary Health Care includes:
– Primary Care (physicians, midwives & nurses);
– Health promotion, illness prevention;
– Health maintenance & home support;
– Community rehabilitation;
– Pre-hospital emergency medical services… and…
– Coordination and referral to other areas of health care.

19. Cont.…
 It is the first level of contact with the health system to promote
health, prevent illness, care for common illnesses, and
manage ongoing health problems.
 Primary Health Care involves concerted effort to provide
rural population of developing countries with least bare
minimum of health services.
 Some services are also provided community and hospitals
 Primary Health Care is different in each community depending
upon:
– Needs of the residents;
– Availability of health care providers;
– The communities geographic location; &
– Proximity to other health care services in the area.

20. Elements of primary health care
1. Education about prevailing health conditions and methods
to prevent and control them
2. Promotion of food supply and proper nutrition
3. Adequate water supply and basic sanitation
4. Maternal and child health care with family planning
5. Immunization against major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs

21. Principles of primary health care
Equitable distribution
Community participation
Intersectoral coordination
Appropriate technology

22. Health Care Delivery System in India
India is a union of 28 states and 7 union territories.
States are largely independent in matters relating to
the delivery of health care to the people.
Each state has developed its own system of health
care delivery, independent of the Central
Government.
The Central Government’s responsibility consists
mainly of policy making , planning , guiding,
assisting, evaluating and coordinating the work of
the State Health Ministries.

23. Health System in India
The health system in India has 3 main links

24. At the central level
The official “organs” of health system at
national level are

25. Ministry of Health and
Family Welfare

26. Organization Structure

27. Functions of MoHFW
Union list
 International health relations and administration of port
quarintine
 Administration of Central Institutes
 Promotion of research
 Regulation and development of medical, pharmaceutical, dental
and nursing professions
 Establishment and maintenance of drug standards
 Census and collection and publication of other statistical data
 Coordination with states

28. cont….
Concurrent List:
 Prevention of Communicable disease
 Prevention of food adulteration
 Control of drug and poison
 Vital statistics
 Labour welfare
 Economic and social planning
 Poulation control and family planning

29. Directorate General of
Health Services

30. Organization chart

31. Functions of Directorate General of Health
services
General functions
 Surveys
 Planning
 Coordination
 Programming and appraisal of all health matters
Specific function
 International health relations and quarantine of all major
ports in country and international airport.
 Control of drug standards
 Maintain medical store depots
 Administration of post graduate training programmes

32. Cont…
 Administration of certain medical colleges in India
 Conducting medical research through Indian Council of
Medical Research ( ICMR )
 Central Government Health Schemes.
 Implementation of national health programmes
 Preparation of health education material for creating health
awareness through Health Education Bureau
 Collection, compilation, analysis, evaluation and
dissemination of information
 National Medical Library

33. Central Council of health

34. Organization chart

35. Functions
To consider and recommend broad outlines of
policy related to matters concerning health like
environment hygiene, nutrition and health
education.
To make proposals for legislation relating to
medical and public health matters.
To make recommendations to the Central
Government regarding distribution of grants-in-
aid.

36. State Level

37. At District level
There are 593 ( year 2001 census) districts in
India. Within each district, there are 6 types of
administrative areas.
1. Sub –division
2. Tehsils ( Talukas )
3. Community Development Blocks
4. Municipalities and Corporations
5. Villages and
6. Panchayats

38. Disrtict Level
Districts
Tehsils /Talukas (200-600
villages)
Community Development Blocks
(approx 100 Villages & 80,000 -
1.2 Lac Pop)
Municipalities & Corporations
Municipal Board
(10,000- 2 Lac Pop)
Corporations (> 2 lac
pop)
Town Area Committee
(5,000-10,000 Pop)
Panchayats
Villages

39. Health Services
 Out patient services -Patients who don’t require hospitalization
can receive health care in a clinic. An out patient setting is
designed to be convenient and easily accessible to the patient.
 Clinics – Clinics involve a department in a hospital where patients
not requiring hospitalization, receive medical care.
 Institutions – Hospitals – Hospital have been the major agency
of health care system.
 In broad sense the health services should be
a. Comprehensive
b. Accessible
c. Acceptable
d. Provide scope of community participation and….
e. Available at an affordable cost by country and commuity

40. Health care systems
 Intended to delivery healthcare services and represented by five
major sectors different from each other by health technology
1. Public health sector
a. Primary health care
 Primary health centres
 Sub centres
b. Hospitals/Health centres
 Community health centres
 Rural hospitals
 District hospitals/health centres
 Specialist hospitals
 Teaching hospitals
c. Health insurance schemes
 Employees State Insurance
 Central Govt. Health Schemes
d. Other agencies
Defense services
Railways

41. Cont…
2. Private sector
a. Private hospitals, polyclinic, nursing homes and
dispensaries
b. General practitioners and clinics
3. Indigenous system of medicine
a. Ayurveda and Siddha
b. Unani and Tibbi
c. Homeopathy
d. Unregistered practitioners
4. Voluntary health agencies
5. National health programmes

42. Primary health care in India

43. Introduction
 In 1977, GoI launched Rural Health Scheme based on the
principle of “placing people’s health in people’s hand”
 Subsequently in the international conference of Alma-
Ata(1978)the goal of “Health for all” by 2000 through
primary health care approach was set.
 Keeping in view WHO “Health for all” by 2000 GoI
formulated National health policy 2002

44. Cont….
 More recently GoI formulated NRHM and Indian Public Health
Standards (IPHS) in this regards
 In order to provide quality care in the public health agencies of
health care delivery IPHS are being prescribed.
 These standards provides basic promotive, preventive and
curative primary health care to the community and……
…….achieve and maintain an acceptable quality of care
 These standards would help monitor and improve functioning
of the health care delivery system

45. Rural Health care system in India
Primary Health Centre (PHC)
A Referral unit for 4-6 Subcentres; 4-6 bedded manned with a
Medical Officer in-charge and 14 subordinate paramedical staff
no. of PHCs with specialized Health Services
Community Health Centre (CHC)
A 30 bedded Hospital/ Referral unit for 4 no. of PHCs with
specialized Health Services
Sub Centre (SC)
Most peripheral contact point of community with Primary Health
Care system; manned with one MPW(M) and MPW(F)

46. Rural Health care system in India
The health care infrastructure in rural areas has
been developed as a three tier system and is
based on the above population norms.
Health Facility
Population Norms
Plain Area
Hilly/Tribal/Difficult
Area
Sub-Centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1,20,000 80,000

47. Sub Center
 The most peripheral and first contact point between the primary
health care system and the community.
 The Ministry of Health & Family Welfare is providing 100%
Central assistance
 They are established on the basis of
 One SC for every 5,000 pop in general and…
 One SC for every 3,000 pop in hilly, tribal and backward areas
 Each Sub-Centre is manned by one Male and one female Health
Worker.
 One Lady Health Worker (LHV) is entrusted with the task of
supervision of six Sub-Centers.

48. Cont….
Sub Centre are assigned tasks relating to
interpersonal communication
…..in order to bring about behavioral
change and provide services in relation to….
Maternal and child health,
Family welfare,
Nutrition,
Immunization,
Diarrhea control and
Control of communicable diseases programmes.
The sub centre are provided with basic drugs
for minor ailments.

50. Primary Health Center
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.
The PHCs are established and maintained by the
State Governments.
At present, a PHC is manned by a Medical Officer
supported by 14 paramedical and other staff.

51. Cont….
It acts as a referral unit for 6 SubCentres.
It has 4 - 6 beds for patients.
The activities of PHC involve curative, preventive,
primitive and Family Welfare Services.
National Health Plan (1983) proposed
reorganization of PHCs on the basis of….
One PHC for every…..30,000 pop in Rural areas
One PHC for every…..50,000 pop in Urban areas

52. PHC Pakyong

53. Functions of PHCs
Medical care
Health programmes
MCH care and family planning
Health education and training
Referral services
Safe water supply and basic sanitation
Prevention and control of locally endemic diseases
Collection and reporting of vital events
Basic laboratory services

54. Staffing of PHCs
Source: IPHS 2012

55. Community Health Center (CHC)
 These were established by upgrading the primary health centers
 CHCs are being established and maintained by the State Government.
 centers,each community health center should cover a population of
8000 to 1.2 lakh
 It is manned by four medical specialists i.e. Surgeon,
Physician, Gynecologist and Pediatrician and….
……supported by 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.

56. Functions of CHCs
 Care of Routine and Emergency Cases in Surgery
 Dressings, I&D, and surgery for Hernia, Hydrocele,
Appendicitis etc.
 Emergencies like Intestinal Obstruction, Haemorrhage, etc.
 Other management including nasal packing, tracheostomy,
foreign body removal etc.
 Fracture reduction and putting splints/plaster cast.
 Conducting daily OPD.
 Care of Routine and Emergency Cases in Medicine
 Daily OPD
 Handling all the emergency and routine cases

57. Cont…
 Maternal Health
 Minimum 4 ANC check ups including Registration &
associated services
1st visit: Within 12 weeks—preferably as soon as
pregnancy
2nd visit: Between 14 and 26 weeks
3rd visit: Between 28 and 34 weeks
4th visit: Between 36 weeks and term
 24 hr delivery services including normal and assisted
delivery and cesarean section
 Managing labour using Partograph.
 Minimum 48 hours of stay after delivery, 3-7 days stay
post delivery for managing Complications

58. Cont….
 Newborn Care and Child Health
 Essential Newborn Care and Resuscitation
 Counseling on Infant and young child feeding
 Routine and emergency care of sick children
 Full Immunization of infants and children against VPDs
 Management of Malnutrition cases.
 Family Planning
 Counseling, provision of Contraceptives, NSV,
Laparoscopic Sterilization Services and their follow up.
 Safe Abortion Services

59. Cont….
All National Health Programmes delivered through
CHCs
School health services
Others
Blood storage facility
Essential laboratory services
Referral (transport) services
Maternal Death review (MDR)

60. Staffing of CHCs

61. Cont…

62. Cont….

63. Thank you