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Lecture Lecture 13 13 PRIMARY HEALTH CARE IN INDIA, PRIMARY HEALTH CARE IN INDIA, VILLAGE LEVEL VILLAGE LEVEL "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".

Lecture 13

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Lecture 13. "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". PRIMARY HEALTH CARE IN INDIA, VILLAGE LEVEL. HEALTH CARE SERVICES. - PowerPoint PPT Presentation

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LectureLecture 13 13PRIMARY HEALTH CARE IN INDIA, PRIMARY HEALTH CARE IN INDIA,

VILLAGE LEVELVILLAGE LEVEL

"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".

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HEALTH CARE SERVICESThe purpose of health care services consists in improving the health status of the population: to reduced the levels of mortality and morbidity, to increase in expectation of life, to decrease in population growth rate, improvements in nutritional status, to reduced levels of poverty, etc.The scope of health services varies widely from country to country and influenced by general and ever changing national, state and local health problems, needs and attitudes as well as the available resources to provide these services. There is now broad agreement that health services should be: •(a) comprehensive •(b) accessible •(c) acceptable •(d) provide scope for community participation, and •(e) available at a cost the community and country can afford. These are the essential ingredients of primary health care which forms an integral part of the country's health system, of which it is the central function and main agent for delivering health care.

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HEALTH CARE SYSTEMSThe health care system is intended to deliver the health care services. It constitutes the management sector and involves organizational matters, it operates in the context of the socioeconomic and political framework of the country. In India, it is represented by five major sectors or agencies which differ from each other by the health technology applied and by the source of funds for operation. These are : 1. PUBLIC HEALTH SECTOR1. PUBLIC HEALTH SECTOR

Primary Primary Health CareHealth Care

Hospitals/Health Hospitals/Health CentersCenters

Health Insurance Health Insurance SchemesSchemes

Other Other agenciesagencies

Primary health Primary health centerscenters

Community health Community health centerscenters

Employees State Employees State InsuranceInsurance

Defence Defence servicesservices

Sub - centersSub - centers Rural hospitalsRural hospitals Central Govt. Central Govt. Health SchemeHealth Scheme

RailwaysRailways

District hospital District hospital /health centre/health centre

Specialist hospitalsSpecialist hospitals

Teaching hospitalsTeaching hospitals

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HEALTH CARE SYSTEMS2. PRIVATE SECTOR(a) Private hospitals, polyclinics. Nursing

homes, and dispensaries(b). General practitioners and clinics3. INDIGENOUS SYSTEMS OF MEDICINEAyurveda and SiddhaUnani and TibbiHomoeopathyUnregistered practitioners4. VOLUNTARY HEALTH AGENCIES5. NATIONAL HEALTH PROGRAMMES

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PRIMARY HEALTH CARE IN INDIA• In 1977, the Government of India launched a Rural Health Scheme,

based on the principle of "placing people's health in people's hands". It is a three tier system of health care delivery in rural areas based on the recommendation of the Shrivastav Committee in 1975. Close on the heels of these recommendations an International conference at Alma-Ata in 1978, set the goal of an acceptable level of Health for All the people of the world by the year 2000 through primary health care approach. As a signatory to the Alma-Ata Declaration, the Government of India is committed to achieving the goal of Health for All through primary health care approach which seeks to provide universal comprehensive health care at a cost which is affordable.

• Keeping in view the WHO goal of "Health for All", the Government of India evolved a National Health Policy based on primary health care approach. It was approved by Parliament in 1983. The National Health Policy has laid down a plan of action for reorienting and shaping the existing rural health infrastructure.

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Village level • One of the basic tenets of primary health care is

universal coverage and equitable distribution of health resources. That is health care must penetrate into the farthest reaches of rural areas, and that everyone should have access to it. To implement this policy at the village level, the following schemes are in operation:

a. Village Health Guides Scheme

b. Training of local Dais

c. ICDS Scheme (Integrated Child Development Services)

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Village Health Guides • A Village Health Guide is a person with an aptitude for social

service and is not a full time government functionary. The Village Health Guides Scheme was introduced on 2nd October 1977 with the idea of securing people's participation in the care of their own health. The scheme was launched in all States except Kerala, Karnataka, Tamil Nadu, Arunachal Pradesh and Jammu and Kashmir which had alternative systems (e.g., Mini-health Centres in Tamil Nadu) of providing health services at the village level.

• The Health Guides are now mostly women. A circular was issued by Government of India in May 1986 that male Health Guides would be replaced by female Health Guides. The Health Guides come from and are chosen by the community in which they work. They serve as links between the community and the governmental infrastructure. They provide the first contact between the individual and the health system.

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The guidelines for their selection are:•they should be permanent residents of the local community, preferably women•they should be able to read and write, having minimum formal education at least up to the VI standard•they should be acceptable to all sections of the community and•they should be able to spare at least 2 to 3 hours every day for community health work.After selection, the Health Guides undergo a short training in primary health care The training is arranged in the nearest primary health centre, subcentre or any other suitable place for the duration of 200 hours, spread over a period of 3 months. During the training period they receive a stipend of Rs. 200 per month.

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Health Guides• On completion of training, they receive a working

manual and a kit of simple medicines belonging to the modern and traditional systems of medicine in vogue in that part of the country to which they belong. Broadly the duties assigned to health guides include treatment of simple ailments and activities in first aid, mother and child health including family planning, health education and sanitation. The manual or guidebook gives them detailed information about medical care of common illnesses - of what they can and cannot do. In practical terms, they know exactly what should be done when confronted with a situation, when they can begin treatment by themselves and when they should refer the patient immediately to the nearest health centre.

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Health Guides• The Health Guides are free to attend to their

normal vocation. They are expected to do community health work in their spare time of about 2 to 3 hours daily for which they are paid an honorarium of Rs. 50 per month and drugs worth Rs. 600 per annum. As the training involves expenditure, the Government will not train another Health Guide from the same village before three years. As of date, there are 3.23 lakh village Health Guides functioning in the country. The training programme is being continued during the Ninth Plan Period (1997-2002) to achieve the national target of one Health Guide for each village or 1000 rural population.

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Local Dais • Most deliveries in rural areas are still handled by untrained dais

who are often the only people immediately available to women during the perinatal period. An extensive programme has been undertaken, under the Rural Health Scheme, to train all categories of local dais (traditional birth attendants) in the country to improve their knowledge in the elementary concepts of maternal and child health and sterilization, besides obstetric skills. The training is for 30 working days. Each dai is paid a stipend of Rs. 300 during her training period. Training is given at the PHC, subcentre or MCH (mother and child health) centre for 2 days in a week, and on the remaining four days of the week they accompany the Health worker (Female) to the villages preferably in the dai's own area. During her training each dai is required to conduct at least 2 deliveries under the guidance and supervision of the HW (F), ANM or HA health assistant (F). The emphasis during training is on asepsis so that home deliveries are conducted under safe hygienic conditions thereby reducing the maternal and infant mortality.

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Local Dais• After successful completion of training, each dai is

provided with a delivery kit and a certificate. She is entitled to receive an amount of Rs. 10 per delivery provided the case is registered with the subcentre/PHC. To each infant registered by her, she will receive Rs.3. These dais are also expected to play a vital role in propagating small-family norm since they are more acceptable to the community. Although the national target is to train one local dai in each village, the Eighth Five Year Plan's objective was to train all untrained dais practising in the rural areas.

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Anganwadi Worker • Angan literally means a courtyard. Under the ICDS (Integrated

Child Development Services) Scheme, there is an anganwadi worker for a population of 1000. There are about 100 such workers in each ICDS Project. As of date over 5320 ICDS blocks are functioning in the country. The anganwadi worker is selected from the community she is expected to serve. She undergoes training in various aspects of health, nutrition, and child development for 4 months. She is a part-time worker and is paid an honorarium of Rs. 200-250 per month for the services rendered, which include health check up, immunization, supplementary nutrition, health education, non-formal pre-school education and referral services. The beneficiaries are especially nursing mothers, other women (15-45 years) and children below the age of 6 years. Along with Village Health Guides, the anganwadi workers are the community's primary link with the health services and all other services for young children.

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Sub-centre level• The sub-centre is the peripheral outpost of the existing health

delivery system in rural areas. They are being established on the basis of one sub-centre for every 5000 population in general and one for every 3000 population in hilly, tribal and backward areas. As on 31st March 2003, 138368 sub-centers were established in the country); the total requirement is estimated to be 1.34 lakh.

• Each sub-centre is manned by one male and one female multipurpose health worker. At present the functions of a sub-center are limited to mother and child health care, family planning and immunization. It is proposed to extend the facilities at all sub-centres for IUD insertion, and simple laboratory investigations like routine examination of urine for albumin and sugar. Creation of these facilities would go a long way in securing greater acceptance of IUD and early detection of complications of pregnancy. The work at sub-centres is supervised by male and female health assistants. According to the revised norm, one female HA will supervise the work of 6 female HWs. The job descriptions of these workers have been published as Manuals by the Rural Health Division of the Ministry of Health and Family Welfare.

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Primary health centre level• The concept of primary health centre is not new to India. The Bhore

committee in 1946 gave the concept of a 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 with emphasis on preventive and promotive aspects of health care. The Bhore Committee aimed at having a health centre to serve a population of 10,000 to 20,000 with 6 medical officers, 6 public health nurses and other supporting staff. But in view of the limited resources, the Bhore Committee's recommendations could not be fully implemented, even after a lapse of 50 years.

• The health planners in India have visualized the primary health centre and its sub-centers as the proper infrastructure to provide health services to the rural population. The Central Council of Health at 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.

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Primary health centre level• The number of primary health centers established since then had

increased from 725 to 5484 - each PHC covering a population of 100,000 or more spread over some 100 villages in each community development block. These centers were functioning as peripheral health service institutions with little or no community involvement. Increasingly, these centers came under criticism as they were not able to provide adequate health coverage, partly because they were poorly staffed and equipped, and partly because they had to cover a large population of one lakh or more. The Mudaliar Committee in 1962 had recommended that the existing primary health centers should be strengthened and the population to be served by them to be scaled down to 40,000.

• The National Health Plan (1983) proposed reorganization of primary health centers 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 and backward areas for more effective coverage. As on 31st March 2003, 22936 primary health centers have been established in the country against the total requirement of about 23,000.

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Functions of the PHCThe functions of the primary health center in India cover all the 8

"essential" elements of primary health care. They are:• Medical care• MCH including family planning• Safe water supply and basic sanitation• Prevention and control of locally endemic diseases• Collection and reporting of vital statistics• Education about health• National Health Programmers - as relevant• Referral services• Training of health guides, health workers, local dais and health

assistants• Basic laboratory servicesIt is proposed to equip the primary health centers with facilities for

selected surgical procedures (e.g., vasectomy, tubectomy and minor surgical procedures) and for paediatric care. In order to reorient medical education (ROME Programmer) towards the needs of the country and community care, three primary health centers have been attached to each of the 148 medical colleges.

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Staffing patternStaffing patternAt present in each community development block, there are one or more PHCs each of which covers 30,000 rural population. In the

new set-up each PHC will have the following staff:At the PHC level:• Medical officer 1• Pharmacist 1• Nurse mid-wife 1• Health worker (female) 1• Block Extension Educator 1• Health assistant (male) 1• Health assistant (female) 1• Lab. technician 1• Driver (subject to availability of

vehicle) 1• Other health workers 4

In total In total 1515

At the sub-centre level:• Health worker (female) 1• Health worker (male) 1• Voluntary worker (paid Rs.50 per month as honorarium) 1

In total In total 33

Notwithstanding the strong criticism Notwithstanding the strong criticism of primary health centers it must of primary health centers it must be emphasized that their be emphasized that their establishment is a valuable national establishment is a valuable national asset. Their establishment is the asset. Their establishment is the fruit of many years of great efforts fruit of many years of great efforts to increase the outreach of the to increase the outreach of the health serviceshealth services..

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Community Health Centers• As on 31st March 2003, 3076 community health centers were

established by upgrading the primary health centers, each community health centre covering a population of 80.000 to 1.20 lakh (one in each community development block) with 30 beds and specialists in surgery, medicine, obstetrics and gynaecology, and paediatrics with X-ray and laboratory facilities. For strengthening preventive and promotive aspects of health care, a new non-medical post called community health officer has been created at each community health centre. The community health officer is selected from amongst the supervisory category of staff at the PHC and district level with minimum of 7 years experience in rural health programmers. Some states have not accepted this scheme and have opted for a second medical officer.

• The specialists at the community health centre may refer a patient directly to the State level hospital or the nearest/ appropriate Medical College Hospital, as may be necessary, without the patient having to go first to the sub-divisional or District Hospital.

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Staff for community Health Centre :Staff for community Health Centre :

• Medical officerMedical officer 44• Nurse mid-wivesNurse mid-wives 77• DresserDresser 11• Pharmacist/CompounderPharmacist/Compounder 11• Lab. technicianLab. technician 11• RadiographerRadiographer 11• Ward boysWard boys 22• SweepersSweepers 33• Other health workersOther health workers: : DhobiDhobi - - 11, , MaliMali - - 11, , ChowkidarChowkidar

--11, , AyaAya - -11, , PeonPeon - - 11..In total In total 25

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JOB DESCRIPTION OF MEMBERS OF THE JOB DESCRIPTION OF MEMBERS OF THE HEALTH TEAMHEALTH TEAM

Medical Officer, PHC• He is the captain of the health team at the primary health centre.

He devotes the morning hours attending to patients in the out-door; in the afternoon he supervises the field work. His tour programme is so designed as to cover all the basic health services including family planning. He visits each subcenter regularly on fixed days and hours and provides guidance, supervision and leadership to the health team. He spends one day in each month organizing staff meetings at the primary health centre to discuss the problems and review the progress of health activities. He ensures that national health programmes are being implemented in his area properly. The success of a primary health centre depends largely on the team leadership which the medical officer is able to provide. The medical officer must be the planner, the promoter, the director, the supervisor, the coordinator as well as the evaluator.

Second Medical Officer• The second medical officer performs identical duties.

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Health worker Male and Female• Under The Multipurpose Worker Scheme, one health worker female and one

health worker male are posted at each sub-centre and are expected to cover a population of 5000 (3000 in tribal and hilly areas). However, health worker female limits her activities among 350-500 families.

HEALTH WORKER MALE (HWM)I. Record Keeping• He will;• Survey all the families in his area and collect general information about each

village/locality in his area.• Prepare, maintain and utilize family records and village registers containing

columns for recording particulars concerning FP, immunizations, vital events, environmental sanitation, other local health programmes, educational activities, services rendered and achievements, etc.

II. Malaria• Identify fever cases. Make thick and thin blood slides. Send the blood slides

for laboratory examination.• Administer presumptive treatment. Record the results of examination of

blood slides.• Educate the community on the importance of blood smear examination for

fever cases, insecticidal spraying of houses, treatment of fever cases.

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HEALTH WORKER MALE (HWM)HEALTH WORKER MALE (HWM)III. Communicable Diseases• Identify cases of diarrhoes/dysentery, fever with rash jaundice,

encephalitis, diphtheria, whooping cough and tetanus, acute eye infections and notify the Health Assistant Male and M.O. PHC immediately about these cases.

• Carty out control measures until the arrival of the Health Assistant Male and assist him in carrying out these measures.

• Give Oral Rehydration Solution to all cases of diarrhoea/dysentery/vomiting.

• Educate the community about the importance of control and preventive measures against communicable diseases and about the importance of taking regular and complete treatment.

• Identify and refer cases of genital sore or urethral discharge or non-itchy rash over the body to Medical Officer.

• Identify and refer all cases of blindness including suspected cases of cataract to M.O.PHC.

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HEALTH WORKER MALE (HWM)HEALTH WORKER MALE (HWM)IV Leprosy• Identify cases of skin patches, especially if accompanied by loss of

sensation and take skin smears from these cases Refer these cases, to M.O. PHC for further investigations.

• Check whether all cases of leprosy are taking regular treatment. Motivate defaulter to take regular treatment.

V Tuberculosis• Identify persons especially 15 years and above with prolonged cough

or spitting of blood and take sputum smears from these individuals. Refer cases to the M.O.PHC for further investigations.

• Check whether all cases of tuberculosis are taking regular treatment. Motivate defaulters to take regular treatment.

• Educate the community on various health education aspect of tuberculosis programme.

• Assist the village Health Guide in undertaking the activities under TB Programme properly. Provide the list of the TB patients living in a village to the village Health Guide so that he is further able to motivate the TB patient in taking regular treatment.

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HEALTH WORKER MALE (HWM)HEALTH WORKER MALE (HWM)VI. Environmental Sanitation• Chlorinate public water sources including wells at regular

intervals.• Educate community on (a) the method of disposal of liquid

wastes; (b) the method of disposal of solid wastes; (c) home sanitation, (d) advantage and use of sanitary type of latrines; (e) construction and use of smokeless chulhas.

VII. Expanded Programme on Immunisation• Administer DPT vaccine, oral poliomyelitis vaccine

measles vaccine (where available) and BCG vaccine to a infants and children in his area.

• Assist the Health Worker Female in administering tetanus toxoid to all pregnant women.

• Assist the Health Assistant Male in the school immunization programme.

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HEALTH WORKER MALE (HWM)HEALTH WORKER MALE (HWM)VIII. Family Planning• Utilize the information from the eligible couple and

child register for the family planning programme.• Spread the message of family planning to the couples

and motivate them for family planning individually and in groups.

• Distribute conventional contraceptives to the couples.• Provide facilities and help to prospective acceptors of

sterilization in obtaining the services.• Provide follow-up services to male family planning

acceptors.• Establish male depot holders in the area. Help the Heath

Assistant Male and Health Assistant Female in training them and provide a continuous supply of convention contraceptives to the depot holders.