WELCOMES YOU ALL..

MODERATOR PRESENTORMr. PRAMOD K S NITULECTURER M.SC. (N) 1st YEAR CON 403/13

HEALTH CARE DELIVERY SYSTEM IN INDIA

INTRODUCTION

EVOLUTION OF HEALTH CARE SERVICES IN INDIA

ROLE OF DIFFERENT COMMITTEES

HEALTH ORGANISATION SYSTEM IN INDIA

GAPS IN STRUCTURE

INTEGRATED APPROACH OF HEALTH CARE DELIVERY CONTRIBUTION BY NGOS &CHALLENGES

INTRODUCTION

INDIA is union of 28 states & 7 union terrorties Older concept – Health care means patient care Objective - freedom from the disease through

hospital system.

DEFINITION

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.”

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

STILL…66 YRS. OF HEALTH SERVICES

Crude Death Rate ↓

Crude birth rate ↓

Life expectancy ↑

S.pox & G. worm Eradicated

Leprosy Eliminated

IMR ↓

Infrastructure – Expanded

Polio Eradicated

ROLE OF DIFFERENT COMMITTEES

1946 – BHORE COMMITTEE (HEALTH SURVEY AND DEVELOPMENT COMMITTEE)Integration of preventive and curative servicesDevelopment of PHC 3 months training in PSM

1962 – MUDALIAR COMMITTEE (HEALTH SURVEY AND PLANNING COMMITTEE)

Strengthening of PHC and district hospital Regional organization

CONT…

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.

PROBLEMS

EnvironmentEducationEmpowerment

DiseasesCommunicable Non CommunicableNew emerging

FertilityPopulationGrowth rate Total Fertility

NutritionMalnutritionObesity

INDIRECTLY RELATED TO HEALTH

DIRECTLY RELATED TO HEALTH

MODEL OF HEALTH CARE SYSTEM

INPUTSHEALTH CARE

SERVICESHEALTH CARE

SYSTEMOUTPUTS

Health Status or Health Problems

Resources

CurativePreventivePromotive

PublicPrivate

VoluntaryIndigenous

Changes in Health Status

HEALTH DEMANDS & NEEDS OF THE COMMUNITY

COMPREHENSIVE &COMMUNITY BASED CARE

CONSTITUTES MANAGEMENT

SECTOR & INVOLVES ORGANIZATION

IMPROVED HEALTH STATUS

EXPRESSED IN TERMS OF LIVES,SAVES, DEATH A

VERTED, DISEASES PREVENTED,LIFE EXPECTENCY

INCREASED

HEALTH ORGANISATION IN INDIA

CENTRAL LEVEL

STATE LEVEL

PERIPHERAL LEVEL

AT THE CENTRE LEVEL

MINISTRY OF HEALTH AND

FAMILY WELFARE

DIRECTORATE GENERAL OF HEALTH SERVICES

CENTRAL COUNCIL OF HEALTH AND

FAMILY WELFARE

A. THE UNION MINISTRY OF HEALTH AND FAMILY WELFARE

DEPARTMENT OF HEATLH

SECRETARY

JT. SECRETARY

DY. SECRETARY

ADMN. STAFF

CENTRAL LIST

International Health, Port Health ResearchTechnical & Scientific Education

FUNCTIONS

International health relations; administration of port quarantine

Administration of central institutes

Promotion of research through research centers

Regulation of medical, pharmaceutical, dental and nursing professions

1. UNION LIST

CONT…

Establishment of drug standards

Census and collection &

publication of other statistical

data

Coordination with other states for promotion of

healthRegulating labor in mines and oil

minesImmigration & emigration

2. CONCURRENT LISTPrevention of extension of

communicable diseases from one

unit to anotherPrevention of

adulteration of foodControl drugs

and poisons Population control and

family planningEconomic and social planningAdministration of ports other

than majorLabor welfare

B. DIRECTORATE GENERAL OF HEALTH SERVICES (DGHS)

ORGANIZATION

DGHS

Additional DGHS

Deputy DGHS (Medical care)

Office Staff

Deputy DGHS(Public health)

Office Staff

Deputy DGHS(Gen. Administrator) Office Staff

FUNCTIONS OF DIRECTORATE GENERAL OF HEALTH

Surveys

Planning

Coordination

Programming

Appraisal of all health matters

International Health relations

Control of drug standards

Medical store depots

Postgraduate training

Medical education

Medical research

CGHS, NHP, CHEB etc.

GENERAL FUNCTIONS SPECIFIC FUNCTIONS

C. THE CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE

The central council of health was set up by the presidential

order on 9th August 1952 under article 263 of the constitution

of India for promoting coordinated and concerted action

between the center and the state for the implementation

of all the programmes and measures pirating to the health of

the nation.

Chairman The Union Health Minister

Members The State Health Minister

FUNCTION OF CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE

1. To consider and recommend broad outlines of policy in regard to matters of health such as,

Provision of remedial and preventive care.

Environment Hygiene.

Nutrition.

Health education and

Promotion of facilities for training and research.

Cont..

2. To make proposals for legislation in fields of medical and public health matters and to lay down.

3. To make recommendations to the central government regarding the health.

4. To established any organization with appropriate functions for promoting and maintain cooperation between central and state health administrations

MILE STONES

NRHM-2005 NHP-2002 NPP-2000 RCH-1996

UIP-1985 NHP-1983

Alma Ata-1978 (HFA)JugglingPriorities

Small pox eradicated-July 5, 1975

NFPP-1952 India Joins WHO-1948

HSDC-1946

STATE LEVEL OF HEALTH CARE

HISTORY:

This started from year1919, when the states (then known as provinces) obtained autonomy, from the central government, in matters of public health.

THE STATE LIST

The government of India act, 1935 gave further autonomy to the states. The health subjects were divided into three lists under the 7th schedule of the India constitution. They are:

 

1 The Union List

2 The State List

3 The Concurrent List

FUNCTIONS UNDER STATE LIST

Public health sanitations , hospitals and dispensaries.

Local government, i.e. the constitutions and powers of municipal corporations, district boards.

Intoxicating liquors that is production, manufacture, possession, transport, purchase and sale of intoxicating liquors.

Cont….

Relief of the disabled and unemployable.

Burials and burial grounds, cremation grounds.

Markets and fairs.

AT THE STATE LEVEL

• STATE MINISTRY OF HEALTH

• STATE HEALTH DIRECTORATE

ORGANIZATION

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 programmesCoordination with government of India and other state government.

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 LEVELThe principal

unit of administration in India is the district under

a collector. There are 597

districts in India.

Districts are known as “ZILA”

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

ORGANIZATION

Panchayats

Villages

Community Development

Blocks

Town Area Committees

Tahsil (Taluka)

District

Sub-division

Corporations

Municipal Boards

Rural Urban

PANCHAYATI RAJ

3 tier structure of rural local self government

Linking the village to the district

3- TIER SYSTEM

PANCHAYAT RAJPANCHAYAT

( AT VILLAGE LEVEL)GRAM SABHA

GRAM PANCHAYA

T

NYAYA PANCHAYA

T

PANCHAYAT SAMITI (AT

BLOCK LEVEL)

ZILLA PARISHAD (AT

DISTRICT LEVEL)

THE GRAM SABHA

It is comprised of all the adult men and women of the village. This body meets at least twice in a year and discuss important issues. They elect members of panchayat.

THE GRAM PANCHAYAT

consists of 15-30 elected members covers the population of 5000 to 20000. chaired by the president i.e. sarpanch/ mukhya/ sabhapati.

There is a vice- president and a secretary. Responsible for overall planning and development of the

villages. The panchayat secretary has been given powers to

functions for wide areas such as maintenance of sanitation and public health, socio-economic development of the villages etc.

THE NYAYA PANCHAYAT

It is comprised of 5 members from the panchayat.

It tries to solve the dispute between two parties/ groups/ individuals over certain matters on mutual consent.

AT THE BLOCK LEVEL

Is known as Panchayat samiti.

Members of panchayat samiti are:o Sarpanches from all the gram panchayats in the

blocko MLAs and MPs residing in the area

representative of women, schedule castes, schedule tribes and cooperative societies.

AT THE DISTRICT LEVEL

The panchayati raj institution at the district level is known as ZILA PARISHAD.

Is headed by the chairman also known as adhikashak.

CONT….

It includes the following members: The heads of all the gram samities in the

district, MLA and MPs from the district, Representatives of women, SC/ST, 2 persons

who have experience in administration, rural development officer etc.

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

Centre Plain area Hilly / Tribal / Difficult area

Community health centre

1,20,000 80,000

Primary health centre

30,000 20,000

Sub-centre 5,000 3,000

COMMUNITY HEALTH CENTRE’S

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, Labor Room and Laboratory facilities.

CONT..

It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.

As on Sep 2013, there are 4,833 CHCs functioning in the country.

In Haryana 2013, there are 108 CHCs functioning.

PRIMARY HEALTH CENTRE’S

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.

CONT….

NRHM - two additional Staff Nurses at PHCs (contractual).

It acts as a referral unit for 6 Sub Centre’s and has 4 - 6 beds for patients.

There were 24,049 PHCs functioning in the country as on Sep 2013.

In Haryana Sep 2013, there were 425 PHCs functioning.

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.

CONT…

Provide services in relation to maternal and child health, family welfare, nutrition, immunization and control of communicable diseases.

Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-Centre’s

1,48,366 Sub Centre’s functioning in the country as on Sep 2013

In Haryana Sep 2013, there were 2465 SCs functioning

ASHA

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

CONT…

ASHA (Accredited

Social Health Activist)

Total Number of ASHA in position as on 30-06-2013

High Focus states 5,72,573

Other than High Focus states 3,17,163

Total Number of ASHA selected and trained up to IV module

High Focus states

4,94,155

Other Than High Focus states

2,89,923

NUMBER OF ASHA WORKERS ACC SEP 2013

A SURVEY REPORT PUBLISHED IN NEW INDIAN EXPRESS

There is only one doctor per 1,700 citizens in India; the World Health Organization stipulates a minimum ratio of 1:1,000.

There are 387 medical colleges in the country—181 in government and 206 in private sector. India produces 30,000 doctors, 18,000 specialists, 30,000 AYUSH graduates, 54,000 nurses, 15,000 ANMs and 36,000 pharmacists annually.

Health ministry claims that there are about 6-6.5 lakh doctors available. But India would need about four lakh more by 2020 to maintain the required ratio of one doctor per 1,000 people

PHC PROGRESS IN INDIA (2012-13)

Progress made in CHCs during 2005-12

INTEGRATED APPROACH OF HEALTH CARE DELIVERY

ICDS – integrated child development scheme

Agriculture, irrigation and engineering

Animal Husbandry

Education

Social and Women's Welfare

Urban Family Welfare Centers

BUDGET IN FIVE YEAR PLANS

FIRST PLAN (1951-56) • BUDGET: 1,960 Crore HEALTH: 5.9%

SECOND PLAN (1956-61) • BUDGET: 4,672 Crore HEALTH: 5%

THIRD PLAN (1961-66) • BUDGET: 8,576 Crore HEALTH: 4.3%

FOURTH PLAN (1969-74) • BUDGET: 15,778 Crore HEALTH: 7.2%

FIFTH PLAN (1974-79) • BUDGET: 39,322 Crore HEALTH: 8.8%

SIXTH PLAN (1980-85) • BUDGET: 97,500 Crore HEALTH: 1.8%

SEVENTH PLAN (1985-90)• BUDGET: 1,80,000 Crore HEALTH:

1.9%EIGHTH PLAN (1992-97) • BUDGET: 79,8000 Crore HEALTH: 9.5%

NINTH PLAN (1997-2002)• BUDGET:8,59,200 Crore HEALTH:

1.25%TENTH PLAN (2002-07)

• BUDGET: 14,84,131.30Crore HEALTH: 1%

ELEVENTH PLAN (2007-12) • BUDGET: 136,147Crore HEALTH: 1.5%

TWELFTH PLAN (2012-17) • BUDGET ALLOCATED: 90,000 Crore

BUDGET SUPPORTBudget Support for Central Departments in Eleventh Plan (2007–12) and Twelfth

Plan (2012–17) Projections (` Crore)

Department ofMoHFW

Eleventh PlanExpenditure (in

Crore)

TwelfthPlan

Outlay( in Crore)

%Increase

Department of Health and Family Welfare

83407 268551 322%

Department of Ayurveda, Yoga &Naturopathy, Unani, Siddha & Homoeopathy (AYUSH)

2994 10044 335%

Department of Health Research 1870 10029 536%

Aids Control 1305 11394 873%

Total MoHFW 89576 300018 335%

HEALTH EXPENDITURE, PUBLIC (% OF GDP) IN INDIA

HEALTH EXPENDITURE, PRIVATE (% OF GDP) IN INDIA

OUT-OF-POCKET HEALTH EXPENDITURE (% OF PRIVATE EXPENDITUTEON HEALTH) IN

INDIA

EXTERNAL RESOURCES FOR HEALTH EXPENDITURE (% OF

TOTALEXPENDITUTEON HEALTH) IN INDIA

NURSES AND MIDWIVES (/ 1000 PEOPLE) IN INDIA

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 & out – government hires individuals on a temporary basis to provide services

Privatization

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

CONCLUSION

“The number of students graduating from secondary schools, which can be expressed as “the percent of health schools that are accredited” which can be expressed as “ the reflection of health care of the country” 

BIBLIOGRAPHY

Park K. Textbook of preventive & social medicine. 22nd ed. Banarsidas Bhanot: Jabalpur; 2005. 671- 702,728,732,745

Stanhope M , L ancaster J. Community & public health nursing.Mosby publishers: U S. 2004;103-4 ,1097-1098

Basavanthappa B T. Community health nursing.2nd edition. Jaypee publishers : New Delhi. 2008; 38,43, 894- 903

Behind_the_numbers_Medical_cost_trends_for_2011 http://pwchealth.com/cgilocal/hregister.cgi?link=reg/ www.pubmed.com www.google.com

Indian Public Health Standards (IPHS) guideline for community health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94

http://www.newindianexpress.com/magazine/India-has-just-one-doctor-for-every-1700-people/2013

www.tradingeconomics.com/india/health-expenditure.html www.haryanahealth.nic.in www.nrhm.gov.in/nrhm-in-state/state-wise-information.html

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