HEALTH CARE DELIVERY SYSTEM IN INDIA By Dr. Vaishali Bhagat Moderator Dr. Chetna Maliye

FRAMEWORK Introduction Historical Background Structural Organization Health care delivery system in India Challenges

Population – 125 crores (17.31% of the world's population,) 0- 25 yrs – 50% of total population UT – 7 States- 29 Sex ratio – 943 females per 1000 males Birth Rate-21.4 Death Rate-7 IMR-40 Under5 mortality rate-52

Introduction A Health System is the sum total of all the organisations , institutions and resources –whose primary purpose is to improve health ( WHO )

Historical background.. year Event 1864 sanitary commissioners appointed in 3 major povinces-Bombay,Madras,Bengal 1888 sanitation look after by local bodies 1896 severe epidemic of plague occur 1904 plague commission recommendated reorganization and expansion of public health department 1912 GOI decided to help local bodies with grants and sanctioned the appointment of Deputy Sanitary commissioner and health officers 1946 Bhore committee appointed

1947 1951 1952 1958 1959 Ministers of centre and state established YEAR EVENT 1947 Ministers of centre and state established 1951 First 5 yr plan 1952 Community development programme launched Central council of health constituted to coordinate health policies between central and state gov. 1958 Panchayati raj, three tier structure recommended Rajasthan was first state to introduce Panchayati raj 1959 Mudaliar committee appointed Health survey and planning committee Strengthening of existing PHC

YEAR EVENT 1963 Chadah committee gave the concept of basic health worker 1965 Mukherjee committee appointed -Strengthening of administrative set up at different level from PHC to state health services. -Separate staff for family planning 1967 Jungalwala committee appointed -Integration of health services -Elimination of private practice by gov. doctors 1973 Kartar Singh committee appointed -Female health worker and male health worker

YEAR EVENT 1974 Shrivastav committee appointed Concept of people’s health in people’s hand Creation of MPW and HA Village health guide or community health volunteer. 1981 Adopted global strategy of health for all 1985 UIP launched 1992 Child Survival and Safe Motherhood(CSSM) launched 1997 Reproductive and Child Health programme launched

YEAR EVENT 2oo5 RCH two,JSY,NRHM,IPHS for CHC launched 2007 11th 5yr plan, IPHS for subcentres and PHC formulated 2008 NCD programme launched as pilot project 2013 NHM,RMNCH+A launched

Organizational Structure In India India is union of 29 state and7 union territories. Each state has developed it’s own system of health care delivery, independent of the central gov. The central gov. responsibility-policy making, planning, guiding, assisting, evaluating and coordinating work of all state ministers. The health system in India has 3 main links 1.central 2.state level 3.peripheral/local

Union Ministry of Health and Family Welfare Headed by Cabinet Minister At central level Union ministry of health and family welfare The Directorate general of Health services The central council of Health and Family Welfare Union Ministry of Health and Family Welfare Headed by Cabinet Minister Minister of State Deputy Health Minister

Union Ministry Of Health And Family Welfare Dep. Of Health Dep. Of Family Welfare Was created in 1966 Secretary to gov. of India Headed by Secretary to gov. India Joint Secretary Additional Secretary Deputy Secretary Commissioner Administrative staff Joint Secretary Administrative staff

Directorate General of Health Services Principal adviser in both medical and public health matter Directorate General of Health Services[DGHS] Additional Director General of Health Services Team of Deputies Administrative Staff Directorate-three main links 1.Medical care and Hospitals 2.Public Health 3.General administration

Central Council of Health and Family Welfare Chairman- Union Health Minister Member- State Health Minister Functions- 1.To consider and recommend broad outline of policy regarding environment hygiene, nutrition and health education. 2.To make proposal for legislations regarding medical and public health matter. 3.To make recommendation to central gov. regarding distribution of grant.

At State level The State Health administration was started in1919 State list is responsibility of state including provision of 1.Medical care 2.Preventive health services. 3.Pilgrimages within the state

State Health Directorate and Family Welfare State Ministry of Health and Family Welfare Headed by Health Minister and Deputy Minister State Health Directorate and Family Welfare Administrative Officer-Director of Health Services Assisted by Deputy Director and Assistant Director Chief technical adviser relating to Medicine and Public Health

At district level 6 types of administrative area 1)Sub division 2)Tahsils 3)Community development block 4)Muncipalities and corporations 5)Villages 6)Panchayat

Panchayati raj 3 tier structure of rural local self gov. Link village to district Gram panchayat at village level Panchayat samiti at block level Zilla parishad at district level

Health Care System -Levels Primary Health Care Provided at PHC and sub centre Secondary Health Care Provided at District hospital and CHC Tertiary Health Care Provided at regional and central level Institution

Health Care Systems It is represented by 5 major sectors or agencies which differ from each other by health technology applied and by source of fund for operation. 1.Public health sector a)Primary health care PHC Sub centres b)Hospitals/Health centres CHC District hospitals Specialist hospitals Teaching hospitals

c) Health insurance scheme Central gov c) Health insurance scheme Central gov. health scheme Employees state insurance scheme d)Other Agencies Defense services Railways 2.Private sector a)Private hospitals,polyclinics,Nursing home and dispensaries b)General practitioners and clinics 3.Indian System of Medicine Ayurveda and sidha Unani Homeopathy Unregistered practitioner 4.Voluntary Health Agencies 5.National Health Programmes

Primary Health Care Delivery system In 1977-Rural health scheme on principle of placing people’s health in people’s hands Three tier system of health care delivery system Basic tenet of primary health care is universal coverage village level 1)Anganwadi worker 2)ASHA worker

Under ICDS prog. 1 AWW for 1000 population Anganwadi Worker Under ICDS prog. 1 AWW for 1000 population Training for 4 month Functions- 1.MCH care 2.Family planning 3.Immunization 4.Referral services 5.Nutrition and education

1 ASHA for 1000 population ASHA worker key component of NRHM Functions- 1.VHND 2.Health information 3.Councelling 4.Depot holder 5.Information to subcentre,PHC 6.Accompany preg.women 7.DOTS provider 8.National prog.

Sub-Centre Peripheral outpost of existing health care system One subcentre for 5,000 population in plain and 3,000 population in hilly tribal,difficult area Manned by at least one ANM / Female Health Worker and one Male Health Worker. Provide services in relation to maternal and child health, family welfare, nutrition, immunization and control of communicable diseases. Provided with basic drugs for minor ailments. Ministry of Health & Family Welfare is providing Central assistance to all the Sub-Centres since April2002 152326 Sub Centre’s functioning in the country as on March 2014.

Primary health Centre One PHC for 30,000 population in plain and20,000 population in hilly,tribal,difficult area Provide an integrated curative and preventive health care with emphasis on preventive and promotive aspects of health care. Manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centre’s and has 4 - 6 beds for patients. There were 25020 PHCs functioning in the country as on March 2014.

Community health Centres One CHC for 1.20 lakh population in plain area and 80,000 population in hilly, tribal difficult area 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. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2014, there are 5,363 CHCs functioning in the country.

Urban health care delivery system in India NUHM is part of NHM launched in2013 Special focus on urban slum-By making them available essential health care services and reducing out of pocket expenditure on health

Total % GDP on health expenditure

IPHS NHM IPHS launched in 2005 Set of uniform standards to improve quality of health care delivery in the country IPHS for CHC launched in2005 and for PHC and Sub centre launched in 2007 It serves as benchmark for assessing functional status of health facilities NHM Launched in 2013 Two submission 1)NRHM in 2005 2)NUHM in2013 Main components are Health system strengthening in rural and urban area-reproductive-maternal-neonatal-child and adolescent health and communicable, NCD It envisages achievement of universal access to equitable,affordable and quality health care services that are accountable and responsive to people’s need

NHM has 6 financing components NRHM –RCH flxipool NUHM-flexipool Flexi pool for communicable diseases Flexi pool for NCD including injury and trauma Infrastructure maintenance Family welfare control sector component

Challenges Population of India Increased burden of disease Low % of GDP on health expenditure

References: Park Textbook of Preventive and Social Medicine,23rd edition,Prem Nagar,Jabalpur(M.P.),India:Banarsidas Bhanot;2015 SRS Bulletin2014 WHO,Global health expenditure database NHM,Ministry of Health and Family Welfare,GOI

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