HEALTH ARE DELIVERY

1. PRESENTED BY -RISHABH
KUMAR
MBBS 2009
BATCH
HEALTH
CARE
DELIVERY
SYSTEM IN
INDIA

2. CONTENTS

3. 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.

4. 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.”

5. EVOLUTION OF HEALTH CARE
SERVICES IN INDIAChristian 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

6. 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

7. ROLE OF DIFFERENT
commiteescoCOMMITTEESc
 1946 – BHORE COMMITTEE (HEALTH SURVEY AND
DEVELOPMENT COMMITTEE)
 Integration of preventive and curative services
 Development of PHC
 3 months training in PSM
 1962 – MUDALIAR COMMITTEE (HEALTH SURVEY AND
PLANNING COMMITTEE)
 Strengthening of PHC and district hospital
 Regional organization

8. 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.

9. PROBLEMS
Environment
Education
Empowerment
Diseases
Communicable
Non Communicable
New emerging
Fertility
Population
Growth rate
Total Fertility
Nutrition
Malnutrition
Obesity
INDIRECTLY RELATED TO
HEALTH
DIRECTLY RELATED TO
HEALTH

10. MODELOF HEALTH CARE
SYSTEM
INPUTS
HEALTH CARE
SERVICES
HEALTH CARE
SYSTEM
OUTPUTS
Health Status or
Health Problems
Resources
Curative
Preventive
Promotive
Public
Private
Voluntary
Indigenous
Changes in
Health Status

11. 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

12. HEALTH ORGANISATION IN INDIA

13. AT THE CENTRE LEVEL
MINISTRY
OF HEALTH
AND
FAMILY
WELFARE
DIRECTORATE
GENERAL OF
HEALTH
SERVICES
CENTRAL
COUNCIL OF
HEALTH AND
FAMILY
WELFARE

14. A. THE UNION MINISTRYOFHEALTH
AND FAMILYWELFARE
DEPARTMENT OF
HEATLH
SECRETARY
JT. SECRETARY
DY. SECRETARY
ADMN. STAFF
DEPARTMENT OF FAMILY
WELFARE
SECRETARY
JT. SECRETARY
DY. SECRETARY
OFFICE STAFF

15. CENTRALLIST
 International Health,
 Port Health Research
 Technical & Scientific Education

16. FUNCTIONS

17. CONT…
Establishment of drug standards
Census and collection & publication of other statistical data
Coordination with other states for promotion of health
Regulating labor in mines and oil mines
Immigration & emigration

18. 2. CONCURRENT LIST

19. B. DIRECTORATE GENERALOF
HEALTH SERVICES (DGHS)
Administrative Staff
Team Of Deputies
Additional Director Of Health Services
Principal Adviser To Union Government

20. ORGANIZATION
DGHS
Additional
DGHS
Deputy
DGHS
(Medical
care)
Office
Staff
Deputy
DGHS
(Public
health)
Office
Staff
Deputy
DGHS
(Gen.
Administ
rator)
Office
Staff

21. FUNCTIONS OFDIRECTORATE
GENERALOFHEALTH
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

22. THE CENTRALCOUNCIL OF
HEALTHAND FAMILYWELFARE
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

23. FUNCTION OF CENTRALCOUNCIL
OF HEALTHAND 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.

24. 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

25. MILE STONES
NRHM-2005
NHP-2002
NPP-2000
RCH-1996
UIP-1985
NHP-1983
Alma Ata-1978 (HFA)
Juggling
Priorities
Small pox eradicated-July 5, 1975
NFPP-1952
India Joins WHO-1948
HSDC-1946

26. STATE LEVEL OF HEALTH
CARE

27. 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

28. 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.

29. Cont….
Relief of the disabled and unemployable.
Burials and burial grounds, cremation
grounds.
Markets and fairs.

30. AT THE STATE LEVEL
• STATE MINISTRY OF HEALTH
• STATE HEALTH DIRECTORATE

31. ORGANIZATION

32. STATE MINISTRYOF HEALTHAND
FAMILYWELFARE
HEADED - Cabinet minister and deputy
minister. (Political head)
RESPONSIBILITY - formulating policies
Monitoring the implementation of these
policies and programmes
Coordination with government of India
and other state government.

33. STATE HEALTH DIRECTORATE
AND FAMILYWELFARE
 Principle advisor in matters relating to
medicine and public health
 Assisted by joint director, regional joint
director and assistant directors.

34. AT THE DISTRICT LEVEL
The principal unit of administration in India is
the district under a collector.
There are 672 districts in India.
Districts are known as “ZILA”

35. 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

36. ORGANIZATION
Corporations
Panchayats
Villages
Community
Development
Blocks
Town Area
Committees
Tahsil
(Taluka)
District
Sub division
Municipal
Boards
Rural Urban

37. PANCHAYATI RAJ
 It is a three tier structure of rural local self
government of India linking village to the district
 The three institutions are
- Panchayat
- Panchayat Samiti
- Zilla Parishad

38. Contd
 At village level Panchayati Raj consist of:
- Gram Sabha
- Gram Panchayat
- Nyaya Panchayat
Every Panchayat consist of Sarpanch , Up
Sarpach and a Pachayat secretary whose
functions are to cover entire field of civic
admindstration including sanitation and
public health.

39. Contd
 At Block level Panchayati Raj agency is the
Panchayat Samiti consisiting of village
sarpachas,MLA’s and MP’s residing in that area ,
representatitives of women , SC and ST’s and
cooperative societies .
 At the District level the Zilla Parishad consist of all
heads of Panchayat Samitis ,MLA’s and MP’s of the
area and two persons of experience in
adminstration, public life or rural development.

40. HEALTH CARE DELIVERYSYSTEM
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

42. 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.

43. 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.

44. 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.

45. 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.

46. PRIMARY HEATH CARE
DEFINITION:
Essential health care based upon practical
and scientifically sound socially acceptable
methods and technology made universally
accessible to individuals and families in the
community at an affordable price.

47. Contd…
 Hallmarks of Primary Health Care:
-Acceptability
-Affordability
-Availability
-Accessibility
Pillars of Primary Health Care:
-Equitable distribution
-Community participation
-Intersectoral Coordination
-Appropriate technology

48. Components of PRIMARY
HEALTH CARE
- Education of health problems and their control
- Locally endemic diseases prevention and control
- Essential drugs
- Maternity and Child health care
- Immunisation
- Nutrition and proper food supply
-Treatment of common diseases
-

49. Levels of Primary Health
care
 Primary level: Includes
-Village level
-Sub centre
-PHC
Secondary level:First referral unit
Includes CHC
TERTIARY LEVEL: 2ND referral unit
Includes gov hospitals and medical colleges

50. Village level
 At village level following schemes are in operation:
- village health guide scheme
- training of local dais
- ICDS scheme
- ASHA scheme

51. Village Health guide
scheme
 Introduced on 2nd October 1977.
 Village health guides serve as first contact between
individual and heath system.Criteria of their
selection:
-permanent residents
-formal education till 6th standard
-acceptable to all sections of society

52. Local dais
They are trained traditional birth attendants
-Trained for 30 working days
-paid a stipend of Rs 300.
-Training given at PHC or sub centre
for 2 days a week.
- Each dai is required to conduct
atleast 2 deliveries supervised by
ANM of FHW.

53. Aanganwadi Worker
-1 per 1000 population
-100 such workers in each ICDS project
- She is trained in various aspects of health nutrion
and child development for a period of 4 months
- Salary 1500 per month
Beneficiaries are nursing mothers,pregnant
women,adolescent girls and children.

54. Functions of Aanganwadi
Worker
- Health checkup
- Maintanence of growth charts
- Immunisation
- Supplementary nutrition
- Heath education
- Non formal pre school education
- Referral services

55. ASHA (Accredited Social
Health activist)
 Selection :
- Must be the resident of the village
-Age between 25 to 45 years
-Preferrably a women
-Formal education till 8th class
-Having communication and
leadership skills
-Suggested norm 1per 1000.

56. Functions of ASHA
- Create awareness on nutrition,sanitation,
Hygiene and healthy environment.
- Counsel women on birth preparedness,
safe delivery,breast and complementary
feeding,immunisation and contraception
- Mobilise community to sub centres and PHC
- She will work with the village health and sanitation
committee.

57. Contd..
- Escort pregnant women and children req treatment
to the PHC’s.
- Provide primary medical care for minor ailments like
diarrhoea and injuries
- Provider of DOTS.
- Depot holder for ORS,IFA tablets,
DDK’s,chlororoquine, OCP’s and condoms.
- Inform about the births and deaths in her
community.

58. Role and integration with
ANM
- ANM will hold fortnightly meetings with ASHA
- She will act as resource person in the training of ASHA
- Inform ASHA about date and time of outreach session.
-Will participate in organising health days
- She would educate ASHA on all her resposibilties and
use her in motivating all sections of community on
health issues.

59. Evaluation of ASHA’s work
 % of newborns weighed and families counselled
 % of children with diarrhoea receiving ORS
 % of deliveries with skilled assistance
 % of institutional deliveries
 % of completely immunised children below 2yrs of
age.

60. Sub centre
 Peripheral outpost of the health care delivery in
rural areas.
 1 per 5000 in plains and per 3000 in hilly areas.
 Staff – 3
1 MPW male
1 MPW female
1 volunteer worker
No. of subcentres in India ,152326(2014)

61. Functions of Sub Centre
 Antenatal care
 Intranatal care
 Child health care
 Family planning and contraception
 Counselling for safe abortion
 Adolescent care
 School health services

62. Primary Health Centres
 First contact point between village community and
Medical Officer.
 Staff of PHC - 15
- Medical officer – 1 Pharmacist - 1
- Nurse -1 Health worker(f)- 1
- Heath Educator – 1
- Health assistant ( m and f ) -2
- Clerk – 2 lab assistant -1
- driver -1 class 4 - 1

63. Functions of PHC and medical
officer
 PHC:
- OPD,emergency and referral services
-Maternal and child health care
-Family planning services
-MTP services
-prevention/management of RTI/STI.
-nutrional services.
-school/adolescent health services
-National heath programmes.

64. Contd…
- Disease survillience and epidemic control
- Collection and reporting vital events
- Sanitation promotion
- Prompt referral to CHC’s
- Training of health workers, birth attendants , ASHA
,ANM ,Aanganwadi,pharmacist.
- Vasectomy and tubectomy
- Basic laboratory services

65. Community heath centres
 Each CHC acts as referral centre for 4 PHC’s
 Staff 30-31
-Physician,General Surgeon- 1 each
-Pediatrician,Gynaecologist- 1 each
-Nurse- midwife – 9
-pharmacist and lab tech – 1each
-radiographer and ophthalmic ass -1
other staff – 15

66. Suggested population norms
 Doctor:1 per 1000
 Nurse:3 per 1 doctor
 Health worker:1 per 5000 & 3000
 Health assistant:1 per 30000 & 20000
 Pharmacist:1 per10000
 Lab technician:1 per 10000
 ASHA:1 per 1000
 Trained dai:1 per 1000
 AWW:1 per 400 & 800

67. RURAL HEALTH STATISTICS
 No. of subcentres : 152326
 No. of PHC’s : 25020
 No. of CHC’s : 5363
 No. of districts : 672
 No. of villages : 640867
 Rural population : 68.9%
 CBR : 21.4 (SRS)
 CDR : 7.0 (SRS)
 IMR : 40

68. PHC PROGRESS IN INDIA (2012-13)

69.  Progress made in CHCs during 2005-12

70. INTEGRATEDAPPROACH 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

71. Health planning
 Steps of health planning
1- analysis of heath situation
2- establishment of goals
3- assessment of resources
4- fixing priorities
5- formulating plan
6- programming & implementation
7- monitoring
8- evaluation

72. BUDGET IN FIVE YEAR PLANS
• BUDGET: 1,960 Crore HEALTH: 5.9%FIRST PLAN (1951-56)
• BUDGET: 4,672 Crore HEALTH: 5%SECOND PLAN (1956-61)
• BUDGET: 8,576 Crore HEALTH: 4.3%THIRD PLAN (1961-66)
• BUDGET: 15,778 Crore HEALTH: 7.2%FOURTH PLAN (1969-74)
• BUDGET: 39,322 Crore HEALTH: 8.8%FIFTH PLAN (1974-79)
• BUDGET: 97,500 Crore HEALTH: 1.8%SIXTH PLAN (1980-85)
• BUDGET: 1,80,000 Crore HEALTH: 1.9%SEVENTH PLAN (1985-90)
• BUDGET: 79,8000 Crore HEALTH: 9.5%EIGHTH PLAN (1992-97)
• BUDGET:8,59,200 Crore HEALTH: 1.25%NINTH PLAN (1997-2002)
• BUDGET: 14,84,131.30Crore HEALTH: 1%TENTH PLAN (2002-07)
• BUDGET: 136,147Crore HEALTH: 1.5%ELEVENTH PLAN (2007-12)
• BUDGET ALLOCATED: 90,000 CroreTWELFTH PLAN (2012-17)

73. Twelth five year plan goals
 IMR - 25
 MMR - 100
 TFR - 2.1
 Under 3 yr malnutrition - 50% reduction
 Anaemia in 15 to 49 – 28%
 0 to 6 child sex ratio - 950
 TB- mortality reduction by 50 %
 Leprosy- zero incidence
 Malaria - incidence < 1/1000
 Filaria – Mf prevalence <1%
 Dengue – CFR<1%
 HIV/AIDS – ZERO NEW INFECTIONS
 Kala Azar - Elimination by 2015

74. BUDGET SUPPORT
Budget Support for Central Departments in Eleventh Plan (2007–12) and Twelfth
Plan (2012–17) Projections (` Crore)
Department of
MoHFW
Eleventh Plan
Expenditure (in
Crore)
Twelfth
Plan 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%

76. HEALTH EXPENDITURE, PUBLIC
(% OF GDP) IN INDIA

77. HEALTH EXPENDITURE, PRIVATE
(% OF GDP) IN INDIA

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

79. EXTERNALRESOURCES FOR HEALTH
EXPENDITURE (% OF
TOTALEXPENDITUTEON HEALTH) IN
INDIA

80. NURSESAND MIDWIVES (/ 1000
PEOPLE) IN INDIA

81. 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

82. 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

83. 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”

84. 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

85.  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

86. THANK YOU 