Achievements of Public Health Care System In

India
• The planning commission was set by Government of India in 1951-52 and soon work started for drafting first five year plan.

• Year after year ‘Health care’ started expanding through implementation of recommendations by various Committees, (14)
launching of five year plans(12) conducting of health surveys(NFHS-5, DLHS-5, National as well as State health
infrastructure (Health care institutions) services (Comprenensive ) and programmes (16) along with drafting policy
prescriptions(5) and enactment and enforcement of various legislations. (12)
• Eradication of Small pox as declared by the International commission in 1977 is noteworthy as it is first greatest
achievement of the 20th century in health sector.
• India became a signatory in 1978 for the WHO, Alma-Ata declaration of ‘Health for all by 2000 AD’ goal and
adopted primary health care approach to achieve the said goal
• Eradication of Guinea worm in the year 2000
• Eradication of Poliomyelitis (Jan 2011) as declared by WHO in January 2013 is noteworthy as it is
second greatest achievement of the 20th century in health sector.
• Millennium Development Goals-2000-2015
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• Sustainable Development Goals- 2015-2030
 PUBLIC HEALTH CARE SYSTEM-India
(Health services by Governments)

According to Chapter IV of the Constitution of India, Health is a state subject meaning that the health of the people

will be the responsibility of State Government. In view of this Government has started health institutions both in

rural and urban areas .They are as follows;

A. Allopathy

1..Primary Health Care –Alma-Ata declaration 1978-HFA 2000

- Subcenters

- Primary Health Centers

[Link] Health Care

Community Health Centers

District Hospitals

State level Hospitals

2
[Link] Health Care
Medical college Hospitals, Super-speciality / APEX Hospitals

[Link] Insurance Schemes

Employees State Insurance Services (ESIS)
Central Government Hospitals and Health Scheme (CGHS)

[Link] Services
Defense Services & Railways

[Link]

3
 Alma-Ata 1978
• International Conference on primary health care was held in
Alma-Ata, USSR, from 6-12 September 1978, jointly organized
by WHO and UNICEF
• Got committed from all the member countries to work
towards achieving the Goal of ‘Health for all by 2000’
• Attainment by all citizens of the world by 2000 AD, a
level of health that will permit them to lead a socially
and economically productive lives
• It was resolved in the conference that primary health care is
the key to achieve HFA 2000
• Accordingly National Health Policy-1983 drafted 21 goals to
be achieved by 2000 AD

4
 Important HFA goals
• 1 Crude Birth Rate………………….. 21/1000 population
• [Link] Death Rate…………………. 9/1000 population
• [Link] Mortality Rate……………..Less than 60/1000
Lb’s
• [Link] Mortality Rate………… Less than 2/1000Lb’s
• 5. Total Fertility Rate………………….Less than 2
• [Link] Reproduction Rate…………….1
• [Link] protection Rate……………More than 60%
• [Link] Low Birth Weight……………Less than 10%
5
 Primary Health Care
• Primary Health Care has been defined as essential
health care, which is based on Practical, scientifically
sound, socially acceptable methods and technology
made universally accessible to the individuals and
family, through their full participation and at a cost
which the community and country can afford to
maintain at every stage of its development in a spirit
of self-reliance and self determination
• Is equally valid for all countries from the most to the
least developed
• The concept has been accepted by all the countries
as the key to the attainment of HFA-2000 AD
• Accepted as an integral part of the Country’s health
system
6
• In the Indian context , Primary health care is provided by the complex of
subcentres, which are under primary health centres.
• Primary health care is the first level of contact of individuals, the family and
community with the national health system where primary (essential) health care
is provided.
• As a level of care, it is close to the people, where most of their health problems
can be dealt and resolved.
• It is at this level that health care will be most effective with in the context of area’s
needs and limitations
• Delivery of primary health care is the foundation of rural health care system and
forms an integral part of the national health care system in India. It is one of the
main instruments of action for
1. Developing vast human resources of the country
2. Accelerating the socio-economic development
3. Attaining improved quality of life
• This is the essential health care provided at the first level of contact of the
individual or family with the health system.
• It is provided at the level of subcentres and primary health centres by the health
assistants and doctors. 7
 Principles of Primary
Health Care
[Link] distribution- Rich / poor, Rural / Urban, Living in
plain /hilly /tribal/ water body areas, male/female, adult/
child, any race ,religion, ethnicity
[Link] participation-Communitization
Democratic decentralization in the form PRI’s,
VHS&NC’s, ASHA’s, ARS/ RKS
[Link] coordination-
Planning with other sectors with in the Government
system
4. Appropriate Technology-
Materials, Methods or Media
8
 Elements of Primary Health
Care
Alma-Ata Declaration has outlined 8 (Eight) essential
ELEMENTS

1. Education concerning prevailing health problems and the

methods of preventing and controlling them
2. Locally endemic diseases prevention and control
3. Expanded programme on Immunization against major infectious
diseases
4. Maternal and child health care, including family planning
5. Essential drugs provision
6. Nutrition and food supply
7. Treatment of common diseases and injuries and
8. Safe water supply and basic sanitation
9
 Primary Health Institutions

• In the Indian Context , Primary health institutions

are
• Subcenter
• Primary Health Centers &

• Communitization
-ASHAS
-Village Health Sanitation & Nutrition Committees-VHN &SC’s
-Arogya Raksha Samithis (Rogi Kalyan Samithis)-ARS/RKS
-Panchayati Raj Institutions (PRI’s)-ZP’s,TP’s,GP’s
10
 Primary Health Care Institutions

The health care infrastructure in rural areas has been

developed following the principles and components of
primary health care as a two-tier system and is based on
the following population norms:

Population Norms

Type Plain Area Hilly/Tribal/Difficult Area

• SubCenters 5000 3000

• Primary Health Center 30,000 20,000

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 Subcenter
[Link] Subcenter is the most peripheral and first contact point between the primary
health care system and the community.

2. Each Subcenter is manned by one Auxiliary Nurse Midwife (ANM) and one Male
Health Worker MPW(M)

STAFFING PATTERN

A. STAFF FOR SUBCENTER: Number of Posts

1. Health Worker (Female)/ANM-one year Trained 1

2. Health Worker (Male) 1

3. Voluntary Worker (Paid @ Rs.100/- p.m. as honorarium) 1
Total: 3
12
 Subcenter
[Link] Lady Health Worker (LHV) is entrusted with the
task of supervision of Six Subcenters.
[Link] 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 programs.
[Link] Subcenters are provided with basic drugs worth of
Rs 10,000 for minor ailments needed for taking care of
essential health needs of men, women and children.

13
 Subcenter
• [Link] central government was providing 100%
Central assistance to all the Subcenters in the
country to begin with in the form of salary of ANMs
and LHVs rent and contingency , in addition to drugs
and equipment kits.

• [Link] salary of the Male Worker is borne by the State

Governments.

• [Link] are Subcenters functioning in the country as

on March, 20

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 Health Worker (Female)/
ANM
Job responsibilities
[Link]
[Link] at home and at Clinic- Reproductive and child
health- child health. mothers' health, fertility
regulation, RTI’s and STI’s
3. Care in the community-Depot holder, mothers'
meetings, promote FW programme
4. Others- cleanliness, meetings coordination,
registers records and reports

15
 Health Worker (Male)
Job responsibilities
1. Record keeping
2. Vector Borne disease control programs
3. Leprosy
4. Tuberculosis
5. Environmental sanitation
6. Immunization
7. Family planning

16
 Primary Health Center (PHC)
 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 under the Minimum Needs Programme (MNP)/ Basic
Minimum Services Programme (BMS).
 At present, a PHC is manned by a Medical Officer supported by
14 paramedical and other staff. It acts as a referral unit for 6
Subcenters.

17
 Staff norms for a PHC
STAFF FOR A PRIMARY HEALTH CENTER

1. Medical Officer 1
2. Pharmacist 1
3. Nurse Mid-wife (Staff Nurse) 1
4. Health Worker (Female)/ANM 1
5. Health Educator 1
6. Health Assistant (Male) 1
7. Health Assistant (Female)/LHV 1
8. Upper Division Clerk 1
9. Lower Division Clerk 1
10. Laboratory Technician 1
11. Driver (Subject to availability of Vehicle) 1
12. Class IV 4
Total: 15

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Primary Health Center
It acts as a referral unit for 6 Subcenters.
It has 4 - 6 beds for patients.
The activities of PHC involve curative, preventive,
promotive and Family Welfare Services.
There are PHCs functioning as on March, 20 in the
country.

19
 Functions of the PHC
The functions of the PHC’s though out India cover all the essential elements of
Primary health care as outlined in Alma-Ata declaration

1. Medical care
2. MCH including Family planning / RCH as per ICPD, CAIRO-1994
3. Safe Water supply and basic sanitation
4. Prevention and control of locally endemic diseases
5. Collection and reporting of vital statistics
6. Education about health
7. National health programs as relevant
8. Referral services
9. Training -Health staff, ASHA’s,
10. Basic laboratory services
11. Coordination with NGO’s, PRI’s,
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Challenges in Rural Health Care
1. Gaps in manpower and infrastructure in Government sector at the primary health center level

2. Suboptimal functioning of the infrastructure and poor referral services

3. Plethora of hospitals in Government,, voluntary and private sector and not having appropriate manpower, diagnostic and therapeutic services and

drugs

4. Availability and utilization of services are poorest in the most needy remote rural area in the districts.

5. Suboptimal intersectoral coordination

6. Increase dual disease burden of communicable and Non communicable diseases because of ongoing demographic, life style and environmental

transition

7. Increasing awareness and expectations of the population regarding health care services

8. Escalation of costs of health care ever widening gaps between capable and affordable

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 Secondary Health Care & Institutions

 This refers to an intermediate level of health care where

specialist facilities are available to deal with the complex
health problems referred from the primary level.
 The community health centers and the district hospitals
represent the secondary health care level.
 The community Health centers are the ones which are
upgraded from primary Health centers or Taluk hospitals /
combined hospitals
 The External agency funding support has been availed
under the ‘Health systems Development and Reforms
project’ in many states
22
 Community Health Centers
 CHCs are being established by upgrading the primary health centers, each CHC
covering a population of 80,000 to 1’2lakh (one in each community development
block)

 These centers are being maintained by the State Government under MNP/BMS
programme .

 It is 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, Labour 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 there are CHCs functioning in the country.

23
• CHC is established and maintained by the State Governments and as per
standards it is supposed to be manned by four Medical specialists i.e.
Surgeon, Physician, Gynecologist and Pediatrician supported by
21paramedical and other staff.
• It has 30 in-door beds with one OT, X-ray, and Labour Room and
Laboratory facilities and serves as a referral centre for 4 PHCs. It provides
facilities for emergency obstetrics care and specialist consultations.
• Indian Public Health standards lays down that this CHC is to be manned
by 6 Medical Specialists including Anesthetist and an eye surgeon (for 5
CHCs) supported by 24 paramedical and other staff with inclusion of two
nurse midwives in the present system of seven nurse midwives.
• As per norm, one commonly Health Center for every 80,000 population to
1.20 lakh population or one out of every four PHC’s should be upgraded as
CHC to function as a referral institution under ‘Rural Health’.

24
• For Upgradation of CHCs as per the Indian Pubic Health Standards (IPHS), State/UTs have been requested

to carry out the facility survey of all CHCs so as to gauge the exact requirement of funds in terms of

upgradation of the facility as far as manpower, building, equipments [Link] are being provided every

year as requested by the States in their annual Programme Implementation Plan under NHM (Rural)

• An FRU (First Referral Unit)

is a CHC provided with facilities for blood transfusion, Anesthetist & a Gynecologist. FRU facilitiess will

reduce the Maternal Mortality.

25
 Staff norm

STAFF FOR COMMUNITY HEALTH CENTRE:

1. Medical Officer # 4
2. Nurse Mid– Wife staff Nurse) 7
3. Dresser 1
4. Pharmacist/ Compounder 1
5. Laboratory Technician 1
6. Radiographer 1
7. Ward Boys 2
8. Dhobi 1
9. Sweepers 3
10. Mali 1
11. Chowkidar 1
12. Aya 1
13. Peon 1
Total: 25

• # Either qualified or specially trained to work as Surgeon, Obstetrician, Physician and Pediatrician. One
of the existing Medical Officers similarly should be either qualified or specially trained in Public Health.

26
 Communitization of Health care

• ASHA

• Village Health Sanitation and nutrition committee

• Arogya Raksha Samithis /Rogi Kalyan Samitis ( Madhya

pradesh)

• Panchayati Raj Institutions-ZP’s, TP’s & GP’s

27
 Communitization of Health care

The Health planners of the country evolved a new concept to involve the community under
NRHM in the form of Communitization of Health care.
 There should be convergence between people and government employees for reforms to take
place in health services.
 Ownership and management of health services should be enlarged: so that ownership moves
beyond public health functionaries and involves the common people
 The building which houses the public health institution, say a PHC or rural hospital, is not
owned by the doctor nor the ambulance the private property of the employees of public
health institutions. All this is public property, which has been paid for by people and must
serve the needs of the people.
 The concept of communitization of health services is based on the strong belief that the
people own the entire health machinery.
 The problems identified in any area such as spreading of communicable dieases, maternal
mortality, child mortality or malnutrition should not be matters of concern only for the
health department, rather these should become matters of people’s concern

28
• To move towards communitization of health services, the following things need to be done
• People should be made partners in managing public health institutions
• Community representatives should be involved in finding solutions if infrastructure or services
are not properly functioning
• If government property is being misused, people should have enough confidence and powers
that they can stop that misuse.
• Community representatives should have a significant role in the day to day functioning of the
health services at the local level.
• People should be given responsibility. People can take the responsibility to instil regularity in
health services provided at the village level. People can take up responsibilities to support
various activities for immunization, control of communicable diseases etc in the villages. They
should be provided training.
• Communitization of health services means that both public health employees and common
people should develop a feeling that ‘this health institution is ours,’ at an equal level.

29
 COMMUNITIZATION
 It is one of the five approaches under NRHM for
ensuring better community participation;
 Committees / organizations have been formed at
various level viz.
[Link] , a community volunteer for every village.
[Link] Health Sanitation & Nutrition Committee at
village level,
[Link] Raj Institutions at village/block level,
4. Arogya Raksha Samitis/RKS at PHC and CHC and
the

30
 ASHA
• Accredited Social Health Activists (ASHAs)
• is community health workers instituted by the
government of India's Ministry of Health and Family Welfare
(MoHFW) as part of the National Rural Health Mission
(NRHM).
• The mission began in 2005; full implementation was
targeted for 2012. Once fully implemented, there is to be
"an ASHA in every village" in India, a target that translates
into 250,000 ASHAs in 10 states.
• The grand total number of ASHAs in India was reported in
July 2013 to be 870,089. There are 859,331 ASHAs in 32
states and union territories as per the data provided by the
states in December 2014. This excludes data from the states
of Himachal Pradesh, Goa, Puducherry and Chandigarh,
since the selection of ASHA was under way in these states.
31
• Roles and Responsibilities
• ASHAs are local women trained to act as health educators and
promoters in their communities.
• The Indian MoHFW describes them as health activist(s) in the
community who will create awareness on health and its social
determinants and mobilize the community towards local health
planning and increased utilization and accountability of the existing
health services.
• Their tasks include motivating women to give birth in hospitals,
bringing children to immunization clinics, encouraging family
planning (e.g., surgical sterilization), treating basic illness and injury
with first aid, keeping demographic records, and improving village
sanitation .
• ASHAs are also meant to serve as a key communication mechanism
between the healthcare system and rural populations.
• She will act as a depot holder for essential provisions being made
available to all habitations like Oral Rehydration Therapy (ORS), Iron
Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK),
Oral Pills & Condoms, etc.
32
• Selection
• ASHAs must primarily be female residents of the village that they have been
selected to serve, who are likely to remain in that village for the foreseeable
future. Married, widowed or divorced women are preferred over women who
have yet to marry since Indian cultural norms dictate that upon marriage a
woman leaves her village and migrates to that of her husband.
• ASHAs preference for selection is they must have qualified up to 10,
preferably be between the ages of 25 and 45, and are selected by and
accountable to the gram panchayat (local government). If there is no suitable
literate candidate, a semi-literate woman with a formal education lower than
eighth standard, may be selected.
• Although ASHAs are considered volunteers, they receive outcome-based
remuneration and financial compensation for training days. For example, if
an ASHA facilitates an institutional delivery she receives ₹600 (US$9.30) and
the mother receives ₹1,400 (US$22). ASHAs also receive ₹150 (US$2.30) for
each child completing an immunization session and ₹150 (US$2.30) for each
individual who undergoes family planning] ASHAs are expected to attend a
Wednesday meeting at the local primary health centre (PHC); beyond this
requirement, the time ASHAs spend on their CHW tasks is relatively flexible.

33
 Impact of incentive-based work on Health services
• A study on effectiveness of "ASHA INCENTIVE" on
enhancing the functioning of ASHA in motivating couples
having two or less children to undergo permanent
sterilization in Surendranagar district of Gujarat, India
by Nimavat Jh et al., shows contribution of ASHAs toward
achievements in female sterilization shows that
maximum motivation was done by ASHAs, and ASHAs
performance was increased; 1.13 times for eligible
couples and 1.14 times for couples having two or less
children after introduction of an incentive, and incentive
showed a significant impact on motivation of eligible
couples

34
[Link] Health Sanitation and
Nutrition Committee( VHSNC)
The NRHM conceptualized the Village Health and Sanitation
Committee (VHSC) as responsible for village-
level health planning and monitoring, formed within the
overall framework of the Gram Panchayat (village council), in
which women, village members from vulnerable groups and
minority communities should be adequately represented
.
At the village level there are village health and
sanitation committee of panchayat members anganwadi
workers teachers and community health volunteers
village health nutrition and sanitation committee (VHNSC),
is one of the elements in implementation of the
National Health Mission (NHM), .
35
Role of Village Health & Sanitation Committee (VHSC) has been
expanded so as to include 'Nutrition' part

In each monthly meeting, about two or three issues are discussed

and plans for resolution are drawn up. Inputs/support
for Village Health Planning. They are particularly envisaged as being
central to 'local level community action' under NRHM, which would
develop to support the process of decentralized Health Planning.

36
 [Link] Raksha Samithis/RKS
The Aarogya Raksha Samithi/Rogi Kalyan Samithi is a hospital based
management committee which is constituted in every District Hospital (DH),
Community Health Centres (CHC) and Primary Health Centres/First Referral
Unit’s (PHC/FRU).
ARS/RKS was established with the motto of making optimum utilisation of
hospital funds focused on the welfare of the patients by ensuring citizen
participation in the decision making. The RKS committee constitutes of a
group of trustees who manage the affairs of the hospital.
Other than the facility staff it consists of members from local Panchayat Raj
Institutions (PRIs), legislative body, civil society and officials from
Government sector who are responsible for proper functioning and
management of the hospital / Community Health Centre / First Referral Units.

37
 RKS (Rogi Kalyan Samithi)/ARS Funds ARS/RKS Committee is free to prescribe,
generate and use the funds with it as per its best judgement for smooth
functioning and maintaining the quality of services for patient welfare. While
donation would be the most important modus of fundraising, user charges could be
levied with adequate safety nets for the socially and economically backward groups
and disadvantaged communities. The amounts donated by Chief Minister, other
ministers, MLAs, MPs and civil society representatives also contribute to RKS funds.
The ARS/RKS Funds mainly consists of the following Grant-in-aid from the State
Government and/or State level society (societies) in the health sector and/or
District Health Society – Corpus Fund Grants and donations from trade, industry
and individuals
38
 4. Panchayath Raj Institution (PRI’S)
• The 73rd and 74th amendments (1993) to the Indian Constitution has served as a
breakthrough towards ensuring equal access and increased participation in political
power status through Panchayath Raj Institutions (PRI’s)-(1987 in Karnataka) both
for men and women. The PRIs will play a central role in the process of Planning and
Development.
In spite of the progress made, a high proportion of the population, especially in rural
areas, continues to suffer from preventable diseases, pregnancy and childbirth
related complications as well as malnutrition.
In addition to old unresolved problems, the health system in the country is facing
emerging threats and challenges. The rural public health care system in many states
and regions is in an unsatisfactory state leading to pauperization of poor households
due to expensive private sector health care.
• Even though the Panchayaths have historically been an integral part of rural India,
the Constitution (73rd Amendment) Act, 1992 has institutionalized the Panchayat Raj
Institutions at the Village, Intermediate (Taluk) and the District levels, as the three
tier of governance.
• The aim was to strengthen local government organizations with clear areas of
jurisdiction, adequate power, authority and funds commensurate with responsibilities
and with an emphasis on reservations for deprived classes of the population in
Panchayaths including of the leadership positions.
39
• Panchayaths have been assigned 29 rural development activities, which are related to health and population stabilization. The
XI schedule includes Family Welfare, Health and Sanitation, (including hospitals, primary health centers, and dispensaries,)
and the XII schedule includes Public Health. Thus the possible realm of influence of the Panchayaths extends over a
significant proportion of public health issues.
• The Gram panchayaths, where empowered has the potential to act as a community level accountability mechanism to ensure
that the functions of the Gram/village Panchayat in the area of public health and family welfare, actually respond to people's
needs.

Functions of Gram Panchayaths, Taluk Panchayaths, and Zilla Panchayaths

A. Gram Panchayaths

a) Public Health and Family Welfare:

Implementation of Family welfare program
Prevention and remedial measures
Regulation of sale of meat, fish and other perishable food articles
Participation in program of human and animal vaccination
Licensing of eating and entertainment establishments
Destruction of stray dogs
Regulation of curing, tanning and dyeing of skins and hides
Regulation of offensive and dangerous trades

40
b) Rural sanitation
1. Maintenance of general sanitation
2. cleaning of public roads, roads, drains, tanks, and other public
places
3. Maintenance and regulation of burning and burial
grounds
4. Construction and maintenance of public latrines
5. Disposal of unclaimed corpses and carcasses
6. Management and control of washing and bathing ghats
c) Women and Child Development
1. Participation in the implementation of women and child
welfare programs
2. Promotion of school health and nutrition programs
41