Health Care Delivery

System in India
 Introduction
Health is…..
……..a state of complete Physical, Mental
and Social well being and not merely an
absence of disease or infirmity….
…..which allows a person to
live a socio-economically productive life.

Illness is…..
…a state in which a person’ s physical,
emotional, intellectual, social or spiritual
functioning is diminished or impaired.
Cont….

Health care is...

…….multitude of services rendered to
individuals or communities by the agents
of health services or professional for the
purpose of
Promoting
Restoring and
Maintaining health

Embraces all the goods and services

designed for “prevention, promotion and
rehabilitation interventions” includes
Medical Care
 Health Care provider
 A person or organization that provides services
and/or health care personnel….
….to deliver proper health care in a systematic
way to any individual in need of health care
services.

 Could be a government…or…
….the health care industry,
….a health care equipment company,
….an institution such as a hospital or laboratory.

 Health care professionals may include physicians,

dentists, and other support staff.
Cont….

• Functions of Health Care Delivery System:

• 1) To provide health services.
• 2) To raise and pool the resources accessible to
pay for health care.
• 3) To generate human and physical sources that
makes the delivery service possible.
• 4) To set and enforce rules of the game and
provide strategic direction for all the different
• players involved.
Cont…

• Characters of Health Care Delivery System:

1) Orientation toward health.

2) Population perspective.
3) Intensive use of information.
4) Focus on consumer.
5) Knowledge of treatment outcome.
6) Constrained resources.
 Philosophy of Health Care Delivery
System:
• Everyone from birth to death is part of the
market potential for health care services.
• The consumer of health care services is a
client and not customer.
• Consumers are less informed about health
services than anything else they purchase.
• Health care system is unique because it is not
a competitive market.
• Restricted entry in to the health care system.
 Goals/Objectives of Health Care
Delivery System:
• 1) To improve the health status of population
and the clinical outcomes of care.
• 2) To improve the experience of care of
patients families and communities.
• 3) To reduce the total economic burden of
care and illness.
• 4) To improve social justice equity in the
health status of the population.
 Principles of Health Care Delivery
System:
1. Supports a coordinated, cohesive health-care delivery system.
2. Opposes the concept that fee-for-practice.
3. Supports the concept of prepaid group practice.
4. Supports the establishment of community based, community
controlled health-care system.
5. Urges an emphasis be placed on development of primary care
6. Emphasizes on quality assurance of the care
7. Supports health care as basic human right for all people.
8. Opposes the accrual of profits by health-care-related
industries.
Components of healthcare
delivery system
1. Structure of health system

 Aspects of the design of health services that influences the

way in which they are delivered Includes….
 Number and type of personnel and staff
 Way of these personnel organized to work
 Nature and extend of facility and equipment
 Range of services offered
 System of management and amenities
 Financing
 Enumeration and determination of the eligible population for
these services
 Governance and decision making
 Cont…

2. Process of health care delivery

 Consists of two parts
 Behavior of professionals
 Recognition of the problem i.e diagnosis
 Diagnostic procedure
 Recommendation of treatment or management
 Appropiate follow up

 Participation of people
 Utilization of services
 Understanding the recommendations
 Satisfaction with the services
 Participation in decision making
 Levels of health care

Primary Health care

Provided at the community level
Tertiary health
care
Secondary health care
Provided at PHC, CHC, DH etc.

Tertiary health care

Provided at hospitals
 Primary health care
 Primary Health Care as defined by the World Health
Organization (WHO) in 1978 is…
 Essential health care; based on
 practical,
 scientifically sound, and
 socially acceptable method and technology….

 …….made universally accessible to individuals

and families of the community through their full
participation….
 ……at a cost that community and country can
afford to maintain every stage of their development in
the spirit of self determination.
Cont…

Definition

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
 What is there in Primary
Health Care..?????
 Primary Health Care includes:

– Primary Care (physicians, midwives & nurses);

– Health promotion, illness prevention;

– Health maintenance & home support;

– Community rehabilitation;

– Pre-hospital emergency medical services… and…

– Coordination and referral to other areas of health care.

Cont.…

 It is the first level of contact with the health system to promote

health, prevent illness, care for common illnesses, and
manage ongoing health problems.

 Primary Health Care involves concerted effort to provide

rural population of developing countries with least bare
minimum of health services.
 Some services are also provided community and hospitals
 Primary Health Care is different in each community depending
upon:
– Needs of the residents;
– Availability of health care providers;
– The communities geographic location; &
– Proximity to other health care services in the area.
 Elements of primary health care
1. Education about prevailing health conditions and methods
to prevent and control them

2. Promotion of food supply and proper nutrition

3. Adequate water supply and basic sanitation

4. Maternal and child health care with family planning

5. Immunization against major infectious diseases

6. Prevention and control of locally endemic diseases

7. Appropriate treatment of common diseases and injuries

8. Provision of essential drugs

Principles of primary health care
Equitable distribution

Community participation

Intersectoral coordination

Appropriate technology
 Secondary Health Care

• Secondary Healthcare refers to a second tier

of health system, in which patients from
primary health care are referred to specialists
in higher hospitals for treatment. In India, the
health centres for secondary health care
include District hospitals and Community
Health Centre at block level.
 Tertiary Health Care
• Tertiary Health care refers to a third level of
health system, in which specialized consultative
care is provided usually on referral from primary
and secondary medical care. Specialised
Intensive Care Units, advanced diagnostic
support services and specialized medical
personnel on the key features of tertiary health
care. In India, under public health system,
tertiary care service is provided by medical
colleges and advanced medical research
institutes.
 Health Care Delivery System in
India
 India is a union of 29 states and 7 union territories.

 States are largely independent in matters relating to

the delivery of health care to the people.

 Each state has developed its own system of health

care delivery, independent of the Central
Government.

 The Central Government’s responsibility consists

mainly of policy making , planning , guiding,
assisting, evaluating and coordinating the work of
the State Health Ministries.
 Health System in India
The health system in India has 3 main links
At the central level
The official “organs” of health system at
national level are
Ministry of Health and
Family Welfare
Organization Structure
 Functions of MoHFW
Union list
 International health relations and administration of port
quarintine

 Administration of Central Institutes

 Promotion of research

 Regulation and development of medical, pharmaceutical, dental

and nursing professions

 Establishment and maintenance of drug standards

 Census and collection and publication of other statistical data

 Coordination with states

cont….

Concurrent List:
 Prevention of Communicable disease
 Prevention of food adulteration
 Control of drug and poison
 Vital statistics
 Labour welfare
 Economic and social planning
 Poulation control and family planning
Directorate General of
Health Services
 Functions of Directorate General
of Health services
General functions
 Surveys
 Planning
 Coordination
 Programming and appraisal of all health matters

Specific function
 International health relations and quarantine of all major
ports in country and international airport.
 Control of drug standards
 Maintain medical store depots
 Administration of post graduate training programmes
Cont…
 Administration of certain medical colleges in India

 Conducting medical research through Indian Council of

Medical Research ( ICMR )

 Central Government Health Schemes.

 Implementation of national health programmes

 Preparation of health education material for creating health

awareness through Health Education Bureau

 Collection, compilation, analysis, evaluation and

dissemination of information

 National Medical Library

Central Council of health
Organization chart
 Functions
To consider and recommend broad outlines of
policy related to matters concerning health like
environment hygiene, nutrition and health
education.

To make proposals for legislation relating to

medical and public health matters.

To make recommendations to the Central

Government regarding distribution of grants-in-
aid.
 At State Level
• At present there are 29 states in India ,with each state
having its own health administration.
• In all the states, the management sector comprises the
State ministry of Health & a directorate of health.
• It is headed by a minister of health and family welfare
and a deputy minister of health and family welfare.
• The health secretariat is the official organ of the state
minister of health and is headed by a secretary who is
assisted by deputy secretary, under secretary and a
large administrative staff. The secretary is a senior
officer of the Indian administrative services.
State Level
 State health director
• Two separate major departments, medical and public
health were functioning in the state
• The heads of this departments were known as surgeon
general & Inspector general of civil hospitals & director of
public health.
• The directorate of health services or the directorate of
medical and health services. chief technical adviser of state
government.
• The directorate of health and family welfare. assisted by
deputies & assistants.
• Two types: Regional & functional.
• Regional director inspect all the branches of public health.
• functional directors are usually specialist of particular
branch of public health such as mother & child health,
family planning etc.
 At District level
There are 707 ( year 2001 census) districts in
India. Within each district, there are 6 types of
administrative areas.
1. Sub –division
2. Tehsils ( Talukas )
3. Community Development Blocks
4. Municipalities and Corporations
5. Villages and
6. Panchayats
 Disrtict Level
Districts

Tehsils /Talukas (200-600

villages)
Town Area Committee
Community Development Blocks (5,000-10,000 Pop)
(approx 100 Villages & 80,000 -
1.2 Lac Pop)
Municipal Board
Municipalities & Corporations (10,000- 2 Lac
Pop)

Villages
Corporations (> 2 lac
pop)
Panchayats
• Most districts in India are divided into two or
more Sub divisions, each in charge of an
assistants collector.
• Each division is again divided into talukas,
incharge of tehsildar. A taluka usually comprises
between 200 to 600 villages.
• The community development block comprises
approximately 100 villages, and about 80,000 to
1,20,000 population, in charge of a block
development officer.
• Finally, there are the village panchayats, which
are institutions of rural local self - government.
The urban area of the district are organized into..
• Town area committees.(5,000 to 10,000) like
panchayats. provide sanitary services.
• Municipal boards.(10,000 to 2,00,000)-
chairman/president,3-5 year.
• Function – construction, maintenance of roads,
sanitation, drainage, street lighting, water supply,
maintenance of hospitals & dispensaries,
education, registration of death& birth.
• Corporations.(above 2,00,000) -Mayors
• Panchayati raj:
• The Panchayati raj is a 3-tier structure of rural local self
government in India, linking the villages to the district.
The three institutions are:
• Panchayat (at the village level)
• Panchayat Samiti (at block level)
• Zila parisad ( at the district level)
• At Village Level:
• Panchayati Raj at village level consist of:
• The Gram Sabha : Assembly of all adults of village –
twice a year- discuss important issues & proposals
related health matters & elects members of gram
panchayat.
• The Gram Panchayat: It consist of 15-30 elected
members. covers 5000 to 20,000 population.
• Elected president (Sarpanch, Mukhya
Sabhapati),Vice president & a panchayat
secretory.
• It is executive organ of gram sabha & resposible
for overall planning & dev. Of villages.
• The functions of the panchayat secretory is
• Maintainance of sanitation & public health, socio-
economic development of villages
• Nyaya Panchayat:
• Consist of 5 members from panchayat.
• It tries to solve dispute between two parties.
• b) Panchayat Samiti at block level:
• It consist of 100 villages & 80,000 to 1,20,000 population.
• It includes following members: all sarpanches of village
panchayat in the block, MLAs, MPs from the district,
Representative of women, SC,ST & cooperative societies.
• BDO is the ex-officio secretory of the panchayat samiti.is
resposible for community development programme, the
funds provided from government.
• The BDO & his staff give technical assistance & guidance to
the village panchayats engaged in development work.
• Zilla Parishad at district Level:
• It is the agency of rural local self-government
at the district level.
• Members: All the heads of panchayat samities
in the district, MPs, MLAs of district,
Representative of women, SC ST, two person
who have experience in administration, rural
development.
• The collector of district is a non voting
member. Zilla Parishad is headed by the
chirman also known as Adhikasha.
• Supervise & co-ordinate development
programmes carried by the Gram samities in
the blocks.
• Functions & Powers vary from state to state.
In Gujarat District heath & family planning
officers are under zilla parishad.
 Health Services
 Out patient services -Patients who don’t require hospitalization
can receive health care in a clinic. An out patient setting is
designed to be convenient and easily accessible to the patient.

 Clinics – Clinics involve a department in a hospital where patients

not requiring hospitalization, receive medical care.

 Institutions – Hospitals – Hospital have been the major agency

of health care system.

 In broad sense the health services should be

a. Comprehensive
b. Accessible
c. Acceptable
d. Provide scope of community participation and….
e. Available at an affordable cost by country and commuity
 Health care systems
 Intended to delivery healthcare services and represented by five
major sectors different from each other by health technology
1. Public health sector
a. Primary health care
 Primary health centres
 Sub centres

b. Hospitals/Health centres
 Community health centres
 Rural hospitals
 District hospitals/health centres
 Specialist hospitals
 Teaching hospitals
d. Other agencies
c. Health insurance schemes
 Employees State Insurance Defense services
 Central Govt. Health Schemes Railways
Cont…

2. Private sector
a. Private hospitals, polyclinic, nursing homes and
dispensaries
b. General practitioners and clinics
3. Indigenous system of medicine
a. Ayurveda and Siddha
b. Unani and Tibbi
c. Homeopathy
d. Unregistered practitioners
4. Voluntary health agencies
5. National health programmes
Primary health care in
India
 Introduction
 In 1977, GoI launched Rural Health Scheme based on the
principle of “placing people’s health in people’s hand”

 Subsequently in the international conference of Alma-

Ata(1978)the goal of “Health for all” by 2000 through
primary health care approach was set.

 Keeping in view WHO “Health for all” by 2000 GoI

formulated National health policy 2002
Cont….

 More recently GoI formulated NRHM and Indian Public Health

Standards (IPHS) in this regards

 In order to provide quality care in the public health agencies of

health care delivery IPHS are being prescribed.

 These standards provides basic promotive, preventive and

curative primary health care to the community and……
…….achieve and maintain an acceptable quality of care

 These standards would help monitor and improve functioning

of the health care delivery system
Rural Health care system in India
Community Health Centre (CHC)
A 30 bedded Hospital/ Referral unit for 4 no. of PHCs with
specialized Health Services

Primary Health Centre (PHC)

A Referral unit for 4-6 Subcentres; 4-6 bedded manned with a
Medical Officer in-charge and 14 subordinate paramedical staff
no. of PHCs with specialized Health Services

Sub Centre (SC)

Most peripheral contact point of community with Primary Health
Care system; manned with one MPW(M) and MPW(F)
 Rural Health care system in
India
The health care infrastructure in rural areas has
been developed as a three tier system and is
based on the above population norms.

Population Norms

Health Facility Hilly/Tribal/Difficult

Plain Area
Area
Sub-Centre 5000 3000
Primary Health
30,000 20,000
Centre
Community Health
1,20,000 80,000
Centre
 Sub Center
 The most peripheral and first contact point between the primary
health care system and the community.

 The Ministry of Health & Family Welfare is providing 100%

Central assistance

 They are established on the basis of

 One SC for every 5,000 pop in general and…
 One SC for every 3,000 pop in hilly, tribal and backward areas

 Each Sub-Centre is manned by one Male and one female Health

Worker.

 One Lady Health Worker (LHV) is entrusted with the task of

supervision of six Sub-Centers.
Cont….

Sub Centre 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 programmes.

The sub centre are provided with basic drugs

for minor ailments.
 Primary Health Center
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.

At present, a PHC is manned by a Medical Officer

supported by 14 paramedical and other staff.
Cont….

 It acts as a referral unit for 6 SubCentres.

 It has 4 - 6 beds for patients.

 The activities of PHC involve curative, preventive,

primitive and Family Welfare Services.

 National Health Plan (1983) proposed

reorganization of PHCs on the basis of….
 One PHC for every…..30,000 pop in Rural areas
 One PHC for every…..50,000 pop in Urban areas
PHC Pakyong
 Functions of PHCs
 Medical care
 Health programmes
 MCH care and family planning
 Health education and training
 Referral services
 Safe water supply and basic sanitation
 Prevention and control of locally endemic diseases
 Collection and reporting of vital events
 Basic laboratory services
Staffing of PHCs

Source: IPHS 2012

 Community Health Center (CHC)
 These were established by upgrading the primary health centers

 CHCs are being established and maintained by the State Government.

 centers,each community health center should cover a population of

8000 to 1.2 lakh

 It is manned by four medical specialists i.e. Surgeon,

Physician, Gynecologist and Pediatrician and….
……supported by 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.
 Functions of CHCs
 Care of Routine and Emergency Cases in Surgery

 Dressings, I&D, and surgery for Hernia, Hydrocele,

Appendicitis etc.
 Emergencies like Intestinal Obstruction, Haemorrhage, etc.
 Other management including nasal packing, tracheostomy,
foreign body removal etc.
 Fracture reduction and putting splints/plaster cast.
 Conducting daily OPD.

 Care of Routine and Emergency Cases in Medicine

 Daily OPD
 Handling all the emergency and routine cases
 Cont…

 Maternal Health

 Minimum 4 ANC check ups including Registration &

associated services

 1st visit: Within 12 weeks—preferably as soon as

pregnancy
 2nd visit: Between 14 and 26 weeks
 3rd visit: Between 28 and 34 weeks
 4th visit: Between 36 weeks and term

 24 hr delivery services including normal and assisted

delivery and cesarean section
 Managing labour using Partograph.
 Minimum 48 hours of stay after delivery, 3-7 days stay
post delivery for managing Complications
Cont….

 Newborn Care and Child Health

 Essential Newborn Care and Resuscitation

 Counseling on Infant and young child feeding
 Routine and emergency care of sick children
 Full Immunization of infants and children against VPDs
 Management of Malnutrition cases.

 Family Planning

 Counseling, provision of Contraceptives, NSV,

Laparoscopic Sterilization Services and their follow up.
 Safe Abortion Services
Cont….

 All National Health Programmes delivered through

CHCs

 School health services

 Others

 Blood storage facility

 Essential laboratory services
 Referral (transport) services

 Maternal Death review (MDR)

Staffing of CHCs
Cont…
Cont….
 Health services of Urban Area:
• Hospitals: District hospitals, state level
hospitals, medical college hospitals.
• Health services for Defense & Railway
Employers are rendered by specially organized
“Armed Forces Medical Services” & Railway
Health Services.
• National Health Programmes
• The indigenous system of medicine
 Health insurance
• It is at present limited to industrial workers
and their families. The central government
employees are also covered by the health
insurance.
• These are two types
• ESIS
• CGHS
Employees state insurance scheme(ESI)
• It was started under Parliament Act in 1948 to provide for
medical Benefits in cash and kind of sickness, maternity,
employment injury,
• pension for dependent on the death of worker because of
employment injury.
Central Government Health Scheme: (CGHS)
• For central government Employees. Gradually it was
extended for Autonomous organisations employees,
Member of Parliament, retired central government
servants, Widows, governors & retired judges.
Voluntary system:
• NGOs – voluntary in nature & contribute in public health
by providing health services or health education, by
advertising research etc.
 Voluntary Health Agencies

• Tuberculosis Association of India

• Family Planning association of India
• Indian Red Cross Society
• The All India Blind Relief Society
 COMMUNITY NURSING SERVICES:
• 1 ANM for 3000 population (2 per sub centre)
• 1 ANM for 1500 population for hilly areas.
• 1 Health supervisor for 7500 population (for
supervision of 3 ANMs)
• 1 PHN for 1 PHC (3000 population to supervise 4
Health Supervisors)
• 1 PHN officer for 1, 00, 000 population
(Community Health Centre.)
• 2 District Public Health Nursing Officers for each
district.
Thank you