P.G.Guide : Dr.Gajanan VelhalP.G.Student:

Dr amit Gujarathi Dr. Tushar Nale

WHO Health DefinitionHealth- It is state of complete physical,

mental & social wellbeing of individual & not merely absence of disease or infirmity

Non medical dimensions are spiritual, emotional vocational & political

Positive Health- person who is healthy physically, mentally & socially is said to be in state of positive health i.e. highest standard of health

Health care system in India consist of 3 sectors 1. Public sector

2. Private3. Informal network of care

providersHealth care defined as multitude of services

rendered to individual or communities by agents of services for purpose of promoting, restoring & maintaining of health.

Evolution of health system in INDIAPhase I- (1947-1983)- It was based on two

principles 1. None should be denied care for want of ability to pay

2. It was totally state’s responsibility to provide health care to the people

Phase II (1983-2000)- First national health policy of 1983

articulated the need to encourage private initiative in health care service delivery

Phase III (post 2000)-

1. Desire to utilize private sector resources for addressing public health goals

2. Liberalization of insurance sector to provide health financing system 3. Redefining roll of state from being only a provider to a financier of health services as well

Committees & Commissions Bhore committee : Health survey and development Committee

(1943- 1946) report submitted. Stressed on to provide comprehensive health care package by

introducing PHC Short term and long term measure Compulsory 3 months training during medical education to prepare

social physician. Mudaliar committee(1959-62)Health Survey And Planning

Committee It had evaluated the measures taken by Bhore committee Strengthening of existing PHC’s and Taluka and District hospital as

referral Chaddah committee(1963) (Surveillance) Stared the survelilance

activity under NMEP by PHC’s staff (1 per 10,000) additional duties like Vital staitics and FP activity ( Multipurpose worker)

Mukherjee committee(1965)• Recommended that there should be sepetare staff to carry out

Family planning activities • 1966 Establishment of Rural Family planning centers and urban

Family planning centers Junglewala committee(1967)

• Integration Of Health Services so named as Committee on integration of health services.

• There should be unified cadre, Common seniority, Recognition of extra qualification Equal pay for eqal work and special pay for special work ,Elimination of private practice by Gov. doctors

Kartar Singh committee(1973) MPW scheme Recommendation were : Auxiliary midwife to Female multipurpose worker BHW,MSW,Vaccinator to one grope Heal worker Male and Female Male and Female health assistants

Srivastav committee(1974-75) • Medical Education & Support Man-Power • They have studied the medical education and health care services in

india and formulates he suitable curriculum for medical education and health care delivery system

Still…62 yrs. of Health ServicesSr. no

Indicators Rate during 1978

Current rate Target by 2000 AD

1 CBR 33/1000 MYP 22.8/1000MYP 21/1000 MYP2 CDR 14/1000 MYP 7.4/1000 MYP 9/1000 MYP3 IMR 125/1000 Live

births53/1000 live births

60/1000 MYP

4 MMR 4.5/1000 live births

2.54/1000 live births

2/1000 Live births

5 Incidence LBW

30% 30% 10%

6 CPR 23% 46.6% 60%7 Immunizatio

n infants35% 85% 100%

8 Life expectancy

52 Years 64 Years 63 Years

Still…62 yrs. of Health ServicesCrude Death Rate ↓Crude birth rate ↓Life expectancy ↑IMR ↓S.pox & G. worm eradicatedLeprosy eliminatedInfrastructure – expandedGrowth rateLiteracySex ratio

Mile stones: NRHM-2005 NHP-2002

NPP-2000 RCH-1996

UIP-1985 NHP-1983

Alma Ata-1978 (HFA)

Small pox eradicated-July 5, 1975

NFPP-1952 India Joins WHO-1948

HSDC-1946 Juggling

Priorities

Committees and Commissions Single issue addressed by Committee Comprehension was missing recommendations- reiterations of Bhore

Committee. Uni-purpose workers later baptized as Multi-

purpose. Programs worked in complete isolation till 1980

(e.g. NTCP). Fragmented approach to Health.

Administration and Health team Management :can be defined as the universal

process of organizing people and resources efficiently so as to direct activities toward common goals and objectives.

Health Team : Is group of persons having common Health goals, to achievement of which each member of team contributes in accordance with his or her competence and skills and in coordination with function of other team

Administration: Getting the work done

Indian Administrative levels Health administration governed in India at 4

levels 1) National level(Central level) 2) State level3) District level4) Village level

Administration at central level Health administration in India is governed by

the union Ministry of Health and Family Welfare

The central administration provides co-ordination and direction to a network of state health ministries for actual implementation

FUNCTIONS OF UNION HEALTH MINISTRY

UNION LIST ( Function carried out by only central government)

1.1. International health relations & International health relations & administration of port quarantine.administration of port quarantine.

2.2. Administration of central institutes e.g. Administration of central institutes e.g. NICD, AIIHPH etc.NICD, AIIHPH etc.

3.3. Promotion of research through research Promotion of research through research centers & other bodies.centers & other bodies.

4.4. Regulation & development of medical, dental, Regulation & development of medical, dental, pharmaceutical & nursing professions. pharmaceutical & nursing professions.

5.5. Establishment & maintenance of drug Establishment & maintenance of drug standards. standards.

6.6. Census and collection & publication of other Census and collection & publication of other statistical data.statistical data.

7.7. Immigration & emigration.Immigration & emigration.8.8. Regulation of labour in the working of mines & Regulation of labour in the working of mines &

oil fields. oil fields. 9.9. Co-ordination with states and with other Co-ordination with states and with other

ministries for promotion of health.ministries for promotion of health.

FUNCTIONS OF UNION HEALTH MINISTRY

CONCURRENT LIST ( joint responcibilty between central and state governments)

1. Prevention of extension of communicable diseases from one unit to another.

2. Prevention of adulteration of foodstuffs.3. Control of drugs & poisons.4. Vital statistics & registration

5. Labor Welfare( social security and and insurance)

6. Ports other than major7. Economic planning.8. Social planning.9. Population control10. Family Planning.

CENTRAL LEVEL

UNION MINISTRY OF HEALTH & FAMILY

WELFARE

Cabinet MinisterMinister of State

Deputy Health Minister

Dept of Health Dept o f F.W.Secretary to Government of India

Joint Secretaries Additional SecretaryDeputy Secretaries 1 Joint Secretary

Administrative Staff Commissioner F.W

Dept. of AYUSH

2 Joint sec1 Assistant sec.

3 Heads Political ExecutiveTechnical

DIRECTOR - Principle advisor to union government

Medical Public Health matters.

ORGANISATION :

Deputies & other administrative staff.

assisted by

FUNCTIONS –

FUNCTIONS –

General : Surveys, planning , co-ordination, programming & appraisal

of health matters.

Specific Function : 1. International health relations & quarantine

2. Control of drug standards

3. Maintenance of Medical Stores depots

4. Administration of all national institutes

5. Medical Education- Lady Harding Medical College, The

Maulana Azad MC, Medical colleges at Pondicherry and Goa.

6. Emergence of medical research Medical Research – ICMR (1911)

CRC, TRC, Virus Research Centre, Pune, NIV.

7. Implementation of CGHS 8. Implementation of National Health

Program 9. Running central health education bureau 10 . Running Central Bureau of Health

intelligence .11. Running National Medical Library

(1966)

Functions of Department of Health:Health related activities, including various

immunization campaignsControl over various health bodies including

National Aids Control Organization (NACO), National Health Programmes, Medical Education & Training, and International Cooperation in relation to health;

Administers the Hospital Services Consultancy Corporation

Functions of Department of Family & Welfare:Maternal and Child Health Services. Information, Education and Communication.Rural Health Services, Non-Governmental

Organizations and Technical Operations.Policy Formulation, Statistics, Planning,

Autonomous Bodies and Subordinate Offices.Supply of Contraceptives.International Assistance for Family Welfare

and Urban Health Services.Administration and Finance for the

Departments of Health, Family Welfare

Functions of Department of AYUSH: Upgrade the educational standards in the

Indian Systems of Medicines and Homoeopathy colleges in the country;

Strengthen existing research institutions and ensure a time-bound research programme on identified diseases for which these systems have an effective treatment;

Draw up schemes for promotion, cultivation and regeneration of medicinal plants used in these systems;

Evolve Pharmacopoeial standards for Indian Systems of Medicine and Homoeopathy drugs

Central Council of Health and family welfare Set up on 9th August 1952 For promoting coordinated and concerted action between the centre and the states in the implementation of all the programmes and measures pertaining to the health of the nation.

Chairman - Union Health Minister Members - Health Ministers of all states and

union territory Meets once in year

Functions 1) Promoting co-operation between health

organization and at central and state level2) Formulates broad policy and programme 3) Proposing suitable legislation in public

health matters 4) Recommends appropriate framework for

proper distribution of GRANT-In-AID to states for health purposes.

5) Reviews work done in last one year

Health Administration at State level - State list - Mainly Medical care, preventive health services and pilgrimages within the state. State Ministry of Health Minister of Health and Family Welfare( political ) Secretary ( executive) Directors of 1) Health and family welfare 2) Medical education and

research (technical)Assisted by deputy director, additional director and

administrative staff.

Regional level (circle)- Each regional/zonal set-up covers three to five districts and acts under authority delegated by the State Directorate of Health Service

District: An Administrative unit Defined Geographical boundary and Population

Peripheral most Planning unit A self contained segment of National Health System Middle level management organisation Link between state as well as regional structure on one

side and peripheral level structure has CHC, PHC, Sub centre on other side

District officer with overall control is designated as CMHO (Chief Medical Health Officers (CMHOs) Or DMHO (District Medical and Health Officer).Technical head

Sub-divisional/Taluka level - At the Taluka level, health care services are rendered through the office of Assistant District Health and Family Welfare Officer (ADHO)

.

Functions of District Health SystemLiaison between Field units & Headquarter

• Field reports• Inspections• Meetings

Implementation of Policy & Programs District level planning & Action PlansRationale use of Finance & ResourcesCommunication Management

• Plans/Schedules/Progress/ProblemsControl & Monitoring

Health administration at Rural level 3-tier structure

Primary care

Secondary Care

Tertiary care

Levels of Health Care in IndiaLevels of Health Care in IndiaHealth Care services have 3 levels – 1.1. Primary Primary

First level of contact, where essential health care is provided by PHCs and SCs.

2. Secondary2. SecondaryFor treatment of complex problems through district hospital and community health centers.

3. 3. TertiaryTertiaryHighly specialized health care through medical college hospitals, AIMI, Regional Hospitals, Specialized Hospitals and other Apex institutes.

RURAL HEALTH CARE SYSTEMSub Centre (SC)Most peripheral contact point between Primary Health Care System &Community manned with one MPW(F)/ANM & one MPW(M)

Primary Health Centre (PHC)A Referral Unit for 6 Sub Centers 4-6 bedded manned with a MedicalOfficer In charge and 14 subordinate paramedical staff

Community Health Centre (CHC)A 30 bedded Hospital/Referral Unit for 4 PHCs with Specializedservices

At community level

Centre Population NormsPlain Area Hilly/Tribal/

Difficult AreaCommunity Health Centre

1,20,000 80,000

Primary Health Centre

30,000 20,000

Sub-Centre 5000 3000

Manpower at PHCExisting Recommended (IPHS)Medical Officer 1 2(one AYUSH or LMO)Pharmacist 1 1Nurse-midwife (Staff 1 3 (for 24-hour PHCs)(Nurse) (2 may be contractual)Health workers (F) 1 1Health Educator 1 1Health Asstt. (M&F) 2 2Clerks 2 2Laboratory Technician 1 1Driver 1 Optional/vehicles out-sourced.Class IV 4 4Total 15 17/18

Title

Health care delivery system - Health care delivery system - villagevillageProvided through –Provided through –1)1) Village health guideVillage health guide

i) Preferably VIth Std. passed local womenii) Undergoes 200 hours training over 3 monthsiii) Works for 2-3 hours per dayiv) Paid Rs. 50/- and drugs kit Rs. 600/- per year. Education

Village health guide scheme 1) lanuched on 2nd October 1977 2)Centrally sponsored under family and welfare this is in operation in all states except 5

states where alternative health schemes are in progress.

3) 5 states are a) jammu and kasmir ( Rehbar-e- sehat) b)arunachal pradesh ( Medics) c) Tamil nadu ( Mini health worker) d)Kerala ( strenthing og PHC’s) e) Karnataka(strenthing og PHC’s)

2)2) Trained Birth attendant (Local trained Trained Birth attendant (Local trained Dais)Dais)i) Training for 30 working days with certificateii) Provided with delivery kit iii) Rs.10/- per delivery & Rs.3/- per registered child

3)3) Anganwadi workerAnganwadi workeri) Local woman with VIth Std. educationii) Provides non formal education to childreniii) Antenatal services (Nutrition

Urban AreasCentral government health scheme (CGHS)

Started in 1954Beneficiaries- -Mainly for central

government employees & their family members -Ex. M.P.’s, Judges of supreme & high court, freedom fighter, Central Govt. pensioner -Employees of semi autonomous bodies & semigovt. Organizations' -Ex. Governors, EX. V.P.’s etc.

Facilities providedEmergency servicesFree supply of drugsLab & radiological servicesDomiciliary visitsSpecialist consultation at hospital, family

welfare centr level

Urban Health service delivery model

Referral

Primary level health care facility

Community level

Urban Revamping SchemeUrban revamping scheme was introduced following

recommendations by Krishnan committee 1983 .To provide primary health care, family welfare, service

delivery outreach and MCH services in urban areas.HEALTH POSTS: There are 871 health posts functioning in 10 States and

2 UTs.

Type of health post

Type of health post PopulationType A <5000Type B 5000-10000Type C 10000-25000Type D 25000-50000

 If population of the area is more than 50000 then it is to be divided into sectors of 50000 population and a post is established at each sector.

Type-wise staff sanctioned :NAMEOF THE POST

NO. OF POSTS ADMISSIBLE

A B C D

Lady Doctor - - - 1Public Health Nurse

- - - 1

Nurse Mid-wife 1 1 2 3 - 4

Male MPW* - 1 2 3 - 4Class IV - - - 1Comp-cum Clerk - - - 1

Voluntary Women Health Worker*

- - - 1

* At present there is a no new male mpw post is sanctioned

Cont.TYPE OF HEALTH POST NO. OF HEALTH POSTS

A 65B 76C 165D 565

URBAN FAMILY WELFARE CENTRESUrban Family Welfare Centers are on ground

since First Five Year Plan to provide family welfare services in urban areas

Most of UFWCs are equipped to provide contraceptive supplies. At present 1083 centers are functioning.

There are three types of Urban Family Welfare centers based on the population covered by each centre.

Staffing pattern for Urban Family Welfare CentersTYPE POPULATION

COVERED NO. UNITS Staffing Pattern

Type I 10000 - 25000 326 ANM -1, FP Field Worker -1

Type II 25000 - 50000 125

FPExtensionEducator/LHV -1FP Field Worker(Male) -1ANM -1

Type III Above 50000 632

Medical Officer -1(Pref. Female)ANM - 2, LHV - 1, FP Field Worker (Male) - 1 , Storekeeper-cum-clerk -1

ALL INDIA HOSPITAL POST PARTUM PROGRAMMEPAP Smear facility at 105 PPC attached to

Medical Colleges;Medical Termination of Pregnancy;Sterilization (Tubectomy);Provision of all types of contraceptives;Promote family planning as most important

health intervention for Health of Mother & Child;Promote spacing of birth;Follow up services to acceptors;Out reach services

At present 550 centers at district level and 1012 centres at sub-divisional level hospitals are functioning.

There are three types of Post Partum Centers at district level hospitals Type A : covering Medical Colleges/Institutions conducting 3000 or more Obstetric and abortion cases annually

Type B :covering Medical Institutions conducting less than 3000 but 1500 or more cases annually  Type C :covering Institutions conducting less than 1500 cases annually.

NRHM

To implement National health policy 2002Inaugurated on April 12, 2005 Intended for 2005 – 2012to provide accessible, affordable and

accountable quality health services even to the poorest households in the remotest rural regions.

NRHM absorbs Key national programs 1. RCH-II 2. NDCP 3. IDSP 4. Mainstreaming of AYUSH

VisionSpecial Focus on 18 states – with poor public

health indicators these are Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.

Increase spending on health from 0.9% of GDP in 1999 to 2.3% of GDP

To carry out necessary architectural correction in basic health care delivery system

To provide service through ASHA in each village

Vision-contTo strengthen the rural hospitals to meet

public health standardsTo integrate national health programsTo mainstream AYUSHTo decentralize village & district level health

planning & managementTo define time bound goalsTo seek access of rural people to equitable,

affordable , accountable & effective primary health care.

To provide improved health care service under JSY for BPL families

ObjectivesProvides trained & supported village health activist

in underserved areas as per needPreparation of health action plans by panchayats as

mechanism for involvement of communityStrengthening PHC/SC/CHC’s as per IPHS guidelinesInstitutionalization & substantial strengthening of

district level Management of healthIncrease utilization of FRU’s from <20 % to > 75%

by 2010Strengthening of local health traditions related to

public health and PHC

GoalsReduction in Infant Mortality Rate (IMR)

and Maternal Mortality Ratio (MMR) Universal access to public health servicesPrevention and control of communicable

and non-communicable diseases, including locally endemic diseases

Access to integrated comprehensive primary healthcare

Population stabilization, gender and demographic balance.

Goals- cont.Revitalize local health traditions and mainstream

AYUSHPromotion of healthy life styles

Plan of Action Provision of health activist in each village i.e.

ASHAStrengthening of Sub centersStrengthening of PHC’s Strengthening of CHC’s .District health plan – District becomes core

unit of planning, budgeting & implementation.Converging sanitation & hygiene under NRHMStrengthening disease control programs

PPP for public health goals, including private sector

New health financing mechanisms Reorienting Health/ Medical education to

support rural health issues

ROLE OF PANCHAYATI RAJINSTITUTIONS

Bureaucracy

Bureaucracy

Technocracy

Politicians

Judiciary

People

The 5 pillars of DemocracyThe 5 pillars of DemocracyBureaucracy

Technocracy

Politicians

Judiciary

People (citizen)

Staff at different levels in PRIStaff at different levels in PRIPlace Bureaucrat Technocrat Politician

Judiciary1)District C.E.O. D.H.O.

Chairman Sessions (Z.P.) (Z.P.) court

2)Taluka BDO M.S. Civil Panchayat Taluka Hosp. or Samiti court M.O.(PHC) Chairman

3)Village Gram HW Sarpanch Gram

Sevak (Male/Female) Panchayat

-On the basis of recommendation or Report from the Technocrat decision is taken by the Bureaucrat

PlacePlace BureaucratBureaucrat TechnocratTechnocrat PoliticianPolitician JudiciaryJudiciary

1.Mumbai Assistant M.C.

Executive Health Officer(Public

Health)

Chairman ofPublic Health

Committee

SessionCourt

2. Zones(6 zones) Joint M.C.

Deputy Executive

Health Officer

PresidentPrabhag

Samiti

SessionCourt

3. Sub-zones Deputy M.C. Asst. HealthOfficer

Members of Public Health

Committee

SessionCourt

4. Wards Ward Officer M.O.H. MunicipalCouncillors --

5. State Health Secretary D.H.S. Health

Minister High court

A task force would look at the process of making panchayats central to implementation of NRHM

States to indicate in their MoUs the commitment for devolution of funds, functionaries and programs for health, to PRIs

The District Health MissionASHA

Cont-The Village Health CommitteeRogi Kalyan Samitis for good hospital

management.Provision of training to members of PRIs.Making available health related databases to

all stakeholders, including Panchayats at all levels

Organogram of NRHMNational steering group Mission steering group Empowered program committeeMission directorate State health mission

District health mission<--------------->Rogi kalyan samiti Panchayat (Village Health Committee)

Major StakeholdersAccredited Social Health Activist (ASHA)Auxiliary Nurse Midwife and Anganwadi

workerPanchayati Raj Institutions and NGOsDistrict AdministrationState Governments

Village levelASHA

accredited social health activistFemale activist given accreditation after 4

phase trainingThe general norm will be ‘One ASHA per

1000 population’. In tribal, hilly, desert areas the norm could be

relaxed to one ASHA per habitation, dependant on workload etc.

Criteria for SelectionASHA must be primarily a woman resident

of the village - ‘Married/Widow/Divorced’ and preferably in the age group of 25 to 45 yrs.

QualitiesAdequate representation from disadvantaged

population groups should be ensured to serve such groups better.

Training Strategy

Induction TrainingPeriodic TrainingsOn the job training

District LevelDistrict health plan generated by combining

village health plans Elements are drinking water, sanitation,

hygiene and nutritionStrengthen PHC (Primary Health Centers)

and CHC (Community Health Centers)

Higher levelsIntegrate vertical health and family welfare at

district, block, state and national levelsIntegration of vertical health programs (leprosy,

TB, malarial programs, etc.)All health facilities and infrastructure built based

on Indian Public Health Standards (IPHS) standards

Rectify manpower shortage, equipment and other furnishings in health facilities

Strengthen capacities for data collection, processing, evaluation and supervision

Timeline for Milestones to be achieved:Health provider in each villageUpgrading of rural hospitalsBuild new hospitalsDistrict Planning OperationalVillage Health PlansMerger of multiple societies

into District/State MissionOperational PMUsTechnical Support

2005-082005-072005-082005-072006April 05

2005-062005-07

Expected out comeIMR reduced to 30/1000 live births by 2012MMR reduced to 01/1000 live births by 2012TFR reduced to 2.1by 2012Malaria mortality reduction rate -50% by

2010 & additional 10 % by 2012Kala Azar mortality reduction rate -100% by

2010 & sustaining elimination by 2015Dengue mortality reduction rate -50% by

2010 sustaining it at that level by 2012

Japanese encephalitis mortality reduction rate -50% by 2010 sustaining it at that level by 2012

Cataract operations increasing to 46 lakh per annum till 2012

Leprosy prevalence rate- reduce from 1.8 per 10000 in 2005 to less than 1 per 10000 thereafter

TB DOT series- maintain 85% cure rate throughout the mission

Upgrading all CHCs to IPHSIncreasing utilization of FRU from bed occupancy

by referred cases of less than 20% to over 75%

Salient features of 11th five year plan Need to plan for easy Access of clean drinking

water.Need to take stock of habitation survey on rural

water supply and urgent action plan should be designed and opertionaliesd .

The position regarding for waste water disposal in states is harmful and it is need to be addressed priority in coordination with department of drinking water and sanitation. ASHA should have a bathroom in her house which could be taken as a indicator.

A sanitation movement both in interest of social eqity and prevention of diseases should be taken up as priority. All sanitation worker should be examined annually .

Replicate use of SHULAB SAUCHALYA.Introduce environmental sanitation in all school

in rural and urban slum.To promote health education and awareness in

drinking water .(SWAJAL PROJECT)Distribution of key micronutrients among anemic

mother and children

Building up of and effective health system to clearly focus on important outcomes of NHP 2002.

Promotion of high volume care for lower surgical procedures like cataract surgery

Promotion of yoga and exercise.Bring a shift from specific project to program

support as in case of RCH II.Professionalize service delivery by appropriate

measures for increasing number and facility of medical and nursing college.

Better motivation and periodic traning of MPW’s and ANM’s

Uniform system of reporting of data by state and their validation.( introducing NRHM)

Title

Category

Rural Area Total Urban Area Total

Mother’s Package

ASHA’s Package

Rs. Mother’s Package

ASHA’s Package

Rs.

LPS 1400 600 2000 1000 200 1200HPS 700 - 700 600 - 600