HEALTH CARE DELIVERY SYSTEMM.RAJESWARI

ASST.PROFESSER

ACON,HYD.

A health care delivery system is the totality of services offered by all health disciplines. Traditionally the primary purpose of a health care system had been to offer care to ill and injured. For this reason the health care system of the past might be more accurately described as illness care system

India is union of 28 states and 7 union territories.

Under the constitution of india, the states are largely independent in matters relating to the delivery of health care to the people each state, there fore, has developed its own system of health care delivery, independent of the central government.

The central responsibility consists mainly of policy making, planning, guiding, assisting, evaluating , co coordinating the work of the state health ministries, so that health services cover every part of the country and no state behind fro want of these services.

The health system in india has 3 main links i.e central, sate and local or peripheral.

1 – AT THE CENTRAL The official “organs” of the health

system at the national level consist of: The ministry of health and family welfare; The directorate general of health services;

and The central council of health and family

welfare.

UNION MINISTRY OF HEALTH AND FAMILY WELFARE

(1). ORGANIZATION: The union ministry of health and family

welfare is headed by a cabinet minister, a minister of state and a deputy health minister. These are political appointments. Currently, the union health ministry has the following departments:

Department of health and family welfare. the health department is headed by a secretary to the government of India as its executive head, assisted by joint secretaries, deputy secretaries and a large administrative staff.

The department of family welfare was created in 1966 with in the ministry of health and family welfare.

The secretary to the government of India in the ministry of health and family welfare is in over all charge of the department of family welfare.

he is assisted by an additional secretary and commissioner(family welfare), and one joint secretary

AT THE CENTREUnion ministry of health and family welfare1) Organization Cabinet minister

(minister of state & deputy health minister)

Dept of health Dept of family welfare

Secretary to the Govt.of India Secretary to the Govt.of India

Joint secretaries Additional secretary

Deputy secretary Commissioner

Large administrative staff joint secretary

FUNCTIONS Union list International health relations and administration of port

quarantine. Administration of central institutes. Promotion of research through research centers and other

bodies. Regulation & development of medical, pharmaceutical, dental

& nursing professions. Establishment & maintenance of drug standards. Census, and collection and publication of other statistical data. Immigration & emigration. Regulation of labour in the working of mines and oil fields Coordination with states & with other ministries for promotion

of health.

Concurrent list Prevention of extension of communicable diseases

from one unit to another. Prevention of adulteration of food stuffs Control of drugs and poisons Vital statistics Labour welfare Ports other than major Economic and social planning, and Population control and family planning.

Directorate general of health servicesOrganization

Director general of health services

Additional Director general of health services

Team of deputies

large administrative staff

FUNCTIONS GeneralSurveys, planning, coordination, programming and appraisal of

all health matters in the country.Specific International health relations and quarantine Control of drug standards. Medical store depots. Post graduate training. Medical education. Medical research Central govt. health scheme. National health programmes. Central health education bureau. Health intelligence. National medical library.

DIRECTORATE GENERAL OF HEALTH SERVICES

ORGANIZATION : The director general of health services is the

principal adviser to the union government in both medical and public health matters.

The directorate comprises of three main units, e.g., medical care and hospitals, public health and general administration .

FUNCTIONS

The GENERAL functions are surveys, planning, coordination, programming and appraisal of all health matters in the country.

International health relations and quarantine: all the major ports in the country (kolkata, Visakhapatnam, Chennai cochin Mumbai, Kandla) and international air ports (Mumbai-santa Cruz,

Kolkata-Dum Dum, Chennai-Meenambakkam, Tiruchirapalli, Delhi-Palam) are directly controlled by the directorate general of health services.

Control of drug standards: the drugs control organization is part of the directorate general of health services, and is headed by the drugs controller.

. Its primary function is to lay down and enforce standards and control the manufacture and distribution of drugs through both central and state government officers. The drugs act (1940) vests the central government with the powers to test the quality of imported drugs.

MEDICAL STORE DEPOTS

The union government runs medical store depots at Mumbai, Chennai, kolkata, karnal, Gauhati and Hyderabad.

These depots supply the civil medical requirements of the central government and of the various state governments. These depots also handle supplies from foreign agencies..

POST GRADUATE TRAINING The directorate general of health services is

responsible for the administration of national institutes, which also provide post graduate training to different categories of health personnel.

Some of these institutes are :-1. the all India institute of hygiene and public health at kolkata,

2. All India institute of mental health at Bangalore,3. College of nursing at Delhi, 4.National tuberculosis institute at Bangalore,5. National institute of at communicable diseases at Delhi, 6.National institute of health and family welfare at Delhi,etc

MEDICAL EDUCATION

The central directorate is directly in charge of the following medical colleges in India: the lady hardinge, the maul Ana Azad and the medical colleges at Pondicherry, and goa. besides these, there are many medical colleges in the country which are guided and supported by the centre.

MEDICAL RESEARCH

Medical research in the country in organized largely through the Indian council of medical research, founded in 1911 in New Delhi.

The council plays a significant role in aiding, promoting and co coordinating scientific research on human diseases, their causation, prevention and cure.

The research work is done through the councils several permanent research institutes, research units, field surveys and a large number of ad-hoc research enquiries financed by the council.

Tuberculosis Chemotherapy Center at Chennai, Virus Research Centre at Poona, National institute of Nutrition at Hyderabad and Blood group references centre at Mumbai

CENTRAL GOVERNMENT HEALTH SCHEME

National Health Programmes: the various national health

programmes for the eradication of malaria and for the control of Tuberculosis, Filarial, Leprosy, AIDS and other communicable diseases involve expenditure of cores of rupees

CENTRAL HEALTH EDUCATION BUREAU An outstanding activity of this bureau is

the preparation of education material for creating Health Awareness among the people.

The bureau offers training courses in health education to different categories of health workers.

HEALTH INTELLIGENCE

The central bureau of health intelligence was established in 1961 to centralize collection, compilation, analysis, evaluation and dissemination of all information on health statistics for the nation as a whole.

It disseminates epidemic intelligence to states and international bodies.

The bureau has an Epidemiological Unit, a health Economics unit, a national morbidity survey unit and a Manpower cell.

NATIONAL MEDICAL LIBRARY

The central medical library of the directorate general health services was declared the national medical library in 1966.

The aim is to help in the advancement of medical, health and related sciences by collection, dissemination and exchange of information.

Central council of healthOrganization

Chairman – The union health minister

Members – State health ministers

Central Council of Health A large number of health subjects fall in

the Concurrent list which calls for continuous consultation, mutual understanding and cooperation between the Centre and the states.

FUNCTIONS To consider and recommend broad outlines of policy

in remedial & preventive care, envt hygiene, nutrition, HE, trg & research.

To make proposals for legislation in medical & public health matters for development of the country.

To make recommendations to central govt. on grants-in-aid and review utilization periodically.

To establish organization for maintaining cooperation between central and state health administrations.

AT THE STATE LEVEL

. The state list which became the responsibility of the state includes provision of medical care, preventive health services and pilgrimages with in the state. The position has largely remained the same, even after the new constitution of India came into force in 1950.The state is the ultimate authority responsible for all the health services operating within its jurisdiction.

STATE MINISTRY OF HEALTH

The state ministry of health is headed by a minister of health and family welfare and a deputy minister of Health and family welfare. In some states, the health minister is also in charge of other portfolios. The health secretariat is the official organ of the state ministry of health and is headed by a Secretary who is assisted by deputy Secretaries, Under Secretaries and a large administrative staff.

STATE HEALTH DIRECTORATE

For a long time, two departments, medical and public health, were functioning in the nstates; the heads of these departments were known as surgeon general and inspector general of Civil Hospitals and Director of public health respectively.

The public health engineering organizations in most states its part of the public works department of the state government. It has been recommended by experts in the public health that the public health engineering organization in every state should be part of the state health department, and that the Chief Engineer of public health should have the status of an additional Director of Health service.

AT THE DISTRICT LEVEL The principal unit of administration in India is

the district under a collector. There are 593(year 2001) districts in India. There is no “average” district that is districts vary widely in area and population. Within each district again there are 6 types of administrative areas

1. Sub – divisions 2. Tehsils (Talukas) 3. Community Development Blocks 4. Municipalities and Corporations 5. Villages 6. Panchayats

Most districts in India are divided into two or more sub divisions, each in charge of an assistant Collector or sub collector. Each division is again divided in to tehsils (talukas), in charge of a Tehsildar .

A tehsil usually comprises between 200 to 600 villages. Since the launching of the community Development programme in India in 1952.

The block is a unit of rural planning and development, and 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 areas of the district are organized into the following institutions of local self-government

1. Town area committees- (in areas with population ranging between 5,000 and 10,000)

2. Municipal Boards-(in areas with population ranging between 10,000 and 2 lakhs)

3. Corporations-(with population above 2 lakhs

The Town area committees are like panchayats.

They provide sanitary services. The municipal Boards are headed by a chairman/President, elected usually by the members. The term of a Municipal Boards ranges between 3-5 years. The functions of a municipal board are:

Construction and maintenance of roads, sanitation and drainage, street lighting, water supply, maintenance of hospitals and dispensaries, education registration of births and deaths, et

The councilors are elected from different wards of the city.

The executive agency includes the Commissioner, the secretary, the Engineer and the Health officer. Thee activities are similar to those of the municipalities, but on a much wider scale.

PANCHAYATI RAJ The Panchayati Raj is a 3-tier

structure of rural local self government in India, linking the village to the district. The three institutions are:

1. Panchayat-at the village level 2. Panchayat Samiti- at the

block level 3. Zila Parishad- at the district

level

COMMUNITY HEALTH CENTERS

These were established by upgrading the primary health centers,each community health center should cover a population of 8000 to 1 lakh with 30 beds and specialists in surgery ,medicine,obstetrics,paediatrics etc.the community health officer is selected from amongst the supervisory category of staff at phc and district level with minimum of 7 yrs experience in rural health programmes.

INDIAN PUBLIC HEALTH STANDARDS FOR COMMUNITY HEALTH CENTERS:- Every CHC has to provide following services

which are known as assured services. This includes incision and drainage and also

surgery for Hernia,Hydrocoele,Appendicitis,Haemorrhoids,fistulas etc.

Care of routine and emergency cases in medicine

24 hrs delivery services including normal and assisted devices.

Essential and emergency obstetric care including surgical interventions like caesarian,and other medical interventions.

Safe abortion services,new born care,routine emergency care of sick children

CONTD…… rural hospitals:-It is now proposed to upgrade

the rural dispensaries to PHC’s. District hospitals:-There are proposals to

convert the district hospitals to District health center

Health insurance:-There is no universal health insurance in india.Health insurance I snow available to industrial workers and their families only.

Employees state insurance scheme;-It was introduced by an act of parliament in 1948.The facilities under the scheme include

-outpatient care -supply of necessary drugs -lab and x-ray investigations -Domiciliary visits -Hospitalization facilities

VILLAGE LEVEL:-

One of the basic tenants of primary health care is universal coverage and equitable distribution of health services

Village health guides Training of local dais ICDs scheme ASHA scheme

VILLAGE HEALTH GUIDES Village health guide is a person with

an aptitude for social service and is not a full time government functionary.The village health guides scheme was introduced on 2nd

October 1977with idea of securing peoples participation in the care of their own health.The scheme was launched in all states except some states like kerala,Karnataka,Tamilnadu,etc..which have alternative systems of providing health care.

.THE GUIDELINES FOR THEIR SELECTION ARE:

They should be permanent residents of local community ,preferably women

They should be able to read and write having minimum formal education atleast upto 6th standard

They should be acceptable to all sections of community

They should be able to spare atleast 2-3 hrs every day for community health work.

FUNCTIONS OF VILLAGE HEALTH GUIDE:- On completion of training they receive

a working manual and a kit of simple medicines belonging to modern and traditional systems of medicine.

Broadly the duties assigned to health guides include treatment of simple ailments and activities in first aid ,mother and childhealth including family planning,health education and sanitation.

The health guides are free to attend to their normal location .

B.LOCAL DAIS

Most deliveries in rural areas are still handled by untrained dais who are often the only people immediately available to women during perinatal period.

An extensive programme has been undertaken under the rural health scheme to train all categories of local dais in the country to improve their knowledge in the elementary concepts of maternal and child health and sterilization besides obstetric skills

C.ANGANWADI WORKER

Under the ICDS scheme there is an anganwadi worker for a population of 1000.

There are about 100 such workers in each ICDS project

D.ASHA:-(ACCREDITED SOCIAL HEALTH ACTIVIST):-

ASHA must be the resident of village a women preferably in the age group of 25-45 years with formal education upto eighth class having communication skills and leadership qualities.

Adequate representation from the disadvantaged population group should be ensured to serve such groups better.the general norm of selection will bwe one ASHA for 1000 population.

ROLE AND RESPONSIBILITY OF ASHA:-

Asha will take steps to create awareness and provide information to the community on determinants of health such as nutrition,basic sanitation and hygiene practices,healthy living and working conditions ,information on existing health services and the need for timely utilization of health and family welfare services.

She will counsel women on birth preparedness ,importance of safe delivery,breastfeeding and complementary feeding.etc..

ASHA will mobilize community and facilitate them in accessing health and health related services available., at the anganwai/subcenter/primary health centers such as immunization, antenatal checkup, postnatal check up, supplementary nutrition,sanitation and other services being provided by the government

CONTD… She will arrange escort/accompany pregnant

women and children requiring treatment/admission to the nearest pre identified health facility ie primary health center/community health center/first referral unit.ASHA will provide primary medical care for minor ailments such as Diarrhoea,fevers,and first aid for minor injuries.She will be a provider of directly observed treatment short course (DOTS)under revised National Tuberculosis Control programme.

She will also act as depot holder for essential provisions being made available to every habitation like oral rehydration therapy.iron folic acid tablet,oral pills,condoms etc.

ROLE AND INTEGRATION WITH ANGANWADI:- On health day the women ,adolescent girls

and children from village will be mobilized for orientation on health related issues such as importance of nutritious food.

personal hygiene, care during pregnancy,importance of antenatal check up and institutional delivery, home remedies, for minor ailment and importance of immune

Anganwadi workers will inform ANM to participate and guide organizing the health days at anganwadi center

Anganwadi and ANM’s will act as resource persons for training of ASHA

ROLE AND INTEGRATION WITH ANM:- ANM will guide ASHA in performing following

activities. She will hold weekly/fortnightly meeting with

ASHA and discuss activities undertaken during week/fortnight

She will guide her in case ASHA had encountered any problem during the performance of her activity.

Anganwadi and ANM’s will act as resource person for training ASHA.

ANM will participate and guide in organizing health days at anganwadi center.

ANM will guide ASHA in motivating pregnant women for taking full course of IFA tablets and TT injections etc..

ANM’s will orient ASHA on the dose schedule and side effects of oral pill

SUB CENTER LEVEL: It is the peripheral outpost of the existing

health care delivery system in rural areas .They are being established on the basis of one sub center for every 5000 population in general and one for every 30000 population in hilly, tribal and backward areas .

Currently a sub center is staffed by one female health worker known as

Auxiliary nurse midwife-1 One male health worker One health assistant known as lady health

visitor

Health care system in India

HEALTH CARE DELIVERY

CONSUMERS PROVIDERS SYSTEM

PUBLIC SECTOR

Medical officerNurses

Pharmacist Lab technician

BEE, ANM, HA

1015 millionPRIVATE SECTOR

INDIGENOUS SYSTEM OF

MEDICINE

VOLUNTARY HEALTH AGENCIES

NATIONAL HEALTH

PROGRAMMES

HEALTH CARE DELIVERY SYSTEM1. PUBLIC HEALTH SECTOR

a) Primary Health Care

Primary health centers

Sub centers

b) Hospitals/Health centers

community health centers

Rural hospitals

District hospital/health center

Specialist hospitals

Teaching hospitals

c) Health insurances schemes

Employees state insurance

Central Govt. Health scheme

d) Other agencies

Defence service

Railways

2. PRIVATE SECTOR

a) Private hospitals, polyclinics, nursing homes, and dispensaries

b) General practitioners and clinics

3.INDIGENOUS SYSTEMS OF MEDICINE Ayurveda and siddha Unani and tibbi Homeopathy Unregistered practitioners

4. VOLUNTARY HEALTH AGENCIES

5. NATIONAL HEALTH PROGRAMMES

HEALTH CARE IN INDIA Indigenous or traditional medical practitioners

continue to practice throughout the country. The two main forms of traditional medicine practiced are

the ayurvedic (meaning science of life) system, which deals with causes, symptoms, diagnoses, and treatment based on all aspects of well-being (mental, physical, and spiritual), and the unani (so-called Galenic medicine) herbal medical practice.

A vaidya is a practitioner of the ayurvedic tradition, and a hakim (Arabic for a Muslim physician) is a practitioner of the unani tradition.

These professions are frequently hereditary. A variety of institutions offer training in indigenous

medical practice. Only in the late 1970s did official health policy

refer to any form of integration between Western-oriented medical personnel and indigenous medical practitioners.

In the early 1990s, there were ninety-eight ayurvedic colleges and seventeen unani colleges operating in both the governmental and nongovernmental sectors.

Healthcare in India is the responsibility of constituent states and territories of India.

The Constitution charges every state with "raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties".

The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002.

Providing healthcare and disease prevention to India’s growing population of more than a billion people becomes challenging in the face of increased competition for resources.

2.47 million people in India are estimated to be HIV positive.

India is one of the four countries worldwide where polio has not as yet been successfully eradicated and one third of the world’s tuberculosis cases are in India.

According to the World Health Organization 900,000

Indians die each year from drinking contaminated water and breathing in polluted air.

As India grapples with these basic issues, new challenges are emerging for example there is a rise in chronic adult diseases such as cardiovascular illnesses and diabetes as a consequence of changing lifestyles.

India's health care system also includes entities which are world class.

The Apollo set of hospitals are considered amougst Asia's most advanced hospitals.

Many patients seeking treatment from even from Pakistan have come here.

In November 2008, a Pakistani girl was operated on for heart problems.

Thus, India's health care system has progressed and is a leader in South East Asia.

Contents

1 Medical professionals 2 Diseases 3 Issues

3.1 Malnutrition 3.2 Women 3.3 Water and sanitation

4 Healthcare Infrastructure 5 Central government role

6 Expenditure 7 Healthcare in urban India 8 Primary services 9 Health Insurance 10 Medical Tourism 11 Rate of growth

1 Medical professionals

In a 2005 World Bank study, World Bank reported that "a detailed survey of the knowledge of medical practitioners for treating five common conditions in Delhi found that the average doctor in a public primary health center has around a 50-50 chance of recommending a harmful treatment".

Random visits by government inspectors showed that 40% of public sector medical workers were not found at the workplace.

2 Diseases

Malaria is endemic in India. On going government of India education about HIV has led to

decreases in the spread of HIV in recent years. The number of people living with AIDS in India is estimated to be

between 2 and 3 million. The country has had a sharp decrease in the estimated number of

HIV infections; 2005 reports had claimed that there were 5.2 million to 5.7 million people afflicted with the virus.

The new figures are supported by the World Health Organization and UNAIDS.

3 Issues

i) Malnutrition Half of children in India are

underweight, India contributes to about 5.6 million child deaths every year, more than half the world's total.

ii) Women Most Indian women are malnourished. The

average female life expectancy today in India is low compared to many countries, but it has shown gradual improvement over the years.

In many families, especially rural ones, the girls and women face nutritional discrimination within the family, and are anemic and malnourished.

The maternal mortality in India is the second highest in the world.

iii) Water and sanitation Water supply and sanitation in India continue

to be abysmal, despite longstanding efforts by the various levels of government and communities at improving coverage.

The situation is particularly inadequate for sanitation, since only one of three Indians has access to improved sanitation facilities (including improved latrines).

As of 2003, it was estimated that only 30% of India's wastewater was being treated, with the remainder flowing into rivers or groundwater.

The lack of toilet facilities in many areas also presents a major health risk; open defecation is widespread even in urban areas of India, and it was estimated in 2002 by the World Health Organisation that around 700,000 Indians die each year from diarrhoea.

No city in India has full-day water supply. Most cities supply water only a few hours a day. In towns and rural areas the situation is even worse.

4 Healthcare Infrastructure According to the Investment Commission of India the healthcare sector has experienced phenomenal growth of 12 percent per annum in the last 4 years.

Rising income levels and a growing elderly population are all factors that are driving this growth.

In addition, changing demographics, disease profiles and the shift from chronic to lifestyle diseases in the country has led to increased spending on healthcare delivery .

5 Central government role Central government efforts at influencing

public health have focused on the five-year plans, on coordinated planning with the states, and on sponsoring major health programs.

Government expenditures are jointly shared by the central and state governments.

Goals and strategies are set through central-state government consultations of the Central Council of Health and Family Welfare.

Central government efforts are administered by the Ministry of Health and Family Welfare, which provides both administrative and technical services and manages medical education.

States provide public services and health education

6 Expenditure

In the mid-1990s, health spending amounted to 6% of GDP, one of the highest levels among developing nations.

The established per capita spending is around Rs 32000 per year with the major input from private households (75%).

State governments contribute 15.2%, the central government 5.2%, third-party insurance and employers 3.3%, and municipal government and foreign donors about 1.3, according to a 1995 World Bank study.

Of these proportions, 58.7% goes toward primary health care (curative, preventive, and promotive) and 38.8% is spent on secondary and tertiary inpatient care. The rest goes for nonservice costs.

7 Healthcare in urban India Behaviors between middle- and upper-

class citizens from the four largest metros in India - Delhi, Chennai, Kolkata, and Mumbai - appear to vary widely.

In general, those in Chennai appear to be more “westernized” in their attitude towards medical treatment.

Those in Kolkata appear to have a strong relationship with their healthcare provider but are generally more traditional in their attitudes towards medical treatment.

Those in Delhi are most likely to have a positive view of medical care in India but also tend to be more traditional in their attitudes towards medical treatment.

Finally, those in Mumbai are most likely to have a negative view on healthcare in India and also appear to have a weak relationship with their healthcare providers.

8 Primary services Primary health centers are the cornerstone of the

rural health care system. By 1991, India had about 22,400 primary health

centers, 11,200 hospitals, and 27,400 clinics. These facilities are part of a tiered health care system

that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside.

Primary health centers and sub centers rely on trained paramedics to meet most of their needs.

9 Health Insurance The majority of the Indian population is unable to

access high quality healthcare provided by private players as a result of high costs.

Many are now looking towards insurance companies for providing alternative financing options so that they too may seek better quality healthcare.

The opportunity remains huge for insurance providers entering into the Indian healthcare market since75% of expenditure on healthcare in India is still being met by ‘out-of-pocket’ consumers.

10 Medical Tourism India is becoming a location for medical

tourists seeking health care at lower costs than in other countries.

11 Rate of growth India has approximately 600,000 allopathic

doctors registered to practice medicine. This number however, is higher than the actual

number practicing because it includes doctors who have emigrated to other countries as well as doctors who have died.

India licenses 18,000 new doctors a year.