B Y- D R . D H A R M E N D R A G A H W A I

( P G S T U D E N T )

MODERATOR-

PROF. Y.D.BADGAIYAN H E A D O F D E PA R T M E N T

D E PA R T M E N T O F C O M M U N I T Y M E D I C I N E C I M S , B I L A S P U R ( C G )

An Overview of Health Care Delivery System in

India

INTRODUCTION

As is well known , the majority of India’s population lives in the rural areas

and • this segment of population have been given

inadequate attention so far as health and medical care facilities are concerned.

The dense rural population with varied ethnic background , high level of illiteracy, low per capita income have been a challenge to Central and state government to improve the quality of people’ lives.

To cope up with various plans, programmes were developed aiming to improve the level of living and health of the people.

This planned development of about five decades has resulted in increase in the health infrastructure to meet the increasing demand on health services at various level.

At the same time , there has been marked shift in National Health Policy from hospital based services to community based services duly backed by strong referral services.

Today , it is clear that health system in India do not gravitate naturally towards the goal of HEALTH FOR ALL through primary health care as articulated in the Declaration of Alma-Ata.

Health systems in India are developing in directions that contribute little to equity and social justice and

Fail to get best outcomes for their resources.

Three worrisome trends of health care system in India -

1.Health system that disproportionately focus on narrow offer of specialized health care.

2.Health system where a command and control approach focused on short-term results and is fragmenting the service delivery.

3.Health systems where governance has allowed unregulated commercialization of health to flourish.

SHORTCOMINGS OF HEALTH CARE DELIVERY SYSTEM IN INDIA

Common shortcomings

1.Inverse care.2.Impowerising care.3.Fragmented and fragmenting care.4.Unsafe care.5.Misdirected care.

INVERSE CARE

People with most means - whose needs for health care are often less - consume the most health care services.

Whereas those with the least means and greatest health problems consume the least.

Public spending on health services most often benefits the rich more than the poor.

IMPOVERISHING CARE

Wherever people are lack of social protection and payment for health care , they are largely out of pocket at the point of health services.

They can be confronted with catastrophic expenses.

Millions of people fall in to poverty because they have to pay for health care services.

FRAGMENTED AND FRAGMENTING CARE

The excessive specialization of health care providers and the narrow focus on many disease control programmes discourage the holistic approach to the individuals and families.

Health services for the poor and marginalized groups are highly fragmented and severely under resourced .

UNSAFE CARE

• Poor system design that is unable to ensure safety and hygiene standards leads to high rates of hospital acquired-infection.

• Medication error and other avoidable adverse effects are underestimated cause of death and ill health.

MISDIRECTED CARE

Resource allocation clusters around curative services at great cost and it is neglecting the potential of primary prevention and health promotion to prevent up to 70% of disease burden in developing countries.

Health sector lacks to mitigate the adverse effects on health from other sectors and

At the same time, unable to make most of what these sector can contribute to health.

ORGANIZATIONAL SET-UP OF HEALTH CARE

DELIVERY IN INDIA

Health development is integral to overall socioeconomic development.

Ministry of Health and Family welfare plays a vital role in planning and making policies.

Under the Constitutions of India, the item like public health, sanitation, hospitals and dispensaries fall in the state list.

Health care is the subject of state government and each state in India has developed its own system of health care delivery independent of central government.

The central organization is mainly for policy making and planning and is mostly consultative and advisory.

At Central Level

The organization at centre comprise of :1.Union Ministry of Health and Family

Welfare.2.Directorate General of Health Services.3.Central Council of Health and Family

Welfare.

Ministry of Health and Family Welfare is headed by

1. A Cabinet Minister.2.A Minister of State.

Currently it consist of four departments –1.Department of Health and Family Welfare.2.Department of AYUSH.3.Department of Health Research.4.Department of AIDS control.

The Union Ministry –- formulates national policies on health and

gives advise on health allied matters.- coordinates health programmes and policies.-supplies technical information and

equipments.-provides financial and other assistance

towards health measures.In general it promotes the health and well

being of people.

At State Level

The state is ultimate authority responsible for all the health services operating within its jurisdiction.

At present there are 28 states and 9 union territories in India and as many type of health administration.

In all the state it comprises of –1. State Ministry of Health and Family

Welfare.2.Directorate General of Health Services.

The State Ministry of Health and FW is headed by- 1.A Minister of Health and Family Welfare.2.A Deputy Minister of Health and Family Welfare. • Health Secretariat is a official organ-• 1. Health Secretary.(Head)• 2. Joint Secretaries.(2 or 3)• 3. Deputy Secretaries and• 4. Under Secretaries.

Director General of Health Services is chief technical advisor to the state government in all matter of medical and public health.

DGHS is assisted by 2-3 Joint Directors.Joint Directors may be- 1. Regional. 2. Functional.

The Regional Directors are at Divisional level and area classified according to geographical distribution.

The Functional Directors are in particular branch of public health such as –

Maternal and Child health Family Planning Nutrition Health Education.

To coordinate the health and family welfare activities between State government and Central government there are 17 Regional Health Offices.

For the large state there is one regional office while 2-3 smaller state have been linked with one regional office.

At District Level

The District level structure of health services is a linkage between state structure on one side and peripheral structure such as CHC , PHC and sub-center on other side.

The district officer of overall control designated as CMHO.

CMHO are assisted by deputies , programme officers and State Civil Medical Officers of different specialities.

They are responsible for implementing health and family welfare programmes according to policies lay down at higher level.

At Block Level

The block is unit of rural planning and development and comprises about 80,000 to 1.2 lakh population.

One Community Health Center is being established in each block.

The officer in-charge of CHC is k/as Superintendent CHC or Block Medical Officer.

Normally one CHC should have –- 30 bed hospital .- Specialist doctors in Pediatrics, Obstetrics,

Medicine and Surgery .- Four Medical Officer.

At Primary Health Center

The delivery of Primary Health Care is principal objective of rural health care system.

One PHC covers about 20000 – 30000 population.

PHC is manned by Medical Officer and paramedical staff.

The Primary Health Center is expected to provide “essential health care” including MCH and family planning.

MCH services are provided through PHC clinic, sub-center and out reach sessions.

At Sub-center level

Sub-centers are peripheral outpost of health care delivery system.

Each sub center covers 3000-5000 population and manned by one MPW male and one MPW female.

MPW female is crucial to provide MCH services.

At Village level

1.ASHA.2.AWW.3.Village Health Guide.4. Trained dais.

HEALTH CARE REFORMS

The annual report of World Health Organization’s (WHO)  2008 focused on “the place of primary healthcare (PHC) in health systems”.

The report arguing that, in three decades since the Declaration of Alma-Ata (WHO 1978) on primary healthcare, only little has changed.

 Member countries had largely implemented 'selective' primary care focused on provision of medical care and services and treatment of specific conditions.

FOUR SETS OF PHC REFORMS

The WHO report (2008) laid out a four-point framework for Primary Health Care policy.

1.Universal Coverage Reforms.2.Service Delivery Reforms.3.Public Policy Reforms.4.Leadership Reforms.

1.Universal Coverage Reforms

Universal coverage reforms is to improve health equity, end exclusion and promote social justice.

Primary care should be accessible to all and ideally, be free at the point of services.

2.Service Delivery Reforms

Service delivery reforms designed to re-organize services around primary care.

In this sense, the WHO argued that PHC should be the ‘hub’ from which patients are guided through the health care system.

PHC should be delivered by multi-professional teams that provide comprehensive care, co-ordinate hospital and other specialized patient services, build partnerships with patients, and promote disease prevention. 

3.Public Policy Reforms.

 The WHO advocated for public policy reforms that integrate public health initiatives into primary care delivery and

work to promote health in the policies of other sectors that influence community behaviour and outcomes.

'intersectoral collaboration'.

4.Leadership Reforms.

The Leadership Reforms replace disproportionate reliance on command and control on one hand.

The inclusive , participatory , negotiation based leadership is required by the complexity of health system.

INDIAN PUBLIC HEALTH STANDARDS

The health system in India has expanded considerably over the last few decades.

But , due to non availability of man power, problems of access and lack of community involvement, the quality of health services is not up to the mark.

Hence, standards are being introduced in order to improve the quality of health care at public health level.

The Bureau of Indian Standards has already prescribed standards for health care facilities,

but , at present these are not achievable as they are very resource – intensive.

IPHS are the set of standards envisaged to improve the quality of health care delivery in the country.

IPHS defining personnel , equipment and management standards.

It decentralized administration by a hospital management committee and provision of adequate funds and powers to enable these committees to reach desired levels.

Objectives of IPHS

1.To provide optimal support and comprehensive primary health care to the community.

2.To achieve and maintain an acceptable standards of quality care.

3.To make the services more responsible and sensitive to the need of community.

NRHM aims at strengthening hospital care for rural areas.

So, as the first step, requirement for Minimum Functional Grade for CHCs, PHCs and Sub-center are being prescribed.

CONCLUSIONS

There have been significant advances in the healthcare system in India over last few decades.

Despite these recent strides the health system remains ineffective in providing basic minimum care as promised in the Indian Constitution.

The fiscal constrains on the government make it obligatory for the private healthcare providers to take over part of the responsibilities.

New ways for establishing, strengthening and sustaining the public-private co-operation are essential for rejuvenating the system.

At the same time decentralization exercises can make the health system more efficient and improve the quality of healthcare delivery.

All these changes will need to be based on a strong political will and should be accompanied by economic and social reforms.

THANK YOU