health care structure

1. Dr. Abhishek Tiwari,
Assistant Professor
Department of Community Medicine
Motilal Nehru Medical College, Prayagraj

2. What is health care?
To understand how is health care provided to the
people of India
What are the levels of health care delivery
To understand the facilities available at different
levels
Recent modifications
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3. Health care is multitude of services rendered to
individual or communities by agents of health
services for purpose of promoting, restoring and
maintaining health.
Components
1. Structure of HC delivery
2. Process of HC delivery
3. Outcomes of HC
4. Flow of patients in HC system
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4. DEMOGRAPHIC PROFILE - INDIA
1. Total Population ( 2018) = 1359.8 million (world population 7621 million, China
population 1417 million )
2. Crude Birth Rate (2018) =20.0 per 1000 mid year population
3. Crude Death Rate (2018)= 6.0
4. Annual Growth Rate ( 2017 ) = 1.2% (china 0.9 %)
5. Population Doubling Time = 30 Years
6. Population Rural % ( 2017 ) = 66.5
7. Adult Literacy Rate ( 2011 ) = 74.04
8. Sex Ratio (female per 1000 male)(2014-2016)=898
9. Population under 15 yrs ( 2017) = 28.0
10. Age at Marriage Female (2016) = 22.3 yrs
11. Average Family Size ( 2016 ) = 2.3
12. Infant Mortality Rate ( 2016) = 34 per 1000 live birth (47 in MP, 8 in Goa)
13. Maternal Mortality Rate ( per 100,000 Live Births ) (2014-2016) = 130
14. Life Expectancy at Birth (2017) = 67 Male / 70 Female
15. Population Above 60yrs % (2017 ) = 9.0
16. Annual Per Capita GNP (AT CURRENT PRICES 2016-2017 ) = Rs 112432=00
17. Density of Population per sq.km ( 2017)= 876

5. MODEL OF A HEALTH CARE
SYSTEM
INPUTS HEALTH CARE HEALTH CARE OUTPUTS
SERVICE SYSTEM
HEALTH
STATUS OR
HEALTH
PROBLEMS
RESOURCES
CURATIVE
PREVENTIVE
PROMOTIVE
PUBLIC
PRIVATE
VOLUNTARY
INDIGENOUS
CHANGES IN
HEALTH
STATUS

6. HEALTH SYSTEM IN INDIA
• It has 3 main Links :-
1) AT THE CENTER
a) Ministry of Health and Family Welfare
b) D.G.H.S
c) Central Council of Health & FW
2) AT THE STATE
a) State Ministry of Health
b) State Health Directorate
3) AT THE DISTRICT
a) Urban Area :-
i) Town Area Committee = 5000 to 10000 Population
ii)Municipal Board or Municipality = 10000 to 2 Lacs
iii) Corporation = > 2 Lacs Population
b) Rural Area :-
i) Panchayat - at Village Level
ii) Panchayat Samiti – at Block Level
iii) Zilla Parishad – at District level

7. HEALTH CARE SYSTEM IN INDIA
1) Public Health Sector :-
a) Primary Health Care ( PHC’S, Sub Centers )
b) Hospitals / Health Centers ( CHC’S, Rural Hospital,
Distt. Hospitals, Specialist Hospitals, Teaching Hospitals.
c) Health Insurance Schemes ( E.S.I, CGHS )
d) Other Agencies ( Defence Services, Railways )
2) Private Sector:-
a) Private Hospitals, Polyclinics, Nursing Homes, Dispensaries.
b)General Practitioners & Clinics
3) Indigenous System of Medicine:-
Aryuveda & Sidha, Unani, Homeopathy, Unregistered
Practitioners
4) Voluntary Health Agencies
5) National Health Programmes

8. Tier of health care in India
The health care services in India are organized at three levels,
each level supported by the higher level, to which the patient is
referred.
Tertiary
State Hospital Medical Colleges
Secondary
DH / CHC / Taluka Hospital
Primary
PHC / Sub Centre

9. PRIMARY HEALTH CARE –
Philosophy
 Essential health care
 Made accessible at a cost the COUNTRY can afford
 Practical methods, scientifically sound, socially
acceptable to community
 Full participation of community at every stage in spirit of
self reliance and self determination.
 It’s a health system strategy to achieve Universal health
coverage

10. 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

11. PRINCIPLES OF PRIMARY HEALTH
CARE
1. EQUITABLE DISTRIBUTION
2. COMMUNITY PARTICIPATION
3. INTERSECTORAL CO-ORDINATION
4. APPROPRIATE TECHNOLOGY

12. PRIMARY HEALTH CARE
INFRA STRUCTURE
LEVEL POPULATION SIZE FUNCTIONARIES
VILLAGE 1000 •HEALTH VOLUNTEERS
OR VILLAGE HEALTH
GUIDES
•ANGANWADI WORKERS
•TRAINED BIRTH
ATTENDERS
•ASHA
SUBCENTERS 5000 MULTI PURPOSE
HEALTH WORKERS
(MALE AND FEMALE )
PHC 30000 •HEALTH
PROFESSIONALS
( DOCTORS )
•HEALTH ASSTT MALE
AND FEMALE
CHC 100000 to 120000 SPECIALISTS

13. RURAL HEALTH CARE SYSTEM IN INDIA
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
Community Health Centre (CHC)
A 30 bedded Hospital/ Referral unit for 4 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)

14. SUB CENTER
• Most peripheral 1st contact point b/w primary health care
system & community.
• 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.

15. SERVICES PROVIDED AT SC
• Maternal & child health services – ANC , Intranatal , PNC etc.
• Family planning & contraceptive, counseling – MTP, abortion etc.
• adolescent health care, assistance to school health services
• water quality monitoring
• promotion of sanitation including use of toilet and appropriate
garbage disposal
• field visit for - disease surveillance , family welfare service
including STI, RTI, awareness
• community need assessment

16. SERVICES PROVIDED AT SC
• Curative services for minor ailment
• training of TBA (Trained Birth Attendant ) and ASHA
• cooperative services of anganwadi workers ,ASHA, village health
and sanitation committee etc.
• Disease surveillance, National health programme related activities,
coordination and monitoring
• records of vital events
• outreach services.

17. PRIMARY HEALTH CENTER
• PHC is the first contact point between village community and the
Medical Officer.
• Provide an integrated curative and preventive health care to the
rural population with emphasis on preventive & promotive aspects
of health care.
• The PHCs are established and maintained by the State Government
• At present, a PHC is manned by a Medical Officer supported by
14 paramedical and other staff, it is 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.

18. FUNCTIONS OF PHC
1. Medical Care
2. MCH Including Family Planning
3. Safe Water Supply & Basic sanitation
4. Prevention & Control of Locally Endemic Diseases
5. Collection & Reporting of Vital Statistics
6. Health Education
7. National Health Programs – operational activities
8. Referral Services
9. Training of V.H.G, HW, Local Dias, Health Asst.
10.Basic Laboratory Services.

19. STAFFING PATTERN OF PHC
Staff Type A PHC (with
delivery load of < 20
deliveries in a month)
Type B PHC (with delivery
load of more than or equal to
20 deliveries in a month)
Medical Officer- MBBS 1 1
Medical Officer- AYUSH
Accountant cum Data Entry
Operator
1 1
Pharmacist 1 1
Pharmacist- AYUSH
Nurse -midwife 3 4
Health Worker Female 1 1
Health Assistant- Male 1 1
Health Assistant Female/ Lady
Health Visitor
1 1
Health Educator

20. PHC A PHC B
Lab Technician 1 1
Cold Chain and Vaccine
Logistic Assistant
Multi skilled Group D Worker 2 2
Sanitary worker cum watch
man
1 1
Total 13 14

21. COMMUNITY HEALTH CENTER (CHC)
• Covers a population of 8000 to 1.2 lakh
• 4 specialists i.e. Surgeon, Physician, Gynecologist and
Pediatrician are posted along with other staff.
• It should have 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.
• More case load for OPD, IPD focusing on curative services
including obstetrics and other emergency

22. Maternal Health
Minimum 4 ANC check ups
Including Reg.
– 1st visit: Within 12 weeks
preferably as soon as confirmed
– 2nd visit: Between 14- 26 wk
– 3rd visit: Between 28- 34 wk
– 4th visit: Between 36 wk & term
24 hr delivery services including normal & assisted
delivery & cesarean section
– Managing labour using Partograph.
– Minimum 48 hours of stay after delivery, 3-7 days
stay post delivery for managing Complications

23. Newborn Care and Child Health
– Essential Newborn Care and Resuscitation
– Counseling on Infant and young child feeding
– Routine and emergency care of sick children
– Immunization of infants and children against VPDs
– Management of Malnutrition cases.
• Family Planning
– Counseling, provision of Contraceptives, Laparoscopic
Sterilization Services and their follow up.
– Safe Abortion Services

24. STAFFING PATTERN OF CHC
Designation No. Of Post
Block Medical Officer/ Medical Superintendent Senior most specialist
General surgeon 1
Physician 1
General Duty Medical officer-AYUSH 1
Obstetrician and Gynaecologist 1
Paediatrician 1
Anaesthetist 1
Dental Surgeon 1
General Duty Medical Officer 6 (2females )
Specialist-AYUSH 1
Ophthalmologist 1(1for every 5CHC)
Public Health Manager 1
TOTAL 15/16

25. SUPPORT MANPOWER-
PERSONNEL STRENGTH
Staff Nurse 19
Public Health Nurse 1
ANM 1
Pharmacist/Compounder 3
Pharmacist-AYUSH 1
Lab.Technician 3
Radiographer 2
Ophthalmic Assistant 1
Dresser 2
Ward Boy/Nursing Orderly 5
Sweepers 5
Chaukidars 5
Dhobi 1

26. Personnel Strength
Mali 1
Aya 5
Peon 2
OPD Attendent 1
Registration Clerk 2
Statistical Assistant/Data Entry
Operator
2
Accountant/Admin Assistant 1
OT Technician 1
Total 64

27. HEALTH AND WELLNESS CENTERS
• The national health policy 2017 recommended strengthening the
delivery system of primary health care through establishment of
health and wellness centers as the platform to deliver
comprehensive primary health care.
- Govt. of India is committed toward creation of 150000 health
& wellness centers by transforming existing subcenters and
PHCs as basic pillar of Ayushman bharat to deliver
comprehensive primary health care.
- Further there are 7821 SCs which are upgraded as health and
wellness centers – sub centers ( HWC- SCs ) as of total 157411
- 8242 health & wellness centers – primary health centers ( HWC -
PHCs ) has been upgraded out of 24855.

28. URBAN PRIMARY HEALTH CARE
STAFF
SANTIONED
TYPE OF POST
A (
< 5000
POPULATION )
TYPE OF POST
B
( 5000 to 10000
POPULATION
TYPE OF POST
C
(10000 to 25000
POPULATION )
TYPE OF POST
D
(25000 to 50000
POPULATION )
LADY DOCTOR X X X 1
PUBLIC HEALTH
NURSE
X X X 1
NURSE –
MIDWIFE
1 1 2 3 - 4
MALE MPW X 1 2 3 - 4
CLASS IV X X X 1
COMPUTER
CUM CLERK
X X X 1
VOLUNTARY
FEMALE HEALTH
WORKER
X X X 1

29. URBAN FAMILY WELFARE
CENTERS
TYPE POPULATION
COVERED
NO OF
UNITS
STAFFING PATTERN
I 10000 - 25000 326 ANM =1
FP FIELD WORKERS =1
II 25000 – 50000 125 FP EXTN.EDUCATOR/ LHV =1
FP FIELD WORKER ( MALE ) =1
ANM = 1
III >50000 632 MED.OFFR ( FEMALE PREFERED ) = 1
ANM = 2
LHV = 1
FP FIELD WORKER ( MALE ) =1
STORE KEEPER CUM CLERK = 1

30. THANK YOU