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Health Care Delivery System in
Dr Utpal Sharma
Department of Community Medicine
SMIMS, Gangtok, Sikkim
……..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.
…a state in which a person’ s physical,
emotional, intellectual, social or spiritual
functioning is diminished or impaired.
Health care is...
…….multitude of services rendered to
individuals or communities by the agents
of health services or professional for the
Embraces all the goods and services
designed for “prevention, promotion and
rehabilitation interventions” includes
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
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.
Permanent countrywide system of
estabilished institutions with the objective of…
….coping with the various health needs and
demands of population…
…thereby provide health care to individuals and
community with preventive and curative activities
….utilizing health care workers
Includes… concepts ( e.g health and diseases)
Objects(e.g hospitals, health centres)
Persons (health care workers viz. physician,
Together these forms a system interacting
with each other, supporting and controlling
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
Enumeration and determination of the eligible population for
Governance and decision making
2. Process of health care delivery
Consists of two parts
Behavior of professionals
Recognition of the problem i.e diagnosis
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
3. Outcomes of health care
Aspects of health that results from interventions provided by the
4. Flow of patients in health care system
Varies from country to country
India harbors a multistage (three tier) system, where majority of
health care is delivered by community health care worker
Indian system is more cost effective if health workers are skilled
and effectively supervised
Such system could one of the reason to reduced cost of health
care in developing countries
Levels of health care
Primary Health care
Provided at the community level
Secondary health care
Provided at PHC, CHC, DH etc.
Tertiary health care
Provided at hospitals
Alma-Ata international conference
In 1977, World Health Assembly decided to launch a
movement called “Health for all by 2000”
Fundamental principle of this concept was equity, an equal
health status for all the people in all countries
This is to be ensured by equitable distribution of health
In 1978, the note of “Health for all” was reaffirmed and
marked as the major social goal for every country.
It was stated in the declaration that the best way to achieve
HFA is by providing primary health care……
……… especially to vast size of
underserved rural and urban poor
A main social target of governments, international
organizations and the whole world community in the coming
decades should be the attainment by all peoples of the world
by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life. - “HEALTH
FOR ALL BY 2000”
Primary health care is the key to attaining this target as part of
development in the spirit of social justice.
Primary health care is essential health care based on
practical, scientifically sound and socially acceptable methods
and technology, made universally accessible to individuals
and families in the community through their full participation
and at a cost that the community and country can afford.
It forms an integral part of the country's health
system, and of the overall social and economic
development of the community.
It is the first level of contact of individuals, the
family and community with the national health
All governments should formulate national policies,
strategies and plans of action to launch and sustain
primary health care as part of a comprehensive
national health system and in coordination with
Primary health care
Primary Health Care as defined by the World Health
Organization (WHO) in 1978 is…
Essential health care; based on
scientifically sound, and
socially acceptable method and technology….
…….made universally accessible to individuals
and families of the community through their full
……at a cost that community and country can
afford to maintain every stage of their development in
the spirit of self determination.
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
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.
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
– 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
Health Care Delivery System in India
India is a union of 28 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
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
Functions of MoHFW
International health relations and administration of port
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
Prevention of Communicable disease
Prevention of food adulteration
Control of drug and poison
Economic and social planning
Poulation control and family planning
Functions of Directorate General of Health
Programming and appraisal of all health matters
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
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
To consider and recommend broad outlines of
policy related to matters concerning health like
environment hygiene, nutrition and health
To make proposals for legislation relating to
medical and public health matters.
To make recommendations to the Central
Government regarding distribution of grants-in-
At District level
There are 593 ( year 2001 census) districts in
India. Within each district, there are 6 types of
1. Sub –division
2. Tehsils ( Talukas )
3. Community Development Blocks
4. Municipalities and Corporations
5. Villages and
Tehsils /Talukas (200-600
Community Development Blocks
(approx 100 Villages & 80,000 -
1.2 Lac Pop)
Municipalities & Corporations
(10,000- 2 Lac Pop)
Corporations (> 2 lac
Town Area Committee
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
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
b. Hospitals/Health centres
Community health centres
District hospitals/health centres
c. Health insurance schemes
Employees State Insurance
Central Govt. Health Schemes
d. Other agencies
2. Private sector
a. Private hospitals, polyclinic, nursing homes and
b. General practitioners and clinics
3. Indigenous system of medicine
a. Ayurveda and Siddha
b. Unani and Tibbi
d. Unregistered practitioners
4. Voluntary health agencies
5. National health programmes
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
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
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)
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.
Sub-Centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1,20,000 80,000
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%
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
One Lady Health Worker (LHV) is entrusted with the task of
supervision of six Sub-Centers.
Sub Centre are assigned tasks relating to
…..in order to bring about behavioral
change and provide services in relation to….
Maternal and child health,
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
At present, a PHC is manned by a Medical Officer
supported by 14 paramedical and other staff.
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
Functions of PHCs
MCH care and family planning
Health education and training
Safe water supply and basic sanitation
Prevention and control of locally endemic diseases
Collection and reporting of vital events
Basic laboratory services
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
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,
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
Handling all the emergency and routine cases
Minimum 4 ANC check ups including Registration &
1st visit: Within 12 weeks—preferably as soon as
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
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.
Counseling, provision of Contraceptives, NSV,
Laparoscopic Sterilization Services and their follow up.
Safe Abortion Services
All National Health Programmes delivered through
School health services
Blood storage facility
Essential laboratory services
Referral (transport) services
Maternal Death review (MDR)