Health care delivery system in India
Framework
 Introduction
 Evolution of health care services in India
 Role of different committees
 Organizational structure in India
 Health care delivery system in India
 Gaps in structure
 Finance allocation
 Integrated approach of health care delivery
 Contribution by NGOs
 Challenges
Introduction
 Older concept – Health care means patient care

Objective - freedom from the disease through hospital system.
 WHO – “As an integrated care containing promotive, preventive and curative
elements that bear the longitudinal association with an individual, extending
from womb to tomb, and continuing in the state of health as well as disease.”
 Service offered by all health disciplines
 Inter-sectoral coordination and community participation – Responsibility of
providing health care expanded well beyond health sector.
Evolution of health care services in India
 Christian Era – civilization started in Indus Valley
 Environmental sanitation, houses with drainage
 1400 B.C. – Ayurveda and Siddha system
 Developed a comprehensive concept of health
 Post vedic – teaching of buddhism and Jainism
 Rahula Sankirtyana – developed hospital system.
 Moghul empire – Arabic system of medicine (Unani)
 British Gov – British nationals, armed forces, civil servants.
Role of different committees
 1946 – Bhore Committee (Health survey and development committee)
 Integration of preventive and curative services
 Development of PHC
 3 months training in PSM
 1962 – Mudaliar committee (Health survey and planning committee)
 Strengthening of PHC and district hospital
 Regional organization
 1963 – Chaddah committee
 Basic health workers
 Family planning health assistant
Role of different committees cont….
 1965 – Mukerji committee
 Separate staff for the family planning programme
 1967 – Jungalwala committee
 Integration of health services
 Elimination of private practice by Gov. doctor
 1973 – Kartar singh
 Committee on multipurpose worker
 ANM replaced by female health worker
 Basic health worker replaced by male health worker
 Lady health worker designated as female health supervisor.
Organizational structure in India
 Health system has 3 main links
 Central, state and local or peripheral.
 India is a Union of 28 states and 7 territories.
 Health is the responsibility of state.
 Central responsibility
 Policy making
 Guiding
 Assisting
 Evaluating
 Coordinating the work of state health ministries.
At the centre
Official organ
The union ministry
of health and family
welfare
The directorate
general of health
services.
 The union ministry of health and family welfare
Headed by Cabinet minister
Minister of state
Deputy health minister
The central
council of health
and family
welfare.
The union health ministry
Department of health
Department of family welfare
Department of health
Secretary to the Gov. of India (Executive head)
Joint secretary
Administrative staff
Directorate general of health services
Subordinate officer
Department of family welfare
 Was created in 1966
 Headed by the secretary to the government of India.
Secretary
Additional secretary
Commissioner
One joint secretary
Directorate general of health services
- Principal advisor in both medical and public health matter.
DGHS
Additional Director General of health services
Team of deputies
Administrative staff
Directorates - three main units
Medical care
and hospital
Public health
General
administration
The central council of health and family welfare
 Chairman – Union health minister
 Members – State health ministers
Function
 To consider and recommend board outlines of policy in regards to matters of health
 To make proposals for legislation in fields of medical and public health matters and to
lay down.
 To make recommendations to the central government regarding the health.
 To established any organization with appropriate functions for promoting and
maintain cooperation between central and state health administrations.
At the state level
 The state health administration was started in the year 1919.
 The state list which become the responsibility of the state included
 Provision of medical care
 Preventive health services
 Piligrim within the state
State - management sector
State ministry of
health
Directorate of health
and family welfare
services
State ministry of health and family welfare
 Headed - Cabinet minister and deputy minister. (Political head)
 Responsibility - formulating policies
 Monitoring the implementation of these policies and programmes.
State health directorate and family welfare
 Principle advisor in matters relating to medicine and public health
 Assisted by joint director, regional joint director and assistant
directors.
At the district level
 Principal unit of administration in India
 District health organization
 identifies and provide the needs of expanding rural health and family welfare programme
 Within each district again, there are 6 types of administrative areas
 No uniform model of district health organization
District
Rural
Sub-division
Urban
Tahsil (Taluka)
Community
Development
Blocks
Corporations
Municipal Boards
Villages
Panchayats
Town area
committees
Panchayati Raj –
 3 tier structure of rural local self government
 Linking the village to the district
Panchayat Raj
Panchayat
Panchayat Samiti
Gram Sabha
Gram Panchayat
Zilla Parishad
Health care delivery system in India
At the block level
 Objective - to provide primary health care to all the sections of
the society.
 80% of the population is scattered in villages
 20% of rural population have health care facilities
Centre
Plain area
Hilly / Tribal /
Difficult area
Community health
centre
1,20,000
80,000
Primary health centre
30,000
20,000
Sub-centre
5,000
3,000
Community health Centre’s
 Established and maintained by the State Government under MNP/BMS programme.
 As per minimum norms, a CHC is required to be manned by four Medical Specialists
i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical
and other staff.
 It has 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.
 As on March, 2011, there are 4,809 CHCs functioning in the country.
Primary health Centre’s
 First contact point between village community and the Medical Officer.
 To provide an integrated curative and preventive health care with emphasis on
preventive and promotive aspects of health care.
 Established and maintained by the State Governments under the MNP/ BMS
Programme.
 Manned by a Medical Officer supported by 14 paramedical and other staff.
 NRHM - two additional Staff Nurses at PHCs (contractual).
 It acts as a referral unit for 6 Sub Centre’s and has 4 - 6 beds for patients.
 There were 23,887 PHCs functioning in the country as on March 2011.
Sub-Centre
 Most peripheral and first contact point between the primary health care system and
the community.
 Manned by at least one ANM / Female Health Worker and one Male Health Worker.
 Under NRHM, one additional second ANM on contract basis.
 Provide services in relation to maternal and child health, family welfare, nutrition,
immunization and control of communicable diseases.
 Provided with basic drugs for minor ailments.
 Ministry of Health & Family Welfare is providing 100% Central assistance to all the
Sub-Centre’s
 148,124 Sub Centre’s functioning in the country as on March 2011.
Rural health infrastructure: Norms and level of
achievements (All India)
S.
Indicator
No.
1
Rural Population (2011) (Provisional)
covered by
Sub Centre
National Norms
General
Present Avg
Coverage
5000
Tribal/Hilly
/Desert
3000
5624
Primary Health Centre (PHC)
30000
20000
34876
Community Health Centre (CHC)
120000
80000
173235
2
Number of Sub Centre’s per PHC
6
6
3
Number of PHCs per CHC
4
5
4
Rural Population (2011) (Provisional) covered by a:
5
6
HW (F) (at Sub Centre’s and PHCs)
5000
3000
4008
HW (M) (At Sub Centre’s)
5000
3000
15955
Ratio of HA (M) at PHCs to HW (M) at
Sub Centre’s
Ratio of HA (F) at PHCs to HW (F) at
Sub Centre’s and PHCs
1:6
1:3
1:6
1:13
Village
 Accredited Social Health Activist (ASHA) for 1000 population
 Chosen by and accountable to the panchayat
 Act as the interface between the community and the public health system.
 Honorary volunteer, receiving performance-based compensation
 Facilitate preparation and implementation of the Village Health Plan
 The other persons are
 Indigenous dais
 Anganwadi workers
Progress over the years
Progress of Sub Centre’s, which is the most peripheral contact point
between the Primary Health Care System and the community, is a
prerequisite for the overall progress of the entire system.
Percentage of PHCs functioning in Government buildings has
increased significantly from 78% in 2005 to 86.7% in 2011
The % of CHCs in Govt. buildings has increased from 90% in
2005 to 95.3% in 2011
Urban health care delivery system in India
 The government of India has identified “Urban Health” as one of the thrust area
in the tenth Five Year Plan, National population policy 2000, National Health
Policy 2002 and second phase of RCH program
The central government health scheme (1954)
 objective of providing comprehensive medical health care facilities to the
central government employees and their family members.
Urban Family Welfare centers
 launched during the first five year plan.
 At present 1083 centers are functioning and providing outreach services,
primary health services, MCH services and distribution of contraceptives.
Urban health post
 Urban Revamping Scheme – introduced following the recommendations of the
Krishnan Committee in 1983.
 To provide services through setting up of health posts mainly in slum area.
 4 type of health post were set up depending on the allotted population.
 Type A – less than 5000 population
 Type B – between 5000 to 10000 population
 Type C – between 10000 to 25000 populations
 Type D – between 25000 to 50000 populations
 Only Type D health post has a Medical officer.
 Services provided by these posts are outreach of RCH services, first and referral
services and distribution of contraceptives.
Health care delivery services in Delhi
 Well established infrastructure for its people
 One of the highest bed capacity (2.14 beds/1000 persons).
 Public Health expenditure consistently remained above 6 per cent .
 Delhi’s per capita expenditure on health is Rs. 685.
 However, there is multiplicity of agencies operating their health care outlets in
different areas or for defined subset of populations in different areas like Delhi
Government, MCD, NDMC, CGHS, DGHS, ESI and Army etc.
 Primary health care level – Delhi has wide network of 969 dispensaries.
 Secondary and tertiary health care level – there are 706 hospitals including 505
registered nursing homes with 33711 beds. There are 118 hospitals in the
government sector in Delhi.
Health care delivery system in Mumbai
 Mumbai has a vast supply of public and private health care services. The services
range from the super specialty, tertiary-level care hospitals to the general
practitioners.
 The Central Government has its own dispensaries, which are available only for their
employees.
 ESIS - health care services that include hospitals and dispensaries which cater to
employees in the organized sector.
 The various government organisations, such as ports, railways and defence, have
their own health care services for their employees.
 The Municipal Corporation of Greater Mumbai (MCGM) provides major facilities in
the public sector along with the State Government.
Health care delivery system in Mumbai
cont…
 The Department is divided into zonal set-ups for administrative purposes.
 There are five such zones, which cover 23 Wards
 The Deputy Municipal Commissioner handles each zone.
 Each Ward has a separate Ward Office and the Ward Medical Health Officer (MHO)
heads the Public Health Department in that Ward.
 Family welfare and maternal child health programmes are under the supervision of
Officer- Maternal Child Health & Family Welfare at F/South Ward.
 Peripheral hospitals linked to four super specialty hospitals. Health posts and
dispensaries linked to peripheral hospitals in their respective Wards
Private health sector
 India - dominance of Private sector.
 In a NSS survey in 2001-02, 13 lakhs practitioners were working in private sector.
 Accounts 80% of the total facility in the country.
 88% of the towns have a medical facility compared to 24% in rural areas with 90%
of the facilities manned by sole practitioners.
 The private sector has 75% of specialists and 85% of the technology in their
facilities.
 The private sector accounts for 49% beds and an occupancy ratio of 44% whereas
the occupancy rate is 62% in the public sector.
AYUSH
 Old acceptance in the communities in India
 Form the first line of treatment in case of common ailments in most of the places
 Ayurveda is the most ancient medical system with an impressive record of safety and
efficacy.
 Mainstreaming AYUSH to strengthen the Public Health System at all levels.
 AYUSH facilities had been co-located with 208 District Hospitals (36%), 910
Community Health Centres (23%) and 3883 Primary Health Centres in the country
.
Gap in structure
•The availability of manpower is the important prerequisite for the
efficient functioning of the Rural Health services
•Shortfall in the manpower at PHC and Sub centre is shown as on
march 2011
Even out of the sanctioned posts, a significant percentage of posts
are vacant at all the levels.
Shortfall of specialist at CHCs as compared to requirement for
existing infrastructure as on March 2011, Overall 63.9%
specialists at the CHCs
The current position of specialists manpower at CHCs reveal
that as on March 2011, Overall 39.5% of the sanctioned posts of
specialists at CHCs were vacant.
Finance allocation
Health Expenditure in India
2004–05
Health Expenditure in India
2008-09
Type of
Expenditure
Distribution of total
Health Expenditure
(%)
Share of
GDP (%)
Distribution of total
Health Expenditure
(%)
Share of
GDP (%)
Public
Expenditure
19.67
0.84
27
1.1
Private
Expenditure
78.05
3.32
72
3.0
External Flow
2.28
0.10
2
0.1
Total Health
Expenditure
100
4.25
100
4.1
Integrated approach of health care delivery
 Demands coordinated efforts of all sectors such as Agriculture, Irrigation, Animal
Husbandry, Education, Social and Women's Welfare, Housing and Public Works,
Communication, Rural Development, Cooperatives, Industries, Panchayats and
Voluntary Organizations, etc.
ICDS – integrated child development scheme
 Supplementary nutrition for children of less than 6 years of age, pregnant mother,
lactating mother.
 Nutrition and health education to women of reproductive age group
 Monthly health and nutrition day at anganwadi
 Drinking water and toilet facility in anganwadi centre (rural development ministry)
Agriculture, irrigation and engineering:
 Growing more food locally - cereals, pulses, vegetables, fruits etc.
 Identifying water resources for drinking and other purposes
 Providing seeds for kitchen garden and community garden
 Educating the people for composting
Integrated approach of health care delivery cont…
Animal Husbandry:
 Immunizing domestic animals and catties against rabies etc.
 Preventing zoonotic diseases
Education:
 Health education covering nutrition, personal hygiene and environmental sanitation;
 Education about various health problems in the community and their prevention and
control;
 Population education, advantages of small family
 Providing first-aid and treatment of minor ailments and the knowledge of local
health resources.
Social and Women's Welfare:
 Mobilizing women, mahila mandals, mother's club etc. for propagation of health,
nutrition practices, special nutrition programmes for vulnerable groups,
maintenance and use of water resources; proper disposal of excreta, composting,
kitchen garden etc.
 Educating mothers on maternal and child care
Contribution by NGOs
 Providing services like relief to the blind, the disabled and
disadvantaged and helping the government in mother and child health
care, including family planning programmes.
 Greater roles for the NGOs was seen to ensure Health for All through
the primary health care approach.
 Government of India started granting financial aids to NGOs for
various schemes
 Contracting in – government hires individuals on a temporary basis to




provide services
Contracting out – government pays outside individuals to manage specific
function
Subsidies – government gives funds to privet groups to provide specific
services.
Leasing or rental – government offers the use of its facilities to a privet
organization.
Privatization – government gives or sells a public health facility to a privet
group.
Challenges
 Prices of services in private sector
 Earning commission from diagnostic laboratories
 Financial protection against medical expenditure
 Non availability of medical, nursing and paramedical staff
 Inadequate and weak drug control infrastructure
 inadequate drug testing facility
 Extremely high drug cost
 No clear urban health care delivery model
References:
 GOI. Twelfth five year plan (2012-2017) social sector, Volume III.





Planning commission government of India.p1- 47
MOHFW. Rural health care system in India-the structure and current
scenario. Rural health statistics 2011.
GOI. MOHFW. National rural health mission. [online]. [cited 2012
Dec 27]. Available from: http://www.mohfw.nic.in/NRHM.htm
Indian Public Health Standards (IPHS) guideline for community
health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94
GOI. Financing and delivery of health care services in India.
MOHFW 2005; 1-320
Park K. Park's Textbook of Preventive and Social Medicine. 21st ed.
Prem Nagar, Jabalpur, (M.P.), India: M/s Banarsidas Bhanot; 2011