Primary Health Care in India.

Primary Health Care in India.

In 1977 government of India launched a rural health scheme, based on the principles of “Placing people’s health in people’s hands’
As a signatory to Alma-Ata Declaration, the government of India is committed to achieving the goal of Health care approach which seeks to provide universal health care at a cost which is affordable.
Keeping in view the WHO goal of “Health for All” by 2000 AD, the government of India evolved a National Health Policy in 1983.
Keeping in view the Millennium Developmental Goals, the government of India revised the draft of National Health Policy in 2001.

Principles of primary Health Care.
1.Equitable distribution
2.Community participation
3.Intersectoral coordination
4.Appropriate technology
5.Preventive in Nature
6.Man power development.

Primary Health Centre

Primary Health Centers are the cornerstone of rural health services- a first port of Call to a qualified doctor of the public sector in rural areas for the sick and those
Who directly report or referred from Sub-centers for curative, preventive and
promotive health care.

A typical Primary Health Centre covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with4-6 indoor/observation beds. It acts as a referral unit for 6 sub-centres and refer out cases to CHC (30 bedded hospital) and higher order public hospitals located at sub-district and district level.

Standards are the main driver for continuous improvements in quality. The
Performance of Primary Health Centers can be assessed against the set
Standards.
In order to provide optimal level of quality health care, a set of standards are
being recommended for Primary Health Centre to be called Indian Public Health
Standards (IPHS) for PHCs. The launching of National Rural Health Mission
(NRHM) has provided this opportunity.

Assured services or Functions of Primary health canters:
Assured services cover all the essential elements of preventive, promotive,
Curative and rehabilitative primary health care. This implies a wide range of
Services that include:

1.Medical care:
OPD services: minimum 4 hours in the morning and 2 hours in the evening.
24 hours emergency services
Referral services
In-patient services (6 beds)
2.Maternal and Child Health Care including family planning:
Antenatal care: Early diagnosis, minimum three antenatal check up, identification and management of high risk pregnancies, nutrition and health counseling, minimum laboratory investigation urin albumin, test ofr syphilis, chemoprophylaxis for malaria in high endemic area as per NVDCP.
Intra-natal care. (24-hour delivery services both normal and assisted)
Postnatal Care.( Janani Suraksha Yojana (JSY)) Minimum 2 postpartum visit, initiation of breast feeding health education on hygiene, contraception etc,
New Born care.
Care of The Child.
Family Planning
.
3.Medical Termination of Pregnancies using Manual Vacuum Aspiration
(MVA) technique. (Wherever trained personnel and facility exists)

4. Management of Reproductive Tract Infections / Sexually Transmitted
Infections:

5.Nutrition Services (coordinated with ICDS)

6.School Health

7.Adolescent Health Care

8.Promotion of Safe Drinking Water and Basic Sanitation

9.Prevention and control of locally endemic diseases like malaria, Kalaazar,
Japanese Encephalitis, etc

10. Disease Surveillance and Control of Epidemics

11.Collection and reporting of vital events

12.Education about health/Behaviour Change Communication (BCC)

13.National Health Programmes including Reproductive and Child HealthProgramme (RCH), HIV/AIDS control programme, Non communicable
disease control programme etc

14.Referral Services.

15.Training: ASHA, ANM, LHV

16.Basic Laboratory Services

17.Monitoring and Supervision:

18.AYUSH services as per local people’s preference (Mainstreaming of
AYUSH)

19.Rehabilitation

20.Selected Surgical Procedures

21.Record of Vital Events and Reporting

SUBCENTRE

In the public sector, a Sub-health Centre (Sub-centre) is the most peripheral and first contact point between the primary health care system and the community. As per the population norms, one Sub-centre is established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. As sub- centre are the first contact point with the community, the success of any nation wide programme would depend largely on well functioning sub-centre providing services of acceptable standard to the people. The current level of functioning of the Subcentresare much below the expectations.

There is a felt need for quality management and quality assurance in health care delivery system so as to make the same more effective, economical and accountable. No concerted effort has been made so far to prepare comprehensive standards for the Sub-centre. The launching of NRHM has provided the opportunity for framing Indian Public Health Standards.

Objectives of Sub-centres:

i. To provide basic Primary health care to the community.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of
the community.

Assured services or Functions of Primary health centres:
Assured services cover all the essential elements of preventive, promotive,
curative and rehabilitative primary health care. This implies a wide range of
services that include:

1.Maternal and Child Health Care including family planning:
Antenatal care: Early diagnosis, minimum three antenatal check up, identification and management of high risk pregnancies, nutrition and health counseling, minimum laboratory investigation urine albumin, test for syphilis, chemoprophylaxis for malaria in high endemic area as per NVDCP.
Intra-natal care: Promotion of institutional deliveries, skilled reference at home deliveries. Minimum 2 postpartum visit, initiation of breast feeding health education on hygiene, contraception etc,
Others: Provision of facilities under Janani Suraksha Yojna and NRHM.
Postnatal Care:
Child health: Essential New born care, promotion of exclusive breast feeding, immunization of all children, prevention and control of all childhood disease.
.
2.Family planning and contraception: Education motivation and counseling to adopt family planning motheds, provision of contraception.
3.Counseling and appropriate referral for safe abortion services for those in need.
4.Adolescent health care:
5.Assistance to school health services.
6.Control local endemic diseases such as Malaria, filariasis etc.
7.Disease surveillance
8.Water quality monitoring: Disinfection of water sources
9.Promotion of sanitation including use of toilets and appropriate garbage disposal.
10.Field visits
11.Community needs assessment
12.Curative services: Provide treatment for minor ailments, referral service, organizing health day once in month at anganvadi.
13.Training coordination and monitoring: Training of traditional birth attendants ASHA community health volunteers, monitoring of water quality.
14.National Health Programme.
15.Record of Vital Events.

The staff of the Sub center will have the support of ASHA (Accredited Social Health Activists) wherever the ASHA scheme is implemented / similar functionaries at village level in other areas. ASHA is primarily a trained woman volunteer, resident of the village-married/widow/divorced with formal education up to 8th standard preferably in the age group of 25-45 years. The general norm is one ASHA per 1000 population. The job functions of ANM, Male Health worker, ASHA and AWW in the context of coordinated functions under NRHM.

HOSPITALS AND HEALTH CENTRES

Community Health Centres.

Health care delivery in India has been envisaged at three levels namely primary, secondary and tertiary. The secondary level of health care essentially includes,Community Health Centres(CHCs), constituting the First Referral Units(FRUs) and the district hospitals. The CHCs were designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the centre directly. 4 PHCs are included under each CHC thus catering to approximately 80,000 populations in tribal / hilly areas and 1, 20,000 populations in plain areas. CHC is a 30-bedded hospital providing specialist care in medicine, Obstetrics and Gynaecology, Surgery and Pediatrics. These centres are however fulfilling the tasks entrusted to
them only to a limited extent. The launch of the National Rural Health Mission (NRHM)gives us the opportunity to have a fresh look at their functioning.

NRHM envisages bringing up the CHC services to the level of Indian Public Health Standards. Although there are already existing standards as prescribed by the Bureau of Indian Standards for 30-bedded hospital, these are at present not achievable as they are very resource-intensive. Under the NRHM, the Accredited Social Health Activist
(ASHA) is being envisaged in each village to promote the health activities. With ASHAin place, there is bound to be a groundswell of demands for health services and the system needs to be geared to face the challenge. Not only does the system require up gradation to handle higher patient load, but emphasis also needs to be given to quality aspects to increase the level of patient satisfaction. In order to ensure quality of services, the Indian Public Health Standards are being set up for CHCs so as to provide a yardstick to measure the services being provided there.

Objectives of Indian Public Health Standards (IPHS) for CHCs:
To provide optimal expert care to the community
To achieve and maintain an acceptable standard of quality of care
To make the services more responsive and sensitive to the needs of the
community.

Functions of CHCs:
Every CHC has to provide the following services which can be known as the Assured
Services:
1.Care of routine and emergency cases in surgery:
This includes Incision and drainage, and surgery for Hernia, hydrocele,
Appendicitis, haemorrhoids, fistula, etc.
Handling of emergencies like intestinal obstruction, haemorrhage, etc.
2. Care of routine and emergency cases in medicine:
Specific mention is being made of handling of all emergencies in relation to the National Health Programmes as per guidelines like Dengue Haemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are already available under each programme, which should be compiled in a single manual.
3.24-hour delivery services including normal and assisted deliveries
4.Essential and Emergency Obstetric Care including surgical interventions like Caesarean Sections and other medical interventions
5. Full range of family planning services including Laproscopic Services
6.Safe Abortion Services
7. New-born Care
8.Routine and Emergency Care of sick children
9.Other management including nasal packing, tracheostomy, foreign body removal etc.
10.All the National Health Programmes (NHP) should be delivered through the CHCs.Integration with the existing programmes like blindness control, Integrated Disease Surveillance Project, is vital to provide comprehensive services.
11.Others
Blood storage facility
Essential laboratory services
Referral (transport) facility.

Hospitals.
India’s Public Health System has been developed over the years as a 3-tier system, namely primary, secondary and tertiary level of health care. District Health System is the fundamental basis for implementing various health policies and delivery of healthcare, management of health services for defined geographic area. District hospital is an essential component of the District health system and functions as a secondary level of health care which provides curative, preventive and promotive healthcare services to the people in the district.
Every district is expected to have a district hospital linked with the public hospital/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As per the information available, 609 districts in the country at present are having about 615 District hospitals.

However, some of the medical college hospitals or a sub-divisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district) has not been established. Few districts have also more than one district hospital.

Objectives for district hospitals:
The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the needs of the people of the District. The specific objectives of IPHS for DHs are: 
i.To provide comprehensive secondary health care (specialist and referral services) to the community through the District Hospital.
ii.To achieve and maintain an acceptable standard of quality of care.
iii.To make the services more responsive and sensitive to the needs of the people of the district and the hospitals/centres from which the cases are referred to the district hospitals.

 
Definition .
The term District Hospital is used here to mean a hospital at the secondary referral level responsible for a District of a defined geographical area containing a defined population.  
Grading of district hospitals:  
The size of a district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population it serves. In India the population size of a district varies from 35,000 to 30,00,000 (Census 2001). Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a district having a population of 10 lakhs will be around 300 beds. However, as the population of the district varies a lot, it would be prudent to prescribe norms by grading the size of the hospital as per the number of beds. 
Grade I: District hospitals  norms for 500 beds
Grade II: District hospitals norms for 300 beds
Grade III: District hospitals  norms for 200 beds
Grade IV: District hospitals  norms for 100 beds
The disease prevalence in a district varies widely in type and complexities. It is not possible to treat all of them at district hospitals. Some may require the intervention of highly specialist services and use of sophisticated expensive medical equipments. Patients with such diseases can be transferred to tertiary and other specialized hospitals. A district hospital should however be able to serve 85-95% of the medical needs in the districts. It is expected that the hospital bed occupancy rate should be at least 80%.
 
Functions 
District hospital has the following functions: 
1.It provides effective, affordable healthcare services (curative including specialist services, preventive and promotive) for a defined population, with their full participation and in co-operation with agencies in the district that have similar concern. It covers both urban population (district headquarter town) and the rural population in the district.
2.Function as a secondary level referral centre for the public health institutions below the district level such as Sub-divisional Hospitals, Community Health Centres, Primary Health Centres and Sub-centres. 
3.To provide wide ranging technical and administrative support and education and training for primary health care. 

Essential Services 
Services include OPD, indoor, emergency services. 
Secondary level health care services regarding following specialties will be assured at hospital: 

Consultation services with following specialists: 
General Medicine
General Surgery
Obg & Gyne
Paediatrics including Neonatology
Emergency (Accident & other emergency) (Casualty)
Critical care (ICU)
Anaesthesia
Ophthalmology
ENT
Dermatology and Venerology including STI/RTI
Orthopaedics
Radiology
Dental care
Public Health Management 

 Paraclinical services 
Laboratory Services
X-Ray Facility
Sonography (Ultrasound)
ECG
Blood transfusion and storage facilities
Physiotherapy
Dental Technology (Dental Hygiene).
Drugs
Pharmacy
 
 Support Services 
Medico-legal/postmortem
Ambulance services
Dietary services
Laundry services
Security services
Counseling services for domestic violence, gender violence, adolescents, Gender and socially sensitive service delivery be assured. 
Waste management
Ware housing/central store
Maintenance and repair
Electric Supply (power generation and stabilization)
Water supply (plumbing)
Heating, ventilation and air-conditioning
Transport
Communication
Medical Social Work
Nursing Services
Sterilization and Disinfection
Horticulture (Landscaping)
Lift and vertical transport
Refrigeration