Healthcare Facilities in Rural Areas
- indigenous systems of medicine; drugs and pharmaceuticals. Public health being a State subject, the primary responsibility to provide improved access to healthcare services is that of the State Governments. However, under National Health Mission (NHM) financial support is provided to State/UT Governments to strengthen their healthcare systems to provide better and easy access to healthcare services. As per Rural Health Statistics, 2014, there is a shortfall of 36346 Sub Health Centres (SCs), 6700 Primary Health Centres (PHCs), and 2350 Community Health Centres (CHCs) against the specified population norm.
- As per Rural Health Statistics Bulletin (RHS) 2014, a total of 2225 (8.89%) Primary Health Centres (PHCs) are functioning without doctor, 9825 (39.26%) PHCs without Lab Technician and 5739 (22.94%) PHCs without a pharmacist in the country.
- Under the National Health Mission (NHM), financial support is provided to the States /UTs to strengthen their health care system for augmentation of health human resources, provision of free essential medicines, etc. Some key support areas under NHM are:-
- ASHAs: ASHA is a female voluntary health worker who acts as the link between the community and the public health facilities. She provides basic information regarding health and health care services and motivates people to access services from public health facilities.
- Ambulances: Under NHM, support is provided to States/UTs to set-up a patient transport system where people can dial 108 or 102 telephone number for calling an ambulance. Dial 108 system is an Emergency Response System, primarily designed to cater to patients of critical care, trauma and accident victims, etc. 102 services is essentially the basic patient transport system aimed to cater to the pregnant women and sick children though other categories are also taking benefit and are not excluded.
- Mobile Medical Units (MMUs): MMUs provide outreach services in rural and remote areas through a team of staff including one doctor, one nurse, one lab attendant, one pharmacist and a helper and driver.
- Human Resources: Support is provided under National Health Mission to States and UTs for engaging health care staff at public health facilities on contractual basis, for providing incentives to doctors and other staff to work in rural and remote areas, for capacity building of staff, etc.
- Infrastructure: Support under NHM is provided to States/UTs for establishment of new facilities based on population and time to care norms and for up-gradation of existing facilities by constructing new buildings or by renovation of existing ones.
- Drugs & Equipment: To supplement the efforts of States/UTs in ensuring availability of drugs at public health facilities, Government of India has been providing free drugs /funds for free drugs to States/UTs under the Reproductive and Child Health (RCH) and National Disease Control Programmes for Tuberculosis, Vector borne diseases including Malaria, Leprosy and HIV/AIDS etc. Government is also encouraging the States/UTs to provide universal access to free essential medicines in public health facilities by providing funds and incentives under the National Health Mission (NHM). Up to 5% additional funding (over and above the normal allocation of the state) under the NRHM was introduced as an incentive from the year 2012-13 for those States that introduce free medicines scheme.
- Untied Grants to facilities: Under NHM, support is given to States/UTs to strengthen Sub Centres, PHCs, CHCs and District Hospitals by provision of Untied Funds to undertake need based works for improving infrastructure and enhancing service delivery at these facilities.
- Support for Reproductive, Maternal, New-born, Child & Adolescent Health (RMNCH+A): RMNCH+A seeks to address the major causes of mortality among women and children as well as the delays in accessing and utilizing health care services. The RMNCH+A strategic approach provides for ‘continuum of care’ to ensure equal focus on various life stages. The support to States/UTs under National Health Mission for RMNCH+A includes Janani Suraksha Yojana (J.S.Y), Janani Shishu Suraksha Karyakram (J.S.S.K), Maternal and Child Health Wings at facilities with higher case load, Integrated Management of Neonatal and Childhood Illness (IMNCI), Home Based New-born Care (HBNC), establishment of facility- based care for new-born and sick children including New Born Care Corners (NBCCs), New Born Stabilization Units (NBSUs), Special New Born Care Units (SNCUs), Nutritional Rehabilitation Centres (NRCs), Universal Immunization Programme, Rashtriya Bal Swasthya Karyakram (RBSK), Rashtriya Kishor Swasthya Karyakram and Family Planning Services.
- Support for control of communicable and non-communicable diseases: Under NHM, support is provided to States/UTs for the control of the communicable diseases including vector borne diseases such as Malaria and Filariasis, Leprosy and Tuberculosis and for disease surveillance. Under the National Non-Communicable Disease Programmes, NHM supports prevention and control of Blindness, mental health issues, cardiovascular diseases and stroke, deafness, Tobacco related illnesses, oral health issues, Fluorosis, Iodine deficiency disorders, etc. In addition support is also provided to States/UTs for health care of elderly and palliative care.
Primary Health Care is a vital strategy which is a backbone of Health Service delivery for
our country. India was one of the first few countries to recognize the importance of
Primary Health Care Approach. PHC was conceptualized in 1946, three decades before
the Alma Ata declaration, when Sir Joseph Bhore made recommendations, which laid the
basis for organization of basic health services in India. Over the past decades, several
Committees and Commissions have been appointed by the Government to examine issues
and challenges facing the health sector. The purpose of these committees formed from
time to time is to review the current situation regarding health status in the country and
suggest further course of action in order to accord the best of healthcare to the people.
The earliest committees included, the Health Survey and Development Committee (Bhore
Committee) and Sokhey Committee. Other main Committees in the Post Independence
period, included Mudaliar Committee, Chadha Committee, Mukherjee Committee,
Jungalwalla Committee, Kartar Singh Committee; Mehta Committee, Bajaj Committee
amongst others. Some of the recent Committees include the Mashelkar Committee and
the National Commission on Macroeconomics and Health. The committees and
commissions have been headed by eminent public health experts, who have studied the
issues in an in-depth manner and provided overarching recommendations for various
aspects of the health care system in India. The areas covered by them related to
organization, integration and development of health care services / delivery system across
level. health policy and planning, national programmes, public health,human resources.
indigenous systems of medicine; drugs and pharmaceuticals.
Rural Health Scheme: Community Health Volunteer Scheme-Village HealthGuides
Acceptance of the recommendations of the Shrivastav Committee report led to the
launching of Rural Health Scheme in 1977, wherein training of community health
workers, reorientation training of multipurpose workers and linking medical colleges to
rural health was initiated. Also to initiate community participation, the Community
Health Volunteer – Village Health Guide (VHG) scheme was launched on 2nd October
1977. According to the VHG Scheme the village community selects a volunteer was to be
a person from the village, mostly women, who was imparted short term training and
small incentive for the work. VHG acts as a link between the community and the
Government Health System. He / She mainly provides health education and creates
awareness of Maternal and Child Health and Family Welfare Services. He / She has to
keep a track of communicable and treat minor ailments and provide first aid to the
patients.
Alma Ata Declaration – Health for all by 2000
The Alma Ata declaration of 1978 launched the concept of Health For All by year 2000.
It was signed by 134 governments (including India) and 67 other agencies. The Alma Ata
Declaration in 1978 gave an insight into the understanding of primary health care. It
viewed health as an integral part of the socioeconomic development of a country. It
provided the most holistic understanding to health and the framework that States needed
to pursue to achieve the goals of development. The Declaration recommended that
primary health care should include at least: education concerning prevailing health
problems and methods of identifying, preventing and controlling them; promotion of food
supply and proper nutrition, and adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning; immunization against major
infectious diseases; prevention and control of locally endemic diseases; appropriate
treatment of common diseases and injuries; promotion of mental health and provision of
essential drugs. It emphasized the need for strong first-level care with strong secondary
and tertiary-level care linked to it. It called for an integration of preventive, promotive,
curative and rehabilitative health services that had to be made accessible and available to
the people, and this was to be guided by the principles of universality,
comprehensiveness and equity. In one sense, primary health care reasserted the role and
responsibilities of the State, and recognized that health is influenced by a multitude of
factors and not just the health services.13 At the same time, the Declaration emphasized
on complete and organized community participation, and ultimate self-reliance with
individuals, families and communities assuming more responsibility for their own health,
facilitated by support from groups such as the local government, agencies, local leaders,
voluntary groups, youth and women’s groups, consumer groups, other non-governmental
organizations, etc. The Declaration affirmed the need for a balanced distribution of
available resources (WHO 1978). The declaration asserted “PHC 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 at every stage of their development in the spirit of self-reliance and
self determination.”
Several critical efforts outlined Government of India‟s commitment to provide health for
all of its citizens after Alma Ata declarations, which are briefly discussed below.
With a view of evolving a national strategy for securing the objectives of Health For All
and to identify specific programmes for the VI Five Year Plan, The working group on
Health was constituted by the Planning Commission with Shri Kripa Narain, Secretary,
Ministry of Health and Family welfare as its Chairman to review the current health status
keeping in view the physical and qualitative implementations of plan programmes, short
falls and deficiencies and measures for rectifying them. The report of the working Group
on “Health for All by 2000 AD” examined the contextual issues in providing health care.
The report contains a variety of inter-related recommendations, setting out objectives,
strategies and operational goals which are considered feasible in the obtaining conditions.
It is basically set down the parameters of the problem and set out the specific health tasks
and targets to the state in the simplest terms but with full belief, that the goal of Health
For All as spelt out here is an achievable one, given the sustained will and the supporting
efforts to implement the indicated tasks by 2000 AD.
First National Health Policy, 1983
The responsibility of the state to provide comprehensive primary health care to its people
as envisioned by the Alma Ata declaration led to the formulation of India‟s First National
health Policy (NHP) in 1983. The major goal of policy was to provide of universal,
comprehensive primary health services. The policy emphasized the role that could be played
by private and voluntary organizations working in the country to support
government for integration of health services. It stressed the creation of an infrastructure
for primary healthcare; close co-ordination with health-related services and activities like
nutrition, drinking water supply and sanitation; the active involvement and participation of
voluntary organisations; the provision of essential drugs and vaccines; qualitative
improvement in health and family planning services; the provision of adequate training; and
medical research aimed at the common health problems of the people.
Meanwhile, A selective approach as an “interim” measure to the long term process of
comprehensive primary health care implementation was introduced in many countries,
including India as resource constraints made it ”not possible” to achieve Alma Ata goals
within the committed time limit. Thus the focus shifted from the development of health
systems and infrastructure for primary health care and ensuring health equity to several
vertical interventions based on technical justifications and cost effectiveness analysis.
UNICEF also suggested its selective approach, GOBI-FFF (Growth monitoring, Oral
dehydration, Breast feeding, Immunization, Female literacy, Family planning, Food
supplement) for improving child survival. By the turn of the millennium, despite some
gains in health outcomes and vast improvements in the availability of health
infrastructure through a three-tier network, India had yet to achieve most of the goals
enshrined in its first national health policy.
Second National Health Policy, 2002
Nearly twenty years after the first health policy, the Second National Health Policy, 2002
was presented. The NHP 2002 recognized as the noteworthy successes in health since the
implementation of the First NHP 1983. These successes included the eradication of small
pox and guinea worm, the near eradication of polio and the progress towards the
elimination of leprosy and neonatal tetanus. The NHP sets out a new policy framework to
achieve public health goals 23 in the socio-economic circumstances currently prevailing in
the country. The approach aims at increasing access to the decentralized public health
systems by establishing new infrastructure in deficient areas and upgrading the
infrastructure of existing institutions. It sets out an increased sectoral share of allocation
out of total health spending to primary health care.
National Rural Health Mission (NRHM, 2005-2012)
Recognizing the importance of Health in the process of economic and social development
and improving the quality of life of our citizens, the Government of India has launched
the National Rural Health Mission (NRHM) in April 2005 to carry out necessary
architectural correction in the basic health care delivery system. The Mission adopts a
synergistic approach by relating health to determinants of good health viz. segments of
nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming
the Indian systems of medicine to facilitate health care. The mission envisages a
primary health care approach for decentralized health planning and implementation at
the village and district level. The mission was made operational from April 2005
throughout the country with special focus on 18 states having weak demographic
indicators and infrastructure. The Plan of Action includes increasing public expenditure
on health, reducing regional imbalance in health infrastructure, pooling resources,
integration of organizational structures, optimization of health manpower,
decentralization and district management of health programmes, community participation
and ownership of assets, induction of management and financial personnel into district
health system, and operationalizing community health centers into functional hospitals
meeting Indian Public Health Standards in each Block of the Country.
The Goal of the Mission is to improve the availability of and access to quality health
care by people, especially for those residing in rural areas, the poor, women and
children.
NRHM is visualized as an architectural correction of the Indian Public health system to
enable it to effectively handle increased allocations and promote policies that strengthen
public health management and service delivery in the country. It envisages appropriate
health personnel to be placed at different levels starting from village level in fully
functioning health centers with adequate linkages amongst different levels. An illustrative
structure model is depicted in below Figure showing health structures functioning at
different levels with a set of key health personnel performing adequate functioning in
coordination with other sectors.
NRHM has as its key components as provision of a female health activist in each village
called ASHA to promote access to improved health care at household level: a Village
Health Plan formulation through a local team headed by the health and sanitation
committee of the Panchayat: strengthening of rural hospitals for effective curative care
and making them measurable and accountable to the community through Indian Public
Health Standards (IPHS); integration of vertical health and family welfare programmes:
strengthening of primary health care through optimal utilization of funds, infrastructure
and available manpower. NRHM works on five key approaches – communitization
emphasizing community involvement, flexible financing for increased monetary
autonomy at different levels, capacity building to empower multiple stakeholders for
efficient health delivery and human resource management to generate more manpower
and equipping health personnel with adequate multiple skills.The key core strategies under NRHM are :
- Train and enhance capacity of Panchayat Raj Institutions (PRIs) to own, control and manage public health services.
- Promote access to improved health care at household level through the village level worker , ASHA
- Health plan for each village through Village Health Committee of the Panchayat.
- Strengthening sub centers through better human resource development, clearquality standards, better community standards, better community support and an untied fund to enable local planning and action and more multipurpose workers.
- Strengthening existing Primary Health Centers through better staffing and human resource development policy, clear quality standards, better community support and an untied fund enable the local management committee to achieve these standards.
- Provision of 30 – 50 bedded CHC per lakh population for improved curative care to a normative standard. (Indian Public Health Standards defining personnel,equipment and management standards)
- Preparation and implementation of an inter-sector district plan prepared by district health mission, including drinking water supply, sanitation, hygiene and nutrition.
- Integrating vertical health and family welfare programmes at national, state,district and block levels.
- Technical support to national, state and district health mission for public health management.
- Strengthening capacities for data collection, assessment and review for evidence base planning, monitoring and supervision.
Supplementary Strategies under Mission
- Regulation for private sector including the informal Rural Medical Practitioners(RMPs) to ensure availability of quality service to citizens at reasonable cost.
- Promotion of Public Private Parternership for achieving public health goals.
- Mainstreaming the Indian System of medicine (AYUSH) revitalizing local health traditions.
- Reorienting medical education to support rural health issues including regulation of medical care to medical ethics.
- Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.
Primary health care resources in India
Infrastructure
Health Infrastructure is an important indicator to understand the healthcare delivery
provisions and mechanisms in a country. Health Infrastructure indicators is subdivided
into two categories viz. educational infrastructure and service infrastructure.
Educational infrastructure provides details of medical colleges, students admitted to
M.B.B.S. course, post graduate degree/diploma in medical and dental colleges,
admissions to BDS & MDS courses, AYUSH institutes, Nursing courses and Paramedical courses.
Medical education infrastructures in the country have shown rapid growth during the last
20 years. The country has 314 medical colleges 46 with total admission of 29,263 (in 256
Medical Colleges), 289 Colleges for BDS courses and 140 colleges conduct MDS
courses 21547 and 2,783 respectively 47 during 2010-11. There are 2028 Institutions for
General Nurse Midwives with admission capacity of 8033248 and 608 colleges for
Pharmacy (diploma) with an intake capacity of 36115 49 as on 31st March, 2010.
Service infrastructure in health include details of allopathic hospitals, hospital beds,
Indian System of Medicine & Homeopathy hospitals, Sub centers, PHC, CHC and blood
banks.
There are 12,760 hospitals having 576793 beds in the country. 6795 hospitals are in rural
area with 149690 beds and 3748 hospital are in Urban area with 399195 beds. Rural and
Urban bifurcation is not available in the States of Bihar and Jharkhand.
Medical care facilities under AYUSH by management status i.e. dispensaries & hospitals
are 24,465 & 3,408 respectively as on 1.4.2010.There are 1,47,069 Sub Centers, 23,673 Primary
Health Centers and 4,535 Community Health Centers in India as on March 2010. Total No. of
licensed Blood Banks in the Country as on January 2011 are 2445.
Sub Centres (SCs)
The Sub-Centre is the most peripheral and first contact point between the primary health
care system and the community. Each Sub-Centre is required to be manned by at least
one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health
Worker (for details of staffing pattern, and recommended staffing structure under Indian
Public Health Standards (IPHS) see Annexure I). Under NRHM, there is a provision for
one additional second ANM on contract basis. One Lady Health Visitor (LHV) is