Health care delivery system in community health nursing

HEALTHCARE SYSTEM IN INDIA
Heathcare provide by 5 major sectors in India
1. Public health sector
 Primary health care
 PHC's and sub-centres
 Secondary and tertiary health care
 CHC's, rural hospitals district hospitals, speciality
hospitals and teaching hospitals
 Health insurance schemes providing health care -
ESI, CGHS
 Other agencies: defence services, railways

HEALTHCARE SYSTEM IN INDIA
2. Private sector
 Private hospitals, nursing homes, polyclinics etc.
 General practitioners
3. Indigenous systems of medicine (AYUSH)
 Ayurveda, Yoga, Unani, Siddha and Homeopathy etc.
4. Voluntary health agencies
5. National health programs

PRIMARY HEALTHCARE IN INDIA
 In 1977, the government of India launched a rural
health scheme based on the principle of “placing
people’s health in people’s hands”

Village level:
 Universal coverage and equitable distribution of
health resources.
 Everyone should have access to it
 To implement this policy at the village level.The
following schemes are in operation;
1. Village health guides scheme
2. Training of local dais
3. ICDS scheme
4. ASHA scheme

These workers at the village level, are volunteers
from the community itself
 Placing the people's health in people's own hands
 Not full time government functionaries
 Trained to form the first contact
 Free to continue their vocation
 Paid an honorarium for this work

VILLAGE HEALTH GUIDE
 Introduced on 2nd
october 1977
 Mostly women
 Guidelines for their selection
 Permanent member of the local community
 Should be able to read and write and minimum
education upto 6th
std
 Should be acceptable to all sections of the society
 Should be able to spare atleast 2-3 hours everyday for
community work

VILLAGE HEALTH GUIDE
 After selection, short training in primary health care.
 After completion of training they receive: Working
manual and Kit of simple medicines
 Duties assigned to health guides: Treatment of simple
ailments, and refer in time if required
 Paid an honorarium or Rs. 50 per month and medicines
worth Rs. 600 per annum
 Discontinued by the GOI
 The community health work is now delivered by
ASHA,AWW and trained dai

LOCAL DAIS:
 A program has been undertaken under the Rural
Health Scheme
 To train all categories of traditional birth attendants
(dais)
 Training for 30 working days,
 Each dai is paid a stipend of 200 during the training.

LOCAL DAIS:
 Training given at PHC/SC/MCH centre,
 During training, required to conduct at least 2
deliveries
 ASEPSIS during home delivery.
 After completion of training each dai receives delivery
kit and certificate
 The national target is to train one local dai in each
village

ANGANWADI WORKER (AWW):
 Under I.C.D.S. Scheme one AWW for a population of
400 to 800,
 AWW is selected from the community which she is to
serve.
 She is trained for 4 months in various aspects of
health, nutrition and child development with
Honorarium of 1500 per month

Services include:
 Health check-up.
 Growth chart monitoring. Immunization
 Supplementary nutrition.
 Health education
 Non formal pre-school education
 Referral

Beneficiaries:
 Nursing mother
 Pregnant women
 Women in reproductive age
 Children below 6 yr. of age
 Adolescent girls

ACCREDITED SOCIAL HEALTH
ACTIVIST (ASHA):
 Cadre created under NRHM
 Must be a woman
 Resident of the village
 Married/widow/divorced
 Preferred age group 25 to 45 yr.
 Formal education up to VIII std.
 Good communication skills
 Leadership qualities

ACTIVIST (ASHA):
 She Undergoes training
 She will receive performance-based incentives
 Norm of selection is 1 ASHA for 1000 population

ACTIVIST (ASHA):
Roles and responsiblities:
 Create awareness
 Counsel
 Mobilize the community
 Escort/ Accompany
 Community level curative care
 Information of birth/ death/ unusual health problems/
outbreaks
 Co-ordinate with other health and sanitation work

ASHA
Five key activities of an ASHA
 Attending the UHND
 Holding MAS meetings
 Maintaining record
 Home visits
 Visits to the health facility

SUBCENTRE IPHS
 Sub-centres have been categorized into two types
Type-A and Type-B.
 Categorization has taken into consideration
various factors
Catchment area,
health seeking behavior,
 case load,
location of other facilities like PHC/ CHC/
FRU/ Hospitals in the vicinity of the Sub-
centre.

SUBCENTRE TYPE A
 Provide all recommended services except that the
facilities for conducting delivery will not be available
here.
 However, the ANMs have been trained in midwifery;
they may conduct normal delivery in case of need.
 If the requirement for this goes up, the sub centre
may be considered for upgradation to Type B.
 The Sub- centres in the following situations may be
included in this

SUBCENTRE TYPE A
 Sub-centres not having adequate space and
physical infrastructure for conducting deliveries,
 Sub-centres situated in the vicinity of other
higher health facilities like PHC/ CHC/ FRU/
Hospital, where delivery facilities are
availableiii.
 Sub-centres in headquarter area

SUBCENTRE TYPE A
 Guidelines:
 The facilities for conducting delivery will not be
available at these sub-centres and patients may
usually be referred to nearby centers
 Extra payment should be provided to Staff posted in
difficult areas.
 If there is shortage, Health Worker male should be
posted on priority basis in areas endemic for vector
borne diseases.
 Sub-centres where at present no delivery or occasional
delivery may be taking place
 If the case load increases, these Sub-centres should be
considered for up gradation to Type B.

TYPE-B (MCH SUB-CENTRE):
This would include following types of sub-centres
i. Sub- centres with good connectivity to catchment
areas.
ii. They have good physical infrastructure.
iii. They already have good case load of deliveries
iv. There are no nearby higher level delivery
facilities.

TYPE-B (MCH SUB-CENTRE):
Guidelines:
 Provide all recommended services including facilities for
conducting deliveries at the Sub-centre itself.
 Expected to conduct around 20 deliveries in a month.
 They should be provided with all labour room facilities
and equipment including Newborn care corner.
 ANMs of these Sub-centres should be SBA trained. These
centers may be provided extra equipment, drugs, supplies,
materials, 2 beds and budget for smooth functioning.

SERVICES TO BE PROVIDED IN A SUB-CENTRE:
 Expected to provide promotive, preventive and few
curative primary health care services.
 Both types of sub-centres should lay emphasis on non-
communicable diseases related services.
 Providing outreach facilities, where most services are
not delivered in the Sub-centre building itself, the site
of service delivery may be at following places:

SERVICES TO BE PROVIDED IN A
SUB-CENTRE:
 In the village:
 Village Health and Nutrition Day/ Immunization
session.
 During house visits.
 During house to house surveys.
 During meetings and events with the community.
 At the facility premises. routine OPD services
 Two ANM OPD SERVICES
OUTREACH SERVICES

SERVICES TO BE PROVIDED IN A SUB-
CENTRE:
 The main differences in services to be provided by the two types
of Sub-centres are:
 Type A:
 Shall provide all services as envisaged for the Sub-centre except
the facilities for conducting delivery will not be available here.
 Type-B:
 Provide all recommended services including facilities for
conducting deliveries at the Sub-centre itself. This Sub- centre
will act as Maternal and Child Health centre

THE SERVICES PROVIDED AT
SUBCENTRES
1. Maternal and child health(essential)
 Maternal health
Antenatal care
intranatal care
Postnatal care

THE SERVICES PROVIDED AT SUBCENTRES
 Child health
 Newborn care corner
 Counselling on exclusive breast feeding
 Assess on G&D of infants
 Immunization services
 Vitamin A prophylaxis
 Prevention and control of childhood diseases
 Name based tracking of all infants and children
 Identification and follow up, referral and reporting of
AEFI

SUBCENTRES
2.Family planning and contraception
3. Safe abortion services
4.Adolescent health care
5.School health services
6.Water quality monitoring

SUBCENTRES
7.Promotion of sanitation
8.Community need assessment
9.Curative services for minor ailments
10.Training of traditional birth attendants and
ASHA
11.Coordinate services AWW,ASHA and VHSC
12.National health programmes

PRIMARY HEALTH CENTRE LEVEL
Objectives of IPHS for primary health centre
 Overall objective of IPHS is to provide health
care that is quality oriented and sensitive to the
needs of the community.

OBJECTIVES OF IPHS FOR PRIMARY HEALTH
CENTRE
 The objectives of IPHS for PHCs are
 To provide comprehensive primary health care
to the community through the Primary Health
Centres.
 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

PRIMARY HEALTH CENTRE
LEVEL
 PHCs may be of two types depending upon the
delivery case load Type-A &Type-B
 Type-A PHC: PHC with delivery load of less
than 20 deliveries in a month
 Type-B PHC: PHC with delivery load of 20 or
more deliveries in a month

 Services essential(minimumassuredservices )
desirable(shd aspire to achieve at
this level of facility)
1. Medical care
a. OPD services
b. 24 hours emergency services
c. Referral services
d. Inpatient services

LEVEL
2 .MCH care including family planning
1. Antenatal care
 Early registration of pregnancy
 Minimum 4 antenatal checkups
 Minimum laboratory investigations
 Nutrition and health counseling
 Identification and management of high
risks
 Tracking of missed and left out ANC
 Chemoprophylaxis for malaria in
malaria endemic areas

2.Intranatal care
1. Promotion of institutional deliveries
2. Management of normal deliveries
3. Assisted vaginal deliveries
4. Manual removal of placenta
5. Appropriate and prompt referral cases needing
specialist care

2.Intranatal care
1. Management of PIH including referral
2. Minimum 48 hours of stay after delivery
3. Managing labour using partograph
4. Proficient in identification and basic first aid treatment
PPH, eclampsia,

LEVEL
 Postnatal care
1. Ensure postnatal visit 0,3,7 and 42
2. Initiation of early breast feeding
3. Counselling on nutrition, hygiene, contraception,
essential newborncare and immunization
4. Provision of facilities under janani suraksha yojana
5. Tracking out missed and left out PNC

LEVEL
 New born care
 Facilities for ENBC and resuscitation
 Early initiation of breastfeeding
 Management of neonatal hypothermia,infection
protection, cord care and identification of sick new-
born and prompt referral

LEVEL
 Care of the child
 Routine and emergency care of sick children
incl.IMNCI
 Counselling on exclusive breast feeding
 Assess the G&D of the infants and under five
children and make timely referral
 Full immunization of all infants and children
 Tracking of vaccination dropouts
 Vitamin A prophylaxis to the children
 Management of severe acute malnutrition cases and
referral of serious cases

 Full range of family planning
 MTP
 Health education
 Nutritional services
 School health services

LEVEL
 Adolescent health care
 Adolescent friendly clinic for 2hours once a week
on a fixed day
 Adolescent & reproductive health
 Services for tetanus immunization of adolescents
 Nutrional counselling, prevention and
management of nutritional anemia

 STI /RTI management
 Referral services for ICTC and PPTCT services and
services for safe termination of pregnancy
 Outreach services in schools
 Prevention of control of locally endemic diseases
 Collection and reporting of vital events
 Health education and behavioural change
communication
 Promotion of sanitation
 Testing of water quality
 National health programmes

COMMUNITY HEALTH CENTRES
 IPHS are being prescribed to provide optimal expert
care to the community and achieve and maintain an
acceptable standard of quality care.
 These standards would help monitor and improve the
functioning of the CHCs.
 Every CHC has to provide the following services which
have been indicated as essential and desirable.

1. Care of routine and emergency cases in surgery
2. Care of routine and emergency cases in
medicine
3. Maternal health
4. New born care and child health
5. Family planning
6. All the national health programmes

7.Oral health
8.School health services
9. Adolescent health care
10.Blood storage facility
11.Diagnostic services
12.Referral services
13.Maternal death review

MANPOWER FOR CHC
Personnel
Block Health Officer Senior most specialist
General Surgeon 1
Physician 1
Obstetrician & Gynaecologist 1
Paediatritian 1
Anaesthetist 1
Public Health Manager 1
Eye surgeon 1
Dental Surgeon 1
General Duty Medical Officer 6
Specialist of AYUSH 1
General duty medical duty officer for AYUSH 1
Total 15/16

SUPPORT MANPOWER CHC
Staff nurse 19**
Public health nurse 1*
ANM 1*
Pharmacist/ compounder 3
Pharmacist AYUSH 1
Lab technician 3
Radiographer 2
Opthalmic assistant 1
Dresser (certified by red cross/st. johns
ambulance)
2
Ward boys/ nursing orderly 5
sweepers 5
chowkidar 5

SUPPORT MANPOWER CHC
Dhobi 1
Mali 1
Aya 5
Peon 2
OPD attendant 1
Registration clerk 2
Statistical assistant /data entry
operator
2
Accountant /administrative
assistant
1
OT technician 1
Total 64

CHC
 *will be appointed under ASHA scheme
 **for providing the round clock srevice at OT,
labour room, casualty, male ward and female
ward along with provision of leave serve

Health care delivery system in community health nursing

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