Transcript Document

Lecture 13
PRIMARY HEALTH CARE IN INDIA,
VILLAGE LEVEL
"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".
HEALTH CARE SERVICES
The purpose of health care services consists in improving the health
status of the population: to reduced the levels of mortality and
morbidity, to increase in expectation of life, to decrease in
population growth rate, improvements in nutritional status, to
reduced levels of poverty, etc.
The scope of health services varies widely from country to country
and influenced by general and ever changing national, state and local
health problems, needs and attitudes as well as the available
resources to provide these services.
There is now broad agreement that health services should be:
•(a) comprehensive
•(b) accessible
•(c) acceptable
•(d) provide scope for community participation, and
•(e) available at a cost the community and country can afford.
These are the essential ingredients of primary health care which
forms an integral part of the country's health system, of which it is
the central function and main agent for delivering health care.
HEALTH CARE SYSTEMS
The health care system is intended to deliver the health care
services. It constitutes the management sector and involves
organizational matters, it operates in the context of the
socioeconomic and political framework of the country. In India, it is
represented by five major sectors or agencies which differ from
each other by the health technology applied and by the source of
funds for operation. These are : 1. PUBLIC HEALTH SECTOR
Primary
Health Care
Hospitals/Health
Centers
Health Insurance
Schemes
Other
agencies
Primary health
centers
Community health
centers
Employees State
Insurance
Defence
services
Sub - centers
Rural hospitals
Central Govt.
Health Scheme
Railways
District hospital
/health centre
Specialist hospitals
Teaching hospitals
HEALTH CARE SYSTEMS
2. PRIVATE SECTOR
(a) Private hospitals, polyclinics. Nursing homes,
and dispensaries
(b). General practitioners and clinics
3. INDIGENOUS SYSTEMS OF MEDICINE
Ayurveda and Siddha
Unani and Tibbi
Homoeopathy
Unregistered practitioners
4. VOLUNTARY HEALTH AGENCIES
5. NATIONAL HEALTH PROGRAMMES
PRIMARY HEALTH CARE 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". It is a three tier system of health care delivery in rural areas
based on the recommendation of the Shrivastav Committee in
1975. Close on the heels of these recommendations an International
conference at Alma-Ata in 1978, set the goal of an acceptable level
of Health for All the people of the world by the year 2000 through
primary health care approach. As a signatory to the Alma-Ata
Declaration, the Government of India is committed to achieving the
goal of Health for All through primary health care approach which
seeks to provide universal comprehensive health care at a cost
which is affordable.
• Keeping in view the WHO goal of "Health for All", the
Government of India evolved a National Health Policy based on
primary health care approach. It was approved by Parliament in
1983. The National Health Policy has laid down a plan of action
for reorienting and shaping the existing rural health infrastructure.
Village level
• One of the basic tenets of primary health care is
universal coverage and equitable distribution of health
resources. That is health care must penetrate into the
farthest reaches of rural areas, and that everyone
should have access to it. To implement this policy at
the village level, the following schemes are in
operation:
a. Village Health Guides Scheme
b. Training of local Dais
c. ICDS Scheme (Integrated Child Development
Services)
Village Health Guides
• A Village Health Guide is a person with an aptitude for social
service and is not a full time government functionary. The
Village Health Guides Scheme was introduced on 2nd October
1977 with the idea of securing people's participation in the care
of their own health. The scheme was launched in all States
except Kerala, Karnataka, Tamil Nadu, Arunachal Pradesh
and Jammu and Kashmir which had alternative systems (e.g.,
Mini-health Centres in Tamil Nadu) of providing health
services at the village level.
• The Health Guides are now mostly women. A circular was
issued by Government of India in May 1986 that male Health
Guides would be replaced by female Health Guides. The
Health Guides come from and are chosen by the community in
which they work. They serve as links between the community
and the governmental infrastructure. They provide the first
contact between the individual and the health system.
The guidelines for their selection are:
•they should be permanent residents of the local
community, preferably women
•they should be able to read and write, having minimum
formal education at least up to the VI standard
•they should be acceptable to all sections of the
community and
•they should be able to spare at least 2 to 3 hours every
day for community health work.
After selection, the Health Guides undergo a short
training in primary health care The training is arranged
in the nearest primary health centre, subcentre or any
other suitable place for the duration of 200 hours, spread
over a period of 3 months. During the training period
they receive a stipend of Rs. 200 per month.
Health Guides
• On completion of training, they receive a working
manual and a kit of simple medicines belonging to the
modern and traditional systems of medicine in vogue in
that part of the country to which they belong. Broadly the
duties assigned to health guides include treatment of
simple ailments and activities in first aid, mother and child
health including family planning, health education and
sanitation. The manual or guidebook gives them detailed
information about medical care of common illnesses - of
what they can and cannot do. In practical terms, they know
exactly what should be done when confronted with a
situation, when they can begin treatment by themselves
and when they should refer the patient immediately to the
nearest health centre.
Health Guides
• The Health Guides are free to attend to their
normal vocation. They are expected to do
community health work in their spare time of
about 2 to 3 hours daily for which they are paid
an honorarium of Rs. 50 per month and drugs
worth Rs. 600 per annum. As the training
involves expenditure, the Government will not
train another Health Guide from the same village
before three years. As of date, there are 3.23 lakh
village Health Guides functioning in the country.
The training programme is being continued
during the Ninth Plan Period (1997-2002) to
achieve the national target of one Health Guide
for each village or 1000 rural population.
Local Dais
• Most deliveries in rural areas are still handled by untrained dais
who are often the only people immediately available to women
during the perinatal period. An extensive programme has been
undertaken, under the Rural Health Scheme, to train all
categories of local dais (traditional birth attendants) in the
country to improve their knowledge in the elementary concepts
of maternal and child health and sterilization, besides obstetric
skills. The training is for 30 working days. Each dai is paid a
stipend of Rs. 300 during her training period. Training is given
at the PHC, subcentre or MCH (mother and child health) centre
for 2 days in a week, and on the remaining four days of the
week they accompany the Health worker (Female) to the
villages preferably in the dai's own area. During her training
each dai is required to conduct at least 2 deliveries under the
guidance and supervision of the HW (F), ANM or HA health
assistant (F). The emphasis during training is on asepsis so that
home deliveries are conducted under safe hygienic conditions
thereby reducing the maternal and infant mortality.
Local Dais
• After successful completion of training, each dai is
provided with a delivery kit and a certificate. She is
entitled to receive an amount of Rs. 10 per delivery
provided the case is registered with the subcentre/PHC.
To each infant registered by her, she will receive Rs.3.
These dais are also expected to play a vital role in
propagating small-family norm since they are more
acceptable to the community. Although the national
target is to train one local dai in each village, the Eighth
Five Year Plan's objective was to train all untrained dais
practising in the rural areas.
Anganwadi Worker
• Angan literally means a courtyard. Under the ICDS (Integrated
Child Development Services) Scheme, there is an anganwadi
worker for a population of 1000. There are about 100 such
workers in each ICDS Project. As of date over 5320 ICDS blocks
are functioning in the country. The anganwadi worker is selected
from the community she is expected to serve. She undergoes
training in various aspects of health, nutrition, and child
development for 4 months. She is a part-time worker and is paid
an honorarium of Rs. 200-250 per month for the services
rendered, which include health checkup, immunization,
supplementary nutrition, health education, non-formal pre-school
education and referral services. The beneficiaries are especially
nursing mothers, other women (15-45 years) and children below
the age of 6 years. Along with Village Health Guides, the
anganwadi workers are the community's primary link with the
health services and all other services for young children.
Sub-centre level
• The sub-centre is the peripheral outpost of the existing health
delivery system in rural areas. They are being established on the
basis of one sub-centre for every 5000 population in general and one
for every 3000 population in hilly, tribal and backward areas. As on
31st March 2003, 138368 sub-centers were established in the
country); the total requirement is estimated to be 1.34 lakh.
• Each sub-centre is manned by one male and one female
multipurpose health worker. At present the functions of a sub-center
are limited to mother and child health care, family planning and
immunization. It is proposed to extend the facilities at all subcentres for IUD insertion, and simple laboratory investigations like
routine examination of urine for albumin and sugar. Creation of
these facilities would go a long way in securing greater acceptance
of IUD and early detection of complications of pregnancy. The
work at sub-centres is supervised by male and female health
assistants. According to the revised norm, one female HA will
supervise the work of 6 female HWs. The job descriptions of these
workers have been published as Manuals by the Rural Health
Division of the Ministry of Health and Family Welfare.
Primary health centre level
• The concept of primary health centre is not new to India. The Bhore
committee in 1946 gave the concept of a primary health centre as a
basic health unit, to provide, as close to the people as possible, an
integrated curative and preventive health care to the rural population
with emphasis on preventive and promotive aspects of health care.
The Bhore Committee aimed at having a health centre to serve a
population of 10,000 to 20,000 with 6 medical officers, 6 public
health nurses and other supporting staff. But in view of the limited
resources, the Bhore Committee's recommendations could not be
fully implemented, even after a lapse of 50 years.
• The health planners in India have visualized the primary health
centre and its sub-centers as the proper infrastructure to provide
health services to the rural population. The Central Council of
Health at its first meeting held in January 1953 had recommended
the establishment of primary health centers in community
development blocks to provide comprehensive health care to the
rural population.
Primary health centre level
• The number of primary health centers established since then had
increased from 725 to 5484 - each PHC covering a population of
100,000 or more spread over some 100 villages in each community
development block. These centers were functioning as peripheral
health service institutions with little or no community involvement.
Increasingly, these centers came under criticism as they were not
able to provide adequate health coverage, partly because they were
poorly staffed and equipped, and partly because they had to cover a
large population of one lakh or more. The Mudaliar Committee in
1962 had recommended that the existing primary health centers
should be strengthened and the population to be served by them to
be scaled down to 40,000.
• The National Health Plan (1983) proposed reorganization of primary
health centers on the basis of one PHC for every 30,000 rural
population in the plains, and one PHC for every 20,000 population in
hilly, tribal and backward areas for more effective coverage. As on
31st March 2003, 22936 primary health centers have been
established in the country against the total requirement of about
23,000.
Functions of the PHC
The functions of the primary health center in India cover all the 8
"essential" elements of primary health care. They are:
• Medical care
• MCH including family planning
• Safe water supply and basic sanitation
• Prevention and control of locally endemic diseases
• Collection and reporting of vital statistics
• Education about health
• National Health Programmers - as relevant
• Referral services
• Training of health guides, health workers, local dais and health
assistants
• Basic laboratory services
It is proposed to equip the primary health centers with facilities for
selected surgical procedures (e.g., vasectomy, tubectomy and
minor surgical procedures) and for paediatric care. In order to
reorient medical education (ROME Programmer) towards the
needs of the country and community care, three primary health
centers have been attached to each of the 148 medical colleges.
Staffing pattern
At present in each community development block, there are one or
more PHCs each of which covers 30,000 rural population. In the new
set-up each PHC will have the following staff:
At the PHC level:
• Medical officer
1
• Pharmacist
1
• Nurse mid-wife
1
• Health worker (female)
1
• Block Extension Educator
1
• Health assistant (male)
1
• Health assistant (female)
1
• Lab. technician
1
• Driver (subject to availability of
vehicle)
1
• Other health workers
4
In total
15
At the sub-centre level:
• Health worker (female)
1
• Health worker (male)
1
• Voluntary worker
(paid Rs.50 per month as honorarium) 1
In total
3
Notwithstanding the strong criticism
of primary health centers it must
be
emphasized
that
their
establishment is a valuable national
asset. Their establishment is the
fruit of many years of great efforts
to increase the outreach of the
health services.
Community Health Centers
• As on 31st March 2003, 3076 community health centers were
established by upgrading the primary health centers, each
community health centre covering a population of 80.000 to 1.20
lakh (one in each community development block) with 30 beds
and specialists in surgery, medicine, obstetrics and gynaecology,
and paediatrics with X-ray and laboratory facilities. For
strengthening preventive and promotive aspects of health care, a
new non-medical post called community health officer has been
created at each community health centre. The community health
officer is selected from amongst the supervisory category of staff
at the PHC and district level with minimum of 7 years experience
in rural health programmers. Some states have not accepted this
scheme and have opted for a second medical officer.
• The specialists at the community health centre may refer a patient
directly to the State level hospital or the nearest/ appropriate
Medical College Hospital, as may be necessary, without the
patient having to go first to the sub-divisional or District Hospital.
Staff for community Health Centre :
•
•
•
•
•
•
•
•
•
Medical officer 4
Nurse mid-wives 7
Dresser 1
Pharmacist/Compounder
1
Lab. technician 1
Radiographer 1
Ward boys
2
Sweepers 3
Other health workers: Dhobi - 1, Mali - 1, Chowkidar
-1, Aya -1, Peon - 1.
In total 25
JOB DESCRIPTION OF MEMBERS OF THE
HEALTH TEAM
Medical Officer, PHC
• He is the captain of the health team at the primary health centre.
He devotes the morning hours attending to patients in the outdoor; in the afternoon he supervises the field work. His tour
programme is so designed as to cover all the basic health
services including family planning. He visits each subcenter
regularly on fixed days and hours and provides guidance,
supervision and leadership to the health team. He spends one
day in each month organizing staff meetings at the primary
health centre to discuss the problems and review the progress of
health activities. He ensures that national health programmes
are being implemented in his area properly. The success of a
primary health centre depends largely on the team leadership
which the medical officer is able to provide. The medical
officer must be the planner, the promoter, the director, the
supervisor, the coordinator as well as the evaluator.
Second Medical Officer
• The second medical officer performs identical duties.
Health worker Male and Female
• Under The Multipurpose Worker Scheme, one health worker female and one
health worker male are posted at each sub-centre and are expected to cover a
population of 5000 (3000 in tribal and hilly areas). However, health worker
female limits her activities among 350-500 families.
HEALTH WORKER MALE (HWM)
I. Record Keeping
• He will;
• Survey all the families in his area and collect general information about each
village/locality in his area.
• Prepare, maintain and utilize family records and village registers containing
columns for recording particulars concerning FP, immunizations, vital
events, environmental sanitation, other local health programmes, educational
activities, services rendered and achievements, etc.
II. Malaria
• Identify fever cases. Make thick and thin blood slides. Send the blood slides
for laboratory examination.
• Administer presumptive treatment. Record the results of examination of
blood slides.
• Educate the community on the importance of blood smear examination for
fever cases, insecticidal spraying of houses, treatment of fever cases.
HEALTH WORKER MALE (HWM)
III.
Communicable Diseases
• Identify cases of diarrhoes/dysentery, fever with rash jaundice,
encephalitis, diphtheria, whooping cough and tetanus, acute eye
infections and notify the Health Assistant Male and M.O. PHC
immediately about these cases.
• Carty out control measures until the arrival of the Health
Assistant Male and assist him in carrying out these measures.
• Give Oral Rehydration Solution to all cases of
diarrhoea/dysentery/vomiting.
• Educate the community about the importance of control and
preventive measures against communicable diseases and about
the importance of taking regular and complete treatment.
• Identify and refer cases of genital sore or urethral discharge or
non-itchy rash over the body to Medical Officer.
• Identify and refer all cases of blindness including suspected cases
of cataract to M.O.PHC.
HEALTH WORKER MALE (HWM)
IV
•
•
V
•
•
•
•
Leprosy
Identify cases of skin patches, especially if accompanied by loss of
sensation and take skin smears from these cases Refer these cases, to
M.O. PHC for further investigations.
Check whether all cases of leprosy are taking regular treatment.
Motivate defaulter to take regular treatment.
Tuberculosis
Identify persons especially 15 years and above with prolonged cough
or spitting of blood and take sputum smears from these individuals.
Refer cases to the M.O.PHC for further investigations.
Check whether all cases of tuberculosis are taking regular treatment.
Motivate defaulters to take regular treatment.
Educate the community on various health education aspect of
tuberculosis programme.
Assist the village Health Guide in undertaking the activities under
TB Programme properly. Provide the list of the TB patients living in
a village to the village Health Guide so that he is further able to
motivate the TB patient in taking regular treatment.
HEALTH WORKER MALE (HWM)
VI.
Environmental Sanitation
• Chlorinate public water sources including wells at regular
intervals.
• Educate community on (a) the method of disposal of liquid
wastes; (b) the method of disposal of solid wastes; (c)
home sanitation, (d) advantage and use of sanitary type of
latrines; (e) construction and use of smokeless chulhas.
VII. Expanded Programme on Immunisation
• Administer DPT vaccine, oral poliomyelitis vaccine
measles vaccine (where available) and BCG vaccine to a
infants and children in his area.
• Assist the Health Worker Female in administering tetanus
toxoid to all pregnant women.
• Assist the Health Assistant Male in the school
immunization programme.
HEALTH WORKER MALE (HWM)
VIII. Family Planning
• Utilize the information from the eligible couple and
child register for the family planning programme.
• Spread the message of family planning to the couples
and motivate them for family planning individually and
in groups.
• Distribute conventional contraceptives to the couples.
• Provide facilities and help to prospective acceptors of
sterilization in obtaining the services.
• Provide follow-up services to male family planning
acceptors.
• Establish male depot holders in the area. Help the Heath
Assistant Male and Health Assistant Female in training
them and provide a continuous supply of convention
contraceptives to the depot holders.