Primary health care in India

primary health care concepts and latest data

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2. PRIMARY HEALTH CARE Dr. Priyanka (PG 2 nd Year) Public health dentistry SGT university 2

3. CONTENTS 3

4. INTRODUCTION Health has been declared as a fundamental human right. Health care is multitude of services provided to individuals or communities by agents of health services or professions, for the purpose of promoting, maintaining, monitoring or restoring health. 4

5. 5 The best way to provide health care to the vast majority of underserved rural people and urban poor is to develop effective "primary health care" services supported by an appropriate referral system.

6. LEVELS OF HEALTH CARE 6

7. Primary care level First level of contact of individuals, the family and community with the national health system. 7

8. Secondary care level  Patients from primary health care are referred to specialists in higher hospitals for treatment. In India, the health centres for secondary health care include District hospitals and Community Health Centre at block level. 8

9. Tertiary care level Refers to a third level of health system, in which specialized consultative care is provided. This care is provided by the regional or centre level institutions. 9

10. CHANGING CONCEPTS 10

11. Comprehensive Health Care The term “Comprehensive Health Care” was first used by Bhore committee in 1946 . It meant provision of integrated preventive, curative and promotional health services from “womb to tomb” to every individual residing in a defined geographic area. 11

12. Bhore committee suggested that comprehensive health care should replace the policy of providing more medical care. This concept formed the basis of national health planning in India and led to the establishment of a network of primary health centers and sub-centers. 12

13. Basic health services UNICEF/WHO in their joint health policy used this term “Basic health services” It is defined as “ A basic health service is understood to be a network of coordinated, peripheral and intermediate health units capable of performing effectively a selected group of functions essential to health of an area and assuring the availability of competent professional and auxiliary personnel to perform these functions” 13

14. Shortcomings of both these approaches  Lack of community participation Lack of inter- sectoral co-ordination Dissociation from the socio-economic aspects of health. 14

15. Primary health care approach A new approach to health care came into existence in 1978 following an international conference at Alma-Ata (USSR) this is called as “primary health care approach” It has all the hallmarks of a primary health care delivery as first proposed by Bhore committee in 1946 and now espoused by world wide by international agencies and national governments. 15

16. HISTORICAL EVOLUTION OF HEALTH CARE IN INDIA 16 Pandve HT, Pandve TK. Primary healthcare system in India: Evolution and challenges. International Journal of Health System and Disaster Management. 2013 Jul 1;1(3):125.

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18. 18 The International conference co-sponsored by WHO & UNICEF, held in Alma Ata, from 6 th -12 th Sep 1978, finalized on 12 th Sep 1978.

19. 19 1983, India’s National Health Policy 2005, National Rural Health Mission https://mohfw.gov.in/documents/policy 2018, Astana Global conference on Primary health care 2013, National Health Mission

20. 2 nd conference on Primary Health Care 20

21. Selective Primary Health Care 21 Cueto M. The origins of primary health care and selective primary health care. American journal of public health. 2004 Nov;94(11):1864-74.

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23. PRIMARY HEALTH CARE "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 and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self- determination‘’ (WHO/UNICEF, 1978). 23

24. ELEMENTS OF PRIMARY HEALTH CARE(Alma-Ata Declaration) 24

25. The  Declaration of Astana , adopted at the conference, makes pledges in four key areas: Make bold political choices for health across all sectors; Build sustainable primary health care; Empower individuals and communities; and Align stakeholder support to national policies, strategies and plans. 25

26. PRINCIPLES OF PRIMARY HEALTH CARE 26

27. Equitable distribution The first key principle is EQUITY : Health care must be shared equally by all the people irrespective of their ability to pay and all (urban/rural, rich/poor) must have access to them.

28. 28 Social injustice : Health services are mainly concentrated in the major towns and cities resulting in inequality of care to the people in rural areas. The worst hit are the needy and vulnerable groups of the population in rural areas and urban slums.

29. 29 PHC aims to redress this imbalance by shifting the centre of gravity of the health care system from cities (where three-quarters of the health budget is spent) to the rural areas (where three-quarters of the people live), and bring these services as near people's homes as possible.

30. Community participation Universal coverage by primary health care cannot be achieved without the involvement of the local community. There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, besides maximum reliance on local resources such as manpower, money and materials.

31. 31 One such approach in India is use of village health guides and trained Dais, who are selected by the community and trained locally in delivery of services to the community they belong, free of cost. By overcoming cultural and communication barriers, they provide primary health care in ways that are acceptable to the community.

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33. Intersectoral coordination Declaration of Alma-Ata states that “ Primary health care involves in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and other works. This requires strong political will.”

34. 34 To achieve such cooperation: Countries may have to review their administrative system, reallocate their resources; and introduce suitable legislation to ensure that coordination can take place VALUES ACTION POLITICAL WILL

35. Appropriate technology “Technology that is scientifically sound, adaptable to local needs, and acceptable to those for whom it is used, and that can be maintained by the people themselves in keeping with the principle of self reliance with resources the community and the country can afford.”

36. 36 "appropriate" is emphasized because in some countries, large luxurious hospitals that are totally inappropriate to the local needs, are built, which absorb a major part of the national health budget, effectively blocking any improvement in general health services.

37. Focus on prevention 37 Health services should not only be curative but should also promote health and healthy lifestyles with emphasis on prevention.

38. PRIMARY HEALTH CARE IN INDIA 38

39. HEALTH CARE SYSTEMS Public Health sector Primary health care – Primary health centre and Sub centre Hospitals/health centers – CHCs, Rural hospitals, District hospitals/Health centers , Specialist hospitals, Teaching hospitals Health insurance schemes – Employees State Insurance, Central Government Health Scheme Other agencies - Defense services, Railways. 39

40. 2 . Private sector Private hospitals, polyclinics, nursing homes and dispensaries General practitioners and clinics. 3. Indigenous systems of medicine Ayurveda and Siddha Unani and Tibbi Homeopathy Unregistered practitioners Voluntary Health Agencies National Health Programmes 40

41. PRIMARY HEALTH CARE SYSTEMS Village level Sub centre level Primary health centre level 41

42. VILLAGE LEVEL 42

43. 43 Village health guides Scheme introduced on 2 nd Oct. 1977. Village health guide is a person with an aptitude for social service and is not a full time Govt. functionary. The scheme was launched in all states except Kerala, Karnataka, Tamilnadu , Arunachal Pradesh and J & K which had alternative systems (e.g. mini-health centers in Tamilnadu ) of providing health services at village level.

44. 44 Their assigned duties include simple activities in first aid, mother & child health and family planning, health education and sanitation and medical care of common illnesses according to the manual and patient referral to nearest health centre if needed.

45. 45 Local Dais An extensive program has been undertaken, under the rural health scheme(2005), to train all categories of local dais (traditional birth attendants) in the country to improve their knowledge in elementary concept of MCH care, sterilization and obstetric skills.

46. 46 Training period- 30 working days. Training location - PHC, subcentre or MCH centre for 2 days in a week 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 (F).

47. Integrated Child Development Scheme ICDS services are offered through a network of   anganwadi  centers. Number of operating anganwadi centres in September,2017:- All india : 13,56,569 In Haryana: 25962 47 https://icds-wcd.nic.in/icdsdatatables.aspx

48. 48 The beneficiaries are especially nursing mothers. pregnant women, other women (15-45 years), children below the age of 6 years and adolescent girls Along with Village Health Guides, anganwadi workers are the community's primary link with the health services and all other services for young children.

49. Duties: Health check up Immunization Supplementary nutrition Health education Non formal pre school education 49

50. 50 Accredited social health activist community health  worker  Instituted by the government of India's Ministry of Health and Family Welfare ( MoHFW ) As a part of the National Rural Health Mission ( NRHM ). The mission began in 2005. ASHA

51. 51 Requirements: She must be the resident of the village - a woman (married / widow / divorced) preferably in the age group of 25-45 years with formal education up to eighth class, having communication skills and leadership qualities.

52. Duties: Counsel women. Facilitating access to health services. Comprehensive village health plan. Primary medical care Depot holder for essential provisions. Inform about births, deaths, unusual health problems. Promote construction of household toilets. 52

53. Sub centre level 53 Sub-Centers (SC) is the most peripheral outpost of the existing health delivery system in rural areas. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services.

54. Functions: Immunization Antenatal, natal and postnatal care Prevention of childhood diseases. Family planning services. Elementary drugs. National and family welfare programmes . 54

55. Categorization 55 They have been categorized into two types - Type A and Type B. Categorization has taken into consideration various factors namely catchment area, health seeking behavior , case load, location of other facilities like PHC/CHC/Hospitals in the vicinity of the Sub-centre.

56. Type A 56 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 available. Sub-centres in headquarter area Sub-centres where at present no delivery or occasional delivery may be taking place i.e. very low case load of deliveries. If the case load increases, these Sub-centres should be considered for up gradation to Type B.

57. 57 This would include following types of Sub-centres: i. Centrally or better located Sub-centres with good connectivity to catchment areas. ii. They have good physical infrastructure preferably with own buildings, adequate space, residential accommodation and labour room facilities. iii. They already have good case load of deliveries from the catchment areas. iv. There are no nearby higher level delivery facilities. Type B (MCH Sub-Centre)

58. 58 Minimum requirements at sub-centre for meeting the IPHS 1. Maternal health care 2. Child health care 3. Family Planning and contraception 4. Counselling and appropriate referral for safe abortion service 5. Adolescent health care: Education, counselling and referral. 6. Assistance to school health services . 7. Water quality monitoring.

59. 59 8. Promotion of sanitation including use of toilet and appropriate garbage disposal. 9. Field visits by appropriate health workers for disease surveillance, family welfare services including STI, RTI awareness. 10. Community need assessment. 11. Curative services for minor ailments including fever, diarrhoea, worm infestation and first-aid. appropriate and prompt referral if needed.

60. 60 12. To organize Village Health and Nutrition Day at least once in a month. 13. Training of Traditional Birth Attendants and ASHA community health volunteers. 14. Co-ordinate services of anganwadi workers, ASHA, village health and sanitation committee 15. National health programmes.

61. Manpower recommended under Indian Public Health Standards (IPHS) 61

62. 62 nhm.gov.in

63. 63 Primary Health Centre is 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-Centres for curative, preventive and promotive health care. PRIMARY HEALTH CENTRE LEVEL

64. CATEGORIZATION 64 From Service delivery angle, PHCs may be of two types, depending upon the delivery case load – Type A and 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 The services have been classified as Essential (Minimum Assured Services) or Desirable (which all States/UTs should aspire to achieve at this level of facility).

65. 65 Minimum requirements at PHC for meeting the IPHS: Medical care Maternal and Child Health Care Including Family Planning Medical Termination of Pregnancies Management of Reproductive Tract Infections/Sexually Transmitted Infections Nutrition Services (coordinated with ICDS) School Health

66. 66 Adolescent Health Care Promotion of Safe Drinking Water and Basic Sanitation Prevention and control of locally endemic diseases like malaria, Kala Azar, Japanese Encephalitis etc. Collection and reporting of vital events. Health Education and Behaviour Change Communication Other National Health Programmes

67. 67 12.Training to undergraduate, ASHAs, Doctors and paramedics Basic Laboratory and Diagnostic Services 13.Functional Linkages with Sub-Centres 14. Mainstreaming of AYUSH 15.Selected Surgical Procedures 16.Maternal Death Review (MDR). 17. Record of Vital Events and Reporting

68. 68 Manpower recommended under Indian public Health Standards

69. 69 https://mohfw.gov.in/documents/staistics

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71. 71 In Gurgaon district , as on 5 April, 2016 there are : 3 CHC; Farukhnagar , Pataudi, Ghangola 13 PHC; Ghangola , Borakalan , Badshahpur , Bhangrola , Mandpura , Kasan , Gurgaon village, Garhi-harsaru , Bhondsi , Wazirabad, Pataudi, Farukhnagar , Daultabad 76 Sub- centres . DISTRICTWISE COMMUNITY HEALTH CENTRES / PRIMARY HEALTH CENTRES / SUB CENTRES IN HARYANA . Health department of Haryana. http://haryanahealth.nic.in

72. National Urban Health Mission (NUHM) as a sub-mission under the National Health Mission (NHM) (1 st may, 2013) Under the Scheme the following proposals have been approved : 1. 1 Urban Primary Health Centre (U-PHC) for every 50,000 population. 2. 1 Urban Community Health Centre (U-CHC) for5 to 6 U-PHCs in big cities. 3. 1 Auxiliary Nursing Midwives (ANM) for 10,000 population. 4. 1 Accredited Social Health Activist ASHA (community link worker) for 200 to 500 households. 72   India. Department of Health and Family Welfare. National Urban Health Mission‐  Framework for implementation. New Delhi: Ministry of Health and Family Welfare Government of India; May 2013.

73. Urban Primary Health Centre (UPHC), Krishna Nagar Gamri , District Kurukshetra Of Haryana Has Become The First UPHC In The Country Which Has Got “Quality Certification” Under National Quality Assurance Standards (NQAS). 73 https://prharyana.gov.in

74. India’s rank in the  Human Development Index Report 2018 (130 out of 189 countries)   issued by the UNDP depicts the level of ignorance of the health sector in a country like India. 74 https://www.indiaspend.com/budget-2018-indias-healthcare-crisis-is-holding-back-national-potential-29517/ http://hdr.undp.org/en/2018-update India spends 1.4% of GDP on health, less than Nepal, Sri Lanka Where does India stand? 

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76. Primary healthcare failing, tertiary care centres overburdened In 2016, sub- centres were 20% short of human resources, while primary and community health centres were 22% and 30% short, respectively, according to the 2016  Rural Health Statistics (RHS). Most functioning rural health facilities in India lack basic infrastructure–29% of sub- centres did not have regular water supply, 26% lacked electricity supply and 11% did not have all-weather roads connecting them, according to the 2016 RHS data. 76

77. Primary health centres (PHCs) are supposed to be the first point of contact between the village and a medical officer. Each PHC is manned by a medical officer and 14 paramedical staff, and is supposed to be equipped with an operation theatre, six beds, essential laboratory facilities and a pharmacy. While 63% of primary health centres did not have an operation theatre and 29% lacked a labour room, community health centres were short of 81.5% specialists–surgeon, gynecologists and pediatricians. 77

78. Chauhan R et al evaluated seven CHCs and 12 PHCs of Shimla District in terms of health manpower, infrastructure, and services from September 2011 to August 2012. The health centers were assessed according to IPHS guidelines. No specialist doctor was posted at any of CHCs against a sanctioned strength of at least four (surgeon, physician, obstetrician, and pediatrician) per CHC. In 3 (42.8%) CHCs and 8 (75%) PHCs, no pharmacist was posted. Eight (75%) PHCs did not have any staff nurse posted. Three (42.8%) CHCs and 10 (83.3%) PHCs did not have a laboratory technician. In CHCs, separate labor room was available in 6 (85.7%) whereas a separate laboratory was available in all seven. Separate labor room and laboratory were available in four (25%) PHCs. 78 Chauhan R, Mazta SR, Dhadwal DS, Sandhu S. Indian public health standards in primary health centers and community health centers in Shimla District of Himachal Pradesh: A descriptive evaluation. CHRISMED J Health Res 2016;3:22-7.

79. Sodani PR, Sharma K  identified the existing gap with respect to Indian Public Health Standards (IPHS) for availability of infrastructure, human resources, investigative services and essential newborn care services at 24 × 7 primary health centers (PHCs) of Bharatpur district of Rajasthan state.   The study depicted that the availability of human resources, infrastructure and facilities for newborn care services at the 24 × 7 PHCs were not satisfactory as per the prescribed IPHS. 79 Sodani PR, Sharma K. Assessing Indian Public Health Standards for 24 × 7 primary health centers: A case study with special reference to newborn care services. J Nat Accred Board Hosp Healthcare Providers 2014;1:12-6

80. Indian Public Health Standards (IPHS) Guidelines for Primary Health Centres Revised 2012 80

81. Vashist A, Parhar S, Gambhir RS, Sohi RK, Talwar PS. Status of governmental oral health care delivery system in Haryana, India. J Family Med Prim Care 2016;5:547-52. 81

82. Iyer K, Krishnamurthy A, Pathak M, Krishnan L, Kshetrimayum N, Moothedath M. Oral health taking a back seat at primary health centers of Bangalore urban district, India – A situation analysis. J Family Med Prim Care 2019;8:251-5. 82

83. India is one of the fastest growing economies of the world. The very essential components of primary health care– promotion of food supply, proper nutrition, safe water and basic sanitation and provision for quality health information concerning the prevailing health problems – is largely ignored. Access to healthcare services, provision of essential medicines and scarcity of doctors are other bottlenecks in the primary health care scenario. In India certain constraints at the level of planning, implementation and evaluation has to be removed for the success of primary health care concepts. 83 Conclusion

84. At the governmental level, services by doctors in villages do not get rewarded, and, disillusionment can set in rapidly as encouragement does not come from most rural communities at times. Also, India’s progress towards achieving the Millennium Development Goal is slow and it is well known that primary health care is important for achieving the goals. The only thing which can be done is that government should take effective step in order to resolve the health related issues and problem. 84

85. References Park K. Park's textbook of preventive and social medicine. Banarasidas Bhanot . 2017;24 th edition. Peter S. Essentials of Public Health Dentistry;5th Edition. Pandve HT, Pandve TK. Primary healthcare system in India: Evolution and challenges. International Journal of Health System and Disaster Management. 2013 Jul 1;1(3):125. Declaration of Alma-Ata . World Health Organization.1978. Global Conference on Primary Health Care - World Health Organization.2018. https://www.who.int/primary-health/conference-phc 85

86. https://mohfw.gov.in/documents/policy https://mohfw.gov.in/sites/default/files/rural%20health%20care%20system%20in%20india.pdf Rural health care system in India. Ministry of health and family welfare. 2018 Kulkarni P. National Urban Health Mission: An Effort to Achieve Equity in Health. Annals of Community Health. 2014 Mar 1;2(1):3-6.   India. Department of Health and Family Welfare. National Urban Health Mission‐  Framework for implementation. New Delhi: Ministry of Health and Family Welfare Government of India; May 2013. https://icds-wcd.nic.in/icdsdatatables.aspx 86

87. nhm.gov.in Vashist A, Parhar S, Gambhir RS, Sohi RK, Talwar PS. Status of governmental oral health care delivery system in Haryana, India. J Family Med Prim Care 2016;5:547-52. Iyer K, Krishnamurthy A, Pathak M, Krishnan L, Kshetrimayum N, Moothedath M. Oral health taking a back seat at primary health centers of Bangalore urban district, India – A situation analysis. J Family Med Prim Care 2019;8:251-5. DISTRICTWISE COMMUNITY HEALTH CENTRES / PRIMARY HEALTH CENTRES / SUB CENTRES IN HARYANA . Health department of Haryana. http://haryanahealth.nic.in   India. Department of Health and Family Welfare. National Urban Health Mission‐  Framework for implementation. New Delhi: Ministry of Health and Family Welfare Government of India; May 2013. 87

88. https://prharyana.gov.in Rural Health Statistics . Ministry of health and Family Welfare. GOI Chauhan R, Mazta SR, Dhadwal DS, Sandhu S. Indian public health standards in primary health centers and community health centers in Shimla District of Himachal Pradesh: A descriptive evaluation. CHRISMED J Health Res 2016;3:22-7. 88

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