SUB CENTER, PRIMARY HEALTH CENTER, COMMUNITY HEALTH CENTER

CONTENT BASED ON UNIT 3 IN FINAL YEAR B.SC NURSING AS PER MUHS, DETAILED DESCRIPTION OF SUBCENTER, PRIMARY HEALTH CENTER AND COMMUNITY HEALTH CENTER

1. Mrs. Angela Harland Braver Professor . Community Health Nursing UNIT :3 DELIVERY OF COMMUNITY HEALTH SERVICES

2. INTRODUCTION

3. According to democratic principles, it is the moral and constitutional responsibility of the government of India to provide health and social services to the citizens of country. The scope and areas of social services are very extensive. Medical care and education are the basic components of social services. There are various programmes for the welfare of women, aged, handicapped , orphans and children are implemented by the union and state governments. Since the population of the vulnerable section is very large, the benefits of several government programmes do not reach them adequately. Introduction

4. Lack of financial and other resources are the major hindrances in social services although several national and foreign agencies and institutions are making generous contributions for social cause. Public health is a significant base of social services. Government of India is making efforts to provide health services to the grass root level right from the time of independence; yet due to population explosion, this objective is difficult to attain. To attain “Health for all”, nation needs extensive health system or machinery, so that health services can be made available to each person

5. Health care delivery system in India

6. The health services in the public sector are conducted by the union or state governments, which are as follows: Urban health services Autonomous institutions AYUSH Rural health services National health programmes Public sector

7. These are rendered under NUHM. 1. Urban health services

8. The aim of NUHM is to improve the health status of the urban poor, particularly the slum dwellers and other vulnerable segment of the urban population. Under NUHM, support is provided to the states/UT’s for strengthening and up gradation of existing health care delivery infrastructure including Urban family welfare centers, urban health posts and primary health centers. Urban health programmes is being implemented through states and urban local bodies. As being the health is in the concurrent list, constitution mandates the role of states, urban local bodies in the management of urban health care system

9. For the convenience existing urban health facilities are described under the following headings: Health services in metropolitan cities. Sub divisional hospitals/ sub district hospitals Urban – CHC Urban- PHC Urban family welfare centers Urban health post Specialty hospital Teaching institution Super speciality hospitals

10. I n the 7 metropolitan cities: Mumbai, Delhi, Kolkata, Chennai, Ahmedabad, Hyderabad, and Bengaluru, the urban health programme is being implemented through Urban Local Bodies. The health care system in these cities include: 3 tier system comprising of UFWC/ UHP/dispensaries/ maternity homes/ tertiary super specialty hospitals Community health workers/ volunteers Vast network of private hospitals/ NGO’s and charitable trusts. For the other cities of the country, the state health department decides if the urban health services would be run by the local bodies or by the states itself. Health services in metropolitan cities.

11. The term district hospital means a hospital at the secondary level, responsible for health care services of a districts population. The size of the district hospital depends upon the size of the population it serves. In India the population size of a district varies from 35,000 to 30,00,000(census 2011) According to IPHS-2012, the district hospitals are graded as per the number of beds Grade I- 500 beds, Grade II- 400 beds, Grade III- 300 beds Grade IV- 200 beds Grade V-100 beds District hospitals

12. The district hospitals provide effective, affordable health care services, work as a secondary level referral centers and provide wide ranging technical and administrative support and training for the primary health care.

13. The term Sub-district/sub- divisional hospital means a hospital at the secondary referral level responsible for health care services of a Sub-district/sub- division's population. The sub- district hospitals are also categorized as per the number of beds Category I- 31-50 beds Category –II- 51- 100 beds Sub-district/sub- divisional hospitals provide effective and affordable health care services for their defined population. They work as referral center for CHC/PHC/ Sub- centers and provide education and training for primary health care staff Sub-district/sub- divisional hospitals

14. Under NUHM, U-CHC work as a satellite center U-CHC, can be set up for every 4-5 urban primary health centres The U-CHC, would cater to a population of 2,50,000 The U-CHC has indoor 30-50 bedded facility. U-CHC would be set up in cities with a population of above 5 lakhs, wherever required. U-CHC are in addition to the existing facilities to cater to the urban population in the locality. U-CHC may also be established in the metro cities for every 5 lakh population with 100 beds. Urban community health centers (U-CHC)

15. As per NUHM, U-PHC may be established for approximately 50,000 to 60, 000 urban population. The new U-PHC are preferably located within or near a slum for providing preventive , promotive and OPD consultation services, drug/contraceptive dispensing services and lab- diagnosis. They also provide counseling for all communicable and non – communicable diseases. NUHM, also support engagement of ANM’s for conducting outreach services for targeted groups, particularly for slum dwellers and the vulnerable population for providing preventive and promotive health care services Urban Primary Health Center (U-PHC)

16. UFHC are functioning in urban areas from 1950 to provide family planning services for urban population. At present there are 1083 UFWCs functioning in various states and UTs. In 1976, these were reorganized into 3 types by the department with the staffing pattern as follows: Urban family welfare centers (UFWC) Category Number Population covered in thousands Staffing pattern Type I 326 10-25 ANM(1)/ FP field worker (1) Type II 125 25-50 F.P. Ext. Edu /LHV (1) in addition to above Type III 632 Above 50 MO, preferabble female(1) ANM and store keeper, cum clerk (1)

17. Under the revamping scheme in 1983, the government of India established Urban Health Posts in 10 states and Uts with a pre condition of locating them at slums or in the near by area of slums. UHP are categorized in 4 types: A,B,C and D. These posts are providing MCH, first aid, d istribution of contraceptives and other services in the urban areas. URBAN HEALTH POST

18. In these hospitals , only certain diseases, age groups or patients with specific problems are treated and specialists and specially trained nurses care for the patients. TB hospitals, pediatric hospitals, women or maternity hospitals come under this group. Specialty hospitals

19. Hospitals associated with medical colleges come under this category. Along with teaching and training of doctors and nurses, these hospitals provide complete care to people of that area. These serve as tertiary center for referral services. Currently there are 612 government run and 291 private medical colleges. Teaching hospitals

20. I n these hospitals super specialists of different system/organs or diseases are trained and patients are also treated. All India institute of medical sciences (AIMS) is an example of such an institute. These institutes are centers of excellence for health services. To enhance the super specialty and tertiary urban health services and to decrease the patient load on AIMS Delhi, Govt. of India opened such 6 institutes in various states Jodhpur (Rajasthan), Bhopal (MP), Raipur (Chhattisgarh), Patna (Bihar), Bhuvaneshwar ( O disha ) and Rishikesh (Uttaranchal). These institutes were established under Pradhan Mantri Swasthya Suraksha Yojna (PMSSY) Super specialty hospitals

21. Under this category , all such institutions are included which receive central government aid but except few important administrative matters, all other decisions are made by the institute itself. AIMS Delhi, NIMHANS Bangalore are examples of such central sponsored autonomous health institutes. Most of them are central government sponsored and funded. 2. AUTONOMOUS INSTITUTES

22. Government of India with the co-operation of state, other institutions, global agencies is trying to face the challenges of communicable, non communicable and other serious diseases. For the fulfillment of this purposes, the central government is conducting several national health programmes . This could be helpful in bringing down mortality and morbidity rates. Through these programmes , quality of life and health of our citizens also can be improved. In the health services of the country, national health programmes are very significant 3. National health programmes

23. A large part of our population have faith in AYUSH systems of treatment and takes help medical help from the same. Both in villages and cities, dispensaries of Indian system of medicine are found. In Indian context, this is significant that better health care can be provided by a suitable or safe combination of AYUSH and Allopathy . Looking into the special role of AYUSH in Indian population, as a special status, now the separate AYUSH ministry has been created. NHP- 2017 also recognizes the need of standardization and validity of Ayurveda medicines and establish an effective quality control mechanism for AYUSH drugs. 4. Ayush

24. The rural health services are being implemented through a network of primary health care systems: three tier system. The three tier system: it is done according to the size of the population Sub center Primary health center Community health center 5. Rural health services

25. These agencies provide help and strength to the public health system They play a vital role in training, exhibition, propaganda, and in also conducting various community health programmes . Through the services of these agencies , a large part of Indian population is benefitted. Several voluntary agencies work in India. A number of international agencies also make significant contribution in the area of health. b. Voluntary health agencies

26. In the health care system, participation of private sector is very significant. The private sector consists largely of sole practioners or small nursing homes having 1-20 beds, serving an urban and semi urban areas and mainly focused on curative care. 75% of service delivery for mental health, dental health, orthopedics, vascular, cancer diseases and about 40% of communicable diseases and deliveries are provided by the private sector. Services provided by the private sector can be mainly classified into 3 groups: c. Private sector

27. 1 . Private hospitals, Nursing homes and Clinics: based of mixed economy and globalization, private hospitals are being opened rapidly. From small to large metropolitan cities, their network is spreading. They are mainly therapeutic institutions and provide health services to urban population only. The services are comparatively costly, hence the poor and weaker section cannot get their services. 2. Private consultation centers: With the increasing number of allopathic hospitals, the tendency to start health consultation privately is increasing among doctors. Medical council of India and Indian Medical Association keep professionals checks over them.

28. In the rural areas, fake doctors or quacks often start private clinics and consultation which is a mockery of health care of common people and is to be checked. 3. Mission or Religious hospitals: these hospitals are managed by mission, trust or charitable institutions. In many parts of the country, such hospitals and clinics provide medical services either free of cost or at a very cheap rate, to common people. Though they function mainly in urban areas, they provide health care to rural population also, through camps or community care centers.

29. Serious supply gaps and distribution inequalities Need for uniform standards and treatment protocols Need for cost control and quality assurance mechansims Regulations to protect consumer interests and enforcement system Supporting the NGO/ Charitable trusts to serve the poor in under served areas . An overview of the public health sector

30. In the public sector, a Health Sub-center is the most peripheral and first point of contact between the primary health care system and the community. A Sub-center provides interface with the community at the grass-root level, providing all the primary health care services. The purpose of the Health Sub-center is largely preventive and promotive , but it also provides a basic level of curative care. Indian Public Health Standards for Sub-Centers

31. As per population norms, there shall be one Sub-center established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas. As the population density in the country is not uniform, application of same norm all over the country is not advisable. The number of Sub-center and number of ANMs shall also depend upon the case load of the facility and distance of the village/habitations which comprise the Sub-centers. There were 161,829 sub centers in India as of March 31, 2022.

32. To specify the minimum assured (essential) services that Sub-center is expected to provide and the desirable services which the states/UTs should aspire to provide through this facility. To maintain an acceptable quality of care for these services . To facilitate monitoring and supervision of these facilities. To make the services provided more accountable and responsive to people’s needs. Objectives of the Indian Public Health Standards for Sub-Centre

33. In view of the current highly variable situation of Sub centers in different parts of the country and even with in the same State, 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/FRU/Hospitals in the vicinity of the Sub-centers. States shall be required to categorize their Sub-centers into two types as per the guidelines given below and provide services and infrastructure accordingly. This shall result in optimum use of available resources. Categorization of Sub- Centers

34. W ill 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 center may be considered for up gradation to Type B. The Sub-center in the following situations may be included in this category . Type A Sub Center

35. Sub-centers not having adequate space and physical infrastructure for conducting deliveries, due to which providing labor room facilities and equipment at these Sub-centers is not possible. However there may still be demand for delivery services from the community in these areas e,g , Sub-centers located in remote, difficult, hilly, desert or tribal area. In such areas, the transport facility is likely to be poor and the population is still dependent on these Sub-centers for availing delivery facilities. In such situations, ANMs would be required to conduct deliveries at homes and ANMs of these Sub-centers should mandatorily be Skilled Birth Attendance (SBA) trained. Such Sub-centers should be identified for infrastructure up gradation for conversion to Type B Sub-centers on priority.

36. ii. Sub-centers situated in the vicinity of other higher health facilities like PHC/CHC/ FRU/Hospital, where delivery facilities are available iii . Sub-centers in headquarter area iv . Sub-centers 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

37. One ANM (Essential), Two ANMs: (Desirable to split the population between them and one of them provides outreach services and the other is available at the Sub- centre ) One Health Worker (Male) (Essential) Sanitation services should be provided through outsourcing on part time basis Staff recommended

38. The facilities for conducting delivery will not be available at these sub-centers and patients may usually be referred to nearby centers providing delivery facilities. If the requirement for delivery services goes up , the sub center may be considered for up gradation to Type B. These Sub-centers should provide all other recommended services and focus on outreach services, prevalent diseases, tuberculosis, leprosy, Non-communicable diseases, nutrition, water, sanitation and epidemics. Guidelines

39. It is also to be ensured that the Staff of these sub-centers is provided training in all new programmes on priority basis and refresher training is provided regularly.  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

40. This would include following types of Sub-centers: i . Centrally or better located Sub-centers with good connectivity to catchment areas. ii . They have good physical infrastructure preferably with own buildings, adequate space, residential accommodation and labor 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)

41. Such Sub-centers should be developed as a delivery facility and should also cater to adjacent Type A sub centers areas for delivery purpose. Type B Sub-center, will provide all recommended services including facilities for conducting deliveries at the Sub-center itself. They will be expected to conduct around 20 deliveries in a month. They should be provided with all labor room facilities and equipment including Newborn care corner. ANMs of these Sub-centers should be SBA trained. These centers may be provided extra equipment, drugs, supplies, materials, 2 beds and budget for smooth functioning. If number of deliveries is 20 or more in a month, then additional 2 beds will be provided. Guidelines

42. Two ANM (Essential) One Health Worker (Male): (Essential) One Staff Nurse or ANM (if Staff Nurse not available) (Desirable, if number of deliveries at the Sub- centre is 20 or more in a month) Sanitation services should be provided through outsourcing on full time basis Staff recommended

43. Maternal and Child Health Maternal Health i . Antenatal care: Essential Early registration of all pregnancies, within first trimester (before 12th week of Pregnancy). However even if a woman comes late in her pregnancy for registration, she should be registered and care given to her according to gestational age. Minimum 4 ANC including Registration Suggested schedule for antenatal visits Services to be Provided in a Sub-Center

44. 1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for registration, history and first antenatal check-up 2nd visit: Between 14 and 26 weeks 3rd visit: Between 28 and 34 weeks 4th visit: Between 36 weeks and term

45. Associated services like general examination such as height, weight, B.P., anemia, abdominal examination, breast examination, Folic Acid Supplementation (in first trimester), Iron & Folic Acid Supplementation from 12 weeks, injection tetanus toxoid, treatment of anemia etc., (as per the Guidelines for Antenatal care and Skilled Attendance at Birth by ANMs and LHVs ) Recording tobacco use by all antenatal mothers. Minimum laboratory investigations like Urine Test for pregnancy confirmation, hemoglobin estimation, urine for albumin and sugar and linkages with PHC for other required tests.

46. Name based tracking of all pregnant women for assured service delivery. Identification of high risk pregnancy cases. Identification and management of danger signs during pregnancy. Malaria prophylaxis in malaria endemic zones for pregnant women as per the guidelines of NVBDCP. Appropriate and Timely referral of such identified cases which are beyond her capacity of management.

47. Counseling on diet, rest, tobacco cessation if the antenatal mother is a smoker or tobacco user, information about dangers of exposure to second hand smoke and minor problems during pregnancy, advice on institutional deliveries, pre-birth preparedness and complication readiness, danger signs, clean and safe delivery at home if called for, postnatal care & hygiene, nutrition, care of newborn, registration of birth, initiation of breast feeding, exclusive breast feeding for 6 months, demand feeding, supplementary feeding from 6 months onwards, infant & young child feeding and contraception.

48. Provide information about provisions under current schemes and programmes like Janani Suraksha Yojana . Identify suspected RTI/STI case, provide counseling, basic management and referral services. Counseling & referral for HIV/AIDS. Name based tracking of missed and left out ANC cases.

49. i. Intra-natal care : Essential Promotion of institutional deliveries Skilled attendance at home deliveries when called for Appropriate and Timely referral of high risk cases which are beyond her capacity of management

50. Managing labor using Partograph . Identification and management of danger signs during labor. Proficient in identification and basic fist aid treatment for PPH, Eclampsia , Sepsis and prompt referral of such cases as per ’ Antenatal Care and Skilled Birth Attendance at Birth ’ or SBA Guidelines. Minimum 24 hours of stay of mother and baby after delivery at Sub-center. The environment at the Sub-center should be clean and safe for both mother and baby. Essential for Type B Sub- centre

51. Postnatal care: Essential Initiation of early breast-feeding within one hour of birth. Ensure post-natal home visits on 0,3,7 and 42nd day for deliveries at home and Sub-center (mother & baby). Ensure 3, 7 and 42nd day visit for institutional delivery (both for mother & baby) cases. In case of Low Birth weight Baby (less than 2500 gm ), additional visits are to be made on 14, 21 and 28th days. During post-natal visit, advice regarding care of the mother and care and feeding of the newborn and examination of the newborn for signs of sickness and congenital abnormalities as per IMNCI Guidelines and appropriate referral, if needed.

52. Counseling on diet & rest, hygiene, contraception, essential newborn care, immunization, infant and young child feeding, STI/RTI and HIV/AIDS. Name based tracking of missed and left out PNC cases

53. Newborn Care Corner In The Labor Room to provide Essential Newborn Care : Essential If the Deliveries take Place at the Sub-center (Type B) Essential Newborn Care (maintain the body temperature and prevent hypothermia [provision of warmth/Kangaroo Mother Care (KMC)], maintain the airway and breathing, initiate breastfeeding within one hour, infection protection, cord care, and care of the eyes, as per the guidelines for Ante-Natal Care and Skilled Attendance at Birth by ANMs and LHVs.). Post natal visits as mentioned under ‘Post natal Care’. Child Health : Essential

54. Counseling on exclusive breast-feeding for 6 months and appropriate and adequate complementary feeding from 6 months of age while continuing breastfeeding. (As per National Guidelines on Infant and Young Child Feeding, 2006, by Ministry of WCD, Government of India). Assess the growth and development of the infants and under 5 children and make timely referral . Immunization Services: Full Immunization of all infants and children against vaccine preventable diseases as per guidelines of Government of India. Vitamin A prophylaxis to the children as per National guidelines. y Prevention and control of childhood diseases like malnutrition, infections, ARI, Diarrhoea, Fever, Anaemia etc. including IMNCI strategy

55. Name based tracking of all infants and children to ensure full immunization coverage. Identification and follow up, referral and reporting of Adverse Events Following Immunization (AEFI)

56. Education, Motivation and counseling to adopt appropriate Family planning methods.  Provision of contraceptives such as condoms, oral pills, emergency contraceptives, Intra Uterine Contraceptive Devices (IUCD) insertions (wherever the ANM is trained in IUCD insertion).  Follow up services to the eligible couples adopting any family planning methods (terminal/ spacing ) Safe Abortion Services (MTP) Essential  Counseling and appropriate referral for safe abortion services (MTP) for those in need.  Follow up for any complication after abortion/ MTP and appropriate referral if needed. Family Planning and Contraception Essential

57. Essential  Provide treatment for minor ailments including fever, diarrhea, ARI, worm infestation and First Aid including first aid to animal bite cases (wound care, tourniquet (in snake bite) assessment and referral).  Appropriate and prompt referral. Desirable  Provide treatment as per AYUSH as per the local need. ANMs and MPW (M) be trained in basic AYUSH drugs.  Once a month clinic by the PHC medical officer. LHV, HWM and ANM should be available for providing assistance Curative Services

58. Adolescent Health Care Desirable  Education, counseling and referral.  Prevention and treatment of Anemia.  Counseling on harmful effects of tobacco and its cessation. School Health Services Essential  Screening , treatment of minor ailments, immunization, de-worming, prevention and management of Vitamin A and nutritional deficiency anemia and referral services through fixed day visit of school by existing ANM/MPW  Staff of Sub-center shall provide assistance to school health services as a member of team

59. Control of Local Endemic Diseases Essential  Assisting in detection, Control and reporting of local endemic diseases such as malaria, Kala Azar , Japanese encephalitis, Filariasis , Dengue etc.  Assistance in control of epidemic outbreaks as per programme guidelines

60. Disease Surveillance, Integrated Disease Surveillance Project (IDSP) Essential  Surveillance about any abnormal increase in cases of diarrhea/dysentery, fever with rigors, fever with rash, fever with jaundice or fever with unconsciousness and early reporting to concerned PHC as per IDSP guidelines.  Immediate reporting of any cluster/outbreak based on syndromic surveillance.  High level of alertness for any unusual health event, reporting and appropriate action.  Weekly submission of report to PHC in’S’Form as per IDSP guidelines.

61. Water and Sanitation Desirable  Disinfection of drinking water sources.  Promotion of sanitation including use of toilets and appropriate garbage disposal

62. Village Health and Nutrition Day (VHND) VHND should be organised at least once in a month in each village with the help of Medical Officer, Health Assistant Female (LHV) of PHC, HWM, HWF, ASHA, AWW and their supervisory staff, PRI, Self Help Groups etc. The number of VHNDs should be enough to reach every habitation/ Anganwadi center at least once in a month. The ANM is accountable for these services, with the male worker also taking a due share of the work, and being in charge of logistics and organization, especially vaccine logistics. Out reach/Field Services

63. Participation of Anganwadi workers, ASHAs and community volunteers would be essential for mobilization of beneficiaries and local organizational support. Each Village Health and Nutrition Day should last for at least four hours of contact time between ANMs, AWWs, ASHAs and the beneficiaries. The services to be provided at VHND are listed as

64. Early registration and Antenatal care for pregnant women – as per standard treatment protocol for the SBA.  Immunization and Vitamin A administration to all under 5 children- as per immunization schedule.  Coordination with ICDS programme for Supplementary nutritional services, health check up and referral services, health and nutrition education, immunization for children below 6 years, Pregnant & Lactating Mother and health and nutrition education for all women in the age group (15 to 45 years).  Family planning counseling and distribution of contraceptives.  Symptomatic care and management of persons with minor illness referred by ASHAs/AWWs or coming on their own accord.  Health Communication to mothers, adolescents and other members of the community who attend the VHND session for whatever reason. essential

65. Meet with ASHAs and provide training/support to them as needed.  Registration of Births and Deaths. Desirable  Symptom based care and counselling with referral if needed for STI/RTI and for HIV/AIDS suspected cases.  Disinfection of water sources and promotion of sanitation including use of toilets and appropriate garbage disposal

66. For skilled attendance at birth- where the woman has opted or had to go in for a home delivery.  Post natal and newborn visits – as per protocol.  To check out on disease incidences reported to Health Worker or she/he comes across during house visits especially where there it is a notifiable disease. Notify the M.O. PHC immediately about any abnormal increase in cases of diarrhea/dysentery , fever with rigors, fever with rash, flaccid paralysis of acute onset in a child Home Visits- Essential

67. Visits to houses of eligible couples who need contraceptive services, but are not currently using them e.g. couples with children less than three years of age, where women are married and less than 19 years of age, where the family is complete etc.  Follow up of cases who have undergone Sterilization and MTP, as per protocols especially those who can not come to the facility.  Visits to community based DOTS providers, leprosy depot holders where this is needed.  Visits to support ASHA where further counseling is needed to persuade a family to utilize required health services e.g., immunization dropouts, antenatal care dropouts, TB defaulter etc.  To take blood slides/do RDK test in cases with fever where malaria is suspected. desirable

68. These surveys would be done once annually, preferably in April. Some of the diseases would require special surveys- but at all times not more than one survey per month would be expected. Surveys would be done with support and participation of ASHAs, Anganwadi Workers, community volunteers, panchayat members and Village Health Sanitation and Nutrition Committee members. The Male Health worker would take the lead and be accountable for the organization of these surveys and the subsequent preparation of lists and referrals. The surveys would include House to house survey

69. Age and sex of all family members.  Assess and list eligible couples and their unmet needs for contraception.  Identify persons with skin lesions or other symptoms suspicious of leprosy and refer: essential in high leprosy prevalence blocks.  Identify persons with blindness, list and refer: Identify persons with hearing impairment/ deafness, list and refer.  Annual mass drug administration in filaria endemic areas essential

70. Identify persons with disabilities, list and refer and call for counseling where needed.  Identify and list senior citizens who need special care and support.  Identify persons with mental health problems and Epilepsy; list and refer.  In high endemicity areas-survey for fever suspicious of kala - azar , for epidemic management of malaria, for detection of fluorosis affected cases etc.  Any other obvious disease/disorder; list and refer desirable

71. Essential  Focus group discussions for information gathering and health planning. Health Communication especially as related to National Health programmes through attending Village Health Sanitation and Nutrition Committee meetings, ASHA local review meetings and meetings with panchayat members/ sarpanch , Self Help Groups, women’s groups and other BCC activities Community Level Interactions

72. Health Communication especially as related to National Health programmes through attending Village Health Sanitation and Nutrition Committee meetings, ASHA local review meetings and meetings with panchayat members/ sarpanch , Self Help Groups, women’s groups and other BCC activities Coordination and Monitoring

73. Locally available medicinal herbs/ plants should be grown around the sub center as per the guidelines of AYUSH. Promotion of medicinal herbs

74. Recording and reporting of vital events including births and deaths, and in maintaining all records related to sub centers RECORD OF VITAL EVENTS

75. Communicable Disease Programme National AIDS Control Programme (NACP ) Essential Condom promotion & distribution of condoms to the high risk groups. Help and guide patients with HIV/AIDS receiving ART with focus on adherence. IEC activities to enhance awareness and preventive measures about STIs and HIV/AIDS, PPTCT services and HIV-TB coordination. Desirable Linkage with Microscopy Centre for HIV-TB coordination. HIV/STI Counseling, Screening and referral in Type B Sub-centers (Screening in Districts where the prevalence of HIV/AIDS is high). National health programmes

76. Collection of Blood slides of fever patients Rapid Diagnostic Tests (RDT) for diagnosis of Pf malaria in high Pf endemic areas. Appropriate anti-malarial treatment. Assistance for integrated vector control activities in relation to Malaria, Filaria , JE, Dengue, Kala- Azar etc. as prevalent in specific areas. Prevention of breeding places of vectors through IEC and community mobilization. Where filaria is endemic, identification of cases of lymphoedema /elephantiasis and hydrocele and their referrals to PHC/CHC for appropriate management. The disease specific guidelines issued by NVBDCP are to be followed. Annual mass drug administration with single dose of Diethyl carbamazine (DEC) to all eligible population at risk of lymphatic filariasis . Promotion of use of insecticidal treated nets, wherever supplied. y Record keeping and reporting as per programme guidelines. National Vector Borne Disease Control Programme (NVBDCP)

77. Essential Health education to community regarding signs and symptoms of leprosy, its complications, curability and availability of free of cost treatment. Referral of suspected cases of leprosy (person with skin patch, nodule, thickened skin, impaired sensation in hands and feet with muscle weakness) and its complications to PHC. Provision of subsequent doses of MDT and follow up of persons under treatment for leprosy, maintain records and monitor for regularity and completion of treatment National Leprosy Eradication Programme (NLEP):

78. Essential Referral of suspected symptomatic cases to the PHC/Microscopy center Provision of DOTS at Sub-center, proper documentation and follow-up. Care should be taken to ensure compliance and completion of treatment in all cases. Adequate drinking water should be ensured at Sub-center for taking the drugs. Desirable Sputum collection centers established in Sub-center for collection and transport of sputum samples in rural, tribal, hilly & difficult areas of the country where Designated Microscopy Centers are not available as per the RNTCP guidelines. Revised National Tuberculosis Control Programme (RNTCP):

79. Note: These services are to be provided at both types of Sub-centers. National Programme for Control of Blindness (NPCB): Essential Detection of cases of impaired vision in house to house surveys and their appropriate referral. The cases with decreased vision will be noted in the blindness register. Spreading awareness regarding eye problems, early detection of decreased vision, available treatment and health care facilities for referral of such cases. IEC is the major activity to help identify cases of blindness and refer suspected cataract cases. Non-communicable Disease (NCD) Programmes

80. Desirable The cataract cases brought to the District Hospital by MPW/ANM/and ASHAS. Assisting for screening of school children for diminished vision and referral

81. Essential Detection of cases of hearing impairment and deafness during House to house survey and their appropriate referral. Awareness regarding ear problems, early detection of deafness, available treatment and health care facilities for referral of such cases. Education of community especially the parents of young children regarding importance of right feeding practices, early detection of deafness in young children, common ear problems and available treatment for hearing impairment/ deafness. National Programme for Prevention and Control of Deafness (NPPCD)

82. Essential Identification and referral of common mental illnesses for treatment and follow them up in community. IEC activities for prevention and early detection of mental disorders and greater participation/role of Community for primary prevention of mental disorders . National Mental Health Programme

83. Essential IEC Activities to promote healthy lifestyle sensitize the community about prevention of Cancers, Diabetes, CVD and Strokes, early detection through awareness regarding warning signs and appropriate and prompt referral of suspect cases. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke

84. Essential IEC Activities to promote consumption of iodized salt by the community. Testing of salt for presence of Iodine through Salt Testing Kits by ASHAs. National Iodine Deficiency Disorders Control Programme

85. Essential Identify the persons at risk of Fluorosis, suffering from Fluorosis and those having deformities due to Fluorosis and referral . Desirable Line listing of reconstructive surgery cases, rehabilitative intervention activities and referral services. Focused behavior change communication activities to prevent Fluorosis. In Fluorosis affected (Endemic) Areas

86. Essential Spread awareness and health education regarding ill effects of tobacco use especially in pregnant females and Non-Communicable diseases where tobacco is a risk factor e.g. Cardiovascular disease, Cancers, chronic lung diseases. Display of mandatory signage of “No Smoking” in the Sub-center. Desirable Counseling for quitting tobacco. Awareness to public that smoking is banned in public places and sale of tobacco products is banned to minors (less than 18 years) as well as within 100 yards of schools and educational institutions. Spread awareness regarding law on smoke free public places National Tobacco Control Programme

87. Desirable Health education on oral health and hygiene especially to antenatal and lactating mothers, school and adolescent children. Providing first aid and referral services for cases with oral health problems. Oral health

88. Desirable Health education on Prevention of Disability. Identification of Disabled persons during annual house to house survey and their appropriate referral Disability prevention

89. Desirable Counseling of Elderly persons and their family members on healthy ageing. Referral of sick old persons to PHC National Programme for Health Care of Elderly:

90. Lab facilities : Minimum facilities of Urine Pregnancy Testing, estimation of hemoglobin by using a approved Hemoglobin Color Scale (only approved test strips should be used), urine test for the presence of protein and sugar by using Dipsticks should be available. (Instructions should be followed from the leaflet provided by the manufacturer ) Electricity Water Telephone Assured referral linkages Toilets Waste disposal Support services

91. Internal mechanisms: Supportive supervision and Record checking at periodic intervals by the Male and Female Health supervisors from PHC (at least once a week) and by MO of the PHC (at least once in a month) etc . External mechanisms: Sub-centers will be under the oversight of Gram Panchayats . Monitoring Mechanism

92. PHC’S are the corner stone 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 subcenter for curative, preventive and promotive care. It acts as a referral unit for 6 sub centers and refer out cases to CHC’s and higher order public hospitals at sub district and district hospitals. Primary HEALTH CENTERS

93. PHC is established to cover 30,000 population in plains and 20,000 population in hilly/tribal areas. There are 4-6 beds for patients and some diagnostic facilities are also available. Set up

94. Medical Officer- 01 Staff Nurse- 03 ANM/HW(Female)- 01 LHV/ HW (Female)- 01 HA (Male)- 01 Lab technician- 01 Pharmacist – 01 Accountant cum data entry operator- 01 Group D worker- 03 Total- 13 Staffing norms-minimum norms

95. Staff Type A Type B Essential Desirable Essential Desirable MO-MBBS 1 1* MO-AYUSH 1 1** Accountant cum DEO 1 1 Pharmacist 1 1 Pharmacist-AYUSH 1 1 Nurse-midwife staff nurse 3 +1 4 +1 HW-F 1@ 1@ HA-M 1 1 HA-F/LHV 1 1 Health educator 1 1 Lab technician 1 1 Cold chain &vaccine logistic assistant 1 1 Multi skilled group D worker 2 2 Sanitary worker cum watchman 1 Total=13 Total= 18(13+5) 1 Total=14 +1 Total = 21 (14+7) Staffing for phc ( type-a&type-b )

96. * If the delivery case load is 30 or more per month. One of the 2 medical officers should be female. ** to provide choice to the people where ever an AYUSH public facility is not available near the vicinity. @ for sub center area of PHC

97. Medical care (OPD and IPD-6 bed services) Maternal and Child health care including family planning services. MTP services Management of RTI/STI Nutrition services School health services Adolescent health care Promotion of safe drinking water and basic sanitation services Collection and reporting of vital events Functions of phc

98. Health education and behavior change communication National health programmes Referral services Training Basic Laboratory services Monitoring and supervision Mainstreaming of Ayush Selected surgical procedures Record of vital statistics and reporting Maternal death review

99. To provide comprehensive primary health care to the community at PHC’s To achieve and maintain an acceptable standards of quality of care. To make the services more responsive and sensitive to the needs of the community Objectives

100. From service point of view, PHC’S may be of two types: 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 The services are as follows: Services to be provided in phc

101. Essential: OPD Services: A total of 6 hours of OPD services out of which 4 hours in the morning and 2 hours in the afternoon for 6 days in a week. Time schedule may vary from state to state. Minimum OPD attendance should be 40 patients per doctor per day. 24 hour emergency services: appropriate management of injuiries and accidents, first aid, stabilization of the condition of the patients before referral, dog bite/ snake bite/ scorpion bite cases and other emergency conditions Referral services In- patient services.(6 beds) 1. Medical care

102. Essential: A. Antenatal care: Early registration of all pregnancies ideally in the first trimester Minimum 4 antenatal checkups and provision of complete package of services. Associated services like providing iron and folic acid tablets, injections TT Minimum laboratory investigations like Hb , urine albumin, sugar RPR test for syphilis. Nutrition and health counseling, brief advice on tobacco cessation if the antenatal mother is a smoker or tobacco user. Identification and management of danger signs during pregnancy and labor. Timely referral of such cases to FRU’S other hospitals. Tracking of missed and left out ANC. 2. Maternal and child health care including family planning

103. B. Intra natal care (24 hour delivery services- both normal and assisted) Promotion of institutional deliveries Conducting of normal deliveries Assisted vaginal deliveries including forceps / vaccum delivery whenever required. Manual removal of placenta Appropriate and prompt referral for cases needing specialist care Managing labour using partograph Minimum 48 hours of stay after delivery

104. C. Proficient in identification and basic first aid treatment for PPH, eclampsia , sepsis, and prompt referral. D. Post natal care: Ensure post natal care for 0 and 3 rd day at the health facility both for the mother and new born ad sending direction to the ANM of the concerned area for ensuring 7 th and 42 nd day post natal visits. Initiation of early breast feeding Education on nutrition, hygiene, contraception and essential newborn care. Provision of facilities under JSY Tracking of missed and left out PNC

105. E. Newborn care: Facilities for essential new born care and resuscitation Management of neonatal hypothermia, infection prevention, cord care, identification of sick newborn and immediate referral F. Care of the child: Routine and emergency care of children including IMNCI Counseling on exclusive breastfeeding and on infant and young child feeding Full immunization of all infants and children against vaccine preventable diseases as per guidelines of GOI. Vitamin A prophylaxis Growth monitoring Prevention and control of routine childhood diseases, infections like diarrhoea , pneumonia Management and referral of severe acute malnutrition cases.

106. G. Family welfare: Education , motivation and counseling to adopt appropriate family planning measures Provision of contraceptives such as condoms, oral pills, emergency contraceptives, IUD insertions Permanent measures like vasectomy and tubectomy Follow up services Counseling and appropriate referrals for couples having infertility .

107. Essential: Counseling and appropriate referral for safe abortion services for those in need Desirable: MTP using manual vacuum aspiration technique will be provided in the PHC where trained personnel and faculty exist. Medical methods of abortion and referral to the approved facility for MTP of 2 nd trimester. 3. MEDICAL TERMINATION OF PREGNANCIES

108. Essential: Health education for prevention of RTI/STI Treatment of RTI/STI 5. Nutrition services (coordinated with ICDS) Essential: Diagnosis and management of malnutrition, anemia, and vitamin A deficiency 4. Management of reproductive tract infections/ sti

109. Teachers screen students and ANMs visit the schools for screening , treatment of minor ailments and referral. Doctors from CHC/PHC will also visit. Essential : Health service provision: Screening health care and referral Basic medicines to take care of common ailments Immunization Micronutrient management Deworming Desirable: Counseling services Regular practice of yoga and health education First aid rooms /corners 6. School health

110. To be provided preferably through adolescent friendly clinic for 2 hours once a week on a fixed day. Services should be comprehensive. Core package (essential) Adolescent and reproductive health, counseling and services related to sexual health, pregnancy, contraception, abortion, menstrual problems TT immunization Nutritional counseling, prevention and management of nutritional anaemia STI/RTI management Referral services Optional services (desirable) Outreach services in schools and community camps Periodic health checkups and health education activity 7. Adolescent health care

111. Essential: Disinfection of water sources and coordination with public health engineering department for safe water supply Promotion of sanitation including use of toilets and appropriate garbage disposal. Desirable: Testing of water quality using bacteriological strips 9. Prevention and control of locally endemic diseases. 10. Collection and reporting of vital events 11. Health education and behavior change communication 8. Promotion of safe drinking water and basic sanitation

112. RNTCP-Essential All PHCs to function as DOTS Centers to deliver treatment as per the RNTCP protocols through DOTS providers and treatment of common complications of TB and side effects of drugs, records and reports on RNTCP activities as per guidelines. NLEP- Essential Health education Diagnosis and management of leprosy and its complications Training and counseling IDSP: Essential Weekly reporting of epidemic prone diseases. Appropriate preparedness Laboratory services 12. National health programmes

113. NPCB: Essential The early detection of visual impairments and their referral Detection of cataract cases and referral for cataract surgery Provision of basic services for diagnosis and treatment of common eye diseases. Awareness generation Participation of the community in prevention of eye diseases. NVBDCP: Essential Diagnosis of malaria cases, microscopic confirmation and treatment Cases of suspected JE and dengue to be provided symptomatic treatment, hospitalization and case management as per the protocol Complete treatment to kala azar cases Complete treatment of microfilaria positive cases with DEC and participation and arrangement of MDA

114. NACP: Essential IEC activities to enhance awareness and preventive measures about STIs and HIV/AIDS, prevention of parents to child transmission services. Organizing school health education programmes Condom promotion and distribution of condoms to the high risk groups Help and guide patients with HIV/AIDS receiving ART with focus on adherence. Desirable: ICTC Screening of persons with high risk behavior Risk screening of antenatal mothers Linkage with microscopy centers for HIV-TB coordination Pre and post test counseling of AIDS patients by PHC staff in high prevalence states.

115. NPPCD: Essential: early detection of cases of hearing impairment and deafness and referral Basic diagnosis IEC services NMHP: Essential: early identification and treatment of mental illnesses in the community. Basic services for diagnosis and treatment of common mental disorders IEC activities for prevention National programme for prevention and control of cancer, diabetes, CVD and stroke. Cancer: Essential: IEC services for prevention of cancer and early symptoms Early detection of cancer with warning signals Referrals of suspected cancer cases for confirmation of diagnosis

116. Essential Health promotion services to modify individual group and community behavior Early detection , management and referral of DM, Hypertension, and other CVDS Desirable: Survey of population to identify vulnerable , high risk and those suffering with the disease National IDD and control programme : IEC activities to promote the consumption of iodized salt by the people Monitoring of iodized salt through salt testing kits National programme for prevention and control of Fluorosis- in affected districts – referral services and IEC activities. Other non communicable diseases

117. National tobacco control programme : Essential Health education and IEC activities regarding harmful effects of tobacco Promoting quitting of tobacco in the community Making PHC tobacco free Desirable: watch for implementation of ban on smoking in public places, sale of tobacco products within the 100 meters of educational institutions. National programme for health care of elderly: essential: IEC activities on healthy ageing. Desirable: weekly geriatric clinic at PHC. Oral health: oral health check ups and appropriate referral on identification Physical medicine and rehabilitation services: Desirable: primary prevention of disabilities, counseling, community based rehabilitation services. Issue of disability certificate for disabilities by PHC doctor.

118. 13. Referral services: appropriate and prompt referral of cases needing specialist care including- stabilizing of patients, appropriate support for patients during transport, providing transport facilities either by PHC vehicle or other available referral transport. Drop back home for patients as mandated under JSSK 14. Training: Essential: Imparting training to undergraduate medical students and intern doctors in basic health care. Orientation training of male and female multipurpose health workers in various national health programmes including RCH and immunization Skill based training to ASHA’s Initial and periodic training of paramedics in treatment ailments Periodic training of doctors and paramedics through continuing medical education, conferences, skill development trainings, All health staff of PHC must be trained in IMEP

119. Desirable: There should be provision of induction training for doctors, nursing and paramedical staff. Training for new technology introduction Quality assurance in training Appropriate placement of trained person Training of minor repairs and maintenance of available equipment for users. Training of paramedics in indenting, forecasting, inventory, and store management Development of protocols for equipment

120. 15. Basic Laboratory services: Essential: Routine urine, stool and blood tests (HB, platelet count, total RBC, WBC, bleeding time, clotting time) Diagnosis of RTI/STI with wet mounting, grams stain Sputum testing for mycobacterium Blood smear examination for malaria Rapid diagnostic test- pregnancy Rapid test kit for fecal contamination of water Estimation of chlorine level of water using orthotoludine reagent Desirable: Blood cholesterol and ECG

121. 16. Monitoring and supervision: Essential Monitoring and supervision of activities of sub center through regular meetings/ periodic visits, etc. Monitoring of all National health programmes Monitoring activities of ASHAs MO should visit all sub centers at least once in a month Health assistants male and LHV should visit sub centers once a week

122. 17. Functional linkages with sub center: Essential: There shall be a monthly review meeting at PHC chaired by MO and attended by all the multi purpose workers and health assistants. Organizing VHND at anganwadi centers. Desirable: ASHAs and AWW should attend monthly review meeting. Medical officers should orient ASHA on selected topic of health care 18. Mainstreaming of AYUSH: Desirable: Provision of one AYUSH doctor and one AYUSH pharmacist at PHC The signboard of PHC should be mentioned in AYUSH facilities. AYUSH doctors should support implementation of national health programmes . Locally available medicinal herbs plants should be grown around the PHC

123. 19. Selected Surgical Procedures: Desirable: The vasectomy , tubectomy , MTP, hydrocelectomy , and cataract surgeries as a camp/ fixed day approach have to be carried out in the PHC having facilities of OT. During all these surgical procedures universal precautions will be adopted to ensure infection prevention. 20. Record of vital statistics and reporting: Recording and reporting of vital statistics including births and deaths. Maintenance of all the relevant records concerning services provided in the PHC. 21. Maternal death review Desirable: Facility based MDR, shall be conducted at the PHC.

124. The community health centers provide secondary level of health care in rural health services. These were designed to provide referral as well as specialist health care to the rural population. In order to provide quality care in these CHCs , IPHS are prescribed Community health centers

125. CHC is established to cover 1,20,000 population in the plains and 80,000 population in hilly and tribal areas. Community health center is established in each community development block. Each CHC has 30 beds, an X ray room , a delivery room, OT and laboratory. This works as a referral center for 4 PHCs. Set up

126. Doctors -04 (Paediatrics, Gynaecologists, Physician, Surgeon) Nurses -07 Dresser -01 Pharamcist -01 Lab Assistant- 01 Radiographer -01 Ward Boy- 02 Sweepers- 03 Dhobi- 01 Mali- 01 Chowkidar-01 Ayah-01 Class IV worker- 01 Total- 25 Staffing norms

127. Specialty services Surgical services Medical services Maternal health services Newborn care and child health services Family planning services National health programmes Other services: school health, adolescent health, outreach services, blood storage, diagnostics, referral, MDR, record of vital statistics. Functions of chc

128. IPHS for CHC are being formulated to provide optimal specialist care to the community and achieve and maintain an acceptable standard quality of care. It is hoped that these standards would help to monitor and improve the functioning of CHC’S. According to IPHS, facilities and human resource management at CHC. According to IPHS, facilities and human resource management at CHC would be improved and accountability will be shared by community. It is mandatory for every CHC to have Rogi Kalyan Samiti to ensure accountability. Every CHC shall also have the charter of Patient’s rights displayed at the entrance. A grievance redressal mechanism under the overall supervision of RKS would also be set up. IPHS for chc’s

129. To provide optimal expert care to the community. To achieve and maintain an acceptable standard of quality of care To ensure that services at CHC are appropriate with universal best practices and are responsive and sensitive to the clients needs and expectations. Objectives of iphs for chc’S

130. Care of routine and emergency cases in surgery Essential: This includes dressings, incision and drainage and surgery for hernia, hydrocele, appendicitis, haemorrhoids , fistula and stitching of injuries Handling of emergencies like intestinal obstruction, haemorrahage Other management including nasal packing, tracheostomy, foreign body removal Fracture reduction and putting splint/ plast cast Conducting daily OPD Services to be provided at the chc

131. 2. Care of routine and emergency cases in medicine Essential: Specific mention is being made of handling of all emergencies like dengue, haemorrhagic fever, cerebral malaria and others like snake bite cases, poisoning, congestive heart failure, left ventricular failure, pneumonias, acute respiratory conditions, burns, shock and acute dehydration. In case of national health programmes appropriate guidelines should be followed. Conducting daily OPD.

132. 3. Maternal health: Essential: Minimum 4 ANC including registration: Ist visit- within 12 weeks, 2 nd week- between 14 and 26 week, 3 rd week- between 28- 34 weeks, 4 th visit- between 36 weeks and term. 24 hour delivery service including normal and assisted deliveries. Managing labour using partograph . All referred cases of complications in pregnancy, labour and post natal period must be adequately treated Ensure post natal care for 0 and 3 rd day at the health facility both for the mother and newborn and sending direction to the ANM of the concerned area for ensuring 7 th and 42 nd day post natal home visits. Minimum 48 hours of stay after delivery, 3-7 days stay post delivery for managing complications.

133. F. Proficiency in identification and management of all complications including PPH, e clampsia , sepsis etc. during PNC. G. Essential and emergency obstetric care including surgical interventions. H. providing JSY and JSK as per guidelines. 4. Newborn care and Child Health: Essential: Essential newborn care and resuscitation by providing newborn corner in the labour room and operation theatre. Early initiation of breast feeding within one hour of birth and promotion of exclusive breast feeding for 6 months. New born stabilization unit Counseling on infant and young child feeding as per IMNCI guidelines. Routine and emergency care of sick children including facility based IMNCI strategy. Full immunization of infants and children against vaccine preventable diseases and vitamin A prophylaxis.

134. g . Prevention and management of routine childhood diseases, infections and anemia. h. Management of malnutrition cases. Provision of JSSK as per guidelines. 5.Family planning Essential: Full range of family planning services including IEC, counseling, provision of contraceptives, NSV, Laparoscopic sterilization services and their follow up. Safe abortion services as per MTP act Desirable: MTP facility approved for 2 nd trimester of pregnancy

135. 6. National health programmes RNTCP: should provide diagnostic services through established diagnostic services through the microscopy centers which are already established in the CHCs and treatment services as per the technical guidelines and operational guidelines for tuberculosis control. HIV/AIDS control programme : ICTC, blood storage center, STI clinic. NVBDCP: The CHC are to provide diagnostic /linkages to diagnosis and treatment facilities for routine and complicated cases of malaria, filaria , dengue, JE, kala azar in the respective endemic zones. NLEP: diagnosis and treatment of cases and complications including reactions of leprosy along with counseling of patients on prevention of deformity and cases of uncomplicated ulcers.

136. E. NPCB: Vision testing with vision charts. Refraction. Early detection of visual impairments and their referral. IEC activities. Desirable: removal of foreign bodies, diagnosis and treatment of common eye diseases. Surgical services including catract by IOL implantations. F. IDSP: CHC will function as a peripheral unit and collate, analyse and report information to district surveillance G. NPPCD: early detection of cases of hearing impairment and deafness and referral. Provision of basic diagnosis and treatment services for common ear diseases. IEC strategies. H. NMHP: Early identification, diagnosis and treatment of common mental disorders. IEC activities for prevention, removal of stigma and early detection of mental disorders. Follow up care of detected cases who are on treatment.

137. I NPCDCS: Cancer control: Essential: a. Early detection and referral of suspected cancer cases b. Screening for cervical, breast and oral cancers c. Education about BSE d. PAP smear for cancer cervix Desirable: a. Basic equipment such as indirect laryngoscope, punch biopsy forceps and consumable for early cancer detection. b. PPP for lab investigations and confirmation of diagnosis with early warning signals. Diabetes, CVD and strokes Desirable: Early detection: Survey of people through simple measures as history, checking blood sugar. Health promotion, focus will be on health preservation .

138. C. Modify individual, group and community behavior through interventions like- promotion of healthy dietary habits, promotion of physical activity, avoidance of tobacco and alcohol, stress management. D. Treatment and timely referral (complicated cases)of DM, HTN, IHD, CHF. Assured investigations: urine albumin and sugar, blood sugar, blood lipid profile, KFT, ECG J. National IDD programme : IEC activities in the form of posters, pamphlets, interpersonal communication to promote the consumption of iodized salt through salt testing kits. K. National programme for prevention and control of fluorosis: Essential: clinical examination and preliminary diagnostic parameters assessment for cases of fluorosis if facilities are available.

139. Monitoring of village /community level fluorosis surveillance and IEC activities. Referral services. L. National tobacco control programme : Essential: Health education and IEC activities regarding harmful effects of tobacco and second hand smoke . Promoting quitting of tobacco in the community and offering brief advice to all smokers and tobacco users. Making the premises of CHC tobacco free and display of mandatory signs. Desirable : setting up tobacco cessation clinic. M. National programme for health care of elderly: Desirable: medical rehabilitation services. Compilation of elderly data from PHC and forwarding the same to district nodal officers. Visits to the homes of the disabled/ bed ridden persons by rehabilitation workers on receiving information from PHC/ Sub center Geriatric clinic- twice a week.

140. N. Physical medical and rehabilitation Essential: primary prevention of disabilities. Screening early identification and detection. Counseling. Issue of disability certificate for obvious disabilities by CHC doctors based rehabilitation services. Desirable: basic treatment like exercises and heat therapy, ROM exercises , cervical and lumbar traction, referral to high centers and follow up. O. Oral health: Dental care and dental health education services as well as root canal treatment and filling/ extraction of routine and emergency cases. Oral health education

141. 7. O ther services: A. School health: Teachers screen students on a continuous basis and ANMs/HWMs visit the schools for screening, treatment of minor ailments and referral. Doctors from CHC/PHC will also visit one school per week. Main services include- Essential: Health service provision: Screening health care and referral- screening of general health, assessment of anemia/ nutritional status, visual and hearing problems, dental check up physical disabilities , heart problems, skin conditions, learning and behavior disorders. Basic medicines for common ailments. Referral cards for sub district or district hospitals. Immunization: As per national schedule. Fixed day activity. Micronutrient ( vit A and IFA) management De- worming: biannually supervised schedule. IEC. Siblings of students to be covered. Capacity building Monitoring and evaluation Mid day meal

142. Desirable: health promoting schools- counseling services. Regular practice of yoga, physical and health education. Linkage with the out of school children. Health clubs/ cabinets. First aid room/ corners or clinics. B. Adolescent health care: to be provided preferably through adolescent friendly clinic for 2 hours once a week on a fixed day. Services should be comprehensive. Essential: adolescent and reproductive health information counseling and services related to sexual concern, pregnancy, contraception, abortion, menstrual problems. Tetanus immunization. Nutritional counseling , prevention and management of nutritional anemia. STI/RTI management. Referral services, PPTCT services. Safe termination of pregnancy if not available at PHC. Additional services as per local needs .

143. Outreach services in schools and community camps: provide health check ups and health education activities, awareness generation and co curricular activities. C . Blood storage facility. D. Diagnostic Services: in addition to lab facilities and x-ray, ECG should be made available in the CHC with appropriate training to a nursing staff. All necessary reagents glassware and facilities for collecting and transport of samples. E. referral services Maternal death review.

144. Personnel Essential Qualification Block public health unit Block medical officer/ medical superintendent 01 Senior most specialist/ GDMO preferably with experience in public health Public health specialist 01 MD(PSM)/MD/MD community medicine or PG with MBA/DPH/MPH PHN 01 Desirable- +01 Specialty Services General Surgeon 01 MS/DNB (General surgery) Physician 01 MS/DNB (General medicine) Obstetrician and Gynecologist 01 DGO/MD/DNB Paediatrician 01 DCH/MD Paediatrics /DNB Anaesthetist 01 MD (Anesthesia)/DNB/DA/LSAS trained MO Staffing pattern

145. Personnel Essential Qualifications General Duty officer Dental surgeon 01 BDS General duty MO 02 MBBS MO-AYUSH 01 Graduate in AYUSH Nurses and paramedicals Staff Nurse 10 Pharmacist 1, +1 desirable Pharmacist –AYUSH 01 Lab technician 02 Radiographer 01 Dietician +1 desirable Ophthalmic assistant 01

146. Dental assistant 01 Cold chain and vaccine logistic assistant 01 OT technician 01 Community based rehabilitation worker 01, +1 desirable Counselor 01 Administrative staff Registration clerk 02 DEO 02 Account assistant 01 Administrative assistant 01 Group D Staff Dresser 01 Ward boys 05 Driver 01, 3 desirable Total 46, 52- desirable

147. Hope it helped! Thank you