INTERNS’ SEMINAR REPORT

HEALTHCARE SYSTEM IN INDIA

(26.09.22- 23.10.22)

INTERNS – Samhakhani Sujha, Sorokhaibam Daina, Surendra Kumar Lamba,

Thingujam James, Rahul Hidangmayum, Sumit Kumar, Swapnodip Ghosh, Tonjam
Simoni Devi, Vanlalchhuanga, Solomi Debbarma, Sunita Prajapati, Swatha Rai, Sancyvia
Lyngdoh, Salam Linthoinganbi, Siba Shealeaveirhrii, Ukyathang Mog Chowdhury

GUIDE : Prof. Shantibala K

Professor & Rural In-Charge, Department of Community Medicine

SUPERVISORS : Dr. Takhellambam Gitanjali

Dr Priya Laikhuram

Dr. Sandra Fernandez

Dr. Dhinu K

Department of Community Medicine, Regional Institute of Medical Sciences

 Back (L to R ) – Ukyathang Mog Chowdhury, Swapnodip Ghosh, Siba Shealeaveirhrii,
Vanlalchhuanga, Rahul Hidangmayum,Thingujam James, Surendra Kumar Lamba, Sumit Kumar

Front (L to R) – Sunita Prajapati, Sancyvia Lyngdoh, Sorokhaibam Daina, Swatha Rai, Solomi
Debbarma, Salam Linthoinganbi, Samhakhani Sujha, Tonjam Simoni Devi
 ACKNOWLEDGEMENT

We express our heartfelt gratitude to Sir Brogen Singh Akoijam, Professor and Head,
Department of Community Medicine, RIMS for his overall support. We are also grateful to Prof.
Shantibala K, for allowing us to conduct this seminar and also for her support.

We would also like to extend our deepest gratitute towards our supervisors Dr. Takhellambam
Gitanjali, Dr Priya Laikhuram, Dr. Sandra Fernandez and Dr. Dhinu K for their guidance and
valuable advice given throughout the preparation for our seminar. We would also like to
acknowledge Mr. Romesh for taking us to the CHC, PHC and District Hospital for collecting
information regarding our seminar.
Table of Contents
Concepts of Health care

Health care delivery system

Public health sector

Private sector

Indigenous systems of medicines

Voluntary health agencies

National health programs

Problems and issues in health care delivery system

References
Concept of Health Care
“Multitude of services provided to individuals or communities by agents of the health services or
professions, for the purpose of promoting, maintaining, monitoring, or restoring health”

Health care is conventionally regarded as an important determinant in promoting the general

physical, mental and social well-being of people around the world and can contribute to a
significant part of a country's economy, development and industrialization when efficient.

Health care services are required to provide health services at lower cost and in higher amount
so that these can be made available to a large number of individuals.

Medical Care
Those personal services that are provided directly by physicians or rendered as the result of
physician’s instruction.

Medical care is a subset of health care.

Health Services
Permanent countrywide system of established institutions, the multipurpose objective of
which is to cope with the various health needs and demands of the population, and thereby
provide health care to individuals and the community, including a broad spectrum of preventive
and curative activities, and utilizing, to a large extent, multipurpose health workers.

Universal Health Coverage

UHC means that all individuals and communities receive the health services they need without
suffering financial hardship. It includes the full spectrum of essential, quality health services,
from health promotion to prevention, treatment, rehabilitation, and palliative care across the life
course.

The delivery of these services require adequate and competent health and care workers with
optimal skills mix at facility, outreach and community level, and who are equitably distributed,
adequately supported and enjoy decent work. UHC strategies enable everyone to access the
services that address the most significant causes of disease and death and ensures that the quality
of those services is good enough to improve the health of the people who receive them.
Components of Health Service System
1. Structure of Health System:

It consists of the design of the health services, the numbers and types of personnel and
staff, how they are organized to work, the Facility and equipment, the services they
offered, the System of management, accessibility and mode of financing. The eligible
population, and governance and administrative decision making.

2. Process of Health Care delivery

Behavior or performance of the healthcare system/professionals:

 It involves clinical care involving problem (needs) recognition, diagnostic

process, treatment or management and appropriate follow-up

Participation of people:

 consists of utilization of services, understanding of recommendation, their

satisfaction with the services they provided, and their participation and decisions
concerning strategies.

3. Outcomes of Health Care

The aspects of health that results from interventions and the actions of those who are the
targets.

4. Flow of patients in health care system

In India, Community health workers ----> General practitioner ------> Specialists ---->
Hospital (in-patient care)

Evolution of Health System in India

 Phase I (1947-83) : It signifies qualitative data collection. Two principles

1. None should be denied care for want of ability to pay

2. It was the state’s responsibility

 Phase II (1983-2000) :It signifies quantitative data collection.

• Encourage private initiative

• Expanding access to publicly funded comprehensive primary health care

 Phase III (post 2000) : Summarization

• Utilization of private sector resources

• Liberalization of insurance sector

• From a provider to a financier

Changing Concepts
1. Comprehensive Health Care
First used by the Bhore Committee (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.

Criteria given by Bhore Committee

(a) provide adequate preventive, curative and promotive health services

(b) be as close to the beneficiaries as possible
(c) has the widest cooperation between the people, the service and the profession
(d) is available to all irrespective of their ability to pay
(e) look after specifically the vulnerable and weaker sections of the community
(f) create and maintain a healthy environment both in homes as well as working places
2. Basic Health Services

“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 the health of an area and assuring the availability of competent professional
and auxiliary personnel to perform these functions”

- UNICEF/WHO

 Drawbacks of both Comprehensive health care and Basic health services

• Lack of community participation

• Lack of inter-sectoral coordination

• Dissociation from the socio-economic aspects of health

3. Primary Health Care

Health for All
• In 1977, World Health Assembly launched a movement known as ‘Health for All’ (HFA)
by the year 2000
 • The fundamental principle of HFA strategy is equity, an equal health status for people
and countries, ensured by an equitable distribution of health resources
• The first level of contact between the individual, family and community with national
health system
• 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

Primary Health Care

Primary health care is a whole-of-society approach to effectively organize and strengthen

national health systems to bring services for health and wellbeing closer to communities. It has 3
components:

 integrated health services to meet people’s health needs throughout their lives
 addressing the broader determinants of health through multisectoral policy and action
 empowering individuals, families and communities to take charge of their own health.

Elements of Primary Health Care

• Education concerning prevailing health problems and the methods of preventing and
controlling them

• Promotion of food supply and proper nutrition

• An adequate supply of safe water and basic sanitation

• Maternal and child health care, including family planning

• Immunization against major infectious diseases

• Prevention and control of locally endemic diseases

• Appropriate treatment of common diseases and injuries

• Provision of essential drugs

Principles of Primary Health Care

• Equitable distribution

• Community participation

• Inter-sectoral coordination
 • Appropriate technology

Equitable Distribution

• First key principle in primary health care strategy

• Health services must be shared equally by all people irrespective of their ability to pay
and all (rich, poor, urban, rural) must have access to health services

Community Participation

• Promote maximum community and individual self reliance and participation in planning,
implementation and maintenance of health services, making fullest use of local, national,
and other available resources

• Examples of community participation in India -

village health guides, trained dais, ASHA

Inter-sectoral coordination

Involve in addition to the health sector, all related sectors and aspects of national and community
development

Example:

Agriculture sector : Nutritional status can be improved through development in agriculture

which can ensure sufficient amount of healthy food for the community

Appropriate Technology

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

For example, use of ors and standpipes which are socially acceptable and financially more
feasible than house-to-house connections
Health Care Delivery System

“It implies the organization, delivery, staffing, regulation, and quality control of health care
services”

- Dr. J.E Park

1. Public health sector

2. Private sector

3. Indigenous systems of medicine

4. Voluntary health agencies

5. National health programs

Public Health Sector in India

(a) Primary Health Care Village level

Sub-centers

Primary health centers

(b) Hospitals/Health Centers Community health center

Rural hospitals

District hospital/health center

Specialist hospitals

Teaching hospitals

(c) Health insurance schemes Formal Sector

Informal Sector

(d) Other agencies Defence service, Railways

Village Level

To avail the health care into the farthest reach of rural area
Schemes in operation are:

1. ASHA scheme

2. ICDS Scheme

3. Training of Local Dais

1. ASHA – Accredited Social Health Activist

ASHA must be resident of the village. A women-married/ widow/divorced
Preferable age group-25 to 45 yr. With formal education upto eight class.
Communication skill and leadership qualities. One ASHA for 1000 population
And for Hilly/Tribal areas, 1 ASHA for one Habitation

2. Anganwadi Worker
Under ICDS Scheme, 1 AWW for a population of 400-800
 Selected from community she is expected to serve
Undergoes training in various aspects of health for 4 months
Part time worker and is paid Rs 1500 per month for the services rendered

• Services provided
 Health check up
 Mobilize people for immunization
 Supplementary nutrition
 Health education
 Non-formal preschool education

Beneficiaries

- Nursing mother

- Women (15-45 years)

- Children <6 years
- Adolescent girls

3. Local Dais
A scheme for training Dais was initiated – 2001 to 2002
Was implemented in 156 districts in 18 states/UTs
Districts selected were on the basis of the safe delivery rate being less than 30%
As of August, 2022 there are a total of 766 districts in India
Aim: to train at-least one Dai in every village with the objective of making deliveries safe

Training of Local Dais

• All dais are trained to improve their knowledge about MCH & sterilization
• Training – at PHC, sub centre, MCH centre
- 2 days/week for 30 working days
- Conduct at Least 2 deliveries under
guidance of HW/ANM
• Provided with a delivery kit & a certificate

Sub-Centre Level
• Most peripheral unit for direct contact between population and health system of our
country
• Slowly converting to HWC (Health and Wellness Centers)
 • One sub-centre for every
5000 population (general)
3000 population (hilly, tribal and backward areas)
• One Lady Health Visitor (LHV) and one Health Assistant (male) located at PHC are
entrusted with task of supervision of 6 sub-centres
• Categorized into 2 types based on various factors
- Type A
- Type B

Services to be provided in a sub-centre :

• Promotive, preventive & few curative services

• The site of service delivery may be

a. In the village

b. During house visits

c. During house to house surveys

d. During meetings & events with the community

e. At the facility premises

Auxiliary Nurse Midwife (ANM)

• ANMs receive 18 months of training focused primarily on MCH, family planning and
immunization

• ANMs are now officially Multipurpose Workers (MPWs) with a broad set of
responsibilities, including the support of AWWs and ASHA workers

• Some obtain additional training to manage birth complications and refer women with
complications to higher levels of care, and some obtain additional training for insertion of
intrauterine devices

Health Worker Male

• HWM are male health workers who receive six months of training and are linked to a
sub- center (along with an ANM)

• Generally focused on malaria prevention and treatment as well as on encouraging male

sterilization

The services provided at sub centres are

1. Maternal & child health care

2. Family Planning & Contraception

3. Counselling & appropriate referral for safe abortion service

4. Adolescent health care

5. Assistance to school health services

6. Water quality monitoring

7. Promotion of sanitation

8. Field visits by appropriate health workers for disease surveillance, family welfare

9. Services including STI, RTI awareness

10. Community need assessment

11. Training of traditional birth attendants & ASHAs

12. Coordinate services of anganwadi workers, ASHAs, Village Health and Sanitation
Committee
 13. Record of vital events

14. Disease surveillance, Integrated Disease Surveillance Project (IDSP)

15. National Health Programmes

16. Promotion of medicinal herbs

17. Outreach / Field services like VHND, house to house surveys, home visits

PRIMARY HEALTH CENTRE

• The Bhore Committee in 1946 gave the concept of primary health center as a basic health
unit

• The National Health Plan 1983 proposed

a. One PHC for every 30,000 rural population in the plains

b. One PHC for every 20,000 population in hilly, tribal

& backward areas

• From service delivery angle PHC may be of two types, depending upon the delivery case
load

Type A PHC Type B PHC

Deliveries with less than 20 Deliveries with 20 or more per
per month month

STAFFING PATTERN 1.MBBS M.O: 2

1.MBBS M.O: 1 2.AYUSH M.O: 1
2.AYUSH M.O: 1 3.Total staff: 14- 21
3.Total staff: 13- 18
Staffing Pattern

In addition to the services provided in a sub centre the following services are provided
 – Medical termination of pregnancy using manual vacuum aspiration technique

– Nutrition services for malnutrition, anemia, vit-A deficiency

– Prevention and control of locally endemic diseases

– Health education

– Basic laboratory services

– Monitoring and supervision of sub-centers, Health programmes

– Health education

– Basic laboratory services

– Monitoring and supervision of sub-centers, Health programmes

– Physical Medicine and Rehabilitation (PMR) services

– Selected surgical procedures like Vasectomy, Tubectomy

– Maternal Death Review (MDR)

– Mainstreaming of AYUSH

– Functional linkage with sub centres

HWC (Health and Wellness Centre)

• The National Health Policy 2017 recommended strengthening the delivery system of
primary health care, through establishments of HWCs as the platform to deliver primary
health care

• The government of India is committed towards creation of 1,50,000 HWCs by

transforming existing Sub centers and PHCs as basic pillars of Ayushman Bharat to
deliver Comprehensive Primary Health Care (CPHC)

• To ensure delivery of CPHC services, existing SCs covering a population of 3000-5000

would be converted to HWCs with the principle “time to care” to be no more than 30
mins

• HWC- Sub-centre is headed by Community Health Officer (CHO), whereas HWC- PHC
is headed by Medical Officer
 In addition to the services provided in a PHC the following services are provided

 Screening, prevention, control and management of non-communicable diseases

 Care for common ophthalmic and ENT problems
 Basic oral health care
 Elderly and palliative health care services
 Basic trauma care and emergency medical services
 Screening and basic management of mental health ailments

COMMUNITY HEALTH CENTRE

• As of 31st March, 2017, 5,624 CHCs were established by upgrading the PHCs

• 1 CHC in each community development block covers population 80,000 – 1.2 lakh

• Should have - 30 beds

-Specialists in surgery, medicine, OBG, pediatrics & anesthesia

Assured Services in CHC

• Care of routine & emergency cases in surgery & medicine

• 24-hour delivery services, including normal & assisted delivery

• Essential & emergency obstetric care including CS

• Full range of family planning services

• Safe abortion services

• Newborn care

• Routine & emergency care of sick children

• All the National Health programme

 • Oral health

• Blood storage facility

• Diagnostic services

• Referral service

MANPOWER OF CHC
Personnel Strength
Block Health Officer Senior most specialist among below mentioned
specialty

General Surgeon 1
Physician 1
Pediatrics 1
Obs & Gynecologist 1
Anaesthetist 1
Public Health Manager 1
Dental Surgeon 1
Eye Surgeon 1 (1 for every 5 CHC)
General Duty MO 6 (at least 2 female doctors)
Specialist of AYUSH 1
General Duty MO AYUSH 1
Staff Nurse 19
Public Health Nurse 1
ANM 1
Pharmacist/Compounder 3
Pharmacist – AYUSH 1
Lab-Technician 3
Radiographer 2
Ophthalmic Assist 1
Others 33

DISTRICT LEVEL

• District hospital is the secondary referral centre responsible for a district of a

geographical area containing a defined population

• The size of the district hospital depends on the size of the population
Functions of a district hospital

 It provides an effective, affordable health care services to the population with

their full participation and cooperation
 Functions as secondary referral centre for the public health institutions below the
district level
 Provides wide ranging technical and administrative support and education and
training for primary health care
Health Organization at State Level

• State Ministry of Health and Family Welfare

• State Directorate General of Health Services

State Ministry of Health and Family Welfare

State Ministry of Health- Health Secretariat

1. Secretary

2. Additional Secretary

3. Assistant Secretary

4. Deputy Secretary

5. Large administrative staff

Functional Deputy Director

 Immunization
 PHCs
 Health Education
 Tb
 Nutrition
 Leprosy
 MCH
 Statistics
Regional Deputy Director

Inspect all the branches of public health within their jurisdiction, irrespective of their
specialty

Health Insurance
The reduction or elimination of the uncertain risk of loss for the individual or household by
combining a larger number of similarly exposed individuals or households who are included
in a common fund that makes up the loss caused to any one member (ILO 1996)

They can be divided into

A. Formal Sector

- ESIS, CGHS, etc (10%)

B. Informal Sector

- Community Based Schemes

- Government sponsored/ Subsidised Schemes

Employees’ State Insurance Scheme (ESIS)

Employees' State Insurance Corporation is one of the two main statutory social security
bodies under the ownership of Ministry of Labour and Employment, Government of India,
the other being the Employees' Provident Fund Organisation. It is a public sector.

It is an integrated measure designed to

• protect ‘employees’ against the impact of incidences of sickness, maternity, disablement

and death due to employment injury

• provide medical care to insured persons and their families

Eligibility

• Applies to factories and other establishments – Road Transport, Hotels, Restaurants,

Cinemas, Medical/Educational Institutions wherein 10 or more persons are employed

• Employees of the above mentioned establishment, drawing wages upto Rs.21,000 per
month are entitled under ESI Act

• Employer should contribute 4.75% of wages payable to employee

• Employee should contribute 1.75% of wages payable to employee

• Employees earning less than Rs.137/- per day as daily wages are exempted from
contribution

• Cash Benefits

Sickness Benefit (@70% of wages for 91 days)

Maternity Benefit (@100% of wages for 12 weeks)

RGSKY for unemployment (50% of last wages for 1 year)

Dependent benefit (@90% of wages, lifetime for spouse and ~25 years for child)

Funeral Expeneses (Rs. 10000/-)

AYUSHMAN BHARAT

• It is a flagship scheme of Government of India, under the Ministry of Health and Family
Welfare, to achieve the vision of Universal Health Coverage

• This scheme aims to address the healthcare system covering the prevention, promotion
and ambulatory care at the primary, secondary and tertiary level
• It adopts a continuum of care approach, comprising of two inter-related components
which are

• - Health and Wellness Centres (HWCs)

• - Pradhan Mantri Jan Arogya Yojana (PM-JAY)

AB-PMJAY

• It is the second component of Ayushman Bharat

• The first component being Health and Wellness Centres (HWCs)

• This scheme was launched on 23rd September, 2018 in Ranchi, Jharkhand by the
Hon’ble Prime Minister of India Shri Narendra Modi

• Provide a health insurance cover of Rs. 5 lakhs per family per year for secondary and
tertiary care hospitalization to over 10.74 crores poor and vulnerable families

Who are Eligible?

• The households included are based on the deprivation and occupational criteria of Socio-
Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively

• It subsumed the then existing Rashtriya Swasthya Bima Yojana (RSBY) which had been
launched in 2008 under ministry of labour and employment

Benefits covered under PM-JAY

• Medical examination, treatment and consultation

• Pre-hospitalization

• Medicine and medical consumables

• Non-intensive and intensive care services

• Diagnostic and laboratory investigations

• Medical implantation services (where necessary)

• Accommodation benefits

• Food services

• Complications arising during treatment

• Post-hospitalization follow-up care up to 15 day

Chief Minister-gi Hakshelgi Tengbang – CMHT

• It is a public sector launched on 21st January, 2018

• It is an initiative by the Government of Manipur to give residents of the state the privilege
getting financial cover for secondary and tertiary hospitals

Who are eligible for CMHT?

• Widows, Disabled and AAY cards holder will be eligible for the scheme

• Local Media Person & Newspaper hawkers

• Newly added poor families - (State SECC-identified through DC verification process)

Benefits under the scheme

• By showing a CMHT, a beneficiary can get cashless treatment i.e without making any
payment to the empanelled hospitals up-to Rs. 5 Lakh per year per enrolled family on a
floater basis

• Beneficiaries are granted transport allowance up-to Rs. 300 per visit and a total ceiling
allowance of Rs. 3000 per year

• It also allows to cover for the air ticket or train ticket for the beneficiary plus one
Private Sector
Consists of :

- Private hospital, polyclinic, nursing homes, dispensaries

- General Practitioner and clinics

• According to NFHS-5 49.9% of families seek help from private health sector

51.8% urban and 46.4% rural

 • The most commonly reported reason for not using government health facilities at national
level is poor quality of care (48%) followed by long waiting time (46%)

Indigenous System of Medicine

Various indigenous systems involved in delivering health care are

 Ayurveda

 Yoga & Naturopathy

 Unani

 Siddha

 Homeopathy

 Based on definite medical philosophies

 Represent a way of healthy living

 Concepts of prevention and promotion of health

 Basic approach is holistic

 Department of Indian Medicine and Homeopathy (ISM & H) created in 1995 was
renamed to Department of AYUSH in 2003

 NRHM in 2006 implemented and introduced the concept of mainstreaming of AYUSH &
revitalization of local health traditions to strengthen public health services

Homeopathy :

• German physician Dr. Samuel Hahnemann

• Greek words hómoios (similar) and páthos (suffering)

• Key principle similia similibus curentur

Like be treated with likes

• This means in Homeopathy natural diseases are treated with substances that produce
effects similar to the suffering

• AYUSH Doctors are co-located in various health facilities such as PHC, CHC, sub-
district Hospital and District Hospital

VOLUNTARY HEALTH AGENCIES

 An organization that is administered by an autonomous board which hold meeting,
collects funds for its support chiefly from private sources & expends money, whether
with or without paid workers, in conducting a programme directed primarily to
furthering the public health by providing health services or health education, or by
advancing research or legislation for health, or by a combination of these activities

These are non-profit, non-political independent organizations which spends money for
following intentions and named accordingly:

 Missionary or Religious organization - promotion of a religion

 Welfare organization — social relief and welfare
 Professional body IMA — protection of interests of the members of profession
 Voluntary health agency — provision of health services to people
 The United States of America - 20,000 voluntary agencies functioning
 Voluntary health agencies — motor trucks
 Official agencies — railway truck lines

1) Indian Red Cross Society

• Established in 1920

• It’s activities are

- Relief work

- Milk and Medical supplies

- Armed forces

- Maternal and Child welfare services

- Family planning

- Blood bank and first aid

2) Indian Council for Child Welfare

3) Tuberculosis Association of India

4) The Kasturba Memorial Fund

5) Family Planning Association of India

6) All India Women’s Conference

7) The All-India Blind Relief Society

8) Professional bodies (IMA, AIDA)

NATIONAL HEALTH PROGRAMS

• Launched by Central Government to improve the health of the people

• Various international agencies also provide technical and material assistance in

implementation

 Programs related to communicable diseases

 Programs related to non communicable diseases
 Programs related to nutrition
 Reproductive, maternal, neonatal, child and adolescent health
 Health system strengthening programs
National Vector Borne Disease Control Program
Prevention and control of vector borne diseases

- Malaria

- Dengue
 - Lymphatic filariasis

- Kala-azar

- Japanese encephalitis

- Chikungunya

PREVENTION AND CONTROL

• Mosquito nets

- Hole size: 0.0475 inch

- >150 holes/sq inch

• Insecticide treated bed nets (ITBN)

- Deltamethrin, cyfluthrin

- Shelf life: 6 months

• Long lasting Insecticide treated bed nets (LLITBN)

- Addition of chemical barrier

- Shelf life: >3 years

• Use of larvivorous fish like Gambusia fish for vector control

National Tuberculosis Eradication Program (NTEP)

NTP (1962)

Introduction of DOTS

RNTCP (1992)

1st Jan 2020

NTEP

• Goal: eliminate TB by 2025

• Target: decrease incidence by 80%

decrease mortality by 90%

 NIKSHAY

Online monitoring system for TB patients who are on DOTS treatment in country

National AIDS Control Programme

• Launched in 1992

• OBJECTIVES

- Reduce new infection by 50%

- Provide comprehensive care to all PLHIV and treatment

services to all require it

• INTERVENTIONS

- Health education

- Distribution of condoms

- Repeated testing

• GROUPS

- Commercial sex workers

- Injecting drug users

- Long distance truck drivers

- Migrant laborers

- Transgender

- Men having sex with men

• Rate of mother to child transmission of HIV in india is 30%

• For prevention of MTCT: Zidovudine

Nevirapine

Elective CS are done

• Integrated counselling and testing centre(ICTC)

• Centres for counselling and testing of people

- Fixed facility ICTC

- Mobile ICTC

INTEGRATED CHILD DEVELOPMENT SERVICES

• Beneficiaries:

- 3-6y children

- 11-18y adolescents

- 15-45y women

- Pregnant and lactating women

 • Services

- Supplementary nutrition

- Nutrition and health education

- Immunisation

- Health check-up

-Non formal per-school education

Problems and Issues in Health Care Delivery System

Lack of awareness

The level of health awareness is low in the Indian population

1. Low educational status

2. Poor functional literacy

3. Low priority for health in the population

Lack of access

• Barriers to access in the financial, organizational, social and cultural domain can limit the
utilization of services, even in the places where they are available

Manpower crisis in health care

• Lack of adequate number and appropriately trained health care workers and personnels

• Lack of equitable deployment of health care workers as most prefer to work in areas
where infrastructure and facilities for family life and growth are higher

• In general, the poorer areas of Northern and Central India have lower densities of health
workers compared to Southern states

Affordability or the cost of health care

• Almost 75% of health care expenditure comes from the pockets of households and
catastrophic health care cost is an important cause of impoverishment
 • The public health care offers healthcare at low or no cost but is perceived as being
unreliable, of indifferent quality and generally is not first choice, unless one cannot afford
private care

• 7% of India’s population is pushed into poverty every year because of medical debt
according to a study

• According to 2019 report by the National Statistical Office medical expenditure

contributes to 11.9% of debt in rural areas and 12.7% of the debt in urban India

Lack of accountability

• Being accountable has been defined as the procedures and the processes by which one
party justifies and take responsibilities for its activities

• Three types of accountability namely financial, performance and political are important
components of healthcare reforms in India

Fund allocation and inadequate infrastructure

• Not enough funds are allocated for public health care in India

• Inequalities in rural and urban facilities is well known

• India spends only approximately 2.1% of its GDP on health care

• Lack of basic infrastructural facilities such as bed, wards, toilets, running and drinking
water, clean labour rooms for delivery and regular electricity in rural facilities

• Due to lack of modern quality health care in the public sector generally people prefer
private healthcare which is not affordable for most of the rural population due to low
income and lack of basic insurance policy

Challenge in optimal insurance based service

• Insurance market in the country remains largely underpenetrated

• Ayushman Bharat, Employment state insurance etc have helped in bringing insurance
inclusiveness

• 40.5 crore individuals who are eligible are not covered under any insurance scheme
(2021 Niti Aayog report)

Less emphasis on preventive care

• Proper preventative care can help save a huge cost for the patent and reduce the burden
on the limited healthcare infrastructural system in the country
Delay in diagnosis of illness

• Any type of delay may worsen the disease, increase the risk of death and enhance disease
transmission in the community

• Lack of reliable, accurate and affordable diagnostic services in the rural facilities is one
of the important factor for delay in diagnosis of illness

Lack of support for medical research

• The fundamental principles of healthcare practices and policies are derived from good
quality research

• Medical research is vital to ensure the optimization of healthcare practices, policies,

delivery as well as standardization of treatment protocols and long term interventions

Lack of regulation in private sector

• Inadequate legislation and failure to enforce regulations in the private sector and the
consequent variation in quality and cost of services

Health Sector Reform

• Health sector reform refers to fundamental change in policies and institutional

arrangement of the health sector, usually guided by the government

• Aimed at improving the functioning and performance of the health sector and, ultimately,
the health status of the population

Health sector reform deals with

• Equity

• Efficiency

• Quality

• Financing

• Sustainability
Types of health sector reforms

1. Organization and management

2. Financing of health services

3. Public sector reforms

Organization and management

• Decentralization

• Contracting out of services

• Public-Private mix

Financing of health services

• User charges

• Community financing schemes

• Insurance

• Stimulating private sector growth

• Increased resources to health sector

Public sector reforms

• Downsizing the public sector

• Productivity improvement

• Introduction of competition

• Improving geographic coverage

• Increasing role of local government

NQAS

• National quality assurance standards (NQAS) have been developed keeping in mind the
specific requirements for public health facilities

• Standards are meant for providers to assess their own quality for improvement as well as
facilities for certification

• Behiang PHC becomes first to get NQAS certification in Manipur

KAYAKALP

Launched on 15th may 2015 to promote cleanliness and enhance the quality of public health
facilities to appreciate and recognize their effort to create a healthy environment

LAQSHYA

• Started in 2018-2019 in Karnataka

• To reduce preventable maternal and newborn mortality, morbidity and still births
associated with care around delivery in labour room and maternity OT

• To ensure respectful maternity care

NABH

National accreditation board for hospital and health care providers is a constituent board of
quality council of India set up to establish and operate accreditation program for healthcare
organization

• Conclusion: As India is slowly progressing towards being a developed country, more

emphasis is slowly being given towards its healthcare system, contributing ~1.8% of
GDP in 2020-21 and ~2.1 % of GDP in 2021-22. (5% recommended according to WHO)
Following the recommendation of the National Health Policy 2017, India started
promoting Health and Wellness Centres (HWCs) by converting Primary Health Centres
(PHCs) and SubCentres (SCs) which provides easy health access to people suffering from
Non-Communicable Diseases (NCD) like Hypertension and Stroke, by providing
medications and check-ups free of cost. Also taking into account the financial problems
of the citizens of India, they also started introducing various schemes under which people
can get healthcare and medical benefits, free of cost, in various secondary and tertiary
hospitals. The AB-PMJAY scheme (under the Ayushman Bharat programme ) launched
in 23rd September, 2018 by the Prime Minister of India, reduces the occurence of Out of
Pocket Expenditure by including over 10 crore families, where in each families get Rs. 5
Lakhs per family per year. Similar schemes are also introduced in various states. In
Manipur, the Chief Minister-gi Hakshelgi Tengbang (CMHT) was launched on 21st
January, 2018 targeting the similar population as beneficiaries.Though many new
schemes which benefit the citizens of India are introduced, it cannot be fully utilized
because of the lack of awareness which could be accounted to the low educational status,
poor functional literacy and low priority for health in the population. And even though,
 the public health care offers healthcare at low or no cost it is still being perceived
unreliable, of indifferent quality and generally is not the first choice amongst the people.
Underutilization of the benefits given to the people is also a major factor. According to
the 2021 Niti Aayog report, 40.5 crore individuals who are eligible are not covered under
any insurance scheme. However, more light is being slowly given through various health
reforms in the country. Organization and management, financing of health services,
public sector reforms, all constitute the Health Sector reforms. By Improving the
geographic coverage, increasing the role of local government, public-private partnerships,
and with time, people will start to utilize these facilities, which will drastically reduce the
expenses utilized for healthcare.

References

• K. Park. Park’s Textbook of Preventive and Social Medicine.26th ed. Jabalpur: Bhanot
publishers;2021. 1032p.

• J Kishore. J .Kishore’s National Health Programs of India.11th ed. New Delhi: Century
publications;2014. 949p

• Bratati Banerjee. D K Taneja’s Health Policies & Programmes in India. 16 th ed. New
Delhi: Jaypee Medical Publishers;2019. 589p.

• National health portal [internet].India; AYUSH; [updated 05-06-2015; cited 18-10-2022].

Available from: https://www.nhp.gov.in/ayush_ms

• State Health Agency [internet]. Manipur [updated 2022 June 15; cited 2022 October 18]:
Available from http://shamanipur.mn.gov.in/.

• Chief Minister-gi Hakshelgi Tengbang [internet]. Manipur [cited 2022 October 18]:
Available from http://www.cmhtmanipur.gov.in/ cmht/index.html.

• National Health Authority [internet]. India; About Pradhan Mantri Jan Arogya Yojana
(PM-JAY); [updated 08-02-2021; cited 18-10-2022]. Available from:
https://pmjay.gov.in/about/pmjay.