Health care delivery system in India Introduction Health care means patient care .

Its aim is freedom from the disease through hospital system. As an integrated care containing promotive, preventive and curative elements that bear the longitudinal association with an individual, extending from womb to tomb, and continuing in the state of health as well as disease. WHO

Service offered by all health disciplines .Inter-sectoral coordination and community participation and responsibility of providing health care expanded well beyond health sector. Evolution of health care services in India Christian era Civilization started in Indus Valley ,Environmental sanitation, houses with drainage 1400 B.C. Ayurveda and Siddha system Developed a comprehensive concept of health Post vedic teaching of buddhism and Jainism Rahula Sankirtyana developed hospital system. Moghul empire Arabic system of medicine (Unani) British Gov British nationals, armed forces, civil servants. Role of different committees 1946 Bhore Committee (Health survey and development committee) Integration of preventive and curative services Development of PHC 3 months training in PSM 1962 Mudaliar committee (Health survey and planning committee) Strengthening of PHC and district hospital Regional organization 1963 Chaddah committee Basic health workers Family planning health assistant 1965 Mukerji committee

Separate staff for the family planning programme 1967 Jungalwala committee Integration of health services Elimination of private practice by Gov. doctor 1973 Kartar singh Committee on multipurpose worker ANM replaced by female health worker Basic health worker replaced by male health worker Lady health worker designated as female health supervisor. Organizational structure in India Health system has 3 main links Central, State and Local or peripheral. India is a Union of 28 states and 7 territories. Health is the responsibility of state. Central responsibility

Policy making Guiding Assisting Evaluating Coordinating the work of state health ministries.

At the centre -Official organ The union ministry of health and family welfare Headed by Cabinet minister Minister of state Deputy health minister

The union health ministry Department of health and Department of family welfare Department of health Secretary to the Gov. of India (Executive head) Joint secretary Administrative staff Directorate general of health services Subordinate officer

Department of family welfare Was created in 1966 Headed by the secretary to the government of India. Secretary Additional secretary Commissioner One joint secretary Directorate general of health services - Principal advisor in both medical and public health matter. DGHS Additional Director General of health services Team of deputies Administrative staff 1.The central council of health and family welfare Chairman Union health minister Members State health ministers Function

To consider and recommend board outlines of policy in regards to matters of health To make proposals for legislation in fields of medical and public health matters and to lay down.

To make recommendations to the central government regarding the health. To established any organization with appropriate functions for promoting and maintain cooperation between central and state health administrations. At the state level

The state health administration was started in the year 1919. The state list which become the responsibility of the state included

Provision of medical care Preventive health services Piligrim within the state

State - management sector

State ministry of health and family welfare Headed - Cabinet minister and deputy minister. (Political head) Responsibility - formulating policies Monitoring the implementation of these policies and programmes. State health directorate and family welfare

Principle advisor in matters relating to medicine and public health Assisted by joint director, regional joint director and assistant directors.

At the district level Principal unit of administration in India District health organization identifies and provide the needs of expanding rural health and family welfare programme Within each district again, there are 6 types of administrative areas No uniform model of district health organization

Rural

Panchayat Raj 3 tier structure of rural local self government Linking the village to the district Urban Zilla Parishad Gram Sabha Gram Panchayat Panchayat Raj Panchayat Panchayat Samiti

At the block level

Objective - to provide primary health care to all the sections of the society. 80% of the population is scattered in villages 20% of rural population have health care facilities

Community health Centres

Established and maintained by the State Government under MNP/BMS programme. As per minimum norms, a CHC is required to be manned by four Medical Specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2011, there are 4,809 CHCs functioning in the country.

Primary health Centres

First contact point between village community and the Medical Officer. To provide an integrated curative and preventive health care with emphasis on preventive and promotive aspects of health care. Established and maintained by the State Governments under the MNP/ BMS Programme. Manned by a Medical Officer supported by 14 paramedical and other staff. NRHM - two additional Staff Nurses at PHCs (contractual). It acts as a referral unit for 6 Sub Centres and has 4 - 6 beds for patients. There were 23,887 PHCs functioning in the country as on March 2011.

Sub-Centre

Most peripheral and first contact point between the primary health care system and the community. Manned by at least one ANM / Female Health Worker and one Male Health Worker. Under NRHM, one additional second ANM on contract basis. Provide services in relation to maternal and child health, family welfare, nutrition, immunization and control of communicable diseases. Provided with basic drugs for minor ailments. Ministry of Health & Family Welfare is providing 100% Central assistance to all the SubCentres 148,124 Sub Centres functioning in the country as on March 2011.

Rural health infrastructure: Norms and level of achievements (All India) Village

Accredited Social Health Activist (ASHA) for 1000 population Chosen by and accountable to the panchayat Act as the interface between the community and the public health system. Honorary volunteer, receiving performance-based compensation Facilitate preparation and implementation of the Village Health Plan The other persons are

Indigenous dais Anganwadi workers

Progress over the years

Urban health care delivery system in India

The government of India has identified Urban Health as one of the thrust area in the tenth Five Year Plan, National population policy 2000, National Health Policy 2002 and second phase of RCH program

The central government health scheme (1954)

objective of providing comprehensive medical health care facilities to the central government employees and their family members.

Urban Family Welfare centers

launched during the first five year plan. At present 1083 centers are functioning and providing outreach services, primary health services, MCH services and distribution of contraceptives.

Urban health post

Urban Revamping Scheme introduced following the recommendations of the Krishnan Committee in 1983. To provide services through setting up of health posts mainly in slum area.

4 type of health post were set up depending on the allotted population.

Type A less than 5000 population Type B between 5000 to 10000 population Type C between 10000 to 25000 populations Type D between 25000 to 50000 populations

Only Type D health post has a Medical officer. Services provided by these posts are outreach of RCH services, first and referral services and distribution of contraceptives.

Health care delivery services in Delhi

Well established infrastructure for its people One of the highest bed capacity (2.14 beds/1000 persons). Public Health expenditure consistently remained above 6 per cent . Delhis per capita expenditure on health is Rs. 685. However, there is multiplicity of agencies operating their health care outlets in different areas or for defined subset of populations in different areas like Delhi Government, MCD, NDMC, CGHS, DGHS, ESI and Army etc. Primary health care level Delhi has wide network of 969 dispensaries. Secondary and tertiary health care level there are 706 hospitals including 505 registered nursing homes with 33711 beds. There are 118 hospitals in the government sector in Delhi.

Health care delivery system in Mumbai

Mumbai has a vast supply of public and private health care services. The services range from the super specialty, tertiary-level care hospitals to the general practitioners.

The Central Government has its own dispensaries, which are available only for their employees. ESIS - health care services that include hospitals and dispensaries which cater to employees in the organized sector. The various government organisations, such as ports, railways and defence, have their own health care services for their employees. The Municipal Corporation of Greater Mumbai (MCGM) provides major facilities in the public sector along with the State Government. The Department is divided into zonal set-ups for administrative purposes. There are five such zones, which cover 23 Wards The Deputy Municipal Commissioner handles each zone. Each Ward has a separate Ward Office and the Ward Medical Health Officer (MHO) heads the Public Health Department in that Ward. Family welfare and maternal child health programmes are under the supervision of OfficerMaternal Child Health & Family Welfare at F/South Ward. Peripheral hospitals linked to four super specialty hospitals. Health posts and dispensaries linked to peripheral hospitals in their respective Wards

Private health sector

India - dominance of Private sector. In a NSS survey in 2001-02, 13 lakhs practitioners were working in private sector. Accounts 80% of the total facility in the country. 88% of the towns have a medical facility compared to 24% in rural areas with 90% of the facilities manned by sole practitioners.

The private sector has 75% of specialists and 85% of the technology in their facilities. The private sector accounts for 49% beds and an occupancy ratio of 44% whereas the occupancy rate is 62% in the public sector.

AYUSH

Old acceptance in the communities in India Form the first line of treatment in case of common ailments in most of the places Ayurveda is the most ancient medical system with an impressive record of safety and efficacy. Mainstreaming AYUSH to strengthen the Public Health System at all levels. AYUSH facilities had been co-located with 208 District Hospitals (36%), 910 Community Health Centres (23%) and 3883 Primary Health Centres in the country . Gap in structure Finance allocation

Integrated approach of health care delivery Demands coordinated efforts of all sectors such as Agriculture, Irrigation, Animal Husbandry, Education, Social and Women's Welfare, Housing and Public Works, Communication, Rural Development, Cooperatives, Industries, Panchayats and Voluntary Organizations, etc.

ICDS integrated child development scheme

Supplementary nutrition for children of less than 6 years of age, pregnant mother, lactating mother. Nutrition and health education to women of reproductive age group

Monthly health and nutrition day at anganwadi Drinking water and toilet facility in anganwadi centre (rural development ministry)

Agriculture, irrigation and engineering: Growing more food locally - cereals, pulses, vegetables, fruits etc. Identifying water resources for drinking and other purposes Providing seeds for kitchen garden and community garden Educating the people for composting

Integrated approach of health care delivery cont Animal Husbandry:

Immunizing domestic animals and catties against rabies etc. Preventing zoonotic diseases

Education: Health education covering nutrition, personal hygiene and environmental sanitation; Education about various health problems in the community and their prevention and control; Population education, advantages of small family Providing first-aid and treatment of minor ailments and the knowledge of local health resources.

Social and Women's Welfare: Mobilizing women, mahila mandals, mother's club etc. for propagation of health, nutrition practices, special nutrition programmes for vulnerable groups, maintenance and use of water resources; proper disposal of excreta, composting, kitchen garden etc. Educating mothers on maternal and child care Contribution by NGOs Providing services like relief to the blind, the disabled and disadvantaged and helping the government in mother and child health care, including family planning programmes. Greater roles for the NGOs was seen to ensure Health for All through the primary health care approach.

Government of India started granting financial aids to NGOs for various schemes

Contracting in government hires individuals on a temporary basis to provide services Contracting out government pays outside individuals to manage specific function Subsidies government gives funds to privet groups to provide specific services. Leasing or rental government offers the use of its facilities to a privet organization. Privatization government gives or sells a public health facility to a privet group.

Challenges Prices of services in private sector Earning commission from diagnostic laboratories Financial protection against medical expenditure Non availability of medical, nursing and paramedical staff Inadequate and weak drug control infrastructure inadequate drug testing facility Extremely high drug cost No clear urban health care delivery model

References:

GOI. Twelfth five year plan (2012-2017) social sector, Volume III. Planning commission government of India.p1- 47 MOHFW. Rural health care system in India-the structure and current scenario. Rural health statistics 2011. GOI. MOHFW. National rural health mission. [online]. [cited 2012 Dec 27]. Available from: http://www.mohfw.nic.in/NRHM.htm Indian Public Health Standards (IPHS) guideline for community health centers, Revised 2012. DGHS, MOHFW, GOI. 1-94 GOI. Financing and delivery of health care services in India. MOHFW 2005; 1-320 Park K. Park's Textbook of Preventive and Social Medicine. 21st ed. Prem Nagar, Jabalpur, (M.P.), India: M/s Banarsidas Bhanot; 2011

INTRODUCTION

Nursing Council Act came to existence in 1948 to constitute a council of nurses to safeguard the quality of nursing education in the country. The mandate was to establish and maintain uniform standards of nursing education. Indian Nursing Council (INC) is a statutory body that regulates nursing education in the country through prescription, inspection, examination, certification and maintaining its stands for a uniform syllabus at each level of nursing education.

There are six levels of nursing education in India today. They are : 1. 2. 3. 4. 5. 6. Multy Purpose Health Worker Female training (ANM or MPHW-F) Female Health Supervisor training (HV or MPHS-F) General nursing and midwifery (GNM) BSc. Nursing MSc. nursing MPhil and PhD

The ANM, HV, and GNM are conducted in schools of nursing. The last 3 are university level courses and the respective universities conduct examinations. Beside there are several certificate and diploma courses in specialties. Link to Nursing Programmes in India GENERAL NURSING AND MIDWIFERY

The general nursing and midwifery course is conducted in 2178 centers in the country. (As on 12/12/2010) Link to the INC list of recognized institutionshttp://www.indiannursingcouncil.org/pdf/gnm-recognized-NursingInstitution.pdf The syllabus has undergone many revisions according to the change in the health plans and policies of the Government and changing trends and advancements in general education, nursing health sciences and medical technology. The latest revision of syllabus by INC in 2004 has increased the duration of the course from three year to three and half year. The basic entrance has become intermediate or class 12 instead of earlier class 10. Both science and arts students are eligible.

The focus of general nursing education is the care of sick in the hospital. Schools of nursing are generally attached to teaching hospitals. Three Board examinations are conducted, one at the end of each year. On passing the candidates are registered as registered nurse and mid wife by the respective state nursing councils.

PHILOSOPHY

The Indian Nursing Council believes that the basic course in nursing is a formal educational preparation which should be based on sound education principles. The council recognizes that the program as the foundation on which the practice of nursing is built and on which depends further professional education. It also recognizes its responsibility to the society for the continued development of student as individual nurse and citizens.

Purpose

The purpose of general nursing programme is to prepare general nurse who will function as member of the health team beginning with competence for first level position in both hospital and community. The programme is generated to the health needs of the society, the community and the individual and will assist nurses in their personal and professional development so that they may take their maximum contribution to the society as individual citizens and nurses.

Objectives 1. Demonstrate awareness of and skills required in the nursing process in the provision of health care and nursing of patients 2. Apply relevant knowledge from the humanities biological and behavioral sciences in carrying out health care and nursing activities and functions. 3. Show sensitivity and skill in human relationship and communication in his or her daily works 4. Demonstrate skill in the problem solving methods in nursing. 5. Gain knowledge of health resources in the community and the country 6. Demonstrate skill in leadership 7. Demonstrate awareness of necessity of belonging to professional organizations. 8. Promotion of health, precaution against illness, restoration of health and rehabilitation. Students admission

1. Age for the entrance shall be 17 years to 35 years, provided they meet the minimum educational requirement ie 12 years of schooling. 2. Minimum education all students should pass 12 classes or its equivalent, preferably with science subjects 3. Admission of students shall be once a year. 4. Students should be medically fit. The selection committee should comprise tutors, nurse administrators, educationalist/psychologist. The principal of the school shall be the chairperson. Training programme The course in general nursing shall be of three and half years duration as follows,--- two years practice in general nursing , one year community health nursing and midwifery and six months internship which includes nursing administration and nursing research classes. There will be alternate course for male students in lieu of midwifery. The ANM who wishes to under take general nursing course will not be given any concessions. The maximum hours per week per students shall be 36 hours, which includes instructions and clinical field experiences. BACHELOR OF NURSING COURSE (BScNursing)

and

Graduate nursing education started in India in the year 1946 in CMC , Vellore and in the RAK college of nursing at Delhi university. At present 1373 colleges have been recognized by INC to conduct the course under several universities in India. Link to INC list of recognized colleges http://www.indiannursingcouncil.org/pdf/bscrecognized-Nursing-Institution.pdf

Eligibility for admission A candidate seeking admission should have: 1. pass the 2 year of pre university exam or equivalent as recognized by concerned university with science subjects ie Physics, biology and chemistry. 2. students of vocational courses 3. obtained at least 45%of total marks in science subjects in the qualifying exam, if belongs to a scheduled caste or tribe , should have obtained not less than 40 % of total marks in science subjects. 4. completed 17 years of age at the time of admission or will complete this age on or before 31st December of the year of admission 5. is medically fit

Objectives of study The programme is designed : 1. to provide a balance of professional and general education 2. to enable a student to become a professional nurse practitioner who has self direction and is a responsible citizen. Through planned guided experiences students are provided with opportunities to develop

a broad concept of the fundamental principles of nursing care based on sound knowledge and satisfactory levels of skill in providing care to people of all ages in community or institutional setting understanding of the application of principles from the physical biological and social sciences for assessing the health status ability to investigate health care problems systematically ability to work collaboratively with members of allied disciplines towards attaining optimum health for all members of the society understanding of fundamental principles of administration and organization of nursing service understanding of human behaviour and appreciation of effective interpersonal relationship with individuals families and groups ability to assume responsibility for continuing learning appreciation of professional attitudes necessasary for leadership roles in nursing appreciation of social and ethical obligations to society.

Course of study The course of study leading to bachelor of nursing degree comprises 4 academic years. BACHELOR OF NURSING COURSE (POST CERTIFICATE) FOR QUALIFIED NURSES

INC has recognized two modes of programmes at this level.

A. Regular B.Sc (Post Basic) course for those who have 10+2 + GNM (General Nursing & Midwifery) which has a duration of 2 years B. Distance B.Sc (Post Basic) course for those who have 10+2 GNM + 2year Exp which has a duration of 3 years. Philosophy and aims of the programme

Nursing is an integral part of the health care delivery system and shire responsibility in collaboration with other allied health professions for the attainment of optimal health for all members of the society. Education as a life long learning process. It seeks to render appropriate behavioral changes in students in order to facilitate their development, which assist them to live personally satisfied and socially useful lives. The goal of post certificate degree programme leading to bachelor of science in nursing is the preparation of the trained nurse as a generalist who accept responsibility for enhancing the effectiveness of Nursing care

Eligibility for admission The candidate seeking admission must: 1. hold a certificate in General nursing. 2. be a registered nurse 3. have minimum of two years of experience. Now it is relaxed that no experience after GNM is required for admission to this course. 4. have passed pre university exam in the arts /science/commerce or its equivalent which is recognized the university 5. be medically fit 6. have a good personal and professional record 7. have working knowledge of English Programme of study DURATION the programme of the study is two academic years from the date of commencement of programme. Terms and vacations shall be as notified by the university from time to time. OBJECTIVESthe goal of the post certificate programme leading to the bachelor of nursing is the preparation of the trained nurses as a generaralist who accept responsibility for enhancing the effectiveness of nursing care.

Administer high quality nursing care to all people of all ages in homes , hospitals and other community agencies in urban and rural areas Apply knowledge from the physical, social and behavioral sciences in assessing the health status of individuals and make critical judgment in assessing the health status of the individuals and make critical judgment in planning ,directing and evaluating primary, acute and long term care given by themselves and others working with them Investigate health care problems systematically

Work collaboratively with members of other health disciplines Teach and counsel individuals , families and other groups about health and illness Understand human behavior and establish effective interpersonal relationships Teach in clinical nursing situations Identify underlying principles from the social and natural sciences and utilize them in adapting to , or initiating changes in relation to those factors Acquire professional knowledge and attitude in adapting for leadership rol

DEGREE OF MASTER OF NURSING

First two years course in masters of nursing was started at RAK College of Nursing in 1959.and in 1969 in CMC Vellore. At present there are 401 colleges imparting MSc Nursing degree course in different specialties. INC recognized List of Colleges of Nursing for M.Sc(N) course (20102011)http://www.indiannursingcouncil.org/pdf/msc-recognized-Nursing-Institution.pdf

Philosophy 1. The master of nursing programme is offered by institution of higher education and is built up on a recognized bachelors curriculum in nursing (in India-by Indian nursing council) 2. The programme prepares nurses for leadership position in nursing and other health fields who can function as specialists nurse practitioners, consultants ,educators ,administrators and investigators in a wide variety of professional setting in meeting the national priorities and the changing needs of the society 3. The programme prepares nursing graduates who are professionally equipped ,creative, self directed and socially motivated to effectively meet with the needs of the social change 4. The programme encourages accountability and commitment to life long learning which fosters improvement of quality care Objectives Graduates of master of nursing programme demonstrate:

increased cognitive ,affective and psychomotor competencies and the ability to utilise the potentials for effective nursing performance expertise in the utilization of concepts and theories for the assessment ,planning and intervention in meeting the self care needs of an individual for the attainment of fullest potentials in the field of specialty. ability to practice independently as a nurse specialist

ability to function effectively as nurse educators and administrators ability to interpret the health related research ability to plan and initiate change in the health care system leadership qualities for the advancement of practice of professional nursing interest in life long learning for personal and professional learning advancement

Eligibility The candidate seeking admission must: 1. have passed BSc. Nursing/post certificate BSc, or nursing degree of any university 2. have a minimum of one year of experience after obtaining BSc, in hospitals or nursing educational institutions or community health setting 3. for BSc, nursing post certificate, no such experience is needed after graduation the candidate shall be-a registered nurse or registered midwife for admission to medical surgical nursing, community health nursing, pediatric nursing obstetric and gynecological nursing. 4. a registered nurse for admission to psychiatric nursing 5. the candidate shall be selected on merit judged on the basis of academic performances in BSc nursing, post certificate BSc, or nursing and selection tests. Specialties Candidate will be examined in any of the following branches 1. Medical Surgical Nursing -Cardio Vascular & Thoracic Nursing 2. Medical Surgical NursingCritical Care Nursing 3. Medical Surgical Nursing Oncology Nursing 4. Medical Surgical Nursing - Neurosciences Nursing 5. Medical Surgical Nursing - Nephro- Urology Nursing 6. Medical Surgical Nursing -Orthopedic Nursing 7. Medical Surgical Nursing - Gastro Enterology Nursing 8. Obstetric & Gynaecological Nursing 9. Paediatric (Child Health) Nursing 10. Psychiatric (Mental Health) Nursing 11. Community Health Nursing Four common papers are there included in the syllabus. They are:

advanced concepts of health and nursing education and nursing education

bio-statistics, research methodology and nursing research administration and nursing administration

MASTER OF PHILOSOPHY PROGRAMME IN NURSING In 1980 RAK college of nursing started an MPhil programme as a regular and part time course. Since then several universities started taking students for the MPhil course in nursing. Prominent among these are: MGR Medical University, Rajive Gandhi University of Health Sciences, SNDT University and Delhi University and Manipal Academy of Higher Education Philosophy Nursing shares with the whole university a main focus of preparing its students for service and assisting them to achieve a meaningful philosophy of life. The student is encouraged to develop judgment and wisdom in handling knowledge and skills and achieve mastery of problem solving and creative skills. Commitment to life long learning is the mark of truly professional person. In order to maintain clinical competencies and enhance professional practice the student must stay abrupt of the new developments and contribute to the advancement of nursing knowledge. Objectives The objectives of M.Phil degree course in nursing are:

to strengthen the research foundations of nurses for encouraging research attitudes and problem solving capacities to provide basic training required for research in undertaking doctoral work

Duration Duration of the full term M.Phil course will be one year and part time course will be two year. Course of study At the time of admission each candidate will be required to indicate her priorities in regard to the optional courses .a candidate may offer one course from M Phil programme from the department of Anthropology, education, sociology and physiology or any suitable department. The M.Phil studies will be into two distinct parts, part1 and part 2.

Part1----it consist of 3 courses, ie research methods in nursing, major aspects of nursing, allied disciplines Part2----after passing the part1 examination, a student shall be required to write a dissertation. The topic and the nature of the dissertation of each candidate will be determined by the advisory committee consist of 3 members. The dissertation may include results of original research, a fresh interpretation of existing facts, and date or a review article of critical nature of may take. DOCTORATE OF PHILOSOPHY IN NURSING (PhD in Nursing}

Erlier Indian nurses were sent abroad for Ph. D programme. PhD programmes in nursing was first started in India in 1992 Universities where PhD programmes are conducted in India include 1. PhD Consortium by Indian Nursing Council, RUGHS and WHO 2. RAK College of Nursing 3. NIMHANS Banglore 4. Manipal University

Philosophy A candidate for admission to the course for the degree of doctor of philosophy in the faculties of medical science must have obtained an M Phil degree of a university or have a good academic record with first or second class masters degree of an Indian or a foreign university in the concerned subject. The candidate shall apply to the university for the admission stating his qualifications and the subjects he proposes to investigate enclosing a statement on any work he may have done in the subject. every application for the admission of the course must be analyzed by the board of research studies. Board of research studies (medical sciences)- members

dean and the head of the departments concerned Principals/ head of institutions recognized for post graduate medical studies. Two members nominated by the medical academic council Three persons nominated by the medical faculty( for their special knowledge in the medical science

Eligibility criteria

The candidate should be post graduate in nursing with more than 55% of aggregates of marks

Should have research background May or may not published articles in journals The course duration is far regular PhD course is 3 years and for part time is 4 years