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HEALTH CARE DELIVERY SYSTEM

INTRODUCTION:

What comes to your mind when you had detoriation from health?

Hospital and population it covers

Type of service it gives

Is it able to give comprehensive care?

Ivory tower of disease

Alternative health delivery model came in exist

FACTORS DETERMINING HEALTH CARE DELIVERY SYSTEM

 CONSUMERS OF HEALTH CARE

 PROVIDERS OF HEALTH CARE
 FUNDING SOURCES
 OTHER FACTORS: Such has political system, legislation, law, and obligation.

MODELS OF HEALTH CARE DELIVERY SYSTEM:

Input through put out put

Health status Promotive

IMPROVE
Health Curative
HEALTH
problems Preventive
STATUS
Health needs

Resources Allopathic
AYUSH

FIG: as per system theory

Concepts: health status:

How to measure?

• Morbidity mortality
• Demographic
• Environment
• Socio economic
• Cultural
• Medical, health service
• Other (water…)
Mortality:

 IMR: 58 INDIA: 54(WORLD) developed countries it is 5/ 1000

 Life expectancy: 65.3 (12 to 15 more, world)
 Rural death (8.7 per 1000) urban (6)
 UP death rate higher than rest of the states( 9.8) average 8.2
 Kerala least death rate 6.4

DEMOGRAPHIC:

Sl.no content Existing statistics

1 Total population 1087 million(2004)
2 Family size 3
3 Annual growth 1.9
4 May double the population With in 30 years(2025)
5 Rural population 72%
6 Adult literacy 65.4
7 Sex ratio 933
8 GNP 23,241
9 CBR 24.1
10 DEATH RATE 7.5

Morbidity:

 Malaria, filarial, dengue, chikagunya still high

 Cholera out break among under five still seen due to poor environment
conditions
 ARI 13% admissions in wards and 13.6% of total paeds death in hospital
due to ARI
 Leprosy: 60% of worlds cases are in India
 2.3 per 10,000 population seen

 AIDS: 5.7 million cases have been reported in India

 Other: viral hepatitis, TB, helminthes diseases

Other problems:

♦ Population
♦ Nutrition
♦ Environment nutrition population exposure
PEM:
 Common is morasmus
 Severe mall nutrition seen in 2- 3% of preschooler
 Mild moderate cases 80%

Anemia:

 Half of women population, and young adults

 60 to 80% of pregnant mothers are anemic
 Out of total MMR 20 to 40% death are due to anemia
 Iron deficiency very common than folate or B12 deficiency

Low birth weight:

 30% babies born below 2.5 kg, where as developed countries it is 4%

 Main cause is maternal anemia

Nutritional blindness:

 Keratomalacia
 Seen among 1to 3 years of age

Iodine defiency:

 Common in himachal, orissa, Punjab, Darjeeling, west Bengal, arunchala

Environment:

 water 100% in urban, 85% rural

 Waste disposal 29% in urban and only 25 in rural

Medical care problems:

 Uneven
 Crowded in cities
 Inadequate staff
 Essential drug shortage
 74% rural do not have hospital
Resources:

Doctors; 73.6% urban, 26.4% only rural

 HEALTH MAN POWER SUGESTED NORMS:

SL. NO CATAGORY NORMS

1 DOCTORS 1/ 3,500 POPULATION
2 NURSES 1/ 5OOO ‘’
3 FHW, MHW 1/5000: 1:3000(HILLY)
4 DAIS 1 PER VILLAGE
5 FHA 1: 30,000& 1: 20,000(hilly)
6 PHARMACIST 1:10,000
7 LAB TECHNICIAN ‘’ ;;

Finance: GNP 1to 2% only spent

Developed countries 6 to 12%

Through put:

Health services and health care system:

Health care services:

Scope:
 varied
 As per health problems
 Finance

Purpose of health services:

 Reduction in morbidity
 Reduction in mortality
 Increase life expectation
 Decrease population rate
 Improve nutritional status
  Provision of basic sanitation
 Resource development
 Basic sanitation
 Reduce poverty
 Improve food production
 Literacy rate

Goal: HFA

Types of services:

 Curative
 Promotive, preventive
 Rehabilitative

Report of WHO expert committee 1961 says:

• Services should be
• Comprehensive
• Accessible
• Community participation
• Cost: economic affordable

Type of health system

 Modern medicine

 AYUSH

HEALTH CARE SYSTEM:

It can be decided in to sectors (5)

1. public sector:
a. primary care

 primary health centre

 sub centre
b. hospitals and health centers:

 community health centre

 rural hospital
 district hospital
 specialty hospital
 teaching hospital

c. health insurance scheme:

 employee state insurance
 central government health scheme

d. other agencies:
 defense services
 railways

2. private sector:
 private hospital, polyclinic

3. Indegeneous system:
 ( AYUSH):

 Including unregistered practitioners

3. voluntary health agencies:

 national
 international
5. National health programmes:

CONCEPT OF PRIMARY HEALTH CARE

 Bhore committee, 1975 shrivasthav committee

 1977 Rural health scheme: placing health in peoples hand, 3 tier structure
 1978 alma ata

 1983 national health policy

 Goals
 Now in villages rural development is done through rural health mission and
by state projects

Village health guides :(to deliver primary health care in villages)

 Introduced in 1977, October 2nd

 Some states did not e.g. TN instead introduced mini health centers
 Criteria health guides:
 Women only
 Permanent residence
 6th STD
 Accepted by community
 Voluntarily agrees to work
 Honorium salary
 Works only2- 3 hours daily
 Works minimum 3 years after the training
 Training in PHC, Sub centre
 3 month training
 Rs. 200 salaries
 Manual issued
 Drugs charges 600 RS Annually

Dais:

 rural health scheme started training of dais

 Training period is 30 working days
 Stipend of 300
 Training in MCH centers, PHC
 2 days in the centers and remaining days of week in the field
 During the training she has to conduct 2 deliveries under the presents of
FHA
 After successful training she will be given a midwifery kit and a
certificate she get 10 Rs, on registering the case and Rs. 3 on registering
the birth

Anganwadi workers:

P .H.C. Sub-centre ,community centre.

 Insurance scheme, defense,

Private agencies

Health insurance:

Additional health insurance schemesocial insurance schemes)

1. for BPL FAMILY:

 beneficiaries: 3 months to 65 years of age

 premium: Rs. 1 per day per person x 365 days

 family of 5 : Rs 1.50 annually Rs. 548

 family of 7: Rs. 730 per year

 government contribution: Rs. 100 per year

 family of destitute: free health services

 reimbursement: 30,000 on hospitalization

 death due to accident: 25.000/

 job loss: Rs 50 per day x 15 days

2. government national illness assistance fund(1997)

 it is also for BPL

 REEMBERSEMENT: 25000- 50000
 Treatment centers: 3 government hospitals and national institute
 Works under: MOH&FW
 States: AP, TN, WB, BIHAR, RAJ, MAH,….
PRIVATE AND GOVERNMENT COMBINED INSURENCES:

 Kerala
 Only for mother and baby
 BPL families
 Pilot project
 216 hospitals
 Service: surgical procedure, delivery
 Premium: 250 + 5% tax
 Reimbursement: 20,000 on hospital bills

Goa: combined insurance (government+ NGO+ UNDP)

 Coverage: families generating income less than 50,000 per annum

 Reimbursement: 30,000( on producing hospitalization certificate

from dean of hospital or DGHS

 Service coverage: ambulance, illness loss of wage(RS 50 per day),
drugs Rs. 50 per day

PRIVATE SECTOR AND HEALTH INSURANCE

• Government has given permission

• Regulatory body has been appointed to monitor
• Called as insurance regulatory and development body
• It has covered insurance worth of 300 million and predicted to
cover 50 billion with in 5 to 7 years
• Insurance companies so far has taped only 10% of the market
 • It shows till awareness among the people and organization is less
about insurance benefits

Conclusion source; health action JUNE 2010.. DR. K.

GOVINDARAJAN AND ARUNACHALUM..PAGE 26.

Voluntary health agencies:

• National
• International

National voluntary agencies:

Concept:
• Autonomous board
• Does fund raising
• Has paid and without paid workers
• Conduct programme for publicon health and related matters

Functions:
• Supplementing the work of government
• Why?
• Pioneering: research, health programme and projects
• Education: health education
• Demonstration of projects: Rockefeller and bore hole latrines
• Voicing out the work of government
• Recommendation for health legislation: asking public opinion

List of voluntary agencies in India:

♦ Indian red cross
♦ Hind kusht nivaran sangh
♦ Indian council for child care
♦ TB association of India
♦ Bharath sevak samaj
♦ Central social welfare board
♦ Kasturba memorial fund’ family planning association of India
.

Indian Red Cross:

 1920
 400 branches
Function:
♦ relief work
♦ Armed force( red cross home)
♦ Family planning
♦ Blood bank
♦ First aid

HIND KUSHT NIVARAN SANGH:

• 1950
• Head quarters in Delhi
Activities:
• Funds for various leprosy clinic and homes
• Publication of posters
• Training medical and physiotherapy
• Conducting research
• Conference
• Publication journal leprosy in India( quarterly journal)

Council for child Indian welfare:

♦ 1952
♦ Affiliated to international union for child welfare

Activities:
o Child security
• Laws and legislation
• Unable the children to develop physically, mentally, morally
healthy
• Develop environment for child that gives respect and dignity

TB association of India:
 Branches all over activities: fund raising
 Training doctors
 Consultation
 Conference1939

 Health education

Bharath Sevak Samaj:

 1952
 Health placing in people palm
 Activities:
 Improvement of sanitation

Central social welfare board:

 Under the general control of ministry of education

 Autonomous body
 1953
 Activities:
 Surveying the needs of voluntary health associations of India
 Rendering financial aid for deserving projects
 Rural areas welfare of women and children
 Teaching craft
 Distribution of milk to the balwadies
 Literacy classes
 Social education
 Maternity aid for women

Kasturba memorial fund:

 1944
 Improving women of villages through gram sevak

Family planning association of India:

 1949
 Mumbai- head quarters
 Function: training doctors
 Health visitors and social workers
 Personal interviews pertaining family planning
 Has family planning clinics

All India women’s conference:

 1926
  :
 MCH clinic
 Medical education centers
 Adult education centers
 Milk centers
 Family Has branches all over
 Activities planning centers

All India blind relief society:

 1946
Activities:
• Coordinate with different institution dealing with blind
• Eye relief camps
• Health education

Professional bodies:
Activities:
• conferences
• Scientific sessions
• Publication
• Exhibitions
• Research
• Relief camps

International agencies:
ROCK FELLER, CARE, ILO, WHO, UNICEF

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CONTRIBUTION OF ROCK FELLER:

 MEDICAL EDUCATION AND PUBLIC HEALTH

 HOOK WORM CONTROL
 ESTABLISHMENT OF NATIONAL INSTITUTE OF HYGIENE AND PUBLIC
HEALTH IN KOLKATTA
 TRAINING RESERCH WORKERS
 FELLOWSHIP PROGRAMME AND TRAINING
 DEVELOPING GRANTS TO SELECTED INSTITUTIONS
 MEDICAL LIBRARY ESTABLISHMENT
 RESERCH PROJECTS ASSISTANCY NATIONAL INSTITUTE OF VIROLOGY AT
PUNE

FORD FOUNDATION:
 • HAND FLUSH LATRINE
• TRAINING COURSES IN PPUBLIC HEALTH IN ITS TRAINING CENTER AI
SINGUR
• ESTABLISHMENT OF NATIONALINSTITUTE OF HEALTH ADMINISTRATION
AT DELHI
• CALCUTTA WATER SUPPLY AND DRAINAGE PROJECT
• SUPPORTS RESEARCH ON FAMILY PLANNINF AND REPRODUCTORY
BIOLOGY

CARE (COOPERATIVE FOR ASSISTANCE AND RELIEF)

 2ND WAR TIME IT HAS PROVIDED ASSISTANCE IN FIRST AID

 NUTITION PROJECTS: WOMENS HEALTH PROJECT

 ANAEMIA CONTROL PROJECTS
 CHILD SURVIVAL PROJECTS
 ADOLESCENT GIRL PROJECT UNDER ICDS

FAO:
• APPLIED NUTRITION PROGRAMME
• NUTRITION SURVEYS
• TRAINING COURSES
• SEMINARS
• RESEARCH
• ZOONOTIC DISEASES TRAINING PROGRAMME

ILO

 MINIMUM STANDARDS FOR WORK

 SOCIAL JUSTICE
 WELFARE LABOUR FORCE

WHO:
 OUT BREAK OF DISEASES
 VACCINES, DRUGS
 HEALTH LITERATURE
 MEDICAL LIBRARIES
 PROGRAMME PERTAINING ENVIRONMENT AND MCH

UNICEF
 APPLIED NUTRITION
 SCHOOL GARDEN
 SEEDS
 AGRICULTURE TECHNOLOGY AND TOOLS
 National health programme:

• National control programme

• National eradication programmes
• Special programme for mother and child
• Nutrition programme
• Other programme

Classification I1
• Vertical or centrally sponsored
• Horizontal
• District sponsored programmes
• Combined programme
• Intergrated programmes, merged

E’g; eradication programmes

Pulse polio programme 19 2005,not achieved

National leprocy
eradication 1955 2010

filaria 1955, merged 1972 Goal-2015

Yaws 75-76 2005 onwards no new case
Control programme

National vector From 2003 it is not

Borne disease centrally sponsored
combine
programme
National filarial control 1955
Kala azar control 1990
Japanese encephalitis control 1990
Dengue fever control programme 1996
Revised national TB 1992 On since 1962
National AIDS control 1987
Control of blindness 1976
CANCER CONTROL 1975-
76
Control & treatment of 98-99
occupational diseases
Diabetic control programme 7th five
year

MCH PROGRAMME:
 CSSM
 RCH
 RURAL HEALTH MISSION

NUTRITIONAL PROGRAMMES
 BALWADI
 APPLIED
 MID DAY
 IDD CONTROL
 IRON ANF FOLIC ACID
 VIT.A DEFIECIENCY

OTHER PROGRAMMES:
 UNIVERSA IMMUNISATION PROGRAMME
 NATIONAL MENTAL HEALTH PROGRAMME
 National surveillance programme for diseases(1994)
 Intergrated disease surviellane programme(2004)
  National family welfare programme
 National water supply and sanitation programme
 Minimum needs
 20 points programme

Five year plans:

 1951-56: I five year plan

o 2nd five year
o 3rd five year
o annual programmes
o 4th five year
o 5th five year
o out plan
o 6th
o 7th
o annual
o annual
o 8th
 97-2002 9th
o 10th
 11th
 CONCEPT OF PRIMARY HEALTH CARE

 Bhore committee, 1975 shrivasthav committee

 1977 Rural health scheme: placing health in peoples hand, 3 tier structure
 1978 alma ata

 1983 national health policy

 Goals

Village health guides:

Introduced in 1977, October 2nd

Some states did not e.g. TN instead introduced mini health centers
Criteria health guides:
Women only
Permanent residence
6th STD
Accepted by community
Voluntarily agrees to work
Honorium salary
Works only2- 3 hours daily
Works minimum 3 years after the training
Training in PHC, Sub centre
3 month training
200 salaries
Manual issued
Drugs charges 600 RS Annually

Dais:

P .H.C. Sub-centre ,community centre.

Insurance scheme, defense,

Private agencies
 Indigenous system of medicine

Voluntary agencies
 Indian red cross
 Hind kusht nivaran sangh
 Indian council for child welfare
 T.B association
 Bharat sevak samaj
 Central social welfare board
 Kasturba memorial fund
 F.P association of India
 All India womens conference
 All India blind relief society
 Professional bodies
 International agencies

VOLUNATARY ORGANISATION

INDIAN RED CROSS

 Started – 1920
 Over =400 braches
 Aim; 1. relief work
2. milk supplies
3. armed forces
4. technical aid & financial help –affiliated maternity centre
5. F. P. services –affiliated
6. blood bank and first aid, e.g.;

HIND KUSHT NIVARAN SANGH

 1950
 head quarters- Delhi
 financial help , leprosy home and clinic
 conduct field investigation
 posters, publication material
 training medical , physiotherapy
 conduct research
 conference national
 journal –LEPROCY IN INDIA

INDIAN COUNCIL FOR CHILD WELFARE

* 1952
* affiliated to international union for child welfare
* aim: all dimension health by means of law and other means
* state and district
T. B. ASSOCIATION OF INDIA
* 1939
* all most all state
* training, campaign
* it manages national T B center

BHARAT SEVAK SAMAJ

 1952
 sanitation
 all district

CENTRAL SOCIAL WELFARE BOARD

 1953
 automous
 survey the need of voluntary organization
 teach craft , social teaching, literacy
 distribution of milk to balwadis
 M C H activities
 Play centre for children
 Industrial scheme for urban

F P ASSOCIATION OF INDIA

 1949
 head quarters Mumbai
 they conduct F P clinic
 get government aid
 train doctor , health visitors, social worker
 clears queries

THE KASTURBA MEMORIAL FUND

* 1944
* women help through gram sevak

ALL INDIA WOMENS CONFERENCE

* 1926
* M C H clinic, adult education, milk centre ,F P clinic

ALL INDIA BLIND RELIEF SOCIETY

 * 1946
* Coordinate the work of blind institution
* eye relief camp
PROFESSIONAL BODIES

Eg;

INTERNATIONAL ORGANISATION
NATIONAL HEALTH PROGRAMME

Classification of health programme

 Eradication programme
 Control programme
 Mother and child
 Nutritional
 Other

ERADICATION PROGRAMME
1. Guinea worm
2. Pulse polio
3. Filaria
4. Leprosy
CONTROL PROGRAMME
1. T.B.
2. AIDS
3. DIABETES
4. BLINDNESS
5. CANCER
6. MALARIA
7. JAPANES ENCEPHALITIS

M C H PROGRAMME
1. C.S.S.M
2. R.C.H
3. F.P
NUTRITIONAL PROGRAMME
`1. VIT. A. Prophylasis
2. Iron & folic acid
 3. Balwadi
4. Applied
5. Special nutrition
6. Iodine deficiency
7. mid day meal

OTHER PROGRAMME:
 UNIVERSAL IMMUNISATION
 MENTAL HEALTH
 20 POINTS
 MINIMUM POINTS
 WATER SUPPLY & SANITATION
 FIVE YEARS

FIVE YEAR PLAN:

FIRST : 1951-1956
SECOND : 1956-1961
THIRD :1961-1966
FORTH : 1969-1974
FIFTH : 1974-1979
SIXTH : 1980-1985
SEVENTH : 1986-1991
EIGHT : 1992-1997
NINTH : 1997-2002
TENTH : 2002-2007
11 2008-2012
TH
PROBLEMS AT HEALTH CARE DELIVERY SYSTEM

1. Planning :1. Lack of medium ,short term plans

2. Imbalance between rural urban areas

3. P H C structure
4. Referral system: hospital over loaded
 Community centre- no confidence
 Lacks of link between hospital and other
level
 Community participation; poor people not
involved
 Resistance of part of population
 Diverse interest
 Staff; doctor less
 Peon less
 No further growth
 Security lacks
 Unattractive terms
 Selection
 Training
 Lacks orientation programme
 Co-ordination lack of ….voluntary
o govt trust
o attitude
o between directorate of health
services
o intra and inter sector
o decentralization resistancy
o 5. concept/attitude
bare feet doctor
o advance technology-
specialization
o 6. finance management/
control fund not
utilized
o review committee
o research
lacks
Not used this research knowledge in
o Practice
o university
not involved
 o space
not available
o policy making
non health personnel
o Legislation
o ESI scheme
not utilized well
o Service
doctors not available at work
place
o Crowded some centre
o Long waiting hours
o Private practice
o Under utilization of other system
of medicine
o Ambulance service

HEALTH CARE DELIVERY SYSTEM OF U.N:

 INSURANCE: becomes centre place in giving health care.

 COUNTRY : spends first highest finance towards health.
Second highest by Canada. That means it spends 40%
more than Canada.
 MONEY : 2002 census revealed that it has spent $1.4 trillion on health
Care. insurance agency have spent 15%.
 PROGRESS : country has advance technology, science, medicine.
 LIFE : expectation increased due to good health service.

COMPONENT OF HEALTH CARE DELIVERY SYSTEM

1. Private also called as personal care.
2. Public

TYPE OF CARE GIVEN BY PERSONAL CARE COMPONENT:

 Primary
 Secondary
 Tertiary
 prevention
 therapeutic
 treatment
 rehabilitation
WORK FORCE TO DELIVER PERSONAL CARE:

1. Multi disciplinary team. Consist of *physician

• nurse
• dentist
• pharmacist
• optometrist
• nutritionist
• community out reach worker
• mental health care counselor
• translator
• allied health personnel

DELIVERY SYSTEM:

 physician office
 community centre
 community nursing centre
 managed care organization
MANAGED CARE ORGANISATION:
 health maintain organization
 preferred care organisation

H. M. O
 First organized system of health care
 fixed fee
 78 million enrolled
 provides services like specified period hospital stay
 Emergency care, preventive care.

P. P. O.
 Second common type
 It acts as link between care providers and insurance company.
 Fee not fixed
 Can choose preferred doctor, cost

HEALTH INSURANCE

 Enables people to choose own insurance health plan

 Employee pay a defined contribution each year
 Employer, rather than employee has to know knowledge on
different health plans.
 NURSE IN PRIMARY CARE WORK FORCE:

 2 category of nurses ie. N.P and physician assistant

 developed in 1960
 they are also called as generalist

WHO ELSE CAN BECOME GENARALIST

 Certified Nurse Mid wife
 General pediatrician
 Physician - community medicine or O.B.G.

N P.
 M.S.C. speciality
 Adopted special skills – history taking, diagnosis, drug, psy-
social skill, prevention aspect …and physical assessment.
 They are able to perform 60- 80 % of physician work
 Adv: less money equal and better quality care

C. N. M.
 M.S.C.
 5800 [2002]
 Give antenatal, post natal, labour, F. P., prescribe medicine,
referral, newborn ,collaborative services

P. A.
 B. S. C.
 Under doctors license
 40469 [2002]
 skilled – history, physical assessment, medicine, diagnosis ,
treat un complicated medical condition

PUBLIC HEALTH SYSTEM

 Those cannot afford

 Eg; national health service corps provides care for residents of
medically underserved areas
 It also forms health laws
 Gives compulsory immunization
 Water monitor-law
 CHALLENGES FACED BY U. S. HEALTH CARE SYSTEM

 Rising cost
 Access
 Dissatisfied
 Competitive force
 Evidence based care
 System of recording
 Shift of nurses to community
 Continue edu.
 Separate public health sectors
 Technology
 Specialized professional
 Over emphasis –tech-least importance -…..
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