PRIMARY HEALTH NURSING HSIT 1 (PHN)
Item
- Title
-
PRIMARY HEALTH
NURSING HSIT 1 (PHN) - extracted text
-
Indira Gandhi National Open University
^'✓z School of Health Sciences
HSIT 1 (PHN)
PRIMARY HEALTH
NURSING
Health For All
|/j|X| Indira Gandhi
National Open University
X'~'X School of Health Sciences
HSIT 1 (PHN)
Primary Health
Nursing
Block
1
HEALTH FOR ALL
UNIT 1
Health Concept and Prerequisites
5
UNIT 2
Primary Health Care — Concept and Principles
18
UNIT 3
Health for All
32
UNIT 4
Organisation of Health System based on Primary Health Care
45
UNIT 5
Health Care Resources and Monitoring and Evaluation of
Health Services
60
Appendices
78
Course Committee
Prof. V.C. Kulandaiswamy
Vice-Chancellor
IGNOU
Prof. H.P. Dikshit
Pro-Vice-Chancellor
IGNOU
Prof. R.J. Grade
Ex. Pro-Vicc-Chancellor
IGNOU
Mrs. B. Bhattacharya
Principal
RAK College of Nursing
New Delhi
Dr. (Mrs.) M. Dean
Ex. Principal
College of Nursing
C.M.C Ludhiana
Faculty Members
School of Heal th Sciences
IGNOU
Mrs. S.A. Samuel
Principal
College of Nursing
P.GJ Chandigarh
Prof. M.S. Chan drak ami
Principal
College of Nursing
Trivandrum
Dr. (Mrs.) Madhavi Devi Sharma
Ex. Principal
College of Nursing
AUMS. New Delhi
Dr. S.A. A rum u gam
S.C.S. Koihare
Academy for Women
Madras
Mrs. R.K. Sood
Ex. Nursing Advisor
Nirman Bhawan
New Delhi
Mrs. Girija Kumariamma
Assoc. Prof.
College of Nursing
Kotuyam
Prof. (Col.) P.K. Duua
Director, SOHS
Mrs. Uma Han da
Reader, SOHS
Mrs. Pity Koul
Lecturer, SOHS
Mrs. Rita Sarkar
Lecturer, SOHS
Dr. (Mrs.) Sulochana Krishnan
(Course Reviewer) SOHS
Dr. N.P. Sinha
Consultant, SOHS
Block Preparation Team
Dr. (Mrs.) Madhavi Devi Sharma
(Editor)
Ex. Principal
College of Nursing
ADMS, New Delhi
Mrs. Pity Koul (Writer)
School of Health Sciences
IGNOU
Mrs. Sumathi Kumaraswamy
Deputy Director of Health
Services (Nursing) Madras
Mrs. Sim rat Kour NJ. Singh
CMC, Ludhiana
Mn. B. Bhattacharya
RAK College of Nursing •
New Delhi
Mrs. S.A. Samuel
College o( Nursing
PGI Chandigarh
Dr. S.P. Kamra (Langauge
editing)
School of Humanities
IGNOU
Coordinators
Mn. Reena Bose
Calcutta
Mrs. Uma Handa, Reader
School of Health Sciences
Dr. L Lobo
Centre of Community Medicine
AUMS, New Delhi’
Mrs. Pity Koul, Lecturer
School of Health Sciences
Prof. B.N. Koul (Format editing)
STRIDE. IGNOU
Dr. (Mrs.) Jogindra Vati
Ex-Lecturer, School of Health
Sciences, IGNOU
Production
Director
School of Health Sciences
IGNOU
Sept. 1997 (Reprint)
© Indira Gandhi National Open University, 1994
ISBN-81-7263-554-0
AU rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other
means, without permission in writing from the Indira Gandhi National Open niversity.
Further information on the Indira Gandhi National Open University courses may be obtained from the
University’s office at Maidan Garhi, New Delhi-110 063
Printed and published on behalf of the Indira Gandhi National Open University, New D
Director, School of Health Sciences, New Delhi.
Laier typeset by ADR Enterprises, G-51, Saket 110 017
Printed at Mis. Prabhat Offset Press, Darya Ganj, New Delhi-2
by he
COURSE INTRODUCTION ,
India comprises 80 per cent of rural population. There is a great imbalance in provision
of medical care facilities and it has become a great challenge to provide health services
to underserved population. Primary health care has been considered as the main
instrument of action for providing Health For All.
Primary health nursing addresses to the health needs of the community at all levels of
care — primary, secondary and tertiary, in homes, school, health centres and hospitals
etc.
The course on primary health nursing is divided into four blocks.
Block 1 deals with the concepts related to Health For All which focus on how goal of
health for all can be achieved and what type of services are needed to achieve this goal.
Block 2 focuses on Family Health Care which focuses on the concepts and services
provided to the family. Block 3 deals with Maternal and Child Health Care. Study of
maternal and child health is extremely essential because these constitute the larger and
vulnerable segment of population. Block 4 explains the various elements of primary
health care and the role of nurse in providing primary health care related to all these
elements.
After studying the course on Primary Health Nursing, you should be able to:
•
Explain the concepts of Health For All and Primary Health Care,
•
Explain the concepts related to Family Health Care,
•
©
Provide Maternal and Child Health Care, and
Perform your role as a nurse in providing primary health care.
BLOCK 1 HEALTH FOR ALL
In India the development of health services through primary health care approach is
started with the recommendations and guidance provided by the Health Survey and
Development Committee (Bhore Committee, 1946) followed by various committees. The
International Conference held in Alma-Ata in 1978 declared primary health care as the
main instrument of action towards achieving Health For All by the year 2000 AD.
Government of India agreed upon the Primary Health Care approach for providing
health care services. As health care providers, we all need to understand and/or refresh
our knowledge and skills related to the concepts of primary health care, and Health For
All etc. We must also be interested to learn and understand how the goal of health for
all can be achieved? What type of health manpower and health system is required for
providing the health services and how should we evaluate such services.
This block is divided into five units. Unit 1 deals with Health Concepts and
pre-requisites. Unit 2 explains the Primary Health Care concept and principles, Unit 3
deals with Health For All, Unit 4 focuses on Organisation of Health Care System at
various levels, and Unit 5 explains the Resources, Monitoring and Evaluation of Health
Services.
As a distance learner you have to study these materials by self study. We have given
check your progress questions at appropriate places. These arc given to make self
assessment. We have also given answers to check your progress questions at the end of
each unit. While working on check your progress questions you should not read through
these answers. Instead you should make every effort to do them by yourself. We hope
the information given in this block may help you in improving your knowledge and skill
so as to provide effective health care to the people you serve.
UNIT 1 HEALTH CONCEPT AND
PREREQUISITES
Structure
1.0
1.1
1.2
1.0
Changing Concepts of Health
Definitions of Health
Health a Relative Concept
Dynamics of Health
Physical Dimension
Mental Dimension
Social Dimension
Spiritual Dimension
Determinants of Health
1.4.1
1.4.2
1.4.3
1.4.4
1.4.5
1.5
1.6
1.7
1.8
\c
Dimensions of Health
1.3.1
1.3.2
1.3.3
1.3.4
1.4
Vcc_\vx^ <_Jl
Objectives
Introduction
Health Concept
1.2.1
1.2.2
1.2.3
1.2.4
13
'V'vAV-V
Heredity
Environment
Life Style
Socioeconomic Conditions
Health and Family Welfare Services
Prerequisites of Good Health
Let Us Sum Up
Glossary
Answers to Check Your Progress
OBJECTIVES
In this unit you will learn the concept of health and prerequisites of health. After
completing this unit, you should be able to:
Explain the concept of health, .
Define health,
List and explain the various dimensions of health,
©
Discuss determinants of health, and
List and explain prerequisites of health.
1.1 INTRODUCTION
You have already studied the concepts of health in your basic Nursing Programme.
We shall now review and try to build on that in order to help you gain a deeper
understanding of health. This will enable you to develop knowledge and skill in
promoting the health of the people you serve.
Health is considered a fundamental human right and a worldwide social goal.
In this unit, we shall try to concentrate on the concept and definition of health
and the concept of positive health and well-being. An individual is said to be healthy
if he enjoys good health in four areas or dimensions i.e. physical, mental, social and
spiritual well-being. These dimensions will be explained in Section 1.3. Health is
affected by various interlinked factors. We shall examine how these factors affect
health in Section 1.4. At the end you will learn about the prerequisites of good health.
W hope that this knowledge will help you to contribute effectively towards promotion
°f health.
n
-
* 1
5
Health for All
1.2
HEALTH CONCEPT
Every individual and, in fact, all communities have their own concept of health, which
has some relationship with their culture. The oldest concept of health is “absence of
disease”. Even now, maintenance of health is neglected except in conditions of ill-health.
It is only during the past few decades that health is conceived as a fundamental human
right and a worldwide social goal; that is it is essential to the satisfaction of basic
human needs and an improved quality of life. It is to be attained by all people. The
perception of health varies among the members of a community including various
professional groups (e.g. biomedical scientists, social scientists, specialists, health
administrators, ecologists, etc.) which give varied views on the concept of health. You '
will learn about these changing concepts in the following subsection.
1.2.1 Changing Concepts of Health
Health has evolved as a concept from an individual concern to a worldwide social go^
and encompasses the whole quality of life. A brief account of changing concepts of
health is given below. Figure 1.1 will give you an overview of changing concepts of
health. These are :
”
i)
6
Biomedical concept
ii)
Ecological concept
iii)
Psychosocial concept
iv)
Holistic concept
i)
Biomedical Concept: This concept stresses the germ theory i.e.,disease or
ill-health is caused due to disease causing organisms. The individual was
considered to be healthy only if he was free from disease. The human body
was viewed as a machine and disease was considered a consequence of the
breakdown of the machine; and one of the doctor’s tasks was to repair the
machine. This concept was criticized on the basis that it had minimized
the role of social, environmental, psychological and cultural determinants of
health.
This model was found to be inadequate to solve some of the major health
problems (e.g. malnutrition, chronic diseases, accidents, drug abuse, mental illness,
environmental pollution, population explosion). In other words, we can say that
this concept focussed on the view that diseases can only be caused by the
organism without taking other causative factors into consideration. For example,
typhoid, cancer, malaria, hepatitis and accidents all lead to disease and/or ill-health
of a man; but you will agree that only typhoid, malaria and hepatitis are caused by
organisms whereas cancer and accidents are not. So this concept needed to be
changed.
ii)
Health Concept and
Prerequisites
Ecological Concept: Dubos defined health as the relative absence of pain and
discomfort and a continuous adaptation and adjustment to environment to ensure
optimal function, which leads to longer life expectancy and a better quality of life.
Ecology focuses on mutual relationship between man and his environment and
visualizes health as a dynamic equilibrium between man and his environment.
Maladjustment of a human being to his environment results in disease.
The ecological concept raises two issues, imperfect man and imperfect
environment For example, environmental pollution caused by deforestation and
urbanisation, resulting in water pollution, overcrowding and air pollution creates
an imbalance between man and environment thus affecting his health.
iii)
Psychosocial Concept: This concept visualizes health not only as a biomedical
phenomenon but that it is also influenced by various other factors, e.g. social,
psychological, cultural, economic and political. These factors are essential in
defining and measuring health. This health is both a biological and social
phenomenon.
If we are physically tired, our capacity to respond to social interactions will be
diminished. Some studies have shown that single people who live isolated,
friendless lives, face a much greater chance of becoming ill or dying than people
with close relatives and good friends.
iv)
Holistic Concept: This concept is a synthesis of all the concepts mentioned above.
It focuses on the impact of socioeconomic, political, environmental and biomedical
influence on health. It sees the well-being of a person as a whole in the context of
his total environment.
The holistic approach to health insists that total good health and well-being can be
achieved only by understanding the whole person in a perspective that includes
physical, mental, social and spiritual dimensions. All these four aspects are not
separate but they are constantly interacting. In other words, we can say that it
corresponds to the ancient view that health implies a sound mind in a sound body,
in a sound family and in a sound environment
We know from our daily experience that problems in one area of our lives affect
other areas as well; emotional strain and conflicts can lower our resistance to
illness.
Check Your Progress 1
i)
Traditionally health is viewed as absence of
ii)
Changing concepts of health include
ii)
a)
..................................................
b)
............................................
c)
............................
d)
....................................................
Tick ( V ) the diseases caused by an organism:
a)
Malaria
b)
Typhoid
7
c)
Health for All
iv)
Cancer
d)
Poisoning
c)
Hepatitis
f)
Accidents
Explain the ‘holistic approach’ to health.
1.2.2 Definitions of Health
We understand the meaning of health but still we find.difficult to define it. Different
people have different perceptions of health. Some feel,that when an individual is free
from any sickness or disease he is healthy; others feel that an individual is said to be
healthy if he is able to perform activities of daily living normally. Still others feel that
an individual is healthy if he is well adjusted in social life and can function effectively
even in stressful situations. What exactly is meant by health? You will be able to
understand better if you go ihrough the following definitions.
Health is defined as:
a)
The conditions of being sound in body, mind or spirit and especially free from
physical disease or pain (Webster).
b)
Soundness of body or mind; that condition in which their functions are duly and
efficiently discharged (Oxford English Dictionary).
c)
A condition or quality of the human organism expressing its adequate functioning
in.given conditions — genetic and environmental.
d)
“A state of relative equilibrium of body, form and function which result
from its successful dynamic adjustment to forces tending to disturb it.
It is not passive interplay between body substance and forces impinging
upon it but an active response of body forces working towards readjustment.”
(Perkin)
The above mentioned definitions give varied views of health. We shall now try to look
into the most widely accepted definition of health given by World Health Organisation
(WHO) which states:'
Health is a state of complete physical, mental and social well-being and not
merely an absence of disease or infirmity.
If you look at the definition carefully, you will realize that three aspects or
dimensions emerge from it. These are: (a) Physical (b) Mental and (c) Social.
Physical well-being means having the physical strength, endurance and energy to
work towards your goals. Mental well-being is ability to cope with the world in a
way that brings you satisfaction; social well-being means development of
relationships with others -— both with people in your immediate surroundings
and with the larger community through cultural, spiritual and political
activities.
This also implies that goal of health now calls for not only the cure or alleviation
of disease. It calls for even more than prevention of disease. Rather it looks beyond, to
strive for maximum physical, mental, and social efficiency for the individual, for
his family, and for the community.
8
Check Your Progress 2
Health Concept and
Prerequisites
i)
Health is defined as a state of relative
of body,, form and
functions by its dynamic adjustment to forces that disturbs it.
ii)
Health is defined by the World Health Organisation as:
1.2.3 Health as a Relative Concept
Health is a relative concept; this may be due to ecological conditions and the fact that
standards of health vary among cultures, social classes and age groups.
This implies that health is not an ideal-state and there are no international standards
fixed for health. We cannot say that individuals of the same age, belonging to different
countries and cultures will have the same health standards. There may be variations in
weight and height of an individual belonging to different countries and socioeconomic
groups but both will be healthy. We can further clarify this concept by the following
example:
A new bom baby in India weighs 2.8 kg. on an average compared to 3.5 kg. in
the developed countries and yet compares favourably in health.
1.2.4 Dynamics of Health
The concept of health dynamics visualizes health as a dynamic phenomenon and as a
process of continuous change, i.e. the health of an individual keeps on changing and is
not static. It varies within a continuum that ranges from optimum well-being to various
levels of dysfunction including the state of total dysfunction, namely death. Health and
sickness form a continuum ranging from total well-being to death with many
intermediate stages.
You can also say that health is a dynamic quality of life rather than a static entity. No
longer is the individuals thought of as being “healthy ” or “ unhealthy ”, Individuals
might function normally throughout a day with varying degrees of efficiency, depending
upon the many factors which affect their state of well-being which fluctuates on a health
continuum rather than remaining static at one point (sec Fig. 1.2).
Optimum well-being
Fig. 1.2: Health continuum
Health is not merely a continuum of physical well-being or of mental,
spiritual or social well-being but a combination of all four dynamically
interrelated.
If you look at Fig. 1.3, you will find that health and sickness lie along a continuum.
The lowest point of the scale is death and the highest point corresponds to positive
health. A person may be healthy today but may fall sick tomorrow. The transition from
optimum health to ill-health can also be rather gradual.
9
Health for All
Positive health
Well-being
Better health
Freedom from sickness
Unrecognised sickness
Mild sickness
Dysfunction
Severe sickness
Death
Fig. 13: The Health and Sickness Scale
Check Your Progress 3'
i)
State true or false (use T for true and F for false)
a)
ii)
Standards of health vary among cultures, social classes and age groups.
b)
There are no fixed international standards of health.
c)
Health is static.
The health of an individual keeps on changing on a........................... which
ranges from optimum well-being to various levels of dysfunction.
DIMENSIONS OF HEALTH
1.3
The definition given by WHO as mentioned above (in sub-section 1.2.2) covers three
dimensions of health, i.e. physical, mental and social (Fig. 1.4). But as per the advances
in knowledge you can think of more dimensions which could be spiritual, emotional,
vocational and political, etc. Of these we shall focus mainly on three dimensions and
also the spiritual dimension.
Fig. 1.4: Dimensions of Health
1.3.1
Physical Dimension
It means normal functioning of a body or we can say that it is a state of health in
which every cell of the body functions at optimum level and there is a balance in
functioning within organs and the systems of body. Physical health includes a good
complexion, clean and healthy skin, good body maintenance, good clothing, cleanliness,
good appetite, happy disposition, sound sleep, regular activity of bowels and bladder.
Other signs include normal pulse rate at rest, normal blood pressure and normal
exercise.
We spoke about physical health and its components, now we shall talk about assessment
of physical health .which includes:
self assessment of overall health
10
— general observation
— clinical examination
— nutrition and dietary assessment
— biochemical and laboratory investigation.
You will know more about this under Block 2 in Family Health Care and in your
courses in II year.
If you are working in a community, the overall health status of the community can be
assessed by knowing the mortality rate and life expectancy of the community.
1.3.2 Mental Dimension
As we said that health is more than mere absence of illness, similarly we can say that
mental health is not merely the absence of mental disease or mental illness. Mental
health and physical health are interdependent A poor mental health adversely affects the
physical health and vice versa. Mental health is the ability of an individual to adjust to
varied situations and to respond to varied experiences with a sense of purpose and with
flexibility. Mental illness is not simply the absence of mental illness but it is the ability
to find happiness and fulfillment to adjust and change and to grow throughout one’s life.
Mental health is happiness; the ability
o
to get along with other people
o
o
to cope up with the demands of the world without undue stress
to be satisfied with the sense of achievement and personal fulfillment.
Mental health has been defined as:
o
a state of balance between the individual and the surrounding world
o
stale of harmony between the individual and the surrounding world
©
state of harmony between oneself and others
o
a coexistence between the realities of self, those of other people, and the
environment.
Mental ill-health can lead to disturbances in physical and psychological functioning of
body and may lead to illness like hypertension, peptic ulcer and bronchial asthma.
We hope you have now understood the definition of mental health. We will now
explain the characteristics or attributes of a mentally healthy person.
a)
A mentally healthy person is free from internal conflicts, he is not at ‘War* with
himself.
b)
He is well adjusted, i.e. he is able to get along well with others. He accepts
criticism and is not easily upset.
c)
He searches for identity.
d)
He has a strong sense of self esteem.
e)
He knows himself, his needs, problems and goals.
f)
He knows his strengths and weaknesses.
g)
He has good self control—balances rationality and emotionality.
h)
He faces problems and tries to solve them intelligently, i.e. problems of stress and
anxiety.
1.3.3 Social Dimension
We spoke about the physical and mental dimensions. Now we come to the third
dimension of health, i.e. social health. This aspect visualizes the individual as a member
of a family, community and the world and focuses on the well-being of a. person
socially and economically.
Social well-being has been defined by J.E. Park as:
“The quality and quantity of an individual’s interpersonal ties and extent of
involvement with the community.”
Health Concept and
Prerequisites
Health for All
This means that social well-being implies harmony and integration within the individual,
between each individual and other members of society and between individuals and the
world in which they live.
The social dimension includes practising social skills, social functioning and the ability
of a person to see himself as a member of larger society.
If you try to recall the discussion on the dimensions of health, you will realize
that all the three are interrelated and interdependent. We cannot take them in
isolation. If an individual is physically unhealthy, this will affect his mental
health as well as social health and vice versa. If physical health is affected, there
will be imbalance within the individual which will affect his mental as well as social
health.
1.3.4 Spiritual Dimension
You will agree that another important dimension which could be examined is the
spiritual dimension. This includes a study of principles of ethics, beliefs, purpose
in life and commitment to some higher being. Spiritual well-being is not in isolation
from mental well-being of a person. It is now believed that spiritual values
influence our behaviour and mental well-being e.g. if you do meditation, it helps to
keep you free of mental worries and stresses of daily life and gives freshness and
peace of mind.
To sum up the above discussion on dimension of health we can say that the individual
functions as a whole or as an integrated unit with each dimension of health having an
influence upon other dimensions. For instance physical illness has an effect on one’s
emotional well-being, spiritual state and social relationships. The psychosomatic aspects
of health also illustrates dynamic interrelation among these dimensions of health. For
example, an individual beset with social and emotional problem has a physical problem
of high blood pressure or peptic ulcer.
All the concepts related to dimensions of health introduce us to the concept of positive
health which can be slated as follows:
If an individual is in a state of well-being biologically, psychologically, socially
and spiritually he is said to have positive health.
The next question is: what are the factors that affect the health of an individual? The
answer to this question is given in Section 1.5, i.e. determinants or factors affecting
health.
Check Your Progress 4
i)
What are the main dimensions of health?
a)
.....................................................
b>
'
c)
:............. -
................... -.................................................................................................... .......
d).................................................................... =........... ..................................................... '
ii)
'Fill in the blanks:
a)
Physical well-being means optimal
of body and there is
a balance within the organs and systems of body.
b)
Mental health is the ability of an individual to......................••
situations.
c)
Social well-being implies harmony and
................ •••• within the
individual, between individuals and other members of society.
12
Health Concept and
1.4
DETERMINANTS OF HEALTH
Prerequisites
\
The health of an individual is affected by factors within the individual and within the
society in which he or she lives. These factors may be health promoting or deleterious.
These factors are given below (Fig. 1.5).
Fig.1.5: Determinants of health
o
Heredity
e
Environment
o
Life Style
o
Socioeconomic conditions
o
Health and family welfare services
We shall now discuss these determinants in detail.
1.4.1 Heredity
An individual’s physical and mental characteristics are inherited from his parents and
these physical and mental traits of an individual are determined by genes during
conception. The health of the mother, her nutritional status, the drugs she takes and the
investigation she undergoes influence the health of the foetus. The genetic characteristics
cannot be altered after conception and the genetic influence of the parents can lead to
some genetic disorder in the child, which could be chromosomal anomalies like,
haemophilia and Down’s syndrome, errors of metabolism and mental retardation, etc.
Thus the health status of an individual depends to some extent on his genetic
constitution.
1.4.2 Environment
Environment refers to the surroundings in which an individual lives. The environment
may be internal as well as external. The internal environment or microenvironment
pertains to the tissues, organs and systems of the body and the harmonious relationship
between them. The external environment or macroenvironment consists of all those
things to which an individual is exposed after conception—such as, air, water, food,
housing, etc. Environment is divided into three components: physical, biological and
psychosocial; each of these have a direct impact on the physical, mental and social well
being of human beings. Now we shall have a quick look at different types of
environment.
i)
Physical environment
Physical environment includes housing, water, air, light, noise, excreta disposal, etc.,
with which man is in constant interaction. A defective physical environment continues
to be a major health problem in developing countries including India.
13
Health for All
The environmental hazards could be water pollution, air pollution, noise pollution and
urbanization, etc. We shall further try to explain this with the example given below.
Consider that if a person lives in an environment where there are no sanitary drains, no
proper housing, no proper disposal of refuse and excreta and no water supply. There
will be fly breeding. You can now imagine the hazards that man will be exposed to in
this physical environment which will affect his health. These hazards would be
diarrhoea, cholera, typhoid etc. On the contrary, if he lives in a safer environment, with
proper sanitary conditions, he is less exposed to hazards of health.
ii)
Biological environment
Biological environment includes all living things which surround man, including man
himself. The living things may be viruses, bacteria, insects, rodents, animals and
plants — some of which may act as disease producing agents, reservoirs of infection,
intermediate host and vectors of diseases in their interaction with man.
iii)
Psychosocial environment
Psychosocial environment refers to the people who live around the individual — may be
at home, at school, at workplace, at neighbourhood and in professional organisation.
This implies that man is a member of a social group, member of a family, of a caste, of
a community and of a nation. If a person has healthy interactions with all these groups
he feels healthy and happy. If he is frustrated in his interactions he feels mentally
unhappy, which affects his health.
1.4.3 Life Style
Life style refers to the way of living or the way the people live. It reflects social values,
attitudes and activities of an individual. It refers to the way we behave, work, eat, rest,
sleep, and perform other activities of daily living. It consists of cultural and behavioural
patterns and personal habits of an individual. Life style affects the health of an
individual. A healthy life style helps to promote health and a poor life style has ill
effects on health. For example in India due to persistence of a poor traditional life style,
there are risks of death and illness connected with lack of sanitation, poor nutrition,
personal hygiene habits, customs and cultural patterns. Some life styles can promote
health, e.g. adequate nutrition, enough sleep, sufficient physical activity, adequate
education and employment
Many of our health practices are those that we have learnt from our parents or have
adopted at an early age. These have become so intricately woven into the fabric of our
current health behaviours that to become aware of them and their possible harmful
effects requires a conscious effort to examine our lives from the perspective of health.
We further have to make a concerted effort to change habits which die hard, e.g.
dangers of cigarette smoking are well known; every cigarette pack carries a warning that
‘Cigarette smoking is dangerous to health’ and also there are media campaigns to alert
people to this danger; but despite this people continue to smoke.
Another factor is the quality of modem life styles which are often the source of health
problems. Due to a fast moving life, man is exposed to stress and strain which are
caused by pollution, poor nutrition and psychological stress.
1.4.4 Socioeconomic Conditions
The health of an individual is determined by his socioeconomic development, e.g. per
capita G.N.P., education, nutrition, employment, housing and the political system of the
country. We sail glance through these components to have an overview.
i)
Economic status: This is an important factor in seeking health care as it determines
the purchasing power, standards of living, life style and family size—which affects our
health.
14
ii)
Education: This is a major factor which influence health. Illiteracy leads to
ignorance which can result in poverty, malnutrition, high infant and child mortality rates
etc. Even if the health facilities are available the people, because of ignorance, will not
be in a position to avail them. They also will not have healthy habits, thereby leading to
ill-health.
iii) Occupation: This is a crucial factor which determines health. A person who is
involved in some productive work or is employed will be healthy as compared to one
who is unemployed; because unemployment means loss of income and inability to meet
even basic needs. This can result in physical as well as mental damage.
iv) Political system: The health system is influenced by the political system of the
country. Implementation of health technologies, choice of technology, resource
allocation, manpower policy, and the degree of availability and accessibility of health
services depends, to greater extent, on political will and political decisions. This affects
the health of a community as a whole. Poor health patterns can only be changed by
changing the entire socio-political system in a given community. The health hazards of
the people related to their working and living environments can only be removed by
social, economic and political actions.
1.4.5 Health and Family Welfare Services
The health services cover a wide range of individual and community services for
prevention and treatment of disease and promotion of health. Health and Family Welfare
Services aim at improving the health status of a population. This concept is clarified in
the following example:
Immunizing the children can reduce the threat of incidence of communicable diseases
like Polio, Diptheria, Whooping cough. Water-bome disease can be prevented by
provision of safe and wholesome water supply to a community. Maternal and child
health services will help to reduce the morbidity and mortality, in women and children.
If we analyze the above examples we can conclude that immunization provision of safe
water, and care of pregnant women are the health and family welfare services
preventing communicable disease, water-bome disease and infant and maternal mortality
which is the ultimate goal of the health services.
Check Your Progress 5
i)
List the various determinants of health.
ii)
Recall any situation in your social environment which has made you feel happy.
Give two reasons for your happiness (use the blank space for writing the answer).
1.5
PREREQUISITES OF HEALTH
We hope you have now got a better idea about the determinants of health i.e. what
factors affect the health of an individual and the community as a whole. Having
assimilated all these ideas, you are now in a better position to identify some of the
prerequisites of health. These could be identified at three levels.
at the level of individual
i)
ii)
at the level of the environment
iii)
at the level of the society
Health Concept and
Prerequisites
Health for All
Let us elaborate each level, as follows:
i)
At the level of individual: In order to be healthy, an individual has to
•
ii)
iii)
follow hygienic practices which include cleaning and care of each body part,
clothing, footwear, etc;
•
take a well balanced diet;
•
avoid unhealthy practices — overeating, undcreating, smoking, drinking, using
drugs, immoral behaviour;
•
take good rest, sleep well, do active and passive exercises and select healthy
recreational activities; and
•
resort to preventive screening and take immunizations.
At the level of the environment: The prerequisites for a healthy environment
include:
•
Sanitary housing
•
•
Safe water supply
Clean air
•
Standard light and sound
•
•
Safe surroundings — proper measures to avoid accidents
Proper disposal of excreta
•
Good placement of school, hospital, recreation facility, markets, parks,
trees, slaughter houses, etc.
•
Removal of harmful vectors.
At the level of the society: As you know, an individual cannot be healthy, if his
social environment i.e. the harmonious relationship and adjustment with his
surroundings, is not good. So to enjoy positive health, an individual should seek:
•
Good social relationship and working condition in the family;
•
Healthy relationship and good working conditions in the workplace;
•
Good social relationship with the neighbourhood; and
•
Association with professional organisations.
1.6 LET US SUM UP
In this unit, we have discussed the concept of health which traditionally means the
absence of disease. The definition of health by WHO which states “Health is a
state of complete physical, mental, and social well-being and not merely the absence
of disease.” Relative concept of health, i.e. we cannot set international standards of
health and the health of an individual varies from culture to culture and country to
country. We also explained dimensions of health, i.e. physical dimension which
refers to the physical well-being of an individual; mental dimension refers to the
ability of an individual to adjust to varied situations and act purposefully and the
social dimension which relates to the relationship of an individual with the society or
the people with whom he lives. If an individual experience well-being in all these
dimensions, he is said to enjoy positive health. You have also learnt about the
determinants of health which include: heredity—the effect of genes on the physical
and physiological characters of an individual; environment, i.e. physical, biological
and psychosocial environments of the individual which influences health, and his life
styles or ways of living (the standards of living, i.e. eating, behaving, rest, sleep, etc.);
socioeconomic conditions, i.e., level of income and education which affect the
health of an individual and health services which cover individual and community
services for prevention and treatment of disease. At the end, we talked of
prerequisites of good health which include healthy and hygienic practices, good
environmental condition and social well-being.
16
1.7
Health Concept and
Prerequisites
GLOSSARY
Adaptation
:
Change or response to stress of any kind; may be normal,
self protective, or developmental.
Causative factor invading a susceptible host through a
favourable environment to produce disease.
Agent
Bacteria
:
Single celled organism that reproduces ascxually.
Culture
:
Standards for decisions on what is, what can be, how to feel,
about it and how to do it.
The prevailing and persistent guides influencing, thinking and
actions of people within a culture.
Cultural values
Gene
A
:
basic unit of genetic information located on the chromosome.
ANSWERS TO CHECK YOUR PROGRESS
1.8
Check Your Progress 1
i)
Disease
ii)
a)
b)
c)
d)
iii)
iv)
a, b, c
The holistic approach to health is achieved by understanding the whole person in a
perspective that includes physical, mental, social and spiritual dimension.
Biomedical concept
Ecological concept
Psychosocial concept
Holistic concept
Check Your Progress 2
i)
Equilibrium
ii)
Health is a state of complete physical, mental and social well-being and not
merely and absence of disease or infirmity.
Check Your Progress 3
i)
a)
b)
c)
ii)
Continuum
True
True
False
Check Your Progress 4
i)
.i) Physical
b) Mental
c) Social
d) Spiritual
ii)
a)
b)
c)
Functioning
Adjust
Integration
Check Your Progress 5
Heredity
Environment
Life style
Socioeconomic conditions
Health and Family Welfare Services
i)
a)
b)
c)
d)
c)
ii)
Write your own.
17
UNIT 2 PRIMARY HEALTH CARE —
CONCEPT AND PRINCIPLES
Structure
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.0
Objectives
Introduction
Primary Health Care — the Concept
Definition and Elements of Primary Health Care
2.3.1
Definition
2.3.2
Elements of Primary Health Care
Principles of Primary Health Care
2.4.1
2.4.2
2.4.3
2.4.4
Equitable Distribution of Resources
Manpower Development
Community Participation
Appropriate Technology
2.4.5
Intersectoral Coordination
Role of the Nurse in Promoting Primary Health Care
Let Us Sum Up
Answers to Check Your Progress
OBJECTIVES
In this unit you will learn about the concept of Primary Health Care (PHC) and the
related principles. On completion of this unit, you should be able to:
•
Discuss and explain the concept of primary health care,
•
Define primary health care,
•
List the elements of primary health care,
•
Explain the principles of primary wealth care, and
•
Explain and illustrate the role of a nurse in promoting primary health care.
2.1 INTRODUCTION
In Unit 1 you have learnt about the concept of health and prerequisites for good health.
You were explained that health is a state of physical, mental and social well-being of an
individual. It is not merely the absence of disease or infirmity. You have also
understood how health is affected by many factors, like heredity, environment, ways of
living, socioeconomic status, health services etc. Now you may be interested to know
how an individual or community can attain these three important dimensions or aspects
of health: namely, physical, mental and social well-being. The answer to this question is
given in this unit i.e. by focussing on primary health care so that individual can attain a
desirable level of health.
You know that during the last two decades the common slogan for health, in all
countries, has been “Health For AU”; and India is politicaUy committed to achieve
this goal. The Alma Ata Declaration has stated that primary health care is
the strategy to achieve this goal. In this unit you will learn about the concept
of primary health care, which is considered to be an essential care, which is
acceptable, accessible and affordable to an individual, community and the
country as a whole. You will also learn about Alma Ata Declaration and the
components of primary health care. The principles of primary health care are
explained in Section 2.5. At the end we will discuss the role of the nurse in
promoting primary health care.
- 18
2.2
PRIMARY HEALTH CARE — THE CONCEPT
Primary Health Care —
Concept and Principles
You have heard and learnt about primary health care and all of you are providing this
care in the areas of your practice i.e. hospital, clinic or community setting. Before we
start the discussion on this concept, you should try to decide which kind of care the
nurse is providing in each of the situations described below:
•
A nurse assisting a Surgeon in mitral valvotomy in a specialised institution;
o
•
A nurse assisting a doctor while doing appendectomy in a district hospital; and
A Female Health Worker immunizing a child at a subcentre.
If you think for a while, you will be able to realize that the female health worker is
providing primary health care but the other two nurses arc engaged in secondary or
tertiary care.
Primary health care is now a widely disseminated concept, but most of us are still not
clear as to its current meaning. We shall, therefore, try to explain how the concept of
PHC has evolved.
You know when a new programme or technology in any area is implemented, it
becomes imperative to evaluate its effectiveness. It is the same with health care
approaches. Primary health care has evolved from re-examination and evaluation of
existing health care approaches and assimilation of new experiences. The
implementation of new knowledge and technology in terms of vertical programme, for
eradication of disease did not achieve expected results and it was realized that there
was a need for establishment of permanent health services in rural areas to deal with
the day-to-day work in the control and prevention of diseases and promotion of health
(see Fig. 2.1).
Fig. 2.1: Concept of Primary Health Care
It was realised that the world’s priority health problems required development of new
approaches for their solution. Hence the approach in health services was shifted from
curative to a preventive approach; from urban to rural populations; from privileged to
the underprivileged; from unipurposc to multipurpose workers and from vertical mass
campaigns to a system of integrated health services forming a component of overall
social and economic development.
19
Health for All
Based on this, a shift in emphasis on health services to Basic Health Services
Approach was conceptualised in 1970. This concept focused on increasing
accessibility and availability of health services to the rural populations of
developing countries. It was conceived as first level care or first contact care.
Now the concept of Basic Health Services paved the way for Primary Health
Care; the ideas contained in Basic Health Services were further expanded to cover
accessibility, availability, acceptability, affordability and appropriateness of
health services.
In May 1977, the Thirtieth World Health Assembly adopted a resolution in which it
was decided that the main social target of Governments and of the World Health
Organization in coming decades should be “Health For Ail” by the year 2000 A.D.
The basis of “Health for All” strategy is the Primary Health Care. In 1978, an
international conference on primary health care was held at Alma Ata in USSR. jointly
by WHO and UNICEF. This led to the concept of Primary Health Care. This concept
of PHC was recommended by various health committees in our country starting from
1946.
We shall briefly highlight the recommendations of these committees.
If you review reports and recommendations of various committees on health you will
realize that the concept of primary health care dates back to various Health Committees
constituted from time to time. Among these, the Bhore Committee (1946), Mudaliar
Committee (1961), Multipurpose Health Worker Scheme, Kartar Singh Committee
(1974), Community Health Worker Scheme (1977), serve as milestones in the history of
Primary Health Care in India. We will not go into the details of these Committees but
just take a brief look at the suggestions made by each.
•
The Bhore Committee, also known as Health Survey and Development Committee,
besides suggesting a health system design, laid special emphasis on certain basic
essentials like suitable housing, sanitary surroundings and provision of safe
drinking water. You can appreciate that these essentials arc now the components
of PHC.
e
A Community Development Programme was launched in October 2, 1952;
and it was proposed to establish one Primary Health Centre with three subcentres
for every Community Development Block covering a population of about 60,000.
Primary health centres were conceived as the nuclei for providing the services like
medical care, control of communicable disease, maternal and child health (MCH),
environmental sanitation and collection of vital statistics through the network of
subcentres. So you can understand that PHC concept was stressed here also.
•
Next we come to the Health Survey and Planning Committee (Mudaliar
Committee, 1961) which studied the functioning of Primary Health Centres and the
progress made. Besides other recommendations, the committee suggested greater
use of auxiliary health personnel.
•
On the recommendations of the Kartar Singh Committee (1973), Family
Planning and MCH were integrated. Our government decided to adopt an
integrated approach towards the deliver)' of health services by introducing the
multipurpose health worker scheme and the utilisation of services of health
supervisors.
•
Minimum Needs Programme was introduced during the Fifth Five Year Plan
(1974-79) to give priority to development of rural health services. During the
Fifth Plan, the health components consisted of: establishment of one PHC for
each Community Development Block and one subcentre for every 10,000
population; making up of the deficiencies in buildings including residential
quarters for PHC staff; provision of drugs and upgradation of one PHC
(in every four PHCs) to 30-bedded Rural Hospital known as Community
Health Centres.
,
Look at Fig'. 2.2. You will get a clear idea about the development of PHC concept
20
4
Primary Health Care —
Concept and Principles
Basic essentials like housing,
sanitary surroundings.
Provision of state drinking water.
Creation of Public Health.Nurses in
the Primary Health Centres.
I
Kartar Singh Committee
1973
V Five Year Plan
1977
Minimum Needs
Programme
■>
Greater use of auxiliary personnel
for carrying out routine duties
rather than by highly trained doctors.
Manpower development,
training of nursing personnel at
different levels of service —
professional and auxiliary.
4
Multipurpose health worker scheme.
Integrated approach towards delivery
of health services by introducing
health worker scheme and utilization
of services of supervision.
Increase in the auxiliary nursing
personnel.
■»
Establishment of one PHC for each
community development block and
one subcentre for 10,000 population.
Provision of drugs, upgradation of one
PHC in every 4 PHCs to 30-beddcd
Rural Hospital known as Community
Health Centre.
Fig. 2.2: The development of PHC concept
This clearly indicates that PHC concept has its roots in the initial stages of our national
health care approach. Ultimately, after reviewing the health situation from time to time,
World Health Assembly, in its meeting in May 1977 decided that in coming decades the
slogan for all the countries should be to achieve the goal of ‘Health for All (HFA) by
2000 AD’. It was only after that the Primary Health Care (PHC) was considered to be
the strategy to achieve this goal. Later on, in 1978 an International Conference on PHC
was organised at Alma Ata in USSR, jointly by WHO and UNICEF, which made many
declarations in addition to defining Primary Health Care (PHC). We. hope you may be
interested to go through these recommendations which is given in Appendix^! and then
we shall tum our attention to the definition and elements of PHC.
With all the above concepts in mind, let us now concentrate on the definition of PHC.
Check Your Progress 1
i)
What is meant by Basic Health Services?
ii)
Basic Health.Service concept came in
iii)
A conference in Alma Ata was held in Sept
by
...................................
21
Health for All
2.3 DEFINITION AND ELEMENTS OF
PRIMARY HEALTH CARE
2.3.1 Definition
Primary Health Care is defined in Alma-Ata Declaration (1978). The Alma -Ala
Declaration states:
Primary Health Care is essential health care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation and at a
cost that the community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination.
If you look at the definition, you will find that it involves
•
accessibility, which means, continuing and organised supply of care that is
geographically, financially, culturally within easy reach of the whole
community;
•
acceptability implies that care has to be appropriate and adequate in quality and
quantity to satisfy the health needs of people and has to be provided by methods
acceptable to them within their socio-cultural norms;
•
affordable implies that whatever the methods of payment used, the services should
be affordable by community and country;
•
appropriate technology which means using appropriate methods, techniques and
locally available supplies and equipment which together with the people using
them can contribute significantly to solving a health problem.
Primary health care is based on socially accepted methods which the country can afford.
Thus self-reliance and self-determination are emphasised.
Thus we can say primary health care is a practical approach to making essential health
care universally accessible to individuals, families and community in an acceptable and
affordable way and with their full participation.
The significance of PHC is to have contact with members of the community for
providing continuing health care in the light of national health system.
PHC focuses on promotive, preventive, curative, rehabilitative and emergency care to
meet the main health problems in the community, giving special attention to the
vulnerable groups such as mother and child.
So combining all these ideas of Primary Health Care, we can briefly say that PHC is
based on socially accepted methods which the country can afford. Thus self-reliance and
self-determination are emphasized.
Check Your Progress 2
i)
Define Primary Health Care.
ii)
The key words in primary health care are
iii)
Tick ('V ) the appropriate PHC activities, from the list given below:
a)
A nurse is assisting the doctor in mitral valvotomy.
b)
A nurse is giving an intramuscular injection of antibiotic to an adult patient
having pneumonia.
c)
A Nurse is giving post-operative care to a patient who has undergone
appendictomy.
d)
A female health worker is immunizing a child at a subcentre.
e)
A nurse is giving Inj. T.T. in the hospital emergency room to a child who met
with a road accident.
2.3.2
Primary Health Care —
Concept and Principles
Elements of Primary Health Care
We hope our discussion on concept and definition of PHC may have benefited you.
Now you will be interested to know what does this Primary Health Care include
or what type and what level of care is involved. The eight essential elements
or components of Primary Health Care as outlined in the Alma-Ata Declaration
are:
o
Education concerning prevailing health problems and the methods of preventing
and controlling them;
o
Promotion of food supply and proper nutrition;
o
An adequate supply of safe water and basic sanitation;
o
Maternal and child health care including family planning;
o
Immunization against major infectious diseases;
o
Prevention and control of locally endemic disease;
o
Appropriate treatment of common diseases and injuries; and
•
Provision of essential drugs.
We shall only list these elements here. These are described in detail in Block 4 of this
course (HS 1TI, Block 4, Units 1-6).
Hope you have got the idea of the components of Primary Health Care. In order to
achieve the target of Health For All (HFA), every health professional should be
committed and concerned with the above care context so that he makes it a part of his
daily health care practice.
Check Your Progress 3
i)
Which of the above mentioned components do you think nurses have a major role
to play?
ii)
Select one component and give two reasons.
To conclude, primary health care has evolved partly in the light of experience,
positive and negative, gained in basic health services in a number of countries.
With this understanding and definition of Primary Health Care and its elements we
introduce you to the principles of Primary Health Care which are given below.
23
Health for All
2.4 PRINCIPLES OF PRIMARY HEALTH CARE
The description and meaning of the five basic principles which provide the framework
of the Primary Health Care Approach can be summarized as follows:
i)
Equitable distribution of resources
ii)
Manpower development
iii)
Community involvement or participation
iv)
Appropriate Technology
v)
Intersectoral Coordination
These principles are indicated in Fig. 2.3. Let us now briefly discuss each of these
principles.
Fig. 23: Principles of PHC
2.4.1 Equitable Distribution of Resources
As you know, the attainment of a high level of health is the fundamental right of an
individual or you can also say that all human beings' have an equal right to health. You
will be interested to know how people can ensure this right The answer is that all the
people of the world/country should be provided with equal opportunities to develop
health to the fullest and to maintain i. So we can say that equitable distribution means
that health services must be shared equally by all people irrespective of their ability to
pay; and all the people—rich or poor, rural or urban—must have access to the health
services.
It you look at health statistics you will find that the health situation as indicated by
health status indicators, e.g. Infant Morality Rate (IMR), Maternal Mortality Rate
(MMR), Birth Rate (BR), Death Rate (DR), etc. is lower in urban areas than in rural
areas. Why this difference? It is because health services are mainly concentrated in cities
and towns thus resulting in inequality of care for rural people. These statistics reflect
how health related resources are distributed within the countries—including access to
health services, education and income-earning opportunities. This is called social
injustice.
The inability to receive health care services by majority of rural people and those living
in urban slums is inaccessibility.
The main aim of PHC is to bridge this gap by shifting this concentrated health care
system from cities or urban areas (where three quarters of health budget is spent) to the
rural areas (where three quarters of people live) and bring the services as near as
possible to them.
The other feature of health equity in society is health status of women and the disparity
in health between genders which indicates that women suffer more from health problems
than men. This is a critical indication of health inequality. What can you, as a health
care provider do? You can only provide care to an individual, diseased/or healthy,
irrespective of any disparity; but, in general, these facts call for explicit policies and
strategies to reduce inequalities in health.
24
2.4.2 Manpower Development
The manpower development in the context of health includes both professional and
auxiliary health personnel, members of community and supporting staff.
Primary health care, aims at mobilizing the human potential of the entire community by
making use of all av^lable resources. This can only be achieved if the individuals and
families accept greater responsibility for their health.
The requirement of health manpower will vary according to the varying needs of groups
of the population and desired outputs.
Primary health care focusses on:
o
education and training of health workers to perform functions relevant to countries
health problems,
o
o
reorientation of health personnel,
planning health manpower according to the needs of health system, in terms of
right kind of manpower, right number, at right time and in the right place.
At the first level of contact between individual and health care system, primary health
care is provided by community health workers acting as a team. These workers have to
be trained and retrained so that they can play a progressive role in providing primary
health care.
The second category of health personnel arc traditional medical practitioners and birth
attendants. They are often part of the local communities, culture and traditions and exert
influence on local health practices. Therefore these indigenous practitioners need to be
trained accordingly for improving health of the community.
These workers arc to be trained and retrained in order to apply their technical skills to
solve health problems as per social needs, guide, teach and supervise community health
workers and village health guide and traditional/trained birth attendants and educate
community on all matters pertaining to their health.
Lastly we can say that family members are often main providers of health care, mainly
women play an important role in promoting health, thus they can contribute significantly
to primary health care, especially in ensuring the application of preventive measures.
Women’s organization can be taught and encouraged to discuss on questions as
nutrition, child care, sanitation and family planning. School teachers and adolescent girls
can be trained on human sexuality and home nursing.
Similarly young people can be educated on health matters. They can be effective in
carrying these messages to their homes thus promoting primary health care.
2.4.3 Community Participation
We now come to the most essential and sensitive principle of PHC, i.e. community
participation. Community participation is the process by which individuals, families
and communities assume the responsibility in promoting their own health and welfare.
By their own health decisions, they develop the capacity to contribute to their own and
the community’s development. Realizing the fact that a community can become the
agent of its own development, a continuous effort should be made towards the
involvement of the local community in planning, implementation and maintenance of
health services.
The term community involvement in health describes a process in which partnership is
established between government and local communities’in planning and implementation
of health activities. It aims at building local self-reliance and gaining social control over
primary health care infrastructure and technology. For example, one such approach
which is followed in our country (India) is training of village health guides and dais.
They are selected by the local community and are trained locally in the delivery of
primary health care and are involved in planning the care for the community.
This concept is an essential feature of PHC. The individuals in the community know
their own situation better and are motivated to solve their common problems. Thus it
can be stated that involvement of community in health matters will require attainment of
Primary Health Care —
Concept and Principles
Health for All
capacity by individuals to appraise a situation, weigh the various possibilities and
estimate what can be their own contribution.
Your contribution in community participation, as a member of the health system, is to
motivate the community to learn and solve their own health problems, explain, advise
and provide clear information about favourable and adverse consequences of the health
interventions proposed as well as their relative cost.
Having understood the idea of community participation, you will be interested to know
about the areas in which individuals, families and communities can participate.
Involvement of these arc:
•
involvement of the community in assessment of the situation, and
o
definition of the problem and setting of priorities.
Planning of the primary health care activities and subsequently cooperating fully when
these activities are carried out. All these means acceptance of a high degree of
responsibility by the individuals for their own health care, for example, by adopting a
healthy life style, by applying principles of good nutrition and hygiene and by making
use of immunization services.
2.4.4 Appropriate Technology
Appropriate technology means the technology that is scientifically or technically sound,
adaptable to local needs, culturally acceptable (i.e. acceptable to those who apply it and
for whom it is used) and financially feasible.
This implies that technology should be in keeping with the local culture. It must be
capable of being adapted and further developed, if necessary. In addition, it should be
easily understood and applicable by the community.
The Health for AU target requires first and foremost scientifically sound health technol'ogy that people can understand and accept and which the nonexpert can apply. It also
implies use of cheaper, scientificafiy valid, acceptable and available equipments, proce
dures and techniques rather than those costlier and nonaffordable and nonaccessible to
the community. For e.g. oral rehydration fluid, locally prepared weaning food and stand
pipes rather than house to house connection, cooperative food stores.
It is socially, economically and professionally acceptable to take the technology closer to
the people, consumer, wherever possible. For example, making rehydration salts, for
babies available to mothers in every home is likely to be more useful than expecting the
mothers to take the baby to the special centre.
We cannot afford to continue the use of sophisticated technology which is inappropriate
for meeting the local health needs of people. For example, we know that expensive
hospitals which are inappropriate to local needs are being built. These absorb a major
part of the national budget, thereby affecting the improvement of general health services.
The concept of appropriate technology can further be explained by taking the example
of ORT (oral rehydration therapy). The ORT packets, for diarrhoea, prescribed by WHO
cannot be made available to each home; so the community is taught how to prepare
sugar and salt solution to combat dehydration in a child with diarrhoea. With these
concepts in mind, we shall discuss the principles of intersectoral coordination.
2.4.5 Intersectoral Coordination
We now come to the principle which focuses on the concept that health of an
individual, family and community is affected by other sectors in addition to health
sector. Let us now try to learn more about this principle.
It is now realized that health cannot be attained and/ or primary health care (PHC)
cannot be provided by the health sector alone. PHC requires the support of other
sectors; these sectors serve as entry points for the developments and implementation of
PHC. In our country the sectors responsible for economic development, antipoverty
measures, food production, water purification, sanitation, housing, environmental
protection and education all contribute to health.
26
■
Development of PHC will rest on proper coordination at all levels between the
health and all sectors concerned.
Declaration of Alma-Ata'states that “Primary Health Care involves in addition to
the health sector all related services and aspects of national and community
development; in particular, agriculture, animal husbandry, food, industry, eduction,
housing, public works, communication and other sectors.” WHO (1978, HFA
Series No. 1)
Primary Health Care —
Concept and Principles
We shall now explore the importance of these related sectors in providing PHC. We
shall first discuss the importance of agriculture sector, water supply, sanitation and
housing, then we will talk about public works, communication and education sector and
mass media. So let us begin with agriculture sector first.
Agriculture sector ensures the production of food for family consumption. Also
nutritional status can be improved through programmes in agriculture, e.g. 'grow more
food’ and ‘Kitchen garden projects’. Similarly you know that water supply is very
important for household use. A regular supply of clean water helps to decrease mortality
and morbidity, in particular among infants and children. You are aware that many
diseases like cholera, typhoid, diarrhoea, viral hepatities are waterbom. Safe disposal of
wastes and excreta also has a significant influence on health.
Housing has a positive aspect on health, provided it is properly adapted to local climatic
and environmental conditions. Housing needs to be proof against insects and rodents that
carry diseases.
We have so far discussed the effect of agriculture sector, water supply and sanitation
and housing on primary health care, now we shall discuss about public works,
communication, education sector and mass media.
Certain aspects of public works and communication are of strategic importance to
primary health care. Feeder roads not only connect people to the market but make it
easier for them to reach other villages, bringing in new ideas and also the supplies
needed for health. TV and radio communication serve as important vehicles for
learning regarding health and health practices. Mass media can play a supportive
educational role by providing valid information on health and ways of attaining it, and
depicting the benefits to be derived from improved health practices, it could help to
creat awareness regarding various health programmes, i.e. family planning,
immunization, growth monitoring, diarrhoeal disease and ORS etc. in the people who
are isolated. We all know that various messages are carried on TV or radio, regarding
FP, ORS, nutrition, diarrhoeal diseases etc.
Now we come to educational sector which has a vital role to play in development
and operation of PHC. Community education helps people to understand their health
problems, possible solutions to them and the cost of different alternatives.
Instructional meterial/literature can be developed and distributed through the
educational system. Associations of parents and teachers can assume certain
responsibilities for primary health care activities within schools or the community:
such as sanitation programmes, food for health campaigns or courses on nutrition and
first aid, adult literacy programme, kitchen garden projects, courses on human sexuality
and home nursing.
Check Your Progress 4
i)
ii)
List the principles of Primary Health Care.
Fill in the blanks with appropriate words.
a)
Equitable distribution means that health services must be
.................
by all people.
27
Health for All
b)
In community participation individuals, family and
assume
c)
in promoting their own health and welfare.
Appropriate technology means technology that is
sound,
to local needs and
iii)
List the areas where community can be involved.
. iv)
The health related sectors are:
2.5
ROLE OF THE NURSE IN PROMOTING
PRIMARY HEALTH CARE
feasible.
Four main aspects of the Nursing Role in Primary Health Care were identified by WHO
study group in their meeting in Geneva from 9-13 December, 1985 (WHO Technical
Report Series No. 738). The roles identified are:
The Nurse as a Direct Care Provider
Nurse as a Teacher and Educator
Nurse as a Supervisor and Manager
Nurse as a Researcher and Evaluator
Let us now discuss each one of them for better understanding.
The Nurse as a Direct Care Provider
You as a nurse need to develop a variety of skills which you have to utilise in both
clinical and community settings, in order to participate actively in providing care in
relation to the components of PHC.
In the foregoing section you have already learnt about the essential eight
components of primary health care. So, in order to provide and participate in
such care, you have to develop a variety of clinical and community skills. It is
by developing these skills that you shall be able to provide the proper nursing
care to the patients, individuals, families and community. For example, if we
take one of the components of PHC, i.e. control of communicable disease, your
role as a direct care provider at all levels—subcentre, PHC, community centre and
hospital is to identify and give immunization to children and educating the parents
regarding the control of these diseases. Similarly, in providing MCH care you as a
health provider not only have to examine the mothers to identify risk factors, and
give T.T., but also teach them about mother craft, immunization, nutrition, rest and
sleep, exercise etc.
28
Nurse as a Teacher and Educator
X
Primary Health Care —
Concept and Principles
Your central concern as a nurse is promotion of health, prevention of disease and
disability. This calls for your role as an educator when you have to educate the
individuals and family about a healthy life style and the community on the primary
prevention of ill-health as well as protective and supportive heath measures.
Your role as a teacher involves the training of other health care personnel, professional
colleagues and auxiliary personnel. This brings us to the role of the nurse as supervisor
and manager.
Nurse as a Supervisor and Manager
If you are engaged in providing Primary Health Care, you have to exercise some kind of
leadership. Your duties in this regard include supervising other personnel in providing
care, planning health service for the community in conjunction with other members of
the health team and organising and administering community health services. While
performing these functions you are involved in:
o
assessing the health needs of the community,
o
o
o
listening to the community’s view on these needs,
communicating with the community, and
advising them accordingly.
As a community organizer, your role is to involve people in their own health care and
explain the importance of cooperation of other sectors of society concerned with health
e.g. housing, sanitation, agriculture, industry and education sector. So from your role as
a direct care provider and teacher and educator you, as a primary health care nurse,
assume the role of a manager on a wider scale.
The Nurse as a Researcher and Evaluator
Primary health care system has to be dynamic, as it deals with living human beings.
Hence a nurse has to be dynamic in her services by bringing about changes and
innovations in the health care provided based on facts. For this she has to be prepared
to take the role of a researcher and evaluator.
This role involves monitoring, observing, analysing the health conditions, the health
servics and the health care provided. For example, when an individual falls sick, then
you, as primary care provider, are in a better position to determine the individual
patient’s health needs and to understand the problems involved in meeting these needs.
With your knowledge and skills, you are able to recommend changes or innovations in
primary health care services. For you to play this role effectively you need to have
updated records. You will study about records in Block 2, Unit 5 of this course.
Check Your Progress 5
i)
2.6
List the four main aspects of the Nurse’s Role in Primary Health Care.
LET US SUM UP
In this unit we discussed the concepts and definition of Primary Health Care. Primary
Health Care is a practical approach to making essential health cafe universally accessible
to individuals, families and community in an acceptable and affordable way and with
their full participation. You also learnt .that the elements of primary health care are
education concerning preventing health problems, promotion of food supply and proper
nutrition, adequate supply of safe water and basic sanitation, maternal and child health,
immunization, treatment of common diseases and injuries, and provision of drugs and
vaccine.
29
Health for All
Principles of Primary Health Care have also been explained in detail. These are:
•
equitable distribution, which means that health services must be shared equally by
all people — rich or poor, rural or urban;
•
manpower development;
•
community participation; or the process by which individuals, families and
communities assume the responsibilities in promoting their own health and welfare
and take their own health decisions;
appropriate technology which means that technology that is scientifically or
technically sound adaptable to local needs, culturally acceptable and financially
feasible; and.
the principle of intersectoral coordination which focuses on the concept that the
health of an individual, family and community is affected by other sectors in
addition to the health sector.
•
•
At the end we discussed the role of the nurse in promoting primary health care. The
four roles are identified as (1) Nurse as direct care provider; (2) Nurse as teacher and
educator; (3) Nurse as a supervisor and manager and (4) Nurse as a researcher and
evaluator.
2.7 ANSWERS TO CHECK YOUR PROGRESS
Check Your Progress 1
i)
It is first level care which focuses on increasing access and availability of health
services to the rural population and which is affordable.
ii)
1970
iii)
September 1978
WHO and UNICEF.
Check Your Progress 2
i)
Primary Health Care is essential health care based on practical, scientifically sound
and socially acceptable methods and appropriate technology made universally
accessible to individuals and families in the community through their full
participation and at a cost that the community and country can afford to maintain
at every stage of their development in the spirit of self reliance and self
determination.
ii)
Accessibility, availability, acceptability, affordability, appropriatness
iii)
b, c, d, e
Check Your Progress 3
i)
Maternal and Child Health Care including family welfare
Immunization against major infectious diseases.
Education concerning promotion of health and prevention of illness.
ii)
Nutrition
Mothers and children form the largest group of the population (about 70 %)
Mothers and children are high risk/more vulnerable groups.
Check Your Progress 4
i)
— Equitable distribution
— Manpower development
— Community participation
— Appropriate technology
30
— Intersectoral approach
ii)
iii)
a)
Shared equally by all people
b)
Community, responsibility
c)
Scientifically, Adaptable, Financially
Primary Health Care
Concept and Principles
Assessment of situation or a problem
Definition and setting of priorities
/
Planning the activities for providing Primary Health Care
iv> ^Agriculture sector
Water supply and sanitation/public works
Housing
Communication and mass media
Education sector
Check Your Progress 5
Direct care provider
Teacher and education
Supervisor and manager
Researcher and evaluator
31
UNIT 3 HEALTH FOR ALL
Structure
3.0
3.1
3.2
Objectives
Introduction
Health For All
3.2.1
3.2.2
3.3
Strategy for Health For All
3.3.1
3.3.2
3.4
3.5
3.6
3.0
Concept of Health For All
Definition and Meaning for Health For All
Global Strategy
National Strategy for Health For All by 2000 AD
Nursing in Support of Health For All
3.4.1
Strategics and Actions Proposed at International Level
3.4.2
Strategies and Actions Proposed at National Level
Let Us Sum Up
Answers to Check Your Progress
OBJECTIVES
In this unit we shall discuss about Health For All (HFA). After studying this unit, you
should be able to:
o
Define Health For All,
•
Discuss the meaning of Health For All,
•
Describe global strategy for attaining Health For All,
•
•
Explain the national strategy adopted to achieve the goal of Health For All,
List the targets and achievement in Health For AH, and
•
Discuss the role of nursing services in support of Health For All.
3.1 INTRODUCTION
In Unit 1 we have discussed the concepts and prerequisites of health and in Unit 2 we
discussed about Primary Health Care (PHC); its concept, principles, elements and role of
nurses in promoting the primary health care. You have seen that primary health care is
the essential care which should be easily available, acceptable, accessible and affordable
to an individual and community as a whole. You have also become aware of Alma-Ata
Declaration (see Appendix 1) which affirms that primary health care is considered as the
basic strategy for achieving goal of Health For All by the year 2000 AD.
32
As you have learnt in Unit 2 that in May 1977 the thirtieth World Health Assembly
adopted a resolution in which it was decided that main social target of Governments
and of World Health Organization in the coming decades should be the attainment by
all people of the world by the year 2000 AD of a level of health that will permit
them to lead socially and economically productive life. This is popularly known as
Health for All by the year 2000 AD (HFA/2000). In this unit we shall discuss the
concept, definition and meaning of Health For All. Achievement of goal of Health For
All aims at restructuring of health system and reorientation and training at different
categories of health workers/professionals. Fulfillment of these aims is only possible
through development of an appropriate strategy. We shall discuss the global and
national strategies for HFA, in Section 3.3 and focus on achievements and targets of
HFA. At the end we shall discuss nursing in support of Health For All at
international level and national level. As you go through this unit you are required to
refer the appendices given at the end of this unit for broader perspective wherever
indicated in the text.
I
Health for All
3.2
HEALTH FOR ALL
We shall discuss about the concept and definitions of Health For All in the following
subsections.
3.2.1 Concept of Health For All
As you know, there is a vast contrast in the health, status of people in developed and
developing countries despite of much scientific and technological advances in health
care. You are also aware that most people in developed countries and elites of the
developing countries including India enjoy good health, nutrition, sanitation, safe
drinking water, education, income etc.
In India 80% of the population lives in rural area and urban slums in contrast to
10-20% who live in urban areas. It is only this small fraction of urban people who
enjoy ready access to health services and facilities whereas the rest of the 80-85% are
living in rural and urban slum areas do not have access to health services and/or
facilities. Similarly if we look at health status of India as reflected by the number of
indicators of health, as shown in Table 1, the need for urgently improving our health
status is obvious.
The disparities in health and socio-economic conditions between rich and poor, within
countries and between countries, and the concern of members of WHO regarding status
of health and deterioration of existing health status lead to new thinking in provision of
health care in order to narrow this gap and finally eliminate it. It was also realized that
the underprivileged population constituting 80% of the total population have an equal
claim to their rights and privileges of health services such as:
o
o
o
o
health care,
protection from vaccine prevented communicable diseases (VPD) of childhood e.g.
Diphtheria, Tetanus, T.B. Whooping cough, Polio etc.,
maternal and child health care, and
treatment and control of non-communicable disease.
So there was felt a need among healjh planners/administrators for evolving a health care
approach that would answer the problems and needs of underprivileged. Ultimately the
thirtieth World Health Assembly resolved in May 1977 that the main social target of
Governments and WHO in the coming decades should be the attainment of Health For
All by year 2000 AD.
Further, there are several other experiences and developments which led to the evolution
of goal of ‘Health For All’ by the year 2000 which are as follows.
•
In 1972-73 a WHO study on the development of health services concluded that
there was a widespread dissatisfaction among people with their health care systems
which were failing to cope with primary health care problems in countries at all
stages of development.
Fig. 3.1: Diagrammatic Representation of the Development of the Concept of Health For All (HFA)
Health for All
•
In developed countries, health care system despite their expensive and impressive
infrastructure and highly specialized technologies, the emerging health problems of
people are not being solved. The principal reason for this discrepancy is that new
health problems require completely new approaches which emphasize individual
self-reliance s and commitment to good health.
•
Similarly most of the developing countries including India face major problems
with control of infectious disease, provision of safe water and basic sanitation
services, the provision of care during pregnancy and delivery and elevating
standard of living to a ‘minimum acceptable level’.
•
In the rural areas and rapidly expanding urban areas million of people still remain
without access to essential health care and life saving measures.
All the above concepts led to a continuing discussion of how health care system should
evolve and how WHO could best support countries struggling to improve their health
systems.
Expressing the ideas that were dominating the International discussion during
1960s and early 1970s the World Health Assembly (WHA) decided in a
ground breaking resolution in 1977 that “main social targets of governments
and WHO in the coming decades should be the attainment of all citizens of
the world by the year 2000 of a level of health that will permit them to lead
a socially and economically productive life” with the adoption of this
resolution the HFA movement was born and the slogan was created.
With this concept in mind we shall discuss next the definition and meaning of Health
For All, after examining your memory.
Check Your Progress 1
i)
The approach to achieve the goal of Health For All by the year 2000 is
a)
ii)
Hospital Care
b)
Technological Development
c)
Primary Health Care
d)
Research
i? The basis for evolution of Health For All concept includes
a)
........................................................................
b)
c)
..................
d)
e)
.'......................................................................................................
3.2.2 Definition and Meaning for Health For All (HFA)
HFA has been defined as “the attainment of a level of health that will enable every
individual to lead a socially and economically productive life.”
If you analyse this definition you will realise that the goal of HFA implies realization of
WHO’s objective of attainment by all people of the highest possible level of health
which includes, physical, mental and social well-being; secondly it also implies that as a
minimum, all people in all countries should atleast have such a level of health that they
are capable of being economically productive, ^removal of unemployment and
povertyjand participating actively in the social life of the community in which they live
i.e., have education, housing, water supply and sanitation.
Health For All means that health care/services are to be made accessible/
within reach of every individual in a given community.
34
It implies the removal of obstacles to health, that is, elimination of ignorance,
malnutrition, disease, contaminated water supply, unhygienic housing etc.
“Health For All” is a holistic concept. It calls for efforts in education, agriculture,
industry, housing or communication first, as much as in public health and medicine. It
symbolizes the determination of countries of the world to provide an acceptable level of
healthful living to all people.
Health for All
It is an expression of the feeling for social justice from all those who suffer inequity in
health care services.
It is intended to draw attention to the importance of health, to a serious search for new
ways of solving the problems of health and to help mobilize all available resources for
health.
To have a correct perception of the meaning of “Health For All” you should be
convinced that HFA does not mean that as of the year 2000, we shall all be free of
disease and disability.
Health for all means that health is to be brought within the reach of every one in a
given country including the remotest part of a country and the poorest members of the
society. By health is meant not just the availability of health services but a personal
well-being and a state of health that enables a person to lead a socially and
economically productive life.
“Health For All” means that health should be regarded as an objective of economic
development and not merely as one of the means of attaining it.
o
Health begins at home, in school and in work place.
o
People will use better approaches for preventing disease and alleviating
unavoidable illness and disability.
There will be an even distribution among the population of whatever health
resources are available.
o
That the essential health care will be accessible to all individuals and families, in
an acceptable and affordable way and with their full involvement
o
The achievement of the Health For All goal, calls for dramatic changes, a social
revolution in health development. It aims at bringing about the change in the mentality
of people, restructuring of health system, and reorientation and training of health
workers/professionals. So, to bring about these changes the practical shape to the slogan
of HFA could be given only through development as a strategy. You will learn about
these strategies for Health For All in Section 3.3.
Check Your Progress 2
i)
Fill in the blanks:
Health For All concept focuses on health care services brought within the reach of
every individual in a given
ii)
Obstacles to the goal of health include:
iii)
Health For All calls the efforts in:
iv)
Define the goal of HFA.
35
Health for All
3.3
STRATEGY FOR HEALTH FOR ALL
As you have seen in Unit 2, Alma-Ata conference called on all governments to formu
late national policies, strategies and plans of action and set down the principles of
Primary Health Care which is the basis of “Health For'All” strategy.
In 1981, global strategy of HFA was evolved by WHO through consultations with
countries, regions and at the global level. That strategy defines the broad lines of action
to be undertaken at policy and operational levels, nationally and internationally, both in
the health sector and in other social and economic sectors.
This was followed by individual countries developing their own strategies for achieving
HFA and synthesis of national strategies for developing regional strategies.
Let us discuss the global and national strategics in the following sub-sections.
3.3.1 Global Strategy
The global strategy for Health For All is based on the following fundamental principles.
•
Health is a fundamental human right and a worldwide social goal
•
The existing gross inequality in the health strategies is of common concern to all
countries and must be drastically reduced
•
People have the right and the duty to participate individually and collectively in
the planning and implementation of their health care
•
Governments have a responsibility for the health of their people
•
Countries must become self-reliant in health matters.
Health is an integral part of the overall development of the countries. Energy generated
by improved health should be channelled into sustaining development of a country.
Better use must be made of the world’s resources to promote health and development
and this will help to promote world peace and prevent conflict among nations.
3.3.2 National Strategy for Health For All by 2000 AD
Alma-Ata declaration (as you have seen in Appendix-1) and India’s commitment to
HFA by 2000 AD resulted in the formulation of National Health Policy.
•
The Government of India convened a national conference in February 1980 to
discuss the national strategies and action plan to achieve Health For All.
•
In July 1980 the Planning Commission of India appointed a working group on
Health For All to evolve national strategies for implementation of health care
programmes to move towards the goal for Health For All by 2000 AD and to
suggest suitable indicators to monitor the progress achieved from time to time. The
working group submitted its report in 1981 which was accepted by the
Government of India.
Thus a National Health Policy was evolved by Government of India in August 1983,
which commits the government and people of India to achieve the goal of Health For
All by 2000 AD. We shall briefly highlight the health strategies in health policy (for
details of health policy refer Appendix-2).
The policy lays stress on the preventive, promotive, public health and rehabilitation
aspects of health care and points to the need of establishing comprehensive primary
health care services to reach the population in the remotest ares of the country.
The health policy in India has the following key elements:
•
Creation of a greater awareness of health problems in the community and means
to solve these by the communities,
•
Supply of safe drinking water and basic sanitation using technologies that the
people can afford,
Reduction of existing imbalance in health services by concentrating more on the
rural health infrastructure.
•
36
•
Establishment of a dynamic health management information system to support
health planning and health programme implementation,
•
Provision of legislative support to health protection and promotion,
•
Concerted actions to combat widespread malnutrition,
•
Research into alternative methods of health care delivery and low-cost health
technologies, and
Greater coordination of different systems of medicine.
®
Health for All
The health strategics include restructuring the health infrastructure developing health
manpower and research development.
WHO has established 12 global indicators as the basic point of reference to assess the
progress towards Health For All. (These arc discussed in Unit-5.) The National Health
Policy has laid down specific goals with respect to various health indicators to be
achieved by different dates 1990 to 2000 AD. (These are given in Table 1.) The most
important indicators to achieve HFA arc:
i)
Reduction of Infant Mortality Rate from the present level of 87 to below 60 by
2000 AD
To raise the life expectancy at birth from present level of 58 years to 64 by 2000
AD
ii)
To reduce the crude death rate from the present level of 10.4 to 9 by 2000 AD
iii)
iv)
To reduce the crude birth rate from present level of 27 to 21 by 2000 AD
v)
To achieve a net reproduction rate of 1 by 2000 AD
vi)
To provide potable water to the entire rural population by 2000.
Table-1
National Health Policy Goals for Health and Family Welfare Programmes
Targets
S. No.
Index
Existing level
1990
2000 AD
1
2
3
4
5
1.
Crude Birth Rate
32.0 (1987)
27.0
21.0
2.
Ciuuc Death Rate
10.8 (1987)
10.4
9.0
3.
Infant Mortality Rate
95.0 (1987)
87
Below 60
4.
Perinatal Mortality Rate
53.8 (1985)
5.
Maternal Mortality Rate, MMR
4-5 (1976)
2-3
Below 2
6.
Pre-school Child (1-5 yrs)
Mortality Rate
24 (1976-77)
15-20
10
7.
Life expectancy at birth (yrs)’
58.1 M (1986-91)
59.1 F (1986-91)
57.6 M
57.1 F
64 yrs M
64 yrs F
8.
Percentage effective couple
protection
39.9 (March 1988)
42.0
60.0
9.
Net Reproduction Rate
1.48 (1981)
1.17
1.00
1.56
30-35
10.
Natural Growth Rate (Annual)
2.12 (1987)
11.
Family size
4.4 (1975)
12.
Percentage of deliveries by trained
birth attendants
40-50 (1988)
80
100
13.
Pregnant mothers receiving
ante-natal care (%)
60 (1988)
60-75
100
14.
Immunization Status, percentage
coverage
a. TT (pregnant mothers)
86.6
100
100
b. TT (School Children 10 years)
'-88.7
100
100
1.20
2.3
Corud..
37
Health for All
15.
c. TT (School Children 16 years)
86.5
100
100
d. DPT (Children below 3 yrs)**
96.0
85
85
e. Polio (infants)***
83.5
70
85
f. BCG (infants)****
94.3
80
85
g. DT (New school entrants
5-6 yrs)*****
87.5
85
85
h. Typhoid (New school entrants
5-6 yrs)
62.6
85
85
20(1988-89)
60
80
TB: percentage of disease arrested
cases out of those detected
62 (1987-88)
75
90
Blindness, incidence of (%)
1.4 (1987-88) '
0.7
0.3
Leprosy: percentage of disease
arrested cases out of those
detected******
16.
17.
When the health policy was formulated, life expectancy was 52.6 for males and 51.6
for females.
Coverage was 25% when the Health Policy was drafted.
Coverage was 5% when the Health Policy was drafted.
Coverage was 65% when the Health Policy was drafted.
Coverage was 20% when the Health Policy was drafted.
Implies the no. of cases cured after 1983, expressed as a proportion of the total
estimated 4 million cases.
Note: (1) The Planning Commission set the following goals in addition to the above
1985
1990
2000
Birth weight below 2500g
25%
18%
10%
Vitamin A distribution coverage
50%
50%
50%
You must be aware that during the sixth and seventh Five Year Plans, steps were
already undertaken to implement the strategies outlined in National Health Policy.
Some of these are:
a)
to establish one health subcentre for every 5,000 rural population (3,000 in tribal
and hilly areas) with one male and female health worker
b)
to establish one primary health centre for every 30,000 rural population (20,000 in
hilly and tribal areas)
c)
to establish Community Health Centres (CHC) each serving a population of one
lakh
d)
to train Village Health Guides (VHG) selected by the community for every village
or 1,000 rural population
e)
to train traditional birth attendants (TBA) or dais in each village
f)
training of various categories of health personnel, e.g., multipurpose workers
(MPW).
These schemes are expected to ensure the availability of adequate infrastructure and
medical and paramedical manpower to take us nearer the goal of universal provision of
Primary Health Care as envisaged in the National Health Policy.
Activity
Mention the rates in numbers against each indicator given below as per the latest Health
Statistics Report of your state
i)
Infant mortality rate
ii)
Maternal mortality rate
iii)
Birth rate
iv)
Death rate
v)
Literacy rate
vi)
Population
Health for All
Check Your Progress 3
Fill in the blanks:
i)
The basic strategy to achieve health for all is
ii)
Ministry of Health and Family Welfare (India) formulated National Health Policy
to achieve goal of HFA in
iii)
The most important indicators to monitor progress towards Health For All are:
With the above background we shall now focus our attention on nursing in support of
Health For All in the following section.
3.4 NURSING IN SUPPORT OF HEALTH FOR ALL
We shall begin with the development of the role of nursing in support of Health
For All.
In 1979, WHO and International Council of Nurses (ICN) conducted a workshop in
Nairobi on the role of nursing in Primary Health Care for leaders of Nurses
Associations in which the commitment of the nursing profession to the goal of
attaining Health For All by 2000 was formally confirmed. Subsequently, National
Nurses Association planned their own strategies in relation to their own National
Health Policies. The Trained Nurses Association of India (TNAI) also participated in
this exercise.
In 1981, an informal meeting was convened in Geneva by WHO on 16-20 November to
consider the role of nursing in contributing to the achievement of the goal of HFA/2000
through Primary Health Care.
Strategies and actions proposed for change at international and national level are
discussed in the following sub-sections.
3.4.1 Strategies and Action Proposed at International Level
Five basic strategies have been proposed by the WHO-ICN meeting by Nurses which
are listed below. (See Fig. 1.)
i)
the development in each country of a corps of nurses that is well informed about
health care and ready to bring necessary changes in the nursing system
ii)
the inclusion of nursing personnel at all levels of policy making
and administration so that the profession can contribute to determining the
action plan
iii)
the involvement of nurses, and the use of their skills, in initiating or extending
primary health care
iv)
fundamental changes at all levels of nursing education (basic, post-basic and
continuing) to ensure that the priority needs of population are functionally
integrated into the education and into nursing practice
v)
research into nursing administration practice, and education, that will demonstrate
nursing’s contribution to primary health care.
39
Health for All
Fig. 1: Five strategies for change adapted by National Nurses Associations for their role in
HFA through PHC
We have listed the strategies for change. We shall now learn about the actions proposed
for each strategy as given below.
i)
Development of corps of well-informed Nurses
This will require
a)
arranging and developing a series of international, national and regional
workshops or other meetings, mat would bring together small groups of key
nurses for orientation and guidance in planning for primary health care in their
own country. The purpose of these workshops would be!
•
To help the nurses to understand the thrust of PHC nationally and
internationally
• . To interpret needs of these countries in their struggle for HFA/2000 and
enable them to develop over all nursing plans of action at local, regional,
and national level, taking into account local needs and resources
•
b)
ii)
Develop texts, guides and communication aids, which will include review of
current publications related to PHC and production of specific material on
nursing in PHC.
Nursing at policy and decision making levels
•
•
40
To establish the regional support system and lines of communication
between and among countries for sharing plans, exchanging methodologies
and report on the progress as the plan is further developed and put into
effect.
This will require planning and implementing training programmes and
continuing educational programmes that will orient nurses and train them in
administration and management techniques, political and legislative processes,
and help them to analyse existing legislation and enable them to develop
action programmes to bring about necessary changes.
Creation of administrative post in nursing at all levels of Government. This
can be accomplished through coordinated efforts of national nursing
associations.
o
iii)
Establishing a system for collection and compilation of information, on the
supply and training of nurses as per the needs of community.
Health for All
Nursing practice and primary health care
This calls for preparing and educating the nurses to assume responsibility for the
provision of first level care in the community. This can be achieved by
o
o
o
o
iv)
conducting workshops, seminars and other continuing or in-service education
programmes,
encouraging the Nurses to practice Primary Health Care.
providing facilities like housing, attractive remuneration and opportunity for
continued learning to the public health nurses working at the periphery.
making efforts to close the existing gap between nursing education and nursing
services.
Fundamental changes at all levels of nursing education
This will require the administrative support from the national and local government in
order to change the system of nursing education.
This change involves reorientation in basic nursing education, post-basic nursing
cducation_and organizing continuing education programmes.
Basic Nursing Education
This will include
o
o
Change of curriculum for current systems of nursing education and practice, and
Formulating strategies for bringing about a change in basic nursing education from
emphasis on care of sick individuals in hospitals to community based nursing
education.
Post-basic Nursing Education
This will involve
o
c
Preparation of nurses for leadership roles in administration for supervisory posts in
organizations and agencies at all levels of health care planning and management,
and for teaching post in primary health care.
Preparation of nurse researchers who can conduct or direct investigations into
Primary Health Care (PHC) issues as well as encourage systemic inquiry into
questions related to community based nursing practice.
Continuing Education
This involves:
Organising workshops, seminars and in-service programmes to enable nurses to acquire
additional knowledge and skills related to PHC.
v)
Research in nursing administration, practice and education for primary
health care
This needs inclusion of research skills in all the nursing education programmes and
continuing education programmes. Nurses at all levels should develop an enquiring and
problem solving attitude for working towards the goal of PHC.
Priority should be given to research into
•
•
the design and evaluation of programmes in which nurses provide primary health
care, and
study of problems that arise from the nursing in primary health care field.
Government and intersectoral support should be sought for proposals that will enable
nurse to initiate and/or collaborate with others in research methods and design for
Primary Health Care (PHC).
Develop projects to demonstrate usefulness of research findings in nursing practice.
You may have got a good idea of our discussion about nursing strategies and actions
proposed in support of health for all. Before moving to the next subsection, have a look
at a brie! summary of what you have learnt in the above subsection from the following
Table 2.
41
Table 2: Strategies and Action Proposed
Health for Alt
Strategies
i)
ii)
Action proposed
Develop a corps of nurses that is well
informed about PHC and ready to bring
necessary changes in the nursing
system
Arrange series of workshops.
Inclusion of nursing personnel at all
levels of policy making & administration
so that the profession can contribute to
determine the action to be taken
Orient nurses in political and legislative
processes
Develop texts, guides and communication
slide.
Planning training programme
Creation of administrative positions in
nursing at all levels of Government
Establishing systems for of information
on the supply training of nurses as per
the community needs
Involvement of nurses and the use of
their skills in initiating & extending PHC
iii)
Preparation of nurses to assume
responsibility for the provision of first
level care in the community
Encourage nurses for the practice of
PHC
Provide facilities for nurses working at
periphery
Utilise approaches to close the gap
between nursing education & nursing
services
Fundamental changes at all levels of
nursing education to ensure that the
priority needs of population arc
functionally integrated into
education and into nursing practice
iv)
Obtain administrative support
Reorientation in basic nursing
education
Reorientation in post-basic nursing
education
Organizing continuing education
Research into nursing administrati',n,
practice & education that will
demonstrate the need for nursing’s
contribution to PHC, clarify the
implications and evaluate the results
v)
Include research in postgraduate
programme
Find Government and intersectoral
support
Develop projects to demonstrate
usefulness of research in nursing
practice
Strategies and Actions Proposed at National Level
3.4.2
We discussed the strategies proposed by International Council of Nurses. Now we shall
turn our attention towards the action taken by our National Nursing Associations (TNAI)
in this regardA Conference on Primary Health Care was held by the TNAI in 1979 at Chandigarh, to
propose various actions in support of health for all by nurses.
The nurses resolved and recommended to reorient and restructure various nursing
education programmes towards primary health care and also upgrading nursing education
to university level academic programme to prepare nurses who can provide primary
health care. The major resolutions and recommendations made in the conference are:
i)
Resolutions adopted
•
«
42
The association to organize continuing education programme for nurses at
national, state and city level, on Primary Health Care.
The Public Health Nurses of the association to plan regional workshops and
give directions to implement Primary Health Care in a coordinated way.
•
The student nurses of the association to organize school health services and MCH
Clinics in selected rural areas of slums and practice meeting the Primary Health
Care needs of the family and community while they are stil| under training.
•
The nurses association to take action for reserving two thirds of the posts of health
supervisors created at the district/subdivisional and at the block levels, for
registered nurses-midwives to practice primary health care.
To urge Central and State Governments to create positions for registered nurses at
the block level and above.
•
•
To urge the State Governments to create posts at the State Directorate of Health
Services, as is the pattern in West Bengal to strengthen Primary Health Care at
state level.
ii)
Recommendations
o
Period of clinical practice for students in public health field be increased to six
months from three months.
o
Teachers in the nursing school/college to be reoriented to the Primary Health Care
concept.
o
The reorientation course be at least of three months duration.
o
There should be more nurse administrations at the state and central directorate of
health services.
o
That more posts should be created at the district and block Primary Health Centre,
and sub-centre level for general nurses-midwives (GNM).
Health for All
3.5 LET US SUM UP
You have studied the concept and definition of health for all by the year 2000 AD.
This implies “attainment of a level of health that will enable every individual to lead a
socially and economically productive life.” This concept has emerged out of the fact that
existing health care approach was not able to solve the health problems mainly in
developing countries including India and there is gross inequality in health service
distribution within a country and among countries. You have also learnt about the
global strategy which defines the broad lines of action to be undertaken at policy and
operating levels, nationally and internationally. This focuses on that 1) health a
fundamental human right, 2) reduction of gross inequalities in health status,
3) participation of people in their own care, and 4) self-reliance of communities in
health matters.
We have focussed our discussion on national strategy that resulted in the formulation of
national health policy in 1983 with laid down specific targets and goals to be achieved
by the year 2000 AD. This is to be considered in relation to various health indicators
like, infant mortality rate, maternal mortality rate, immunization, safe water supply and
demographic .data, like crude death rate, and birth rate and net reproductive rate. At the
end of the discussion we have appraised you of the role of nurse in support of health
for all where we have discussed the strategies and actions proposed for achieving the
goal.
These are
1)
Development of corps of well-informed Nurses
2)
- Nurses at policy and decision making devels
3)
Nursing practice and primary health care
4)
Fundamental changes at all levels of nursing education
5)
Research in nursing administration, practice and education for primary health care.
Finally we have talked about the actions taken by National Nursing Associations and
Organizations for achieving the goal of Health For All where we focussed on
recommendations and resolutions passed by our National Nursing Association. The main
recommendation and resolution was to restructure and reorient the nursing education
system as a whole towards PHC and HFA.
43
Health for All
ANSWERS TO CHECK YOUR PROGRESS
3.6
Check Your Progress 1
i)
ii)
c
a)
cause of death and disease
b)
c)
nutritional status
water supply and sanitation
d)
literacy and economic situation
e)
demographic trends
Check Your Progress 2
i)
ii)
iii)
iv)
community
poverty; malnutrition; ignorance; disease; contaminated water supply; poor housing;
etc.
agriculture, industry, education, housing and communication
the attainment of a level of health that will enable every individual to lead a
socially and economically productive life.
Check Your Progress 3
i)
Primary Health Care
ii)
iii)
1982
Infant mortality rate (I MR)
Maternal mortality rate (MMR)
Crude death rate (CDR)
Crude birth rate (CBR)
Net reproductive rate (NRR)
Life expectancy
44
UNIT 4 ORGANIZATION OF HEALTH
SYSTEM BASED ON PRIMARY
HEALTH CARE
Structure
4.0
4.1
4.2
4.3
Objectives
Introduction
Meaning and Characteristics of Health System Based on Primary Health Care
Structural Organization of Health System
4.3.1
4.3.2
4.3.3
4.4
Health System Infrastructure Based on Primary Health Care
4.4.1
4.4.2
4.4.3
4.4.4
4.5
4.6
4.0
Central Level
State Level
District Level
Village Level
Sub-centre Level
Primary Health Centre Level
Referral System
Let Us Sum Up
Answers to Check Your Progress
OBJECTIVES
In this Unit you will learn about organisation of Health System based on Primary Health
Care (PHC). After studying this unit you should be able to:
•
Define the health system,
o
List the characteristics of health system,
•
Describe the organizational structure of health system, at Central, State and District
levels, and
•
Explain the health system infrastructure based on Primary Health Care.
4J
INTRODUCTION
~
In Unit 1 you revised and reviewed the concept of health which is “a complete
state of physical, mental and social well-being and not merely the absence of
disease or infirmity.” (WHO 1946). Second Unit dealt with concepts and
principles of Primary Health Care. In Unit 3 you have learnt that in 1977 thirtieth
World Health Assembly decided that main target of governments and WHO in
the coming decades should be to achieve goal of Health For All by the year
2000 AD.
In this Unit we shall discuss the definition and essential characteristics of health system.
Health system intends to develop its own health care delivery system independent of the
Central Government
We shall also focus our attention on health system infrastructure at Central, State and
District levels. And at the end we shall introduce you to the health care system/
infrastructure based on Primary Health Care which mainly focuses on rural health
services.
Let us begin with the definition and characteristics of health system.
45
Health for All
4.2
MEANING AND CHARACTERISTICS OF HEALTH
SYSTEM
Health system can be broadly defined as coherent whole of many interrelated
component parts, both sectoral and inter-sectoral, as well as community itself, which
produces a combined effect on the health of the population. Health system should
consist of coordinated parts extending to the home, the work place, the school and
community.
If you try to understand the above definition you will be interested to learn that
what are interrelated conapOnent parts. The components of health system include
concepts (c.g. health and disease), ideas (e.g. equity coverage, effectiveness, efficiency,
impact), objects (e.g. hospitals, health centres, health programmes) and persons
(e.g. providers and consumers). Together these form a unified whole in which all the
components interact to support or control one another. Of all these components
discussed here we shall mainly highlight the objects and persons (health system
infrastrucure).
The health system aims at delivering the health services to the beneficiaries.
It constitutes the management sector and involves organisational matters, and
also in allocating resources, translating policies into services, evaluation and health
education.
The aim of health system is health development which includes continuous and
progressive improvement of the health status of a population, i.e. community.
Health system encompasses promotive, preventive, curative and rehabilitative aspects and
also caters care of the extremely disabled and incurable.
Hope you have now understood the meaning of health system as discussed above. We
shall now turn our attention towards the essential characteristics of the health system as
given below.
These characteristics/principlcs are applicable to all health system based on primary
health care.
The system should encompass the entire population on' the basis of equality and
responsibility. It should include components from the health sector and from other
sectors, whose interrelated actions contribute to health (e.g. education sector, public
works, animal husbandry and agriculture sector etc). Health is a subject of overall
socioeconomic milcu of the community.
•
Primary health care, consisting of at least the essential elements included in the
declaration of Alma-Ata should be delivered at U?c first point of contact between
individuals and health system. (See Unit 2, Section 2, for reference of essential
elements of PHC.)
•
At intermediate levels more complex problems should be dealt with and more
skilled and specialized care as well as logistic support should be provided.
•
Better trained staff, i.e., supervisory staff, should provide continuing education/
training to primary health care workers, as well as guide the public of different
communities and community health workers on practical problems arising in
connection with all aspects of primary health care.
The central level should coordinate all parts of the system and provide planning
and management expertise. It should also provide highly specialized care, teaching
for specialized staff, the staffing of such institutions (as central laboratories), and
central logistic and financial support
•
If you think deeply for a while and analyse what docs these above mentioned
characteristics indicate? These clearly indicate that health system is not a separate entity.
It includes components and actions not only from the health sector but also from other
health related sectors such as agriculture, education, environment, animal husbandry
communication etc., at various levels (central, intermediate and local). We shall discuss
this in the following sections.
46
i
v
r»
«
Organization of Health
System Based on
Primary Health Care
Check Your Progress 1
• i)
ii)
Fill in the blanks:
a)
Health system is defined as coherent whole of many
sectoral .and
as well as community itself.
b)
Health system aims at
c)
Health system constitutes management sector and involves
matters.
d)
The aim of health system is health
parts, both
the health services.
List the characteristics of health system.
4.3 STRUCTURAL ORGANIZATION OF HEALTH
SYSTEM
You know that health system in India is organized at three levels, i.e. Central level.
State level and District level.
Let us begin with organization at Central level.
4.3.1 Organization at Central Level
The official “organs” of the health system at the national level consist of :
i)
The Ministry of Health and Family Welfare (MHFW);
ii)
The Directorate General of Health Services (DGHS); and
iii)
The Central Council of Health and Family Welfare.
We shall talk of the organization and functions of each one of them.
i)
Ministry of Health and Family Welfare
Organization
The Union Ministry of Health and Family Welfare is headed by a Cabinet Minister,
a Minister of State and a Deputy Health Minister. These are political appointments.
Currently, the Union Health Ministry has two broad departments:
•
Department of Health, and
•
Department of Family Welfare.
The Health Department is headed by a Secretary to the Government of India as its
executive head who is an IAS officer and is assisted by joint secretaries, deputy
secretaries and a large administrative staff. The Department of Family Welfare was
created in 1966 within the Ministry of Health and Family Welfare. The Secretary to the
Govt, of India in the Ministry of Health and Family Welfare is in overall charge of the
Department of Family Welfare. He is assisted by an Additional Secretary- &
Commissioner (Family Welfare)^ and one Joint Secretary.
Functions
The functions of. the Union Health Ministry are set out in the Seventh Schedule of
Article 246 of the Constitution of India under (a) the Union List and (b) the
Concurrent list.
47
Health for All
4.2
MEANING AND CHARACTERISTICS OF HEALTH
SYSTEM
Health system can be broadly defined as coherent whole of many interrelated
component parts, both sectoral and inter-sectoral, as well as community itself, which
produces a combined effect on the health of the population. Health system should
consist of coordinated parts extending to the home, the work place, the school and
community.
If you try to understand the above definition you will be interested to learn that
what are interrelated component parts. The components of health system include
concepts (e.g. health and disease), ideas (e.g. equity coverage, effectiveness, efficiency,
impact), objects (e.g. hospitals, health centres, health programmes) and persons
(e.g. providers and consumers). Together these form a unified whole in which all the
components interact to support or control one another. Of all these components
discussed here we shall mainly highlight the objects and persons (health system
infrastructure).
The health system aims at delivering the health services to the beneficiaries.
It constitutes the management sector and involves organisational matters, and
also in allocating resources, translating policies into services, evaluation and health
education.
The aim of health system is health development which includes continuous and
progressive improvement of the health status of a population, i.e. community.
Health system encompasses promotive, preventive, curative and rehabilitative aspects and
also caters care of the extremely disabled and incurable.
Hope you have now understood the meaning of health system as discussed above. We
shall now turn our attention towards the essential characteristics of the health system as
given below.
These characteristics/principlcs are applicable to all health system based on primary
health care.
•
The system should encompass the entire population on the basis of equality and
responsibility. It should include components from the health sector and from other
sectors, whose interrelated actions contribute to health (e.g. education sector, public
works, animal husbandry and agriculture sector etc). Health is a subject of overall
socioeconomic milcu of the community.
•
Primary health care, consisting of at least the essential elements included in the
declaration of Alma-Ata should be delivered at tljc first point of contact between
individuals and health system. (See Unit 2, Section 2, for reference of essential
elements of PHC.)
•
At intermediate levels more complex problems should be dealt with and more
skilled and specialized care as well as logistic support should be provided.
•
Better trained staff, i.e., supervisory staff, should provide continuing education/
training to primary health care workers, as well as guide the public of different
communities and'community health workers on practical problems arising in
connection with all aspects of primary health care.
•
The central level should coordinate all parts of the system and provide planning
and management expertise. It should also provide highly specialized care, teaching
for specialized staff, the staffing of such institutions (as central laboratories), and
central logistic and financial support
If you think deeply for a while and analyse what does these above mentioned
characteristics indicate? These clearly indicate that health system is not a separate entity.
It includes components and actions not only from the health sector but also from other
health related sectors such as agriculture, education, environment, animal husbandry
communication ex., at various levels (central, inxrmediax and local). We shall discuss
this in the following sections.
46 '
Organization of Health
System Based on
Primary Health Care
Check Your Progress 1
• i)
Fill in the blanks:
a)
b)
Health system is defined as coherent whole of many
sectoral and
as well as community itself.
Health system aims at
the health services.
c)
Health system constitutes management sector and involves
matters.
d)
The aim of health system is health
parts, both
ii)
List the characteristics of health system.
4.3
STRUCTURAL ORGANIZATION OF HEALTH
SYSTEM
You know that health system in India is organized at three levels, i.e. Central level,
State level and District level.
Let us begin with organization at Central level.
4.3.1 Organization at Central Level
The official “organs” of the health system at the national level consist of :
i)
The Ministry of Health and Family Welfare (MHFW);
ii)
The Directorate General of Health Services (DGHS); and
iii)
The Central Council of Health and Family Welfare.
We shall talk of the organization and functions of each one of them.
i)
Ministry of Health and Family Welfare
Organization
The Union Ministry of Health and Family Welfare is headed by a Cabinet Minister,
a Minister of State and a Deputy Health Minister. These are political appointments.
Currently, the Union Health Ministry has two broad departments:
•
Department of Health, and
•
Department of Family Welfare.
The Health Department is headed by a Secretary to the Government of India as its
executive head who is an IAS officer and is assisted by joint secretaries, deputy
secretaries and a large administrative staff. The Department of Family Welfare was
created in 1966 within the Ministry of Health and Family Welfare. The Secretary to the
Govt, of India in the Ministry of Health and Family Welfare is in overall charge of the
Department of Family Welfare. He is assisted by an Additional Secretary &
Commissioner (Family Welfare), and one Joint Secretary.
Functions
The functions of the Union Health Ministry are set out in the Seventh Schedule of
Article 246 of the Constitution of India under (a) the Union List and (b) the
Concurrent list.
47
Health for All
Health is basically a Slate subject, though policy planning and decision making arc at
Centre level and responsibility for cxccution/implcmcntation of the health programmes
lies with the State and Union Territories. At present India has 25 full-fledged States and
7 Union Territories.
a)
Union List: The functions given in the Union List are:
•
•
b)
ii)
Administration of central institutes such as the All India Institute of Hygiene
and Public Health, Calcutta; National Institute for the Control of
Communicable Diseases, Delhi etc.,
Promotion of research through apex research bodies (ICMR) and other bodies,
•
REGULATION AND DEVELOPMENT OF MEDICAL,
PHARMACEUTICAL, DENTAL AND NURSING EDUCATIONAL AND
PROFESSIONAL INSTITUTIONS,
•
•
Establishment and maintenance of drug standards,
Census and collection and publication of other statistical data,
•
Immigration and emigration,
•
Regulation of labour and the working of mines and oil fields,
•
Coordination with States and with other ministries for promotion of
health, and-
•
International health.
Concurrent List: The functions listed under the concurrent list are the
responsibility of both the Union and State Governments. The Centre and the Slates
have simultaneous powers of legislation; the powers of the state are restricted to
the framework of such legislation as may be undertaken by the Centre. The
concurrent list includes:
•
Prevention of extension of communicable diseases from one unit to another
•
Prevention of adulteration of foodstuffs
•
Control of drugs and poisons
•
Vital statistics
•
Labour welfare
•
Ports other than major
•
Economic and social planning, and
•
Population control and family planning.
Directorate General of Health Services
Organization
The Director General of Health Services is the principal adviser to the Union
Government in both medical and public health matters. He is assisted by an Additional
Director General of Health Services, a team of deputies and a large administrative staff.
The Directorate comprises three main units, c.g., medical care and hospitals, public
health and general administration.
Functions
The specific functions of Directorate General of Health Services (DGHS) are the
organization and administration of:
48
•
International health relations and quarantine
•
Control of drugs standards
•
Medical stores depots
•
Post graduate training
•
Medical Education
•
Medical Research
•
National Health Programmes
Central Health Education Bureau
Health intelligence
National Medical Library
Organization of Health
System Based on
Primary Health Care
We shall now highlight the specific functions of DGHS covered in each area of the
above mentioned list of functions.
international health relations and quarantine
®
Direct control of all the major ports of country like Calcutta, Visakhapatnam,
Madras, Cochin, Bombay and Kandla and international air ports (BombaySantacruz, Calcutta-Dum Dum, Madras-Mecnambakkam, Tiruchirapalli, DelhiPalam).
o
Undertaking all the matters relating to the obtaining of assistance' from
international agencies and coordination of their activities in the country.
Control of drugs standard
Functions of DGHS under this are:
o
Lay down and enforce drugs standards and control the manufacture and
distribution of drugs through both central and state government offices.
o
Test the quality of imported drugs as per Drugs Act (1940).
Medical stores depots
o
Union Government runs medical stores depots at Bombay, Madras, Calcutta,
Kamal, Gauhati and Hyderabad. The functions undertaken by these depots are:
Supply the civil medical requirements of the Central Government and of the
various state Governments. Handle supplies from foreign agencies.
Post-graduate training
•
Administration of national institutes which provide training to different categories
of health personnel. Some of these institutes are All India Institute of Mental
Health at Bangalore, RAK College of Nursing at Delhi, National Tuberculosis
Institute at Bangalore, National Institute of Communicable Diseases at Delhi,
Central Institute of Health and Family Welfare at Delhi, etc.
Medical education
•
DGHS is directly in charge of Medical Colleges like the Lady Hardinge, the
Maulana Azad, and the JIPMER at Pondicherry, and Goa.
•
Guiding and supporting of other medical colleges in the country.
Medical Research
•
Organization and financing of Medical Research in the country through the Indian
Council of Medical Research (ICMR). The Council performs following functions
in Medical Research
•
Aiding, promoting and coordinating scientific research on human diseases, their
causation, prevention and cure. The research work is carried through several
permanent research institutes such as Cancer Research Institute at Bombay,
Tuberculosis Chemotherapy Centre at Madras, Virus Research Centre at Poona,
National Institute of Nutrition at Hyderabad etc.
National Health Programmes
•
The Central Directorate plays a very important part in planning, guiding and
coordinating at all. the national health programmes like malaria eradication, control
of tuberculosis, filaria, leprosy, sexually transmitted disease (STD) etc. in the
country.
Central Health Education Bureau (CHEB)
•
Preparation of education material for creating health awareness among people
49
Health for AU
Offering training courses in health education to different categories of health
workers.
Health Intelligence
•
Administration of Central Bureau of Health Intelligence which performs the
functions like collection, compilation, analysis, evaluation and dissemination of all
information on health statistics for the nation as a whole
•
Disseminate epidemic intelligence to stales and international bodies.
National Medical Library
•
•
Earlier (i.e. before 1966) this Library was called Central Medical!Library of
Directorate General of Health Services.
The function of this Library is to help in advancement of medical health and
related sciences by collection, dissemination and exchange of information.
iii) Central Council of Health
The Central Council of Health was set up by a Presidential Order on 9 August,
1952 under Article 263 of the Constitution of India. The council was set up for
promoting coordinated and concerted action between the Centre and the States in
the implementation of all the programmes and measures pertaining to the health of
the nation. The Union Health Minister is the Chairman and the State Health
Ministers are its members.
Functions
The functions of the Central Council of Health are:
•
•
•
•
To consider and recommend broad guidelines of policy matters concerning health
in all its aspects such as the provision of remedial and preventive care,
environmental hygiene, nutrition, health education and the promotion of facilities
for training and research.
To make proposals for legislation in fields of activity relating to medical and
public health matters and to lay down the pattern of development for the country
as a whole.
To make recommendations to the Central Government regarding distribution of
available grants-in-aid for health purposes to the States and to review periodically
the work accomplished in different areas through the utilisation of these grantsin-aid.
To establish any organization invested with appropriate functions for
promoting and maintaining cooperation between the Central and States health
administrations.
Check Your Progress 2
Fill in the blanks:
i)
The official organising health system at the national level consists of
................
a)
b)
c)
ii)
Director General of Health Services is the advisor to the
in
both medical and public health matters.
iii)
Central Council of Health was set up for promoting coordinated and concerted
action between
and
of all the programmes and measures pertaining to the
nation.
50
in the implementation
of the
So far wc discussed the organisation at Central level. Now we shall turn our attention to
the organisation at State level.
4.3.2 State Level
At present there arc 25 States in India and as many types of health administration.
In all the Slates, the management sector comprises the i) Ministry of Health, and
ii) Directorate of Health.
0
State Ministry of Health
Organization
The State Ministry of Health is headed by a Minister of Health and Family Welfare.
The Health Secretariate is the official organ of the State Ministry of Health and is
headed by a Secretary who is assisted by Deputy Secretaries, Under Secretaries and a
large administrative staff. The Secretary is a senior officer of the Indian Administrative
Service.
ii)
State Health Directorate
The Director of Health Services (known in some States as Director of Medical and
Health Services) is the chief technical advisor to the State Government on all matters
relating to medical and public health. He is also responsible to the organization and
direction of all health activities.
The Director of Health and Family Welfare is assisted by a suitable number of deputies
and assistants. The Deputy and Assistant Directors of Health may be of two types,
regional and functional. The Regional Directors inspect all the branches of public health
within their jurisdiction, irrespective of their speciality. The Functional Directors are
usually specialists in a particular branch of public health such as mother and child
health, family planning, nutrition, tuberculosis, leprosy, health education etc.
Functions
The state has the responsibility of administration for all the health services operating
within its jurisdiction. The responsibility of state includes, provision of medical care,
preventive health services and pilgrimages within the state. These arc functions included
in state list.
Check Your Progress 3
i)
Fill in the blanks:
Director of Health Services is the chief
on all matters relating to
to the State Government
and
Activity 1
Identify the organization structure of health and family welfare in your state and present
it diagram matically.
Hope you have understood the organization of health system at Central and State level.
Now wc shall discuss lire organisation at district level.
4.3.3 District Level
The principal unit of administration in India is the district under a Collector. There arc
more that 430 districts in India. Within each district again, there arc 6 types of
administrative areas:
Organization of Health
System Based on
Primary Health Care
Health for All
1)
Sub-Divisions
2)
Tchsils (Taluka)
3)
Villages
4)
Municipalities and Corporations
5)
Community Development Blocks
6)
Panchayats
Most districts in India are divided into two or more sub-divisions, each in charge of an
Assistant Collector or Sub-Collector. Each division is again divided into tehsils (Taluka),
in charge of a Tchsildar. A Tchsil usually comprises urban and rural areas. Urban areas
are divided into Municipalitics/Corporations depending on the population which is
headed by Chairman/Mayors. The community development blocks are headed by Block
Development officers and Panchayats arc the local bodies.
Health Organisation at District Level
Since “Health” is a State subject, there is no uniform “model” of a district health
organization in India, each State has developed its own pattern to suit its policy and
convenience.
Under the Multi-purpose Workers Scheme, it has been suggested to the States to have
an integrated set-up at the district level by having a Chief Medical Officer (CMO) with
three Deputy-CMOs (existing Civil Surgeons, District Health Officers and District
Family Welfare Officers), each of the Deputy CMOs being inchargc of one-third of >’-c
district for all the Health, Family Welfare and MCH programmes. The recent work in.,
group on Health for All by 2000 AD, appointed by the Planning Commission,
recommended that the District Hospitals should be converted into District Health
Centres, each centre monitoring all preventive, promotivc and curative services of one
million population. It has been recommended that the district set up should be
reorganised on the basis of the number of primary health centres it comprises. .
Community Health Centres
Community health centres have been established by upgrading few of the primary health
centre. Each community health centre covers a population of one lakh (one in each
community development block) with 30 beds with specialists in surgery, medicine,
obstetrics and gynaecology, and paediatrics with X-ray and laboratory facilities. For
strengthening preventive and promotivc aspects of health care, a new non-medieal post
called community health officer has been created at each community hcaldi centre. The
community health officer is selected from amongst the supervisory category of staff at
the PHC and district level with minimum of 7 years experience in rural health
programmes. Some states have not accepted this scheme and have opted for a second
medical officer.
The specialists at the community health centre may refer a patient directly to the state
level hospital or the nearest/ appropriate Medical College Hospital, as may be necessary,
without the patient having to go first to the sub-divisional or district hospital.
Check Your Progress 4
Fill in the blanks:
52
i)
Health officer inchargc of district is called
ii)
The functions of Deputy Chief Medical Officer arc:
Before we discuss the infrastructure of health system based on Primary Health Care let
us have a look at the illustration given below. This will give you an overview of health
care delivery system at three levels of health care i.e. primary, secondary and tertiary
levels. As you know a full range of primary health care (first level contact of individual,
family and community health system) arc being rendered through the agency of primary
health centres.
Organization of Health
System Based on
Primary Health Care
Secondary Health Care is being provided through the establishment of Community
Health Centres (upgraded primary health centres covering a population of 1 per 100,000)
sub-divisional and district hospitals where all basic speciality services arc being made
available.
Tertiary care is being provided at Regional Hospitals, Teaching Hospitals and super
speciality hospitals where super speciality services including sophisticated diagnosis- •
specialized therapeutic and rehabilitative services are available.
INSTITUTION
TIER OF DELIVERY
TEACHING
HOSPITALS
SUPER SPECIALITY
HOSPITALS
REGIONAL
I
HOSPITALS
!
TERTIARY
HEALTH CARE
DM & HQ. HOSP. SUPDT.
DMEIO. DPI IN
OTHER SPECIALISTS
1 P.H. SPECIALIST
1 PHYSICIAN. I PAEDIATRICIAN
1 OBSTETRICIAN. 1 SURGEON
I INDIG. PRACTITIONER
(1/100,000)
Pop.
2-3 MOi. BEE/
H.ASSTS/CHO
(1/30.000)
Pop.
I MALE MPHW
1 FEMALE MPHW
(1/5000)
Pop.
VHG.l.TBA.I
AWW-1
(1/1000)
Pop.
SECONDARY
HEALTH CARE
PRIMARY HEALTH
CARE
The present nursing structure since Independence is not well organised and it has
remained stagnat. In order to keep the desired pace with the expansion of the health
services in the country, a memorandum was submitted to the high power committee on
Nurses and nursing profession by the Trained Nurses Association of India, on behalf of
the nurses in India, to improve the organisational structure and nursing services (see
Appendix 3).
4.4 STRUCTURAL ORGANIZATION OF HEALTH
SYSTEM BASED ON PRIMARY HEALTH CARE
As a signatory to the Alma-Ata Declaration, the Government of India is committed
to achieve the goal of Health for All through primary health care approach. Keeping in
view the goal of “Health for All” by 2000 AD, the National Health Policy has laid
down a plan of action for reorienting and shaping the existing rural health infrastructure
within the framework of Sixth (1980-88) and Seventh (1985-90) Five Year Plans. The
establishment of primary health centres in our country in 1952 under the Community
Development Programme has been a valuable national asset in our efforts to increase the
outreach of our health system based on primary health care.
The rural health infrastructure is based on a 3 tier system of services, provided at three
levels
i)
ii)
iii)
Village level
Subcentre level
Primary Health Centre level
53
Health for All
We shall discuss organization of health system at all the three levels as given below.
Let us begin with health organization at village level.
4.4.1 Village Level
One of the basic aims of primary health care is universal coverage and equitable
distribution of health resources. That is, health care must be available and accessible to
rural areas, and that everyone should have access to it. Based on this aim, the health
organization at village level includes the following:
a)
Village Health Guides
b)
c)
Local Dais
Anganwadi Workers
a)
Village Health Guides
The Village Health Guides Scheme was introduced on 2nd October 1977 with the idea
of securing peoples’ participation in the care of their own health. The scheme was
launched in all states except Kerala, Karnataka, Tamil Nadu, Arunachal Pradesh and
Jammu and Kashmir which had alternative systems (e.g. Mini-health Centres in Tamil
Nadu) of providing health services at the village level.
A Village Health Guide is a person who is interested in social service and is not a
government functionary.
The Health Guides come from and are chosen by the community in which they work.
They serve as a link between the community and the governmental infrastructure. They
provide the first contact between the individual and the health system.
The guidelines for their selection are:
•
they should be permanent residents of the local community, preferably women
•
they should be able to read and write, having minimum formal education at least
up to the VI Standard
they should be acceptable to all sections of the community, and
•
•
they should be able to spare at least 2 to 3 hours every day for community health
work.
After selection, the Health Guides undergo a short training in primary health care. The
training is arranged in the nearest primary health centre, subcentre of any other suitable
place for the duration of 200 hours, spread over a period of 3 months. During the
training period, they receive a stipend.
On completion of training, they receive a training manual and a kit of simple medicines
belonging to the modem and traditional system of medicine in vogue in that part of the
country they belong.
Broadly the duties assigned to health guides include
•
•
treatment of minor ailments and provide first aid,
mother and child health including family planning, and
•
health education and sanitation.
The manual or guidebook gives them detailed information about medical care of
common illnesses — of what they can and cannot do. In practical terms, they know
exactly what should be done when confronted with a situation. They are already aware
when they should begin treatment by themselves and when they should refer the patient
immediately to the nearest health centre.
b) Local Dais
Under the Rural Health Scheme based on the principle of “placing people’s health in
people’s hands” (Shrivastav Committee, 1975) is an extensive programme to train all
categories of local dais (Traditional Birth Attendents (TBA)) in the country to improve
their knowledge in the elementary concepts of maternal and child health and
sterilization, besides obstetric skills. The training is for 30 working days. Each dai is
paid a stipend of Rs 300 during her training period. Training is given al the PHC,
subcentre or MCH centre for 2 days in a week, and on the remaining four days of the
week they accompany the Health Worker (Female) (HW (F)) to the villages preferably
in the dai’s own area. During her training each dai is required to conduct at least 2
deliveries under the guidance and supervision of the HW(F), ANM or Health
Assistant (F). The emphasis during training is on asepsis so that home deliveries are
conducted under safe hygienic conditions thereby reducing the maternal and infant
mortality.
Organization of HaKh
System Based on
Primary Health Care
After successful completion of training, each dai is provided with a delivery kit and a
certificate. She is entitled to receive an amount of Rs.2 per delivery provided the case is
registered with the subcentre/PHC. To each infant registered by her, she will receive
Rs 3. These dais are also expected to play a vital role in propagating small-family norm
since they are more acceptable to the community. Although the national target is to train
one local dai in each village, the Seventh Five Year Plan’s objective is to train all
untrained dais practising in the rural areas. Total number of dais trained from 1974 to
date is 5.44 lakhs.
c)
Anganwadi Worker
Anganwadi literally means a courtyard. Under the ICDS (integrated child development
services) scheme, there is an anganwadi worker for a population of 1000. There are
about 100 such workers in each ICDS project As of date over 1600 ICDS blocks are
functioning in the country. The anganwadi worker is selected from the community she is
expected to serve. She undergoes training in various aspects of health, nutrition, and
child development for 4 months. She is a part-time worker and is paid an honorarium
for the services rendered. These services include
o
health check up
o
immunization,
o
o
supplementary nutrition,
health education (non-formal, pre-school, nursing mothers, other women (15-45
years) and children below the age of 6 years).
Alongwith Village Health Guides, the anganwadi workers are the community’s primary
link with the health services and all other services for young children.
4.4.2 Sub-Centre Level
The subcentre is the peripheral outpost of the existing health delivery system in rural
areas. They are being established on the basis of one subcentre for every 5000
population in general and one each in every 3000 population in hilly, tribal and
backward areas. As of date 102,160 subcentres have been established in the country.
The total requirement is estimated to be 1.38 lakhs.
Each subcentre is manned by one male and one female health workers. At present the
functions of a subcentre are limited to mother and child health, family planning and
immunisation. The job responsibilities of HW(F) and HA(F) are given in Appendix 4.
It is proposed to extend the facilities at all subcentre for IUD insertion, and
simple laboratory investigations like routine examination of urine for albumin and
sugar. The work at subccntrcs is supervised by male and female health assistants.
According to the revised norm, one female HA will supervise the work of 6 female
HWs.
4.4.3 Primary Health Centre Level
All of us are now aware about the concept of Primary Health Centre (PHC) and we
hope you all must had an opportunity to work or visit PHC. The Bhore Committee in
1946 gave the concept of a primary health centre as a basic health unit, to provide, as
close to the people as possible, an integrated curative and preventive and promotive
aspects of health care to the rural population with emphasis on preventive and promotive
aspects of health care.
The Bhore Committee aimed at having a health centre to serve a population of 10,000
to 20,000 with 6 medical officers, 6 public health nurses and other supporting staff. But
55
Health for All
in view of the limited resources, the Bhore Committee’s recommendations could not be
fully implemented, even after a lapse of 40 years.
The primary health centre and its subcentres have been visualized as the proper
infrastructure to provide health services to the rural population and to achieve goal of
HFA. The Declaration of Alma-Ata Conference in 1978 setting the goal of Health for
All by 2000 AD for health services focuses on the new approach to health care delivery
system which is based on a new philosophy of equity, and a new approach, the primary
health care approach. The National Health Policy (1983) proposed reorganization of
primary health centres on the basis of one PHC for every 30,000 rural population in the
plains, and one PHC for every 20,000 population in hilly, tribal and backward areas for
more effective coverage.
Functions of the PHC
The functions of the primary health centre in India cover all the essential elements of
primary health care as oudined in the Alma-Ata Declaration. They are:
1)
2)
Medical care
MCH including family planning
3)
Safe water supply and basic sanitation
4)
5)
Prevention and control of locally endemic diseases
Collection and reporting of vital statistics
6)
Education about health and nutrition
7)
National Health Programmes like Malaria, Filaria, Leprosy, Tuberculosis, STD,
AIDS etc.
8)
Referral services
9)
Training of health guides, health workers, local dais and health assistants
10)
Basic laboratory services
It is proposed to equip the primary health centres with facilities for selected surgical
procedures (e.g. vasectomy, tubectomy, MTP and minor surgical procedures) and for
paediatric care. In order to reorient medical education towards the needs of the country
and community care, three primary health centres have been attached to each of the 106
medical colleges.
Staffing pattern
At present in each community development block, there is one PHC which covers
100,000 or more population. By the year 1990, one PHC is envisaged for every 30,000
population. In the new set-up each PHC will have the following staff:
At the PHC Level
Medical officer
Block Extension Educator (BEE)
Health Assistant (male)
Health Assistant (female)
Supporting staff (e.g. compounder,
driver, lab. technician,
ancillary staff)
1
1
1
1
’ At the Subcentre
Health worker (male)
Health worker (female)
1
1
4.4.4 Referral System
In foregoing sections you got a good idea about the organisation of health system in our
country. We shall now talk about referral system.
56
A good referral system is an essential component of health care system. Referrals are
used to provide access to health care for clients in need. In referral, the cases beyond
the competence of a particular institution such as subcentre, primary health centre etc.
are transferred to the higher level institution (see Fig. 4.1).
Organization of Health
System Based on
Primary Health Care
The objective of referral service is to identify contact people within agencies
and to facilitate easy movement of referred cases so that they are not lost in the
system.
The nurse’s responsibility is to act as liaison person dealing with the proper community
or medical resources on behalf of the client. The points to be kept in mind while
referring tire client are:
It is important to determine the efficiency and the cost effectiveness of a service for
example how quickly is the referral made?
Does referral system ease the clients flow?
Does it lessen the cost and time spent seeking treatment for the patient?
An effective referral service is based on best on networking relationship built through
meetings, informal gatherings and telephone conversations. It is also important that all
the health personnel working in various levels of health institutions be instructed to use
the referral system.
The clients who need to be referred are grouped into three categories.
According to J.E. Park and K. Park, these categories are:
Category
1
: .
Fatal condition; life cannot be saved even with treatment
Category
2
:
Serious conditions; life can be, .saved but only with immediate
treatment.
Category
3
:
Minor conditions; life is not threatened and referral can be
safely delayed
For referring the patients you as a health worker has to prepare Reference slips
containing following information.
Patient’s address and Identification number
Present complaint
Treatment given, if any
Reasons for referral
57
Health for All
Name and designation of Person making the referral
Name of PHC making the reference •
Date and time of reference
Check Your Progress 5
Fill in the blanks:
i)
The health system in rural area is organized at the following levels
ii)
Health functionary at village level is
iii)
Rural health scheme was introduced on
iv)
Health guide should be drawn from
v)
Health guides are trained for a period of
vi)
Local dais arc trained for a period of
..............................................
........................................................
months
in concept of
....... .....................................................r...._....................... .................. ...........
vii)
Anganwadi worker caters to a population of
viii)
The services rendered by Anganwadi worker, include
4.5 LET US SUM UP
We have discussed about the organization of health system. Health system is defined as
coherent whole of many interrelated component parts, both sectoral and intersectoral as
well as community itself, which produces a combined effect on the health of the
population. Health system is organized at three levels: centre, state and district level.
At the central level official organs are. Ministry of Health and Family Welfare,
Directorate General of Health Services (DGHS) and Central Council of Health and
Family Welfare. The union ministry of Health is headed by a cabinet minister, a
minister of state and a deputy health minister and it has two departments i.e.
department of health and department of family welfare. These departments are headed
by secretary to the Government of India with an additional secretary for family welfare
department.
At state level the health sector comprises the state ministry of Health and Family
Welfare and Directorate of Health. State ministry of health is headed by a state minister
of health and family welfare and secretary assisted by number of deputy secretaries and
under secretaries. At the directorate level Director of Health and Medical Education is
the chief technical adviser to the state government on all matters related to medicine and
public health. At the district level, Chief Medical Officer (CMO) is head of district
health services with three deputy chief medical officers. Lastly we discussed about the
organisation of health infrastructure based on primary health care, which mainly focuses
on rural health services.
58
These services are organized on three levels i.e. village level, subcentre level and
primary health centre level. At village level the main functionary, is village health guide,
subcentre is manned by one male and one female health worker (HWF and HWM) and
at the primary health centre level Medical Officer is the head assisted by the medical
officers, health assistants and other staff.
Organization of Health
System Based on
Primary Health Care
4.6 ANSWERS TO CHECK YOUR PROGRESS
Check Your Progress 1
i)
ii)
interrelated
intersectoral
a)
b)
delivering
c)
organisational
d)
development
Characteristics of Health System
— serves all
— equality
— prime responsibility
— intersectoral action
— essential elements
— specialized
Check Your Progress 2
i)
a)
Ministry of Health and Family Welfare
b)
The Directorate General of Health Services
c)
Central Council of Health and Family Welfare
ii)
Union Governments
iii)
Centre, state, health.
Check Your Progress 3
i)
Technical adviser, medicine and public health
Check Your Progress 4
i)
Chief Medical Officer
ii)
Deputy CMO in charge of 1/3 district for health, Family Welfare and MCH
programme.
Check Your Progress 5
i)
Village level
Sub-centre level
Primary health centre level
ii)
Village Health Guide
iii)
2 October, 1977
iv)
Community they serve *
v)
three
vi)
30 days
maternal and child health and sterilization and obstetric skills.
vii)
1000
viii)
Health check up
Immunization
Supplementary nutrition
Non-formal pre-school education
Referral services
59
UNIT 5
HEALTH CARE RESOURCES
AND MONITORING AND
EVALUATION OF HEALTH
SERVICES
Structure
5.0
5.1
5.2
Objectives
Introduction
Human Resources Development
5.2.1
5.2.2
5.2.3
5.2.4
5.2.5
5.3
Financial and Material Resources
5.3.1
5.3.2
5.3.3
5.3.4
5.3.5
5.4
5.5
5.6
5.7
5.8
5.0
Strategy and Definition
Sector-wise Distribution
Rural-Urban Distribution
Planning and Ratio in Relation to Population
International Action and Role of WHO
Financial Resources and GNP
Priority in Financial Allocation
Review Distribution and Reallocation of Health Budget
Estimate the Financial Needs and Secure Additional Funds
International Action and the Role of WHO
Monitoring and Evaluation
5.4.1
5.4.2
5.4.3
5.4.4
5.4.5
Definition and Importance of Monitoring
Monitoring vs Surveillance
Evaluation
Elements of Evaluation Process
General Steps of Evaluation
5.4.6
Evaluation of Health Services
Indicators of Health Monitoring and Evaluation'
55.1
55.2
Characteristics of Indicators
Broad Classification of Indicators in Health Measurement
5.5.3
Details of Indicator Selected for Monitoring Progress towards Health For All
Let Us Sum Up
Glossary
Answers to Check Your Progress
OBJECTIVES
After completing this unit you should be able to:
•
Describe the measures to develop human resources for health,
•
Find and explain ways of ensuring community involvement to be adopted by the
ministry of health,
•
Describe the whole gamut of health manpower, including international agencies
engaged in delivery of national health care service,
•
Explain the action required to develop monitoring and evaluation process as part
of managerial process for national health development
5.1
60
INTRODUCTION
In Unit 5 you have learnt the organization of health system based on primary health
care and the action required to promote and support it, which are the main thrusts of the
global strategy of Health For All. Inseparable parts of the strategy are the actions
required to generate and mobilize all possible human and financial resources and
development of suitable monitoring and evaluation process. Resources are needed to
meet the many health needs of a community. No nation, however rich, has enough
resources to meet all the needs or all aspects of health care of its citizens. Therefore an
assessment of the available resources, their proper allocation and efficient utilization are
important considerations for providing efficient health care services. The basic resources
for providing health care are Man, Money and Material which you will learn in the
following broad categories:
i)
Human Resources
ii)
Money and Material Resources.
S2
HUMAN RESOURCES DEVELOPMENT
Health Care Resources
and Monitoring and
Evaluation of Health
Services
The strategy seeks to involve not only the health personnel but also many other
personnel from various sectors as human resources. Primary health care has to mobilize
human potential of the entire community. This is possible on condition that individuals
and families accept greater responsibility for their own health. People need to be
involved in deciding on the health system required by them and the health technology
acceptable to them, in delivering a part of national health programme. This is to be
achieved through SELF CARE and FAMILY CARE and involvement in joint action for
health. Health manpower constitutes a major pan in human resources, so it is explained
in further details.
5.2.1 Strategy and Definition
The term “health manpower” includes both professional (Doctors & Nurses) and
auxiliary health personnel (ANM, MPW, TBA, Lab.Techn.) who are needed to provide
the health care. An auxilliary is defined by WHO as “technical worker in a certain field
with less than full professional training”. Health manpower requirements of a country
are based on
i)
ii)
.
health needs and demands of the populations: The health needs in turn are based
on the health situation and health problems and aspirations of the people.
desired outputs: preventive, promotive, curative or rehabilitative; control or
eradication.
5.2.2 Sector-wise Distribution
The health care system is intended to deliver the health care services. It constitutes the
management sector and involves organizational matters. It operates in the context of the
socioeconomic and political framework of the country. In India, it is represented by five
major sectors or agencies which differ from each other by the health technology applied
and by the source of funds for operation. These are:
i)
Public Sector
a)
Primary health centres
Sub-centres
Anganwadis
b)
Hospitals/health centres
Community health centre
Rural hospitals
District hospitals/health centre
Specialist hospitals
Teaching hospitals
c)
Health Insurance Schemes
Employees State Insurance
Central Government Health Scheme
61
d)
Health for All
Other agencies
Defence services
Railways
ii)
ii)
iii)
Private Sector
a)
Private hospitals, polyclinics, Nursing Homes, and Dispensaries
b)
General Practitioners and Clinics
Indigenous Systems of Medicine
a)
Ayurveda and Siddha
b)
Unani and Tibbi
c)
Homoeopathy
d)
Unregistered practitioners (Naturopathy)
Voluntary Health Agencies & Non-governmental Organizations
a)
Indian Red Cross Society
b)
c)
The Hind Kusht Nivaran Sangh
Indian Council for Child Welfare
d)
Tuberculosis Association of India
e)
f)
Bharat Sevak Samaj
Central Social Welfare Board
g)
The Kasturba Memorial Fund
h)
Family Planning Association of India
i)
All India Women's Conference
j)
k)
The All India Blind Relief Society
Professional Bodies—The Indian Medical Association (IMA),
All India Dental Association (IDA) and Trained Nurses Association of
India (TNAI)
Missionary Bodies—VHAI, CMAI, Ramakrishna Mission
1)
m)
Individuals: Jamked in Maharashtra, Dhenabandhu in Tamil Nadu and
Community Cell in Karnataka
n)
International Agencies—Ford Foundation, CARE (Co-operative for
American Relief Everywhere) WHO, ODA of various countries like UK,
Japan, UNICEF, UNDP, UNFPA.
5.2.3 Rural-Urban Distribution
You have now learned about the sectorwise distribution of health manpower which
does not give the real picture of available manpower according to geographical area.
When we analyse them between rural and urban area we can observe the gross
maldistribution of health manpower. Studies in India have shown that there is a
concentration of doctors and nurses (up to 80 per cent) in urban areas where only
20 per cent of population live. This maldistribution is chiefly attributing to absence
of amenities in rural areas, lack of job satisfaction, professional isolation, lack of
rural experience and inability to adjust to rural life by the professional doctors and
nurses.
5.2.4 Planning and Ratio in Relation to Population
Health manpower planning is an important aspect of community health planning.
It is based on series of accepted ratios such as doctor-population ratio,
nurse-population ratio, bed-population ratio, etc. For your understanding of the
depth of the problem of the availability of health manpower in the state, a set of data
sheets from various government publications is given for your ready reference. See
Appendices 5-14.
62
Health Care Resources
and Monitoring and
Evaluation of Health
Services
5.2.5 International Action and the Role of WHO
International action will include the following:
i)
Information will be collected and used internationally by the WHO regarding
people and groups throughout the world who could provide individual or group
support to countries on various aspects of their strategies;
ii)
UNESCO, in its worldwide literacy programme will be requested to use
health information with a view to providing basic understanding of
nutritional and health needs and of prevention and control of common health
problems;
iii)
WHO will engage in technical cooperation with its member stales and promote
such cooperation among them to ensure the maximum mobilization and
development of personnel, for health;
iv)
WHO will ensure the involvement of other UN organizations like UNDP, UNFPA,
International non-governmental and voluntary organisations by identifying specific
tasks in which they can engage;
v)
WHO will promote dialogue between developing and developed countries to
prevent brain drain of health personnel.
Check Your Progress 1
Outline the five major sectors where the health manpower are engaged.
a)
b)
c)
d)
c)
ii)
5.3
’•
Briefly describe the role of WHO in mobilising human resources.
FINANCIAL AND MATERIAL RESOURCES
Financial and material resources arc as essential as human resources for the
successful implementation of the strategy. It involves efficient use of existing resources
and making provision for the additional resources. Plan outlay on medical, public
health including water supply and sanitation and family welfare during the Seventh
Five Year Plan was only Rs. 3392.9 crore which is 1.9% of the total plan budget (see
Table 1). You may observe from the table that the budget allocation for health sector has
been steadily decreasing from the First Five Year Plan through the Seventh Five Year
Plan.
63
Table 1: Expenditure on Health Sector During the Different Plans
Health for All
Period
Expenditure
(Rs. in Crore)
Percentage of
expenditure on
health to expenditure
on total public sector
65.2
3.3
First Five Year Plan 1951-56
Second Five Year Plan 1956-61
140.8
3.0
Third Five Year Plan 1961-66
225.9
2.6
Annual Plans 1966-69
140.2
2.1
Fourth Five Year Plan 1969-74
335.5
2.1
Fifth Five Year Plan 1974-79
760.8
1.9
Sixth Five Year Plan 1980-85
1821.1
1.9
Seventh Five Year Plan 1985-90
3392.9
1.9
Source: Health Information, India-1988, Central Bureau of Health Intelligence, Ministry of Health
and Family Welfare, Government of India, New Delhi, 1988.
As tire available financial resources is mcarge, there is a need to allot proportionate
funds to each section considering their priorities and risk group (sec Table 2).
Table 2 : Seventh Plan Outlays—Health Sector
(Rs. in crore)
Programme
1)
2)
3)
4)
5)
6)
7)
8)
Minimum Needs Programmes/
Rural Health
Control of Communicable
Diseases
Hospitals and Dispensaries
Medical Education and
Training
1CMR
Indian Systems of Medicine
and Homeopathy
ESI
Other programmes
Total
Source :
Central
schemes
Total
Centrally
sponsored
programmes
Slates/UTs
33.0
1063.4
1096.4
521.5
474.7
1012.7
75.5
100.0
40.0
3.3
957.5
1283.9
41.8
41.8
339.6
557.8
2495.6
3392.9
16.5
65.8
Seventh Five Year Plan, 1985-90, Vol. II, Government of India, Planning Commission,
New Delhi, 1985.
5.3.1 Financial Resources and GNP
Money is an important resource for providing health services. Scarcity of money affects
all parts of the health delivery system. In most developed countries, Government
expenditure for health lies between 6 to 12 per cent of Gross National Product (GNP).
In under-developed countries it is less than 1 per cent of the GNP and it seldom
exceeds 2 per cent of the GNP. To make matter worse, much of the spending is for
services that reach only a small fraction of the population.
To achieve Health For All, WHO has set as a goal the expenditure of 5 per cent of
each country’s GNP on health care. At present India is spending about 3 per cent of
GNP on health and family welfare development.
x-
5.3.2 Priority in Financial Allocation
64
Since money and material are always scarce resources they must be put to the most
effective use, with an eye for maximum output of results on minimum investment. Since
deaths from preventable diseases such as whooping cough, measles, tuberculosis, tetanus,
diptheria, malnutrition frequently occur in developing countries, the case is strong for
investing resources on preventing these diseases rather than spending money on
multiplying prestigious medical institutions and other high cost medical establishments
which caters for a small percentage of the sick citizens absorbing a large portion of the
national health budget. Management techniques such as cost-effectiveness and cost
benefit analysis are now being used for allocation of resources in the field of
community health.
Health Care Resources
and Monitoring and
Evaluation of Health
Services
5.3.3 Review Distribution and Reallocation of Health Budget
i)
Review of the allocation of health budget to primary health care at peripheral,
intermediate and central levels in urban and rural areas and to specific underserved
groups;
ii)
Reallocation of the existing resources or any additional resources for providing
primary health care to underserved population groups;
iii)
Analysis of the needs, in terms of costs and material, for appropriate health
technology and establishment of health infrastructure;
Consideration of cost effectiveness of different technologies, of various health
programmes, to find alternate ways of organising the health system in relation to
die cost.
iv)
5.3.4 Estimate the Financial Needs and Secure Additional Funds
i)
ii)
Estimation of the magnitude of total financial and material needs to implement the
strategy;
Consideration of alternative ways of financing the health system including the
possible use of social security funds; c.g. ESI, CGHS;
iii)
Identifying activities that might attract external grant or loans; e.g
Leprosy control, child survival and Safe Motherhood, Universal Immunization,
AIDS control;
iv)
Encouraging governments (in developing countries) to request for grants and Ioans
from other sources such as external banks, bilateral and multilateral agencies; e.g.
World Bank; Rockfeller Foundation, CARE, Redd Barna, ODA of UK or Japan,
Ford Foundation;
In developed countries, to influence concerned agencies to provide grants and
loans for the strategy; e.g., various religious organisations;
v)
vi)
Presentation to their government a masterplan which outlines the use of all
financial and material resources including direct and indirect financing e.g. local
community resources in terms of available manpower, material and money,
individual payments for service and the use of external loans and grants.
5.3.5 International Action and the Role of WHO
To mobilise financial resources, WHO’s action will consist of the following:
i)
ii)
ensure the exchange of information on alternative ways of financing health
systems;
estimate the order of magnitude of financial needs for the strategy;
iii)
promotion and development of methodology for and support cost-benefit and costeffectiveness studies on health systems and technology;
iv)
strengthen developing countries’ capacities, on request, to prepare proposals for
funding from external sources for health;
v)
use its mechanisms to identify needs and facilitate mobilisation of funds as well as
transfers between countries;
vi)
establishment and coordination of activities of ‘global health for all’. Resources
group representation countries, intergovernmental, bilateral and multilateral
agencies and foundations, as well as nongovernmental organisations, working
together to rationalise the transfer of resources for ‘Health for AH' and to mobilise
additional funds, if necessary.
65
Health for aii
Check Your Progress 2
i)
Tick either True or False against the following statements:
National budget for health sector is:
ii)
5.4
a)
Mainly spent to build urban oriented prestigious curative institution
T/F
b)
c)
Directed to supply wholesome water and sewage system to the rural
population
5% of GNP which is recommended by WHO to achieve health for all
T/F
T/F
d)
At present it is only 3% of GNP
T/F
State in 5 lines regarding the international action for mobilising financial and
material resources.
MONITORING AND EVALUATION
You have learnt all about health service resource in terms of Manpower, Money and
Material distributed through out the country from centre to peripheral level. All these
resources arc allocated for Specified Programme or Task with Definite Goal.
In order to know the progress in implementation of any strategy, and to evaluate die
effectiveness in improving the health status of the people it is essential to set up a
process of monitoring and evaluation. Success of any programme depends on constant
monitoring of its different activities by guidance of an inbuilt predetermined systems of
monitoring and evaluation right at the stage of its inception. Monitoring process as well
as evaluation are complementary to each other to observe and assess the progress of a
planned programme.
We will now explain the process of monitoring and evaluation in the following sub
section.
5.4.1 Definition and Importance of Monitoring
Monitoring, we may define as the day-to-day follow-up of activities during their
implementation stage, to ensure that they arc proceeding as planned and are on
schedule. It is a continuous process of observing, recording, and reporting on the
activities of the organization or project. Monitoring, thus, consists of keeping track
of the course of activities and identifying deviations and taking corrective action if
deviations occur.
5.4.2 Monitoring Vs Surveillance
Definition of monitoring which you have learned is often taken as similar to that of
surveillance. But in public health practice during the past 25 years they have taken on
rather specific some what different meaning.
i)
66
Monitoring
Monitoripg is “the performance and analysis of routine measurements aimed at
detecting changes in the environment or health status of populations.” Thus we
have monitoring of an air pollution, water quality, growth and nutritional status of
children etc. It also refers to the measurement of performance of an ongoing ■
health service or a health professional, or of the extent to which patients comply
with or adhere to advice from health professionals.
In management, monitoring refers to the continuous overseeing of activities to
ensure that they are proceeding according to plan. It keeps track of performance
of health staff, utilization of supplies and equipments, and the money spent in
relation to the resources available so that if anything goes wrong immediate
corrective measures can be taken.
ii)
Health Care Resources
and Monitoring and
Evaluation of Health
Services
Surveillance
Surveillance is defined in many ways. According to one interpretation, surveillance
means to watch over with great attention and authority of the minute details in a
situation. Surveillance is also defined as the continuous scrutiny of the factors
that determine the occurrence and distribution of disease and other conditions
of ill-health. Surveillance programmes can assume any character and dimension—
thus we have epidemiological surveillance, demographic surveillance, nutritional
surveillance etc:
The main objectives of surveillance arc:
a)
b)
c)
to provide information about new and changing trends in the health
status of a population, e.g. morbidity, mortality, nutritional status or other
indicators of environmental hazards, etc.
to provide feedback which may be expected to modify the policy and the
system itself and lead to redefinition of objectives, and
to provide timely warning of public health disasters so that interventions
can be mobilized.
According to the above definitions, monitoring becomes one specific and essential
part of the broader concept embraced by surveillance. Monitoring requires careful
planning and the use of standardized procedures and methods of data collection,
but can then be carried out over extended periods of time by technicians and
automated instrumentation. Surveillance, in contrast, requires professional analysis
and sophisticated judgement of data leading to recommendations for control
activities.
5.4.3 Evaluation
It is to note that both monitoring and surveillance process are only to check the
deviation of any programme or activities from its aim till it reaches to the goal in terms
of its resources. These tools fails to assess the programme achievement at its different
level of implementation which is done by process of evaluation.
The purpose of evaluation is to assess the achievement of the stated objectives of a
programme, its adequacy, its efficiency and its acceptance by all parties involved.
While monitoring is confined to day-to-day ongoing operations, evaluation is mostly
concerned with the final outcome and with factors associated with it. Good planning
will have a built-in evaluation to measure the performance and effectiveness and for
feed-back to correct specific deficiencies.
Evaluation is the process by which results are compared with the intended
objectives, or more simply the assessment of how well a programme is
performing. Evaluation should always be considered during'the planning and
implementation stages of a programme or activity. Evaluation may be crucial in
identifying the health benefits derived (impact on morbidity, mortality, squclae, patient
satisfaction). Evaluation can be useful in identifying performance difficulties. Evaluation
studies may also be carried out to generate information for other purposes, e.g., to
attract attention to a problem, extension of control activities, training and patient
management, etc.
The reasons for evaluation are as follows:
Health services have become complex. There has been a growing concern about their
functioning both in the developed and developing countries. Questions are raised about
the quality of medical care, utilization, and coverage of health services, benefits to
community health in terms of morbidity and mortality reduction and improvement in the
health status of the recipients of care. An evaluation study addresses itself to these
issues.
67
Health for All
5.4.4 Elements of Evaluation Process
Evaluation is perhaps the most difficult task in the whole area of health services. The
components of the evaluation process arc:
a)
Relevance: Relevance or requisiteness relates to the appropriateness of the service,
whether it is needed at all. If there is no need, the service can hardly be of any
value. For example, vaccination against smallpox is now irrelevant because the
disease no longer exists in the world.
b)
Adequacy: Il implies that sufficient attention has been paid to certain previously
determined courses of action. For example, the staff allocated to a certain
programme may be described as inadequate if sufficient attention was not paid to
the quantum of work-ioad and targets to be achieved.
c)
Accessibility: It is the proportion of the given population that can be
expected to use a specified, facility, service, etc. The barriers to
accessibility may be physical (e.g., distance, travel, time); economic (e.g.
navel cost, fee charged); or social and cultural (e.g., caste or language
barrier).
d)
Acceptability: The service provided may be accessible, but not acceptable to all,
e.g., male sterilization, screening for cervical or rectal cancer, insertion of copper
T if the professional worker is malc/fcmale as the case may be.
c)
Effectiveness: It is the extent to which the underlying problem is prevented or
alleviated. Thus it measures the degree of attainment of the predetermined
objectives and targets of the programme, service or institution — expressed, if
possible, in terms of health benefits, problem reduction or an improvement of
an unsatisfactory health situation. The ultimate measures of the effectiveness
will be the reduction in morbidity and mortality rates.
fj
Efficiency: It is a measure of how well resources, money, men, material
and time arc utilized to achieve a given effectiveness. The following examples
will illustrate: the number of immunizations provided in an year as compared to
with an accepted norm using cotton and gauze to clean the windows or chairs;
during personal work on project time, a medical officer who cannot speak the
language of the client of a professional nurse who cannot insert a copper T or
health personnel proceeding on long leave with no replacement.
(g)
Impact: It is an expression of the overall effect of a programme services or
institution, on health status and socioeconomic development. For example, as a
result of malaria control in India, not only the incidence of malaria dropped down
but all aspects of life—agricultural, industrial and social—showed an improvement
If the target of 100 per cent immunization has been reached, it must also lead to
reduction in the incidence or elimination of vaccine preventable diseases. If the
target of village water supply has been reached, it must also lead to a reduction in
the incidence of diarrhoea diseases.
Planning and evaluation must be viewed as a continuous interactive process, leading
to continual modification, both of objectives and plans. Successful evaluation may
also depend upon whether the means of evaluation were built into the design of the
programme before it was implemented.
5.4.5 General Steps of Evaluation
The basic steps involved arc as follows:
68
—
Determine what is to be evaluated
—
Establish standards and criteria
—
Plan the methodology to be applied
—
Gather information
—
Analyse the results
—
Take action
—
Re-evaluate
Determine what is to be evaluated
Generally speaking, there arc three types of evaluation:
a)
b)
c)
Health Care Resources
and Monitoring and
Evaluation of Health
Services
Evaluation of “structure”: This is evaluation of whether facilities,
equipment, manpower and organization meet a standard accepted by experts as
good.
Evaluation of “process”: The processes of medical care include the problems of
recognition, diagnostic procedures, treatment and clinical management, care and
prevention. The way in which the various activities of the programme is carried
out is evaluated by comparing with a predetermined standard. An objective and
systematic way of evaluating the physician (or nurse) performance is known as
“Medical (or nursing) Audit”
Evaluation of “outcome”: This is concerned with the end results, that is,
whether persons using health services experience measurable benefits such as
improved survival or reduced disability. The traditional outcome components are
the “5 Ds” of iil-health, viz. disease, death, disability, discomfort and
dissatisfaction.
Establishment of standards and criteria
Standards and criteria must be established to determine how well the desired
objectives have been attained. Naturally such standards are a prerequisite for
evaluation. Standards and criteria must be developed in accordance with the focus of
evaluation—
i)
Structural criteria: e.g., physical facilities and equipment;
ii)
Process criteria: e.g. every prenatal mother must receive 6 check-ups; every
laboratory technician must examine 100 blood smears, etc;
iii)
Outcome criteria: e.g., an alterations in patient health status (cured, dead,
disabled); or a change in behaviour resulting from health care (satisfaction,
dissatisfaction); or the educational process (e.g., cessation of smoking, acceptance
of a small family norm), etc.
Planning the methodology
A format in keeping with the purpose of evaluation must be prepared for gathering
information desired. Standards and criteria must be included at the planning stage.
Gathering information
Evaluation requires collection of data or information. The type of information required
may include political, cultural, economic, environmental and administrative factors
influencing the health situation as well, as mortality and morbidity statistics. It may also
concern health and related socioeconomic policies, plans and programmes as well as the
extent, scope and use of health systems, services and institutions. The amount of data
required will depend on the purpose and use of the evaluation.
Analysis of results
The analysis and interpretation of data and feedback to all individuals concerned should
take place within the shortest time feasible, once information has been gathered. In
addition, opportunities should be provided for discussing the evaluation results with all
concerned.
Taking action
For evaluation to be truly productive, emphasis should be placed on actions—actions
designed to support, strengthen or otherwise modify the services involved. This may also
call for shifting priorities, revising objectives, or development of new programmes or
services to meet previously unidentified needs.
Re-evaluation
Evaluation is an ongoing process aimed mainly at rendering health activities more
relevant, more efficient and more effective.
69
Health for All
5.4.6 Evaluation of Health Services
Randomized controlled trials have been extended to assess the effectiveness and
efficiency of health services. Often, choices have to be made between alternative
policies of health care delivery. The necessity of choice arises from the fact diat
resources are limited, and priorities must be set for the implementation of a large
number of activities which could contribute to the welfare of the society. An excellent
example of such an evaluation is the controlled trials in the chemotherapy of
tuberculosis in India, which demonstrated that “domiciliary treatment" of pulmonary
tuberculosis was as effective as the more costlier “hospital or sanatorium” treatment. The
results of the study have gained international acceptance and ushered in a new era—the
era of “domiciliary treatment” in the treatment of tuberculosis.
More recently, multiphasic screening which has achieved great popularity in some
countries, was evaluated by a randomized vast outlay of resources required to mount a
national programme of multiphasic screening in UK. Another example is that related to
studies which have shown that many of the health care delivery tasks traditionally
performed by physicians can be performed by nurses and other paramedical workers,
thus saving physician’s time for other essential tasks. These studies arc also labelled as
“health services research” studies.
Check Your Progress 3
i)
Tick cither True or False against the following statements:
Monitoring of any programme is
ii)
a)
Keeping track of course of activities
T/F
b)
Providing information about recent trends in disease pattern
T/F
c)
Identifying deviation and taking corrective action, if needed
T/F
d)
Day-to-day follow up activities during implementation
T/F
List all the seven steps involved in evaluation process in chronological order.
a)
..........
b)
...................
c)
.............................
d)
e)
0
g)
5.5
INDICATORS OF HEALTH MONITORING AND
EVALUATION
Now you have imbibed all about the process of monitoring and evaluation of Health
Services implemented to uplift the health of the people. The level of health has to be
measured in some units as kilogram for weight and meter for height. For this purpose
we have different health indicators to measure the qualitative and quantitative
variables in health.
A question that is often raised is, how healthy is a given community? Indicators are
required not only to measure the health status of a community, but also to compare the
health status of one country with that of another, for assessment of health care needs;
for allocation of scarce resources; and for monitoring and evaluation of health services,
activities and programmes. Indicators help to measure the extent to which the objectives
and targets of a programme are being attained.
70
As the name suggests, indicators are only ah indication of a given situation or a
reflection of that situation. In WHO’s guidelines for health programme evaluation,
indicators are defined as variables which help to measure changes. Often they are
used particularly when these changes cannot be measured sequentially over time, they
can indicate direction and speed of change and serve to compare different areas or
groups of people at the same moment in time.
Health Care Resources
and Monitoring and
Evaluation of Health
Services
5.5.1 Characteristics of Indicators
Indicators have been given scientific respectability; for example, ideal indicators:
a)
should be valid, i.e., they should actually measure what they are supposed to
measure;
b)
should be realiable and objective, i.e., the answers should be the same if
measured by different people in similar circumstances;
c)
should be sensitive, i.e., they should be sensitive to changes in the situation
concerned; and
d)
should be specific, i.e., they should reflect changes only in the situation concerned.
But in real life there are few indicators that comply with all these criteria. Measurement
of health is rar from simple.
5.5.2 Broad Classification of Indicators in Health Measurement
As all of you have learnt that health is multidimensional in nature and each dimension
is influenced by numerous factors, some known and many unknown. Therefore no single
indicator can measure tlie health of people. It must be conceived in terms of a profile
employing many indicators like:
Mortality indicators
Morbidity indicators
Disability (rates) indicators
Nutritional status indicators
Health care delivery indicators
Utilization (rates) indicators
Indicators of social and mental health
Environmental indicators
Socioeconomic indicators
Health policy indicators
Indicators of quality of life
Other indicators for specific situations
We shall now study the same in detail for better understanding.
Mortality indicators
There arc many measurements involved.
a)
Crude death rate: This is considered a fair indicator of the comparative health of
the people. Crude death rate is defined as the number of deaths per 1000
population per year in a given community. It indicates the rate at which people are
dying. Strictly speaking, health should not be measured by the number of deaths that
occur in a community. But in many countries, the crude death rate is the only available
indicator of health. When used for international comparison, the usefulness of the crude
death rate is restricted because it is influenced by the age-sex composition of the
population. Although not a perfect measure of health status, a decrease in death rate
provides a good tool for assessing the overall health improvement in a population.
Reducing the number of deaths in the population is an obvious goal of medicine and
health care, and success or failure to do so is a measure of a nation’s commitment to
better health. In 1991 the crude death rate for India is 9.8 per thousand population. You
could see the statewise estimation in Appendix 5.
b)
Expectation of life: Life expectancy at birth is “the average number of years that
will be lived by those born alive into a population if the current age-specific
71
Health for All
mortality rates persist”. Life expectancy at birth is highly influenced by the infant
mortality rate where that is high. Life expectancy at the age of 1 excludes the influence
of infant mortality, and life expectancy at the age of 5 excludes the influence of child
mortality. Life expectancy at birth is used most frequently. It is estimated for both sexes
separately. It indicates an increase in the health status.
Life expectancy is a good indicator of socio-economic development in general. As an
indicator of long-term survival, it can be considered as a positive health indicator. It has
been adopted as a global health indicator. A minimum life expectancy at birth of 60
years is the goal of health for all by 2000 AD. For India life expectancy is 62.8 for
urban and 53.7 in rural areas at present.
c) Infant mortality rate: Infant mortality rate (IMR) is the ratio of deaths under 1
year of age in a.given year to the total number of live births in the same year; usually
expressed as a rate per 1000 live births. It is one of the most universally accepted
indicators of health status not only of infants, but also of whole populations and of the
socioeconomic conditions under which they live. In addition, the infant mortality rate is
a sensitive indicator of the availability, utilization and effectiveness of health care,
particularly perinatal care. The global strategy of health for all has suggested an infant
mortality rate not more than 50 per 1000 live births by 2000 AD. In 1991 the IMR in
India is 80 per thousand live births. You may study in detail the IMR for your state in
Appendix 5.
d) Child mortality rate: Another indicator related to the overall health status is the
early childhood (1-4 years) mortality rate. It is defined as the number of deaths at ages
1-4 years in a given year, per 1000 children in that age group at the mid-point of
the year concerned. It thus excludes infant mortality. In India the CMR is 18.2 for
urban and 39.4 in rural area at present
Apart from its correlation with inadequate MCH services, it is also related to insufficient
nutrition, low coverage by immunization and adverse environmental exposure and other
exogenous agents.
Mortality indicators represent the traditional measures of health status. Even today they
arc probably the most often used indirect indicators of health. As infectious diseases
have been brought under control, mortality rates have declined to very low levels in
many countries. Consequently mortality indicators are losing the sensitivity as health
indicators in developed countries. However mortality indicators continue to be used as
the starting point in health status evaluation.
Morbidity indicators
To describe health in terms of mortality rates only is misleading. This is because,
mortality indicators do not reveal the burden of ill-health in a community, as for
example mental illness, rheumatoid arthritis. Therefore morbidity indicators are used to
supplement mortality data to describe the developing countries than in the developed
countries. The child mortality rate may be as much as 250 times higher. This indicates
the magnitude of the gap and the room for improvement in the health status of
developing and developed countries.
Maternal (puerperal) mortality rate: Maternal (puerperal) mortality accounts for
the greatest proportion of deaths among women of reproductive age in most of the
developing world, although its importance is not always evident from official statistics.
There are enormous variations in maternal mortality according to country level of
socioeconomic status. At present in India the MMR is 3-4 per ten thousand deliveries
against our national target of below 2 per ten thousand by 2000 AD.
Disease-specific mortality: Mortality rates can be computed for specific diseases. As
countries begin to extricate themselves from the burden of communicabl' diseases, a
number of other indicators such as deaths from cancer, cardiovascular diseases,
accidents, diabetes etc. have emerged as measures of specific disease problems.
Morbidity statistics have also, their own drawback. They tend to overlook a large number
of conditions which are subclinics, inapparent, that is, the hidden part of the iceberg of
disease.
72
The following morbidity rates are used for assessing ill-health in community:
i)
incidence and prevalence
ii)
notification rates
iii)
iv)
v)
attendance rates al out-patient departments, health centres, etc.
admission, readmission and discharge rates
duration of stay in hospital, and
vi)
spells of sickness or absence from work or school
Health Care Resources
and Monitoring and
Evaluation of Health
Services
Nutritional status indicators
Nutritional status is a positive health indicator. Three nutritional status indicators arc
considered important as indicators of health status. They arc:
a)
anthropometric measurements of preschool children, c.g., weight and height,
mid-arm circumference;
b)
heights (and sometimes weights) of children at school entry; and
c)
prevalence of low birth weight (less than 2.5 kg.)
Health care delivery indicators
The frequently used indicators of health care delivery arc:
a)
Doctor-population ratio
b)
Nurse-population ratio
c)
Population-bed ratio
d)
Population per health centrc/subcentre
c)
Population per traditional birth attendant (TBA)
These indicators reflect the equity of distribution of health resources in different parts of
the country, and of the provision of health care.
Utilization rates
In order to obtain additional information on health status the extent of use of health
services is often investigated. Utilization of services—or actual coverage—is expressed
as the proportion of people in need of a service who actually receive it in a given
period, usually a year. It is argued that utilization rates give some indication of the care
needed by a population, and therefore, the health status of the population. In other
words, a relationship exists between utilization of health care services and health needs
and status. Health care utilization is also affected by factors such as availability and
accessibility of health services and the attitude of an individual towards his health and
the health care system. A few examples of utilization rates arc given below :
a)
proportion of infants who arc “fully immunized” against the 6 preventable diseases
through extended programme of immunization (EPI)’
b)
proportion of pregnant women who receive antenatal care, or have their deliveries
supervised by a trained birth attendant
c)
percentage of the population using the various methods of family planning
d)
bed-occupancy rate (i.e., average daily in-patient ccnsus/avcrage number of beds)
e)
average number of patients using the sub-center clinics
f)
average number of people using the anganwadi centers.
The above list is neither exhaustive nor all-inclusive. The list can be expanded
depending upon the services provided. These indicators direct attention away from the
biological aspects of disease in a population towards the discharge of social
responsibility for the organization in delivery of health care services.
Indicators of social and mental health
As long as valid positive indicators of social and mental health are scarce, it is
necessary to use indirect measures, viz, indicators of social and mental pathology. These
73
Health for All
include suicide, homicide, other acts of violence and other crime; road traffic accidents,
juvenile delinquency; alcohol and drug abuse; smoking; consumption of tranquilizers;
obesity, etc. To these may be added family violence, battered-baby and battered-wife
syndromes and neglected and abandoned youth in the neighbourhood. These social
indicators provide a guide to social action for improving the health of the people.
Environmental indicators
Environmental indictors reflect the quality of physical and biological environment in
which diseases occur and in which the people live. They include indicators relating to
pollution of air and water, radiation, solid wastes, noise, exposure to toxic substances in
food or drink. Among these, the most useful indicators are those measuring the
proportion of population having access to safe water and sanitation facilities, as for
example, percentage of households with safe water in the home or within 15 minutes
walking distance from a water standpoint or protected well, adequate sanitary facilities
in the home or immediate vicinity.
Socioeconomic indicators
These indicators do not directly measure health. Nevertheless, they are of great
importance in the interpretation of the indicators of health care.
These include:
rate of population increase
a)
b)
per capita GNP
c)
level of unemployment
d)
dependency ratio
e)
literacy rates, especially female literacy rates
f)
family size
g)
housing; the number of persons per room
h)
per capita “calorie” availability
Other indicator series
a)
Social indicators: Social indicators, as defined by the United Nations Statistical
Office, have been divided into 12 categories: population, family formation, families
and households, learning and educational services, earning activities, distribution of
income, consumption, and accumulation, social security and welfare services,
health services and nutrition, housing and its environment, public order and safety,
lime use, leisure and culture, social stratification and mobility.
b)
Basic needs indicators: Basic needs indicators are used by ILO. Those mentioned
in “Basic needs performance” include calorie consumption; access to water; life
expectancy; deaths due to disease; illiteracy, doctors and nurses per population;
rooms per person; GNP per capita.
c)
Health For All indicators: For monitoring progress towards the goal of health for
all by 2000 AD, the WHO has listed the following four categories of indicators.
—
—
—
—
5.5.3
a)
Health policy indicators
Social and economic indicators releated to health
Indication for the provision of health care
Health status indicators.
Details of Indicators Selected for Monitoring Progress Towards
Health For All
Health policy indicators:
— political commitment to health for all
— resource allocation
— the degree of equity of distribution of health services
— community involvement
74
— organizational framework and managerial process
b)
Health Care Resources
and Monitoring and
Evaluation of Health
Services
Social and economic indicators related to health:
— rate of population increase
— GNP or GDP
— income distribution
— work conditions
— adult literacy rate
— housing
— food availability
Indicators for the provision of health care:
c)
—
—
—
—
d)
availability
accessibility
utilization
quality of care
Health status indicators:
—
—
—
—
—
—
—
—
—
low birth weight (Percentage)
nutritional status and psychosocial development of child
infant mortality rate
child mortality rate (1-4 years)
life expectancy at birth
maternal mortality rate
disease specific mortality
morbidity—incidence and prevalence
disability prevalence
Check Your Progress 4
Situation: In the year 1992 an urban community ‘A’ is inhabited by one lakh people
having birth rate of 40 per 1000 population have evidenced with 320 unfortunate
children who could not see their 1st birthday.
i)
Calculate the total number of live births in the community and calculate the infant
mortality rate of the above community ‘A’.
ii)
List five health care delivery indicators.
a)
■■■■■■..................................
b)
............................
c)
............................................
d)
e)
.................................................................................
..........................................................................................
75
Health for All
5.6
LET US SUM UP
In this unit, you have learnt that for the successful implementation of the strategy of
Health For All. Actions to generate and mobilize resources are required. Three types of
resources namely, human resources and financial and material resources, are required.
All human resources, including community involvement, existing auxilliary health
workers, professional and traditional health workers, will be mobilized for their active
participation in primary health care. Necessary reorientation and training will be given to
the health workers. For the best use of material and financial resources, ministries of
health will ensure redistribution and reallocation of health budget for primary health
care. Financial needs will be assessed and efforts at the national and international levels
will be made to mobilize and secure additional funds for this purpose. International
transfer of resources from developed to developing countries will be rationalized and, if
necessary, these transfers will be increased.
Monitoring and evaluation are the essential parts of the strategy. To monitor progress
during implementation and to evaluate its effect, a suitable monitoring and evaluation
process will be set up. Indicators at the national level such as health indicators for the
provision of health care and health status indicators will be used. At the global level
evaluation will be based on the' number of countries in which certain indicators comply
with predetermined norms. These afe : endorsement of policy at the highest official
level, availability of primary health to the whole population, equitable distribution of
resources, life expectancy at birth over 60 years, literacy rate over 70%, and infant
mortality rate below 50 per 1000 live births. At the international level,.WHO’s
mechanisms will be used for reporting on progress and assessing the impact of the
strategy.
5.7
76
GLOSSARY
Health resources
all the means available for a health system’s
operation, including manpower, money, materials,
buildings, equipment, supplies, skills, knowledge
and technology and operational- time.
Health status
the general term for the state of health of an
individual, group or population measured against
accepted standards at a point of time.
Evaluation
is the systematic assessment of the achievement
of the stated objectives in terms of its relevance,
adequacy, progress, efficiency, effectiveness and
impact of a health programme. It gives a
feedback to correct deficiencies.
Relevance
a programme is relevant if it answers the needs
and social and health policies and priorities it has
been designed to meet.
Adequacy
a programme is adequate if it is proportionate to
requirements.
Efficiency
a programme is efficient if the effort expended on
it is as good as possible in relation to the
resources devoted to it.
Effectiveness
it is effective if the results obtained conform with
the objectives and targets for reducing the extent
of the problem or improving an unsatisfactory
situation.
Impact
it is the overall effect on health status and
socioeconomic development.
Cost benefit
is the relationship between the cost of an activity
and the benefits that accrue from it.
Cost effectiveness
is the relationship between cost and the extent
to which a programme or other activity is
contributing to the attainment of the objectives
and targets for reducing the problem or
improving an unsatisfactory situation.
Health Care Resources
and Monitoring and
Evaluation of Health
Services
5.8 ANSWERS TO CHECK YOUR PROGRESS
Check Your Progress 1
i)
ii)
Public sector
Private sector
Voluntary agencies
Indegenous medicine
International agencies
engage in technical cooperation with its Member States to ensure the
maximum mobilization and development of personnel for health;
b) . organize the collation and international use of information regarding people
and groups who can provide support to the strategy;
c) promote dialogues between developing and developed countries to prevent
the brain-drain of health personnel.
a)
b)
c).
d)
e)
a)
Check Your Progress 2
i)
ii)
a) True
b) False
c) False
d) True
WHO will ensure exchange of information on alternate ways of financing health
systems. It will estimate the order of magnitude of financial needs for the
strategy: Support developing countries on request in preparing proposals for
external funding for health, and will work together with other multilateral and
bilateral agencies, foundations and ‘Health For AH’ Resources group to
rationalize international transfer of resources.
Check Your Progress 3
i)
a)
True
ii)
a)
b)
c)
d)
e)
f)
g)
Identification of problem
Establishment of standard and criteria
Plan the methodology to be applied
Gather information
Analyse the results
Take action
Re-evaluate
b) False
c) False
d) True
Check Your Progress 4
i)
Total Live birth of Community A = Birth Rate x population
40
= ------1000
x 10,0000 = 4000
Deaths of children under 1 yrs
IMR = ------------- ------------------------—
Total Live birth in same year
x 1000
320
IMR of Community A =--------- x 1000
4000
= 80 per 1000
ii)
a)
b)
c)
d)
e)
Doctor-population ratio
Nurse-population ratio
Population-bed ratio
Population per health centre/subcentre
Population per traditional birth attendant.
77
Health for All
APPENDIX 1
ALMA-ATA DECLARATION
You know that the attainment of health for all by the year 2000 was the central issue of
the International Conference on Primary Health Care, held at Alma-Ata in September
1978. The Declaration of Alma-Ata is reproduced here in full.
DECLARATION OF ALMA-ATA
The International Conference on Primary Health Care meeting in Alma-Ata this twelfth
day of September in the year Nineteen hundred and seventy-eight, expressing the need
for urgent action by all governments, all health and development workers, and the world
community to protect and promote the health of all the people of the world, hereby
makes the following Declaration:
I
The Conference strongly reaffirms that health, which is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity, is a
fundamental human right and that the attainment of the highest possible level of health
is a most important worldwide social goal whose realization requires the action of many
other social and economic sectors in addition to the health sector.
II
The existing gross inequality in the health status of the people particularly
between developed and developing countries as well as within countries is politically,
socially and economically unacceptable and is, therefore, of common concern to all
countries.
HI
Economic and social development, based on a New International Economic Order, is of
basic importance to the fullest attainment of health for all and to the reduction of the
gap between the health status of the developing and developed countries. The promotion
and protection of the health of the people is essential to sustained economic and social
development and contributes to a better quality of life and to world peace.
IV
The people have the right and duty to participate individually and collectively in the
planning and implementation of their health care.
V
Government have a responsibility for the health of their people which can be fulfilled
only by the provision of adequate health and social measures. A main social target of
governments, international organisations and the whole world community in the coming
decades should be the attainment by all people of the world by the year 2000 of a level
of health that will permit them to lead a socially and economically productive life.
Primary health care is the key to attaining this target as part of development in the spirit
of social justice.
VI
78
Primary health care is essential health care based on practical, scientifically^spund and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their development in
the spirit of self-reliance and self-determination. It forms an integral part both of the
country’s health system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the first level of
contact of individuals, the family and community with the national health system
bringing health care as close as possible to where people liv.e and work, and constitutes
the first element of a continuing health care process.
VII
Appendices
Pi'rimary health care:
1)
reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country and its communities and is based on the application
of the relevant results of social, biomedical and health services research and
public health experience;
2!)
addresses the main health problems in the community, providing promotive,
preventive, curative and rehabilitative services accordingly;
38)
includes atleast: 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 the major
infectious diseases, prevention and control of locally endemic diseases,
appropriate treatment of common diseases and injuries; and provision of essential
drugs;
<4)
involves, in addition to the health sector, al! related sectors and aspects of national
and community development, in particular, agriculture, animal husbandry, food,
industry, education, housing, public works, communications and other sectors; and
demands the coordinated efforts of all those sectors;
.5)
requires and promotes maximum community and individual self-reliance and
participation in the planning, organisation, operation and control of primary health
Care, making fullest use of local, national and other available resources; and to
this end develops, through appropriate education, the ability of communities to
participate;
6)
should be sustained by integrated, functional and mutually-supportive referral
systems, leading to the progressive improvement of comprehensive health care for
all, and giving priority to those most in need;
7)
relics, at local and referral levels, on health workers, including physicians,
nurses, mid-wives, auxiliaries and community workers as applicable, as
well as traditional practitioners as needed, suitably trained socially and technically
to work as a health team and to respond to the expressed health needs of the
community.
VIII
All governments should formulate national policies, strategics and plans of action to
launch and sustain primary health care as part of a comprehensive national health system
and in coordination with other sectors. To this end, it will be necessary to exercise
political will, to mobilize the country’s resources and to use available external resources
rationally.
IX
All countries should cooperate in a spirit of partnership and service to ensure
primary health care for all people since the attainment of health by people in any
one country directly concerns and benefits every other country. In this context the
joint WHO/UNICEF report on primary health care constitutes a solid basis
for the further development and operation of primary health care throughout the
world.
X
An acceptable level of health for all the people of the world by the year 2000 can be
attained through a fuller and better use of the world’s resources, a considerable part of
which is now spent on armaments and military conflicts. A genuine policy of
independence, peace, detente and disarmament could and should release additional
resources that could well be devoted to peaceful aims and in particular to the
acceleration of social and economic development of which primary health care, as an
essential part, should be allotted its proper share.
79
Health Tor All
APPENDIX 2
HEALTH POLICY
The Government of India adopted a National Health Policy in August 1983. An
abridged para-wise description of the policy is given below:
Para 1: Indroductory
The Constitution directs the state to regard the raising of the level of nutrition and the
standard of living of its people and the improvement of public health among its primary
duties. It is felt that an integrated, comprehensive approach towards the future
development of medical education, research and health services requires to be
established to serve the actual health needs and priorities of the country. It is in this
context that the need has been felt to evolve a National Health Policy.
Para 2: Our heritage
“India has a rich heritage of medical and health sciences. The approach of our ancient
medical systems was of a holistic nature.”
Para 3: Progress achieved
Since Independence, considerable progress has been achieved, especially in reference to
smallpox, plague and cholera. Mortality has decreased from 27.4 to 14.8 and life
expectancy at birth has increased from 32.7 to over 52.
Para 4: The existing picture
The demographic and health picture of the country constitutes a cause for serious and
urgent concent, with special reference to the following:
i)
High rate of population growth
ii)
High mortality rates for women, children and infants
iii)
Malnutrition
iv)
High prevalence of communicable and noncommunicable diseases, especially
dianheal diseases, leprosy, tuberculosis and blindness
v)
Poor access of rural population to potable water supply (31%) and basic
sanitation (0.5%)
vi)
Poverty
vii)
Ignorance
viii)
Almost wholesale adoption of health manpower development policies based on
the Western Models, resulting in the development of a cultural gap between the
people and the personnel providing care
ix)
Establishment of curative centres based upon Western models, which are
inappropriate and irrelevant to the real needs of our people and their socio
economic condition
Emphasis on hospital-based, cure oriented approach and neglect of preventive,
promotive, public health and rehabilitative aspects of health care
x)
xi)
Failure to involve the community in the identification of health needs and
priorities, as wcll as in implementation and management of various health related
programmes.
Para 5: Need for evolving a health policy—the revised 20 point programme
80
India is committed to attaining the goal of “Health for all by the year 2000 AD”
through the universal provision of comprehensive primary health care'Yervices. The
attainment of this goal requires a thorough overhaul of existing approaches to the
education and training of medical and health personnel and the reorganisation of the
health services infrastructures. Furthermore, considering the large variety of inputs into
health, it is necessary to secure the complete integration of all plans for health and
human development with the overall national socio-economic development process,
specially in the more closely health related sectors, e.g., drugs and pharmaceuticals,
agriculture and food production, rural development, education and social welfare,
housing, water supply and sanitation, prevention of food adulteration, maintenance of
prescribed standards in the manufacture and sale of drugs and the conservation of the
environment In sum, the contours of the National Health Policy have to be evolved
within a fully integrated planning framework which seeks to provide universal,
comprehensive primary health care services, relevant to the actual needs and priorities of
the community at a cost which the people can afford, ensuring that the planning and
implementation of the various health programmes is through the organised involvement
and participation of the community, adequately utilising the services being rendered by
private voluntary organisations active in the health sector.
Appendices
It is also necessary to ensure that the pattern of development of the health services
infrastructure in the future fully takes into account the revised 20 Point Programme. The
said programme attributes very high priority: promotion of family planning as a peoples’
programme on a voluntary basis; substantial augmentation and provision of primary
health care facilities on a universal basis; control of leprosy, TB and blindness;
acceleration of welfare programmes for women and children; nutrition programmes for
pregnant women, nursing mothers and children, especially in the tribal, hill and
backward areas. The programme also places high emphasis on the supply of drinking
water to all problem villages, improvements in the housing and environments of the
weaker sections of society; increased production of essential food items; integrated rural
development; spread of universal elementary education, expansion of the public
distribution system, etc.
Para 6: Population stabilisation
Improvement in health status of people cannot be achieved without achieving success in
“securing the small family norm, through vohtntray efforts and moving towards the goal
of population stabilisation. It is necessary to enunciate, separately, a National Population
Policy”.
Para 7: Medical and health education
“The effective delivery of health care services would depend very largely on the nature
of education, training and appropriate orientation towards community health of all
categories of medical and health personnel and their capacity to function as an
integrated team. Towards this end, it is necessary to formulate, separately, a National
Medical and Health Education Policy which:
i)
ii)
iii)
iv)
v)
sets out the changes required to be brought about in the curricular contents and
training programme of medical and health personnel, at various levels of
functioning
takes into account the need for establishing the extremely essential interrelations
between functionaries of various grades
provides guidelines for the production of health personnel on the basis of
realistically assessed manpower requirements
seeks to resolve the existing sharp regional imbalances in their availability
ensures that personnel at all levels are socially motivated towards the rendering of
community health services.”
Para 8: Need for providing primary health care with special emphasis on the
preventive, promotive and rehabilitative aspects
There is disproportionate emphasis on the establishment of curative centres, the large
majority of which are located in the urban areas of the country. It is urgently necessary'
to restructure the health services within the following broad approach:
1)
A well dispersed network of comprehensive primary health care services with the
organised support of volunteers, auxiliaries, para-medics and adequately
trained multi-purpose workers. Services of private voluntary organisations active
in the health field require to be utilised an integrated manner.
2)
The establishment of the primary health care approach would involve large scale
transfer of knowledge, simple skills and technologies to Health Volunteers selected
by the communities and enjoying their confidence. The quality of training of these
health guides/workers would be of crucial importance to the success of this
approach.
81
Health for All
3)
The success of the decentralised primary health care system would depend vitally
on the organised building up of individual self-reliance and effective community
participation; on the provision of organised back up support of the secondary and
tertiary levels of the health care services, providing adequate logistical and
technical assistance.
4)
The decentralisation of services would require the establishment of a well worked
out referral system to provide adequate expertise nearest to the community.
5)
Il is necessary to establish a nation-wide chain of sanitary-cum-epidemiological
stations. The location and functioning of these stations may be between the
primary and secondary levels of the hierarchical structure, depending upon the
local situations and otner relevant considerations. Each such station would require
to have suitably trained staff equipped to identify, plan and provide preventive,
promotive and mental health care services. It would be beneficial depending up on
the local situations, to establish such stations at the Primary Health Centres. The
district health organisation should have, as an integral part of its set up, a well
organised epidemiological unit to coordinate and superintend the functioning of the
field stations. These stations would participate in the integrated action plans to
eradicate and control diseases, besides tackling specific local environmental health
problems.
6)
The location of curative centres should be related to the populations they serve,
keeping in view the densities of population, distances, topography and transport
connections. These centres should function within the recommended referral
system. To maximise utilisation of available resources, new and additional curative
centres should be established only in exceptional cases, the basic attempt being
towards the upgradation of existing facilities. Expenditure or curative centres
should be reduced as much as possible.
7)
With a view to reducing governmental expenditure and fully utilising untapped
resources, planned programmes may be devised, related to the local requirements
and potentials, to encourage the establishment of practice by private medical
professional, increased investment by non-govemmental agencies in establishing
curative centres and by offering organised logistical, financial and technical
support to voluntary agencies in the health field.
8)
While the major focus of governmental efforts would be upon primary health care
and-public health services, speciality and superspeciality services also need to be
provided. To reduce governmental expenditures involved in the establishment of
such centres, planned efforts should be made to encourage private investments in
such fields so that the majority of such centres, within the governmental set up,
can provide adequate care and treatment to those, entitled to free care, the affluent
sectors being looked after by the paying clinics.
9)
Special, well-coordinated programmes should be launched to provide mental health
care as well as medical care and the physical and social rehabilitation of those
who are mentally retarded, deaf, blind, physically disabled, infirm and the aged.
Also, suitably organised programmes would require to be launched to ensure the
prevention of various disabilities.
10)
In the establishment of the reorganised services, the first priority should be
accorded to provide services to those residing in the tribal, hill and backward areas
as well as to endemic disease affected populations and the vulnerable sections of
the society.
11)
In the reorganised health services scheme, efforts should be made to ensure
adequate mobility of personnel at all levels of functioning.
12)
In the various approaches, set out in (1) to (11) above, organised efforts
would require to be made to fully utilise and assist in the enlargement of the
services being provided by private voluntary organisations active in the health
field.
Para 9: Re-orientation of the existing health personnel
82
A dynamic process of change and innovation is required to be brought about
in the entire approach to health manpower development, ensuring the emergence
of fully integrated bands of workers functioning within the ‘Health Team’
approach.
Para 10: Private practice by governmental functionaries
Appendices
It is desirable for the States to take steps to phase out the system of private practice by
medical personnel in government service, providing at the same time for payment of
appropriate compensatory non-practising allowance.
Para 11: Practitioners of indigenous and other systems of medicine and their role
in health care
The country has a large stock of health manpower comprising private practitioners in
various systems, for example, Ayurveda, Unani, Sidha, Homeopathy; Yoga, Naturopathy,
etc. This resource has not so far been adequately utilised. The practitioners of these
various systems enjoy high local acceptance and respect and consequently ex.ert consid
erable influence on health beliefs and practices. It is, therefore, necessary to initiate
organised measures to enable each of these various systems of medicine and health care
to develop in accordance with its genius. Simultaneously, planned efforts should be
made to dovetail the functioning of the practitioners of these various systems and
integrate their services, at the appropriate levels, within specified areas of responsibility
and functioning, in the overall health care delivery system, specially in regard to the
preventive, promotive and public health objectives. Well considered steps would also
require to be launched to move towards a meaningful, phased integration of the indige
nous and the modem systems.
Para 12:
i)
ii)
Problems requiring urgent attention
Nutrition: Adequate nutrition for all segments of the population through a well
developed distribution system, specially in the rural areas and urban slums should
be ensured. The overall strategy would necessarily involve organised efforts at
improving the purchasing power of the poorer sections of the society. Schemes
like employment guarantee scheme to which the government is committed, could
yield optimal results. Measures should be taken to improve dietary practices and to
promote breast feeding. Supplementary feeding programmes directed to the
vulnerable sections of the population should be arranged in chronically
malnourished communities.
Prevention of food adulteration and maintenance of the quality of drugs
iii)
Water supply and sanitation: The provision of safe drinking water and sanitary
disposal of waste waters, human and animal wastes, bodi in urban and rural areas,
must constitute an integrated package.
iv)
Environmental protection: It would be necessary to ensure against the haphazard
exploitation of resources which cause ecological disturbances leading to fresh
health hazards. Environmental appraisal procedure must be developed and strictly
applied in according clearance to the various industrial and developmental projects.
v)
Immunisation programme
vi)
Maternal and child health services: A vicious relationship exists between high
birth rates and high infant mortality, contributing to the desire for more children.
The highest priority would, therefore, require to be devoted to efforts of launching
special programmes for the improvement of maternal and child health, with a
special focus on the less privileged sections of society. While efforts should
continue at providing refresher training and orientation to the traditional birth
attendants, schemes and programmes should be launched to ensure that
progressively all deliveries are conducted by competently trained persons.
vii)
School health programme
viii)
Occupational health services: There is urgent need for launching well-considered
schemes to prevent and treat diseases and injuries arising from occupational
hazards, not only in the various industries but also in the comparatively
unorganised sectors like agriculture.
Para 13: Health education
The recommended efforts, on various fronts, would bear only marginal results unless
nationwide health education programmes, backed by appropriate communication
strategies, are launched to provide health information in easily understandable form, to
motivate the development of an attitude for healthy living. The public health education
83
Health for AU
programmes should be supplemented by health, nutrition and population education
programmes in all educational institutions at various levels. Simultaneously, efforts
would require to be made to promote universal education, specially adult and family
education, without which the various efforts to organse preventive and promotive health
activities, family planning and improved maternal and child health cannot bear fruit.
Para 14: Management information system
Appropriate decision making and programme planning in the health and related fields is
not possible without establishing an effective health information system.
Para 15: Medical industry
The country has built up sound technological and manufacturing capability in the field
of drugs, vaccines bio-medical equipments etc. The available know-how requires to be
adequately exploited to increase the production of essential and life saving drugs and
vaccines of proven quality to fully meet the national requirements, specially in regard to
the national programmes to combat Malaria, TB, Leprosy, Blindless, Diarrhoeal diseases
etc. The production of the essential, life saving drugs under their generic names and the
adoption of economical packaging practices would considerably reduce the unit cost of
medicines, bringing them within the reach of the poorer sections of society, besides,
significantly reducing the expenditure being incurred by the governmental organisation
on the purchase of drugs. In view of the low cost of indigenous and herbal medicines,
organised efforts may be launched to establish herbal gardens, producing drugs of
certified quality and making them easily available.
The practitioners of the modem medical system rely heavily on diagnostic aids involving
extensive use of costly, sophisticated bio-medical equipment. Effective mechanisms
should be established to identify essential equipments required for extensive use and to
promote and enlarge their indigenous manufacture, for such devices being readily
available, at reasonable prices, for use at the health care centres.
Para 16: Health insurance
It would be necessary to devise well considered health insurance schemes, on a
Statewise basis, for mobilising additional resources for health promotion and ensuring
that the community shares the cost of the services, in keeping with its paying capacity.
Para 17: Medical legislation
It is necessary to urgently review all existing legislation and work towards a unified,
comprehensive legislation in the health field, enforceable all over the country.
Para 18: Medical research
Special attention should be paid to:
i)
containment and eradication of the existing, widely prevalent diseases
ii)
translation of available know-how into simple, low cost, appropriate technologies
iii)
applied operational research for improving cost effective delivery of health services
iv)
more effective treatment and preventive procedures for blindness, leprosy and TB
v)
contraceptive research, and
vi)
nutrition research.
Para 19: Inter-sectoral cooperation
It is necessary to secure inter-sectoral coordination of the various efforts in the fields of
health and family planning, medical education and research, drugs and pharmaceutical,
agriculture and food, water supply and drainage, housing, education and socal welfare
and rural devellpment.
Para 20: Monitoring and review of progress
It would be of crucial importance to monitor and periodically review the success of the
efforts made and the results achieved in reference to the goals.
84
Comments about national health policy
Appendices
The Health Policy is a valuable document and provides a clear framework for national
health planning. However, it has been criticised on the following gounds.
i)
ii)
The policy talks of poverty alleviation, (e.g., through the minimum needs
programme), as a necessary precondition for Health For All. However, the policy
does not speak even once about social justice (in health and in other fields such as
land reforms and wages), which is an essential prerequisite for Health For All.
No definite programme has been suggested for promoting community participation
in health.
85
Health for All
programmes should be supplemented by health, nutrition and population education
programmes in all educational institutions at various levels. Simultaneously, efforts
would require to be made to promote universal education, specially adult and family
education, without which the various efforts to organse preventive and promotive health
activities, family planning and improved maternal and child health cannot bear fruit.
Para 14: Management information system
Appropriate decision making and programme planning in the health and related fields is
not possible without establishing an effective health information system.
Para IS: Medical industry
The country has built up sound technological and manufacturing capability in the field
of drugs, vaccines bio-medical equipments etc. The available know-how requires to be
adequately exploited to increase the production of essential and life saving drugs and
vaccines of proven quality to fully meet the national requirements, specially in regard to
the national programmes to combat Malaria, TB, Leprosy, Blindless, Diarrhoeal diseases
etc. The production of the essential, life saving drugs under their generic names and the
adoption of economical packaging practices would considerably reduce the unit cost of
medicines, bringing them within the reach of the poorer sections of society, besides,
significantly reducing the expenditure being incurred by the governmental organisation
on the purchase of drugs. In view of the low cost of indigenous and herbal medicines,
organised efforts may be launched to establish herbal gardens, producing drugs of
certified quality and making them easily available.
The practitioners of the modem medical system rely heavily on diagnostic aids involving
extensive use of costly, sophisticated bio-medical equipment. Effective mechanisms
should be established to identify essential equipments required for extensive use and to
promote and enlarge their indigenous manufacture, for such devices being readily
available, at reasonable prices, for use at the health care centres.
Para 16: Health insurance
It would be necessary to devise well considered health insurance schemes, on a
Statewise basis, for mobilising additional resources for health promotion and ensuring
that the community shares the cost of the services, in keeping with its paying capacity.
Para 17: Medical legislation
It is necessary to urgently review all existing legislation and work towards a unified,
comprehensive legislation in the health field, enforceable all over the country.
Para 18: Medical research
Special attention should be paid to:
i)
containment and eradication of the existing, widely prevalent diseases
ii)
translation of available know-how into simple, low cost, appropriate technologies
iii)
applied operational research for improving cost effective delivery of health services
iv)
more effective treatment and preventive procedures for blindness, leprosy and TB
v)
contraceptive research, and
vi)
nutrition research.
Para 19: Inter-sectoral cooperation
It is necessary to secure inter-sectoral coordination of the various efforts in the fields of
health and family planning, medical education and research, drugs and pharmaceutical,
agriculture and food, water supply and drainage, housing, education and socal welfare
and rural devellpment.
Para 20: Monitoring and review of progress
It would be of crucial importance to monitor and periodically review the success of the
efforts made and the results achieved in reference to the goals.
84
Comments about national health policy
Appendices
The Health Policy is a valuable document and provides a clear framework for national
health planning. However, it has been criticised on the following gounds.
i)
ii)
The policy talks of poverty alleviation, (e.g., through the minimum needs
programme), as a necessary precondition for Health For All. However, the policy
does not speak even once about social justice (in health and in other fields such as
land reforms and wages), which is an essential prerequisite for Health For All.
No definite programme has been suggested for promoting community participation
in health.
85
Health Tor All
APPENDIX 3
Memorandum Submitted to the High Power Committee on Nurses and Nursing
Profession by the Trained Nurses’ Association of India on Behalf of Nurses
in India*
Section-VI
The Nursing Structure
The existing nursing structure, organised after Independence, has remained somewhat
stagnant. It has neither grown nor developed to keep the desired pace with the
expansion of the health services in the country. Despite health survey committees,
recommendations in 1946 and 1954 scarce attention has been paid to improvement in
the nursing profession suggested by these committees. This is so because of the
subordinate status of the profession and the implementation power of these resting with
the non-nurse administrators. Though there has been some upgradation in nursing
education, increase in nursing positions and creation of these at the Health Directorates
at the Centre and in the State Governments, these developments have not surfaced much
in terms of availability of improved nursing care to the masses. Obviously, this is so
because of the isolation of nurses from the planning process and the decision making
machinery of the government.
What we see today is that the valuable contribution of the nursing profession is greatly
undermined. Non-nurse health planners fail to appreciate the significant contribution of
the nursing profession to the protection and promotion of health of the people. They fail
to recognise the underdeveloped and undeveloped leadership potentials of the Nursing
profession. Instead of giving this established health care profession its due place in the
system it has purposefully neglected and lowered the profession to such an extent that
nurses at any level have no autonomy to function independently and pursue the
profession in pace with the trends in health care system.
The growth and development of health services and health manpower over the period of
nearly seven five year plans reveals the lopsided development in various categories of
health professionals.
In view of the present position in Nursing, nurses at various levels are so
placed in the organisational set-up that their involvement in policy formaulation
is not possible. Specially at the Centre the highest positions in Nursing are
merely advisory. There is hardly any coordination of Nursing Service, Education and
community care. Even in the State Health Directorates, each position is attached
with a medical person rather than with nurses. In such an isolated situation
the Nursing profession has remained fragmented and underdeveloped with the result
that Nursing positions are often abolished than expanded and mostly filled on an
adhoc basis. Hardly any efforts are made to fill these positions and prepare Nursing
leaders.
Nursing is a profession and a distinct service in its own right. It is equipped with
necessary comptetence required to be responsible and accountable to the Nursing
components in providing health care to the people as colleagues with other health
professionals.
Therefore, it is essential that Nursing components of the health care be directed by
nurses themselves. We have nurses with professional background of Ph.D. level
available in the country to lake up such leading positions. The Association recommends
the following organisational structure for equipping nurses with the needed authority and
support to function effectively:
As in Govt of India, Report of High Power Committee on Nursing and Nursing Profession.
P 110-113.
86
Appendices
Organisational Structure of Nursing at Central Level
Secretary Health
Director General Health Services
X
J—————————I
Addl. D.G.
Addl. D.G.
Nursing
Medical
4.
Addl. D.G.
P.H.
Dy. Di. G. Nsg. PH
Dy. Dir. G. Nsg. (Hosp.)
J.
4A.D.G.PH
Rsg. urban
J.
J,
A.D.G.PH.
Nsg. Rural
4»
A.D.G. Nsg.
Hosp. Urban
Dy. Dir, G.Nsg. Education &
Research
X
4*
A.D.G. Nsg. A.D.G. Nsg. A.D.G. Nsg.
Rural
Education
Planning,
Research
& Evaluation
Organisational Structure of Nursing at State Level
Secretary Health
D.H.S. Nursing
D.H.S.
1
DDHS Nursing
Education and
Research
ADHS (Nsg.)
Education and
Research
|
1
Principal Nursing
Tutor
1
DDHS Nursing
Hospital
Services
1I
A.D.H.S (Nsg.)
Hospital
Services
Nursing
Superintendent
1
DDHS Public
Health Nursing
1
ADHS (Nsg.)
Public Health Nsg.
|
Regional Nsg.
Health Nurse
i
District Public
Health Nurse
Senior Tutor
Dy. Nursing
Superintendent
Tutor
Asst. Nursing
Superintcndent/Dept. Sister
1
Nsg. Sister/Supcrvisor
Public Health
Nurse (Sr.)
Staff Nurse
L.H.V /Health
Supervisor
Clinical
Instructor
Public Health
Nurse (Jr.)
A.N.M /Health
Worker
A similar organisational structure is suggested for the Railways, Municipal Corporations,
Institutions under Ministries other than Health Ministry and Major Central Undertakings,
etc.
Staffing Norms
The Nursing manpower requirement from the very beginning of health planning has
remained neglected with the result that nurses are in short supply to keep pace with
developments. The Government of India conducted a number of health surveys by
important Committees before and after Independence. These were Bhore Committee
(1946), Mudaliar Committee (1961), Kartar Singh Committee (1974), Shrivastava
Committee (1975) and some others. While these committees mostly concentrated their
attention on the development of Medical Education, very little was done in the sphere of
Nursing Manpower development.
Health for All
The Bhore Committee in 1946 recommended one qualified nurse for 500 populatio and
one ANM for 5000 population to be achieved by 1971. With this population ratio and
one nurse for 1:5 beds, we shall need nearly two million nurses to care for nearly 1000
million population at the tum of the century.
The present growth rate of Nursing manpower in on the dificit side both in quality and
quantity to meet the health care needs of the society.
The Manpower requirment for hospital and and community care projected by the Health
Manpower, Planning, Production and Management Expert Committee of the Government
of India in 1987 suggested the following norms for the hospital and the community care.
Manpower Requirement for Hospital Nursing Services
Categories
Basis of Calculation
Nursing manpower
requirement
1986
1991
2001 AD
4,955
Nursing Superintendent
1: 200 beds
2,500
3,051
Deputy Nursing Supdts.
1 : 300 beds
1,700
2,034
3,003
Departmental Nursing
S upervi sors/S i slcrs
7 : 1000 + 1/Addl.
1000 beds (991 + 7 + 991)
4,080
4,880
7,928
Ward Nursing
Supcrvisors/S i sters
8 : 200 + 30% leave
reserve
26,520
31,730
51,532
Staff Nurses for Wards
1 : 3 (or 1 :9 for each
shift) + 30% leave reserve
2.21,000 2,64,427
4,29,432
For OPD, Blood Bank,
X-Ray, Diabetic Clinics,
CSR etc.
1 : 100 Opt. (1 bed : 5 Opt.)
+ 30% leave reserve
33.160
39,664
64,415
For Intensive (8 Beds
ICU/200 beds)
1 : 1 (or 1 : 3 for each
shift) + 30% leave reserve
26,520
31,730
31,530
For specialized depart
ments and Clinics such
as OT, Labour Room
8 : 200 + 30% leave reserve
26,520
31,730
51,530
3,42,050 4,09,246
6,64,623
Total
Community Care
Community Health
Primary Health Center
Sub Centre
Total requirement
Number
Nurse Midwife
Required
Female Health
Worker required
743
52,052
—
26,439
26,439
26,439
1,61.941
-
1,61,941
78,491
188,380
The placement of nurses in these areas do not indicate Nursing Supervisory support
necessary for quality performance. Especially at the community health centre level,
there should be at least one public health nurse to supervise the work of 7 nurse
midwives. At the sub-centre level also, all categories of personnel are only auxiliaries
like Health Workers, Health Assistants, Health Guides and Traditional Birth Attendants.
There is need for some one to coordinate their work and assist them in case of any
difficulty. One nurse midwife as incharge of sub-centre is important. Community nurses
required to function at the block, district, zone, state and at the central levels are equally
important.
As per INC statistics of 87 we have hardly 2,299 nurses qualified till 1987. With the
present rate, 8,992 nurses per annum would add up barely to 7,04 nurses. The projected
requirements will need facilities to produce nearly 4 lacs more nurses.
88
The Association also feels that these projections are based merely on the basis of bed
allotment to hospitals. But in actual situation the patient census is usually on under
statement of the actual number of patients. More nurses are required to look after the
extra patients in the corridors and on the floor. Obviously, under such a situation nurses’
time in looking after the patients is greatly increased.
Appendices
A Blueprint for the Community
The Bajaj Committee had made certain useful recommendations with regard to the
staffing norms in the community. These are being outlined below in brief, and should
be kept in mind while preparing the blueprint for the Community Health Nursing care
structure.
Every
2,500 Population
Health Worker (F) : 1
10,000 Population
Health Supervisor : 1
30,000 Population (PHC)
Public Health Nurse with special training. She should be able to:
screen high risk mothers and children with nutritional problems,
etc., independently, help Medical Officer Incharge.
The Health Supervisor should be given
CGN course in phased manner.
1,00,000 (Community Health Centre)
Nursing Officer (PH) Gr. Ill
(Gazetted Class-II Junior)
Post equivalent to Departmental Sister
Qualification: B.Sc. Nsg. or M.Sc. Nsg. preferred
Assistant District Nursing Supervisor: 2 Posts in each District.
(Nursing Officer (PH) Gr. B)
Qualification: M.Sc, Nsg. (Equivalent to Dy. Nursing Superintendent)
District Nursing Supervisor
(Nursing Officer (PH) Gr. I)
(Gazetted Class I Senior)
Qualification: M.Sc. Nsg. (Equivalent to Nursing Superintendent)
Career Mobility from Health Worker (F) to Nursing Cadre
S.S.L.C. + 2 = Health Worker (F)
(Equivalent to PUC)
Health Worker (F) Course + 1 Year = Health Supervisor
Health Supervisor + 1 year = G.NJ.1.
G.N.M. + 2 yrs. = B.Sc. Nsg. (PC)
There onwards in usual further course.
More centres for CGN course for Health Supervisor and more Post-certificate B.Sc.
Nursing Courses should be started in all States. The funding of these courses should be
made available by the Government of India.
A Vital Necessity
As pointed out elsewhere Nursing functions performed by a qualified Nurse, Auxiliary
Nurse Midwife and even a student are not generally demarcated and specified in the
hospital setting. Under the circumstances, qualified nurses are replaced by auxiliaries and
students, thus contributing to unsafe and poor nursing care. Therefore, the Association
finds it vitally necessary that Nursing functions of all categories of Nursing personnel be
studied, specified and clearly demarcated. Nurses’ manpower should accordingly be
organised to share these functions.
89
Health for All
The Bhore Committee in 1946 recommended one qualified nurse for 500 populatio and
one ANM for 5000 population to be achieved by 1971. With this population ratio and
one nurse for 1:5 beds, we shall need nearly two million nurses to care for nearly 1000
million population at the tum of the century.
The present growth rate of Nursing manpower in on the dificit side both in quality and
quantity to meet the health care needs of the society.
The Manpower requirment for hospital and and community care projected by the Health
Manpower, Planning, Production and Management Expert Committee of the Government
of India in 1987 suggested the following norms for the hospital and the community care.
Manpower Requirement for Hospital Nursing Services
Categories
Basis of Calculation
Nursing manpower
requirement
1986
1991
2001 AD
4,955
Nursing Superintendent
1: 200 beds
2,500
3,051
Deputy Nursing Supdts.
1 : 300 beds
1,700
2,034
3,003
Departmental Nursing
Supervisors/Sistcrs
7 : 1000 + 1/Addl.
1000 beds (991 + 7 + 991)
4,080
4,880
7,928
Ward Nursing
Supcrvisors/Sisicrs
8 : 200 + 30% leave
reserve
26,520
31,730
51,532
Staff Nurses for Wards
1 : 3 (or 1 :9 for each
shift) + 30% leave reserve
2,21,000 2,64,427
4,29,432
For OPD, Blood Bank,
X-Ray, Diabetic Clinics,
CSR etc.
1 : 100 Opt. (1 bed : 5 Opt.)
+ 30% leave reserve
33.160
39,664
64,415
For Intensive (8 Beds
ICU/200 beds)
1 : 1 (or 1 : 3 for each
shift) + 30% leave reserve
26,520
31,730
31,530
For specialized depart
ments and Clinics such
as OT, Labour Room
8 : 200 + 30% leave reserve
26,520
31,730
51,530
3,42,050 4,09,246
6,64,623
Total
Community Care
Community Health
Primary Health Center
Sub Centre
Total requirement
Number
Nurse Midwife
Required
Female Health
Worker required
743
52,052
—
26,439
26,439
26,439
1,61,941
-
1,61,941
78,491
188,380
The placement of nurses in these areas do not indicate Nursing Supervisory support
necessary for quality performance. Especially at the community health centre level,
there should be at least one public health nurse to supervise the work of 7 nurse
midwives. At the sub-centre level also, all categories of personnel are only auxiliaries
like Health Workers, Health Assistants, Health Guides and Traditional Birth Attendants.
There is need for some one to coordinate their work and assist them in case of any
difficulty. One nurse midwife as incharge of sub-centre is important Community nurses
required to function at the block, district, zone, state and at the central levels are equally
important.
As per INC statistics of 87 we have hardly 2,299 nurses qualified till 1987. With the
present rate, 8,992 nurses per annum would add up bareiy to 7,04 nurses. The projected
requirements will need facilities to produce nearly 4 lacs more nurses.
88
The Association also feels that these projections are based merely on the basis of bed
allotment to hospitals. But in actual situation the patient census is usually on under
statement of the actual number of patients. More nurses are required to look after the
extra patients in the corridors and on the floor. Obviously, under such a situation nurses’
time in looking after the patients is greatly increased.
Appendices
A Blueprint for the Community
The Bajaj Committee had made certain useful recommendations with regard to the
staffing norms in the community. These are being outlined below in brief, and should
be kept in mind while preparing the blueprint for the Community Health Nursing care
structure.
Every
2,500 Population
Health Worker (F) : 1
10,000 Population
Health Supervisor : 1
30,000 Population (PHC)
Public Health Nurse with special training. She should be able to:
screen high risk mothers and children with nutritional problems,
etc., independently, help Medical Officer Incharge.
The Health Supervisor should be given
CGN course in phased manner.
1,00,000 (Community Health Centre)
Nursing Officer (PH) Gr. HI
(Gazetted Class-II Junior)
Post equivalent to Departmental Sister
Qualification: B.Sc. Nsg. or M.Sc. Nsg. preferred
Assistant District Nursing Supervisor: 2 Posts in each District.
(Nursing Officer (PH) Gr. H)
Qualification: M.Sc, Nsg. (Equivalent to Dy. Nursing Superintendent)
District Nursing Supervisor
(Nursing Officer (PH) Gr. I)
(Gazetted Class I Senior)
Qualification: M.Sc. Nsg. (Equivalent to Nursing Superintendent)
Career Mobility from Health Worker (F) to Nursing Cadre
S.S.L.C. + 2 = Health Worker (F)
(Equivalent to PUC)
Health Worker (F) Course + 1 Year = Health Supervisor
Health Supervisor + 1 year = G.N.M.
G.N.M. + 2 yrs. = B.Sc. Nsg. (PC)
There onwards in usual further course.
More centres for CGN course for Health Supervisor and more Post-certificate B.Sc.
Nursing Courses should be started in all States. The funding of these courses should be
made available by the Government of India.
A Vital Necessity
As pointed out elsewhere Nursing functions performed by a qualified Nurse, Auxiliary
Nurse Midwife and even a student are not generally demarcated and specified in the
hospital setting. Under the circumstances, qualified nurses are replaced by auxiliaries and
students, thus contributing to unsafe and poor nursing care. Therefore, the Association
finds it vitally necessary that Nursing functions of all categories of Nursing personnel be
studied, specified and clearly demarcated. Nurses’ manpower should accordingly be
organised to share these functions.
89
Health for All
Recommended Organisational set-up at the Directorate General of Health Services and the
Institutions Under the Central Government
DGHS
Addl. DG(PH)
Addl. DDG(N)
r
ADG (Community
Nsg. service)
DADG
(Community Nsg.)
service
Community Nursing
Officer
ADG (Nsg. Education
& Research)
1
. 1
DADG
(Nsg. Education)
(Hospital)
PHN Supervisor
Principal Tutor
School of Nsg.
1
1
Senior Tutor
PHN
1
Tutor
Clinical Instructor
LHV
11
ANM
Addl. DG(M)
1
ADG (Hospital
Nsg. Services)
DADG
(Nsg. Services)
Nsg. Suptd.
1
Dy. Nsg. Suptd.
|
Asst. Nsg. Suptd.
1
Ward Sister
1
Staff Nurse
Note:
90
a)
The positions up to the DADG level are proposed to be at the office of the Directorate
General of Health Services, positions below the level of DADG are to exist at the
Institutions governed by the Central Government.
b)
The Principal, College of Nursing, will be equal to the rank of ADG(N)’and will be eligible
for promotion to the post of DDG(N)/Addl. DG(N). The salary scales and structure of lite
staff of Colleges of Nursing will be as per norms of the Indian Nursing Council and lire
UGC.
Recommended Organisational set-up at State/Unlon Territory Level
Appendices
Secretary Health
Director Nursing Services
Joint/Dcputy Director Nursing Services
ADNS
Community Nsg.
ADNS
Nsg. Education & Res.
ADNS
Hospital Nsg. Serv.
DADNS
Community Nursing
DADNS
Nsg. Edn. & Res.
DADNS
Nursing Service
Di st. Nsg. Officer
Principal, School of Nsg.
Nursing Suptd.
P.H. Nsg. Officer
Senior Tutor
1
1
Dy. Nsg. Suptd.
P.H.N. at PHC
1
1
Tutor
Asst. Nsg. Suptd.
LHV (HSP)
1
. 1
LHV
Clinical Instructor
Ward Sister
Staff Nurse
LNM
Note: The Principal, College of Nursing, will be equal to the rank of ADNS and will be eligible for
promotion to the post of DDNS/DNS. The salary scales and structure of the staff of Colleges of
Nursing will be as per norms of the Indian Nursing Council and the U.G.C.
91
Recommended Organisational set-up at the District Level
Health for All
Director Nursing Services
Dy. Director Nursing Sen-ices
I
Asst. Director Nursing Services
I
Dy. Asst. Director Nursing Services
“1
District Nsg. Officer
D.M.O.
Asst. Dist. Nsg. Officer
(Community)
Asst. Dist. Nsg. Officer
(Hospt & Nsg. Edn.)
Nsg. Sudpt./Dy Nsg. Suptd.
Principal Tutor
Asst. Nsg. Suptd.
Ward Sister
Dist. P.N.O
HN Supervisor
(CHC)
Tutor
Clinical Instructor
Staff Nurse
D.H.O
I
HN (PHC)
I
LHV/HS
I
LHV
ANM
92
APPENDIX 4
Appendices
JOB RESPONSIBILITIES OF HEALTH WORKER (FEMALE)
Note:
1.
Maternal and child health
1.1
Register and provide care to pregnant women throughout the period of
pregnancy.
1.2
Test urine of pregnant women for albumen and sugar and estimate
haemoglobin level during her home visits and at the clinic.
1.3
Refer eases of abnormal pregnancy and eases with medical and
gynaecological problems to the health assistant (female) or the primary health
centre.
1.4
1.5
Conduct deliveries in her area.
Supervise deliveries conducted by dais and assist them whenever called in.
1.6
Refer cases of difficult labour and newborns with abnormalities and help
them to get institutional care and provide follow-up care to patients referred to
or discharged from hospital.
Make at least three postnatal visits for each delivery conducted and render
advice regarding care of the mother and care and feeding of the newborn.
1.7
1.8
1.9
1.10
2
Assess the growth and development of the infant and take any necessary
action.
Help the medical officer and health assistant (female)in conducting MCH and
family planning clinics at the sub-centre.
Educate mothers individually and in groups for better family health including
MCH, family planning, nutrition, immunization, control of communicable
diseases, personal and environmental hygiene and care of minor ailments.
Family planning
2.1
2.2
2.3
2.4
2.5
3.
Under the multipurpose workers scheme, a health worker (female) is expected
to cover a population of 5,000. She will carry out the following functions:
Utilize the information from the Eligible Couple Register for the family
planning programme.
Spread the message of family planning to the couples and motivate them for
family planning individually and in groups.
Distribute conventional contraceptives to the couples, provide facilities and
help the prospective acceptors in getting family planning services, if necessary',
by accompanying them or arranging for the dais to accompany them to
hospital.
Provide follow-up services to female family planning adopters, identify side
effects, give treatment on the spot for side-effects and minor complaints and
refer those cases that need attention by the physician to the PHC/hospital.
Establish female depot holders, help the health assistant (female) in training
them, and providing a continuous supply of conventional contraceptives to the
depot holders.
2.6
Build rapport with acceptors, village leaders, dais and others and utilize them
for promoting family welfare programmes.
2.7
2.8
Identify woman leaders and help the health assistant (female) to train them.
Participate in mahila mandal meetings and utilize gatherings for educating
women in family welfare programmes.
Medical termination of pregnancy
3.1
Identify the women requiring help for medical termination of pregnancy and
refer them to the nearest approved institution.
93
Health for All
3.2
4.
Nutrition
4.1
4.2
4.3
4.4
5.
7.
8.
10.
Immunize pregnant women with tetanus toxoid.
6.2
Administer BCG vaccination to all newborn infants, and DPT vaccination, oral
poliomyelitis vaccine (where available) and BCG vaccine (if not given at
birth) to all infants ( 0 to 1 year).
Dai training
7.1
List dais in the intensive and twilight areas and involve them in promoting
family welfare.
7.2
Help the health assistant (female) in the training programme of dais. (Also
refer to 1.5 regarding supervision of dais.)
Vital events
Record births and deaths occurring in the births and deaths register and report
them to the health worker (male).
Record keeping
9.1
Register (a) pregnant women from three months of pregnancy onwards;
(b) infants zero to one year of age; and (c) women aged 15 to 44 years
through systematic home visits and at the clinic.
9.2
Maintain the prenatal and maternity records and child care records.
9.3
Assist the health worker (male) in preparing the Eligible Couple Register and
maintaining it uptodate.
9.4
Prepare and submit the prescribed periodical reports in time to the health
assistant (female).
9.5
Prepare and maintain maps and charts for her area and utilize them for
planning her work.
Primary medical care
Provide treatment for minor ailments, provide first aid for accidents and
emergencies, and refer cases beyond her competence to the primary health
centre or nearest hospital. .
Team activities
11.1
94
Identify cases of notifiable diseases, i.e. cholera, plague, poliomyelitis, and
persons with continued fever or prolonged cough, or spitting of blood, which
she comes across during her home visits and notify the health worker (male)
about them.
6.1
10.1
11.
Administer vitamin ‘A’ solution as prescribed to children from 1 to 5 years.
Educate the community about nutritious diet for mothers and children.
Immunization
8.1
9.
Identify eases of malnutrition among infants and young children (0 to 5
years), give the necessary treatment and advice and refer serious cases to the
PHC.
Distribute iron and folic acid tablets as prescribed to pregnant and nursing
mothers, infants and young children ( 0 to 5 years ) and family planning
acceptors.
Communicable diseases
5.1
6.
Educate the community of the availability of services for medical termination
of pregnancy.
Attend and participate in staff meetings at primary health centre/community
development block or both.
Job Responsibilities of Health Assistant (Female)
Appendices
Under the multipurpose workers scheme, a health assistant (female) is expected
to cover a population of 20,000 in which there arc four subcentres, each with
one health worker (female). However, in future she may cover one PHC with
six sub-centres having 5,000 population each.
Note:
The health assistant (female) will carry out the following functions:
1.
Supervision and guidance
1.1
1.2
Strengthen the knowledge and skills of the health worker (female).
1.3
Help the health worker (female) in improving her skills in working in the
community.
1.4
Help and guide the health worker (female) in planning and
organising her programme of activities.
1.5
Visit each sub-centre at least once a week on a Fixed day to observe and
guide the health worker (female) in her day-to-clay activities.
1.6
Assess periodically the progress of work of the health worker (female), and
submit an assessment report to the medical officer of the primary health
centre.
Carry out supervisory home visits in the area of the health worker (female).
1.7
2.
Team work
2.1
Help the health worker to work as part of the health team.
2.2
Coordinate her activities with those of the health assistant (male) and other
health personnel including the dias.
Coordinate the health activities in her area with the activities of workers of
other departments and agencies, and attend meetings at block level.
2.3
3.
4.
Supervise and guide the health worker (female) in the delivery of health care
services to the community.
2.4
Conduct regular staff meetings with the health workers in coordination with
the health assistant (male).
2.5
2.6
Attend staff meetings at the primary health centre.
Assist the medical officers of the primary health centre in the organisation of
the different health services in the area.
2.7
Participate as a member of the health team in mass camps and campaigns in
health programmes.
Supplies, equipment and maintenance of sub-centre
3.1
In collaboration with the health assistant (male), check at regular intervals the
stores available at the sub-centre and help in the procurement of supplies and
equipment.
3.2
Check that the drugs at the sub-centre are properly stored and that the
equipment is well maintained.
3.3
Ensure that the health worker (female) maintains her general kit and
midwifery kit in die proper way.
3.4
Ensure that the sub-centres is kept clean and is properly maintained.
Records and reports
4.1
Scrutinize the maintenance of records by the health worker (female) and guide
her in their proper maintenance.
4.2
Maintain the prescribed records and prepare the necessary reports.
4.3
Review reports received from the health workers (female), consolidate diem,
and submit periodical reports to the medical officer of the primary health
centre.
95
Health for All
5.
Training
5.1
6.
7.
Maternal and child health
6.1
Conduct weekly MCH clinics at each sub-centre with the assistance of the
health worker (female).
6.2
Respond to calls from the health worker (female) and trained dais, and from
the health worker (male) and render necessary help.
Family welfare and medical termination of pregnancy
7.1
Conduct weekly family welfare clinics (alongwith the MCH clinics) at each
sub-centre with the assistance of the health worker (female).
7.2
Personally motivate resistant cases for family planning.
7.3
Provide information on the availability of services for medical termination of
pregnancy and refer suitable cases to the approved institutions.
Guide the health worker (female) in establishing female depot holders for the
distribution of conventional contraceptives and train the depot holders with the
assistance of the health worker (female).
7.4
8.
Nutrition
8.1
9.
11.
Supervise the immunization of all pregnant women, and infants (zero to one
year).
Primary medical care
10.1
Provide treatment for minor ailments, provide first aid for accidents and
emergencies and refer cases beyond her competence to the primary health
centre or nearest hospital.
10.2
Attend to cases referred by the health workers and refer cases beyond her
competence to the primary health centre or nearest hospital.
Health education
11.1
11.2
11.3
11.4
96
Identify cases of malnutrition among infants and young children (zero to five
years), give the necessary treatment and advice and refer serious cases to the
primary health centre.
Immunization
9.1
10.
Organise and conduct training'for dais with the assistance of the health worker
(female).
Carry out educational activities for MCH, family planning, nutrition and
immunization with the assistance of the health worker (female).
Arrange group meetings with readers and involve them in spreading the
message for various health programmes.
Organize and conduct training of woman leaders with the assistance of health
worker (female).
Organize and utilize mahila mandate, teachers and other women in the
community in the family welfare programmes.
Appendices
APPENDIX 5
1991 POPULATION DATA SHEET
Popu
lation
(in 000)
Annual
exponential
growth
rale (%)
Literary
Rate)
C.D.R
(Crude
Death
Rate)
Natural
Increase
(CBR-CDR)
I.M.R
(Infant
Mortality
Rale)
T.F.R
(Total
Fertility
Rale)
1981-91
1971-81
Female
C.B.R
(Crude
Birth
Rale)
2
3
4
5
6
7
8
9
10
846303
2.14
2.22
39.29
29.3
9.8
19.5
80.00
3.9
Andhra Pradesh
66508
2.17
2.10
32.72
26.0
9.7
16.3
73.0
3.1
Anmachal Pradesh
865
3.14
3.04
29.69
30.9
13.5
17.4
NA
NA
3.4
India/Statc/UT
1
INDIA
States
Assam
22414
2.17
2.12
43.03
30.9
11.5
19.4
81.0
Bihar
86374
2.11
2.17
22.89
30.5
9.8
20.7
69.0
5.1
Goa
1170
1.49
2.37
67.09
16.8
7.5
9.3
NA
NA
Gujarat
41310
1.92
2.46
48.64
27.5
8.5
19.0
69.0 ,
3.6
Haryana
16464
2.42
2.55
40.47
33.1
8.2
24.9
68.0
4.4
Himachal Pradesh
5171
1.89
2.15
5Z13
28.4
8.9
19.5
-75.0
3.2
J & K
7719
2.54
2.58
—
_
_
—
—
33
Karnataka
44977
1.92
2.39
44.34
26.8
9.0
17.8
77.0
3.3
Kerala
29098
1.34
1.77
86.13
18.1
6.0
1Z1
17.0
2.0
Madhya Pradesh
66181
2.38
2.27
28.85
35.8
13.8
22.0
122.0
4.7
Maharashtra
78937
2.29
2.21
52.32
26.2
8.2
18.0
60.0
3.4
Manipur
1837
2.57
2.83
47.60
19.6
5.5
14.1
NA
NA
Meghalaya
1775
2.84
2.80
44.85
324
8.8
23.6
NA
NA
Mizoram
690
3.34
3.99
78.60
NA
NA
NA
NA
NA
Nagaland
1209
4.45
4.09
54.75
18.5
3.3
15.2
NA
NA
Orissa
31660
1.83
1.85
34.68
28.8
127
16.1
126.0
3.6
Punjab
20282
1.89
2.16
50.41
28.6
8.0
20.6
53.0
3.3
Rajasthan
44006
2.50
2.87
20.44
34.3
9.8
24.5
77.0
4.7
Sikkim
406
2.51
4.14
' 46.69
26.5
8.8
17.7
NA
NA
Tamil Nadu
55859
1.43
1.63
51.33
20.7
8.8
11.9
57.0
2.5
Tripura
2757
2.95
2.79
49.65
24.4
7.6
16.8
NA
NA
Uttar Pradesh
139112
2.27
2.29
25.31
35.1
11.1
24.0
93.0
5.2
West Bengal
68078
2.21
2.10
46.56
26.7
8.1
18.6
70.0
3.3
A&N Islands
281
3.97
4.98
65.46
19.9
5.7
14.2
NA
NA
Chandigarh
642
3.52
5.67
72.34
14.1
4.0
10.1
NA
NA
D&NHaveli
138
2.89
3.38
26.98
30.4
11.4
19.0
NA
NA
Daman & Diu
102
2.52
2.32
59.40
27.8
9.0
18.8
NA
NA
Union Territories
9421
4.15
4.29
66.99
24.1
6.0
18.1
NA
NA
Lakshadweep
52
2.51
2.37
72.89
27.1
4.7
2Z4
NA
NA
Pondicherry
808
2.90
2.50
65.63
18.9
6.4
1Z5
NA
NA
Delhi
Information under cols. 2 to 6 is as per 1991 Census Data Sheet
Information under cols. 6 to 9 is as per SRS provisional estimates for 1991.
Information under cols. 10 is as per SRS estimates for 1989.
NA - Not available.
97
Health for All
APPENDIX 6
Dais Training Programme: Statement I
SI.
No.
Statc/UT
1
2
Dais
trained
as on
1.4.89
since
1974
3
4
Dais
trained
during
1989-90
(April 89Dec 89)
Total
Dais
trained
as on
31-12-1989
since 1974
Period
up to
which
infor
mation
relates
5
6
7
8
1000
INR
44835 •»
31.3.87
Target
for
1989-90
1.
Andhra Pradesh
3045
44835
2.
Arunachal Pradesh »“ Nil
286
Nil
106
392
31.12.89
3.
Assam
500
12275
250
1704
13979
31.12.89
4.
Bihar
INR
56029
500
INR
56029
31.3.85
5.
Goa
Nil
178
Nil
Nil
178
31.12.89
6.
Gujarat
3672
30841 uc
750
841
31682
31.12.89
7.
Haryana
500
11568
250
90
11658
31.12.89
8.
Himachal Pradesh
INR
9399
50
NIL
9399
31.12.89
9.
J&K
INR
4244
500
INR
4244
31.3.85
10.
Karnataka
6634
36500 uc
1750
863
37363 uc
31.12.89
11.
Kerala ♦♦♦•
Nil
2906
Nil
Nil
2906
31.12.89
12.
Madhya Pradesh
INR
43383
1000
12
43395
13.
Maharashtra
5000
47480 uc
500
29
47509
30.9.89
31.12^89
14.
Manipur
INR
1259
25
INR
1259
30.6.88
15.
Meghalaya
Nil
1137
Nil
INR
1137
31.3.87
16.
Mizoram
50
900
5
INR
900
31.3.89
17.
Nagaland
Nil
Nil
Nil
Nil
Nil
31.12.89
18.
Orissa
40000
34817
750
5
34822
30.9.89
30.9.89
19.
Punjab
600
22213
Nil
Nil
22213
20.
Rajasthan
7856
19889
300
7
19896
30.9.89
21.
Sikkim
INR
254
Nil
Nil
254
31.12.89
22.
Tamil Nadu
13782
35986
250
58
36044
30.9.89
50
NIL '
1427
31.12.89
31.12.89
23.
Tripura
NIL
1427
24.
Uttar Pradesh
Nil
141809
1000
883
142692
25.
West Bengal
INR
25274
1000
INR
25274
31.3.85
26.
A & N Islands
150
104
25
22
126
31.12.89
27.
Chandigarh
165-
367
20
26
393
31.12.89
28.
D & N Haveli
Daman & Diu
238
*
Nil
*
INR
♦
238 UC
*
31.12.88
29.
Nil
★
30.
Delhi
INR
180
20
INR
180
30.9.87
INR
25
21
397
NIL
5
NIL
10
21
407
30.9.89
31.12.89
81979
586196
10000
4656
590852
31.
32.
Lakshadweep .
Pondicherry
Total
Notes:
98
Estimated
No. of
Untrained
Dais
as on
1.4.1989
INR
**♦*
=
=
♦**
uc
**
=
=
=
*
=
Information not received.
Dias training programme has since been stopped from 1980 onwards in
Kerala State
x.
No system of traditional Dais is practised in Arunachal Pradesh.
Under clarification
Figures taken from status Report on Primary Health Care received in
meeting held in Jan.1988.
The number of trained dais prior to 1974 was 43,500 which is not
included in the above statement
Information include in Goa (figures are provisional)
APPENDIX 7
Villages Covered under Village Health Guide (VHG) Scheme & No. of Village Health
Committees (VHGs) Functioning as on 31.12.89
SI.
No.
No. of
Inhabited
Villages
. No.of
villages
having VGH
committees
No.of
villages
covered
under VHG
Sch.
Period
up to
which
information
relates to
2
3
4
5
6
Andhra Pradesh
27379
3257
21955
67546
22022
11200
11200
INR
412
18111
6745
16807
Nil
1054
—
22022
11200
11200
INR
Nii
18111
6745
16807
—
State/UT
1
1.
31.3.87
31.12.89
31.12.89
31.3.85
2.
Arunachal Pradesh
3.
4.
Assam ***
Bihar
5.
6.
7.
Goa, Daman & Diu
Gujarat
8.
Himachal Pradesh
J & K **
Karnataka
27028
Kerala **
1362
Nil
—
14656
— .
30.6.89
—
Madhya Pradesh
Maharashtra
76603
39354
51309
25667
70000
39354
31.12.89
Manipur
2082
2082
4000
4000
737
40
737
31.3.89
31.12.89
21969
540
23297
6862
. 1923 *
12138
21000 *
30.9.89
7
—
240
—
39
35775
9.
10.
11.
12.
13.
14.
Haryana
6477 @
Nil
2448
15.
16.
Meghalaya
Mizoram
2082
4874
737
17.
18.
Nagaland
Orissa
1112
50887
19.
20.
Punjab
Rajasthan
21.
22.
23.
24.
Sikkim
Tamil Nadu **
Tripura
12138
34968
440
4727
148
Uttar Pradesh
112568
35775
25.
West Bengal
38024
3305 S
26.
27.
A & 'N Islands
Chandigarh
491
22
7
28.
29.
30.
D & N Haveli
Delhi
Lakshadweep
72
214
31.
Pondicherry
Total
Note :
INR =
**♦ =
@
=
S
**
*
=
=
=
15831
7
292
592522
22
38000
286
Nil
31.12.89
31.12.89
31.12.89
31.12.89
—
30.9.89
30.6.88 ,
31.3.87
30.9.89
30.9.89
31.12.89
—
31.12.89
31.12.89
31.3.85
31.12.89
31.12.89
Nil
7
71
72
. 7
31.3.89
30.9.87
Nil
292
31.12.89
190584
337471
Nil
30.6.89
Information not received.
The 1981 census could not be held due to disturbed conditions in Assam, so the
figures are as per 1971 census.
Figures excluded for these areas which are under unlawful occupation of Pakistan,
China where census could not be taken up by States Govt.
This figure relates to the existing Health Committee and Villages Panchayats.
Alternative Health Guide Scheme is functioning in these States.
Information relates to the period 30.9.87
(Figures are provisional)
99
APPENDIX 8
Health for All
Health Man Power Working in Rural Areas
Period
Health Workers
Pharmacists
upto
Fcmale/ANM
which
-------------------------------------------------------------------------------- ---------- inforV
P
V
p
S
s
P
V
malion
S
relates
to
SI.
No.
Statc/UT
1
2
3
Health Workcrs(Malc)
4
5
6
7
8
9
10
11
12
1. Andhra Pradesh
8050
7095
955
7027
6277
750
957
506
451
31.3.87
2. Arunachal Pradesh
155
155
Nil
155
155
Nd
188
188
NU
31.12.89
3. Assam
3313
3313
Nil
4706
3592
1114
SOI
801
NU
31.3 89
4. Bihar
1761
1761
Nil
10041
7541
2500
1249
1'249
NU
31.3.85
5. Goa
153
118
35
146
140
6
9
9
Nil
31.12.89
'6. Gujarat
5280
4461
819
6351
5323
1028
1073
732
341
30.9.89
7. Haryana
2519
2131
388
2628
2505
123
440
404
36
31.12.89
8. Himachal Pradesh
1225
1225
Nil
1734
1693
41
464
437
27
31.12.89
9. J & K
381
377
4
696
381
315
72
72
Nd
31.3.85
10. Karnataka
5498
4762
736
9221
8443
778
1758 uc
1437 uc 321
30.6.89
11. Kerala
3400
3176 & 224
4449
4144
305
802
780
22
31.12 89
12. Madhya Pradesh
9736
9328
408
11916
11148
768
465
435
30
30.9.89
13. Maharashtra
8189
7967@@ 222
11381
11185
196
2515
2242
273
31.12.89
14. Manipur
338
338
Nil
673
640
33
219
226
7 +
31.12.88
15. Meghalaya
357
357
Nil
383
340
43
90
71
19
31.3.87
16. Mizoram
371
326
45
375
372
3
65
63
2
31.3.89
17. Nagaland
210
210
Nil
210
134
76
135
135
NU
31.12.89
18. Orissa
4592
4223
369
5051
4887
164
948
878
70
31.12.89
19. Punjab
2803
2386
417
3630
3592
38
1854
1610
244
30.9.89
20. Rajasthan
3761
3420
341
7841
6860
981
2375
2355
20
30.9.89
Nil
295
283
12
NU
NU
NU
31.12.89
Nil @
21. Sikkim
Nil @
22. Tamil Nadu
4561
3852
709
8558
8172
386
1417
1417
NU
30.9.89
23. Tripura
502
365
137
381
378
3
166
182
16 +
31.12.89
24. Uttar Pradesh
11547 ••11363 •• 184
23645
23645
NU
2228
2228
Nil-
31.12.89
25. West Bengal
9070
9070
Nil
6283
6353
70 +
1223
1100
123
31.3.85
26. A &. N Islands
Nil
Nil
Nil
74
74
Nil
72
72
NU
31.12.89
27. Chandigarh
8
8
Nil
14
14
Nil
7
7
NU
31.12.89
28. D & N Havel i
21
*
15
*
6
*
30
*
25
*
5
*
9
*
9
*
NU
♦
31.12.89
30. Delhi
200
192
8
102
89
13
12
11
1
30.9.87
31. Lakshadweep
NIL
Nil
Nil
9
9
Nil
12
12
NU
30.9.89
32. Pondicherry
77
77
Nil
161
161
Nil
40
40
NU
31.12.89
88078
82071
6007
128166
118555
9611
21665
19708
1957
29. Daman & Diu
Total
Note: uc
@
**
*
&
@@
100
.
=
=
=
=
=
=
under clarification
MPW Scheme is not implemented in Sikim
Figures relates to the period ending 313.85
Separate information not available included in Goa
Revised figures received from Kerala
Revised figures received from Maharashtra state
+
S
P
=
=
=
V
=
Exceeding the No. sanctioned
Sanctioned Number
Number in position
Vacant posts
(Figures arc provisional)
31.3.89
Appendices
APPENDIX 9
Health Manpower Working In Rural Areas
SI.
No.
Statc/UT
1
1.
2.
3.
4.
5.
6.
7.
8.
LAB .Technicians
2
P
V
s
P
V
3
4
5
6
7
8
480
371
610
31.3.87
Nil
26
Nil
31.12.89
286
636
Nil
Nil
35 **
INR
480
26
38
INR
130
39
3+
INR
31.3.85
1
202
112
44
Nil
15
987
351
Andhra Pradesh
851
Arunachal Pradesh 39
Assam
286
Bihar
636
Goa, Daman
& Diu
21
Gujarat
858
Haryana
549
Himachal Pradesh
J&K
528
43
20
656
437
484
43
344
234
Karnataka
Kerala
695
253
Madhya Pradesh
13.
14.
Maharashtra
Manipur
15.
16.
17.
Meghalaya
Mizoram
Nagaland
Orissa
Punjab
Rajasthan
Sikkim
505
1205'
19
23
30
31
416
832
898
20
594
25
21.
22.
23.
24.
25.
26.
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
A & N Islands
Period
upto
which
infor
mation
relates to
s
9.
10.
11.
12.
18.
19.
20.
Nurse-Midwives
470
1082
9
15
28
26
416
703
685
7
594
38
19
35
123
10
8
2
2415
512 @
214
465
438
INR
2028
89
118
291
20
2457
674
14
536
2293
484
214
122
28
NIL
31.12.89
31.3.89
148
9
INR
30.6.89
31.12.89
30.9.89
1779
89
110
249
Nil
Nil
Nil
537
214
INR
31.12.89
31.3.89
31.3.87
31.3.89
31.12.89
31.3.89
30.9.89
30.9.89
Nil
31.12.89
Nil
Nil
30.6.89
30.9.89
Nil
31.12.89
31.3.85
317
429
INR
INR
13
Nil
13 +
Nil
886
Nil
886
125
125
30
259 *
1981
259 *
1964
38
5
129
213
31.3.89
31.12.89
31.12.89
31.12.89
291
20
1920
460
INR
Nil
1
9
451
8
899
439
49 uc
869
350
6
4
6
4
Nil
1
38
1
Nil
31.12.89
Nil
3
3
Nil
2
17
16
1
31.3.89
30.9.87
49
89
Nil
17
Nil
31.12.89
27.
28.
Chandigarh
29.
30.
31.
Delhi
Lakshadweep
30
28
11
11
Nil
19
Nil
17
14
30.9.89
19
19
14
2
Pondicherry
Nil
31.12.89
10814
9068
1746
14737
12823
1914
D & N Haveli
Total
Note :
INR
uc
Information not received
Sanctioned and in position as on 31.3.85
Figures relates to the period ending 31.3.86
Figure relates to the period ending 31.12.87
Exceeding the No. sanctioned.
Under clarification
(Figures are provisional)
Health for All
APPENDIX 10
Number of recognised training centres for different courses in the state nursing
councils and board of examinations during the year 1988
Number of recognised training centres
for different courses in
SI Name of the State
No. Nursing Council and
Board of Examination
General
Nursing
Mid
wifery
A.N.MZ
HW
Health
Visitor
HealthSuper
visors
H.V.to
qualify
as a PH
Nurse
8
9
Men Women
2
1
1.
Andhra Pradesh
4
5
6
7
—
58
58
119
—
—
—
• —
—
2.
Assam
4
20
20
20
1
3.
Bihar
—
21
14
35
—
1
—
4.
Gujarat
—
20
12
35
2
—
—
5.
Haryana
1
6
4
9
—
1
1
4
1
—
6.
Himachal Pradesh
—
4
8
—
7.
Kerala
—
50
50
18
—
—
—
8.
Mahakoshal
—
18
18
37
—
—
—
9.
Maharashtra
—
47
40
33
—
—
—
10.
Madras
—
24
22
18
3
—■
—
•—
11.
Karnataka
—
30
31
21
4
—
12.
Orissa
—
5
5
19
1
—
1
13.
Punjab
3
26
21
13
1
—
—
14.
Rajasthan
12
9
8
27
3
—
—
Uttar Pradesh
—
22
13
48
—
4
—
16.
West Bengal
—
22
22
28
—
6
—
17.
Mid India Board
3
8
8
4
—
—
—•
18.
A.F.M.S. Examination
Board
—
8
18
—
—
—
—
Total
23
398
368
490
15
13
2 '
15.
Source:
102
3
.
Indian Nursing Council
Govt, of India, 'Health Information India-1990' Ministry of Health and Family Welfare
DGHS, Central Bureau of Health Intelligence, New Delhi. Nov, 1990.
Appendices
APPENDIX 11
Number of Registered General Nursing Midwfery, Auxiliary Nurses,
Midwives and Health Visitors as on 31.12.1988
SI.
No.
Total Number of Qualified Personnel Entered
in the State Register upto 31st December, 1988
Name of the State
NurSing Council and
Examination Boards
1
General Nursing
Midwifery
Men
Women
3
4
5
6
1205
2
Auxiliary
Health
Nurse-Midwi- Visitors
ves/Health
Workers
1.
Andhra Pradesh
492
13919
12809
2.
Assam
158
2112
2054
46
3.
Bihar
54
8829
7501
1509
4.
Gujarat
402
11728
5220
794
5.
Haryana
115
3046
3511
162
6.
Himachal Pradesh
106
807
1274
137
7.
Karnataka
—
23401
20707
3787
8.
Kerala
315
19729
4078
315
574
9.
Mahakoshal
800
21461
13406
10.
Maharashtra
1505
36021
10469
546
11.
Madras
1019
35002
6228
1161
12.
Orissa
4125
13.
Punjab
1265
14.
Rajasthan
15.
Uttar Pradesh
16.
West Bengal
381
17.
Mid India Board
18.
South India Board
Non Registering Body........... •
......................
..................... ................ do..
19.
A.F.M.S. Examination Board
Total
Grand total
7662
500
110
20406
8534
1830
—
8076 •
10111
322
553
10315
10809
2734
11601
15712
585
’
................do..
11290
234115
245405
........................
132923
15817
132923
15817
AFMS = Armed Forces Medical Services
* Sex-wise break-up not available.
Source: Indian Nursing Council
103
Health for AH
APPENDIX 12
Level of Achievement of Some Norms All India Position as on 31.12.1989
104
SI.
No.
Paramo ters/ind icators
National Norms
Norms achieved/
established
(Approximate)
1
2
3
4
1.
Population covered by a Sub-centre
3000-5000 Pop.
4851
2.
Population covered by a PHC
20,000-30,000 Pop.
30540
3
Population covered by a Community
Health Centre
About
1 lakh Pop.
3.53 Lakhs
4.
No. of sub centres for each PHC
6 Sub-centres
6.3 Sub-Centres
5.
No. of Primary Health Centres for
each Community Health Centre
4 PHCs
11.5 PHCs
6.
Trained Village Health Guide
One for each
Village/1000
Population
1.38 Villages/
1291 Population
7.
Trained Dai
Atleast orte
for each
village
1.00 Villages
1009 Population
8.
Population served by health
WorkersfMale and Female)
M: 3000-5000
F: 3000-5000
7219
4998
1:3.4
9.
Ratio of HA(M):HW(M)
1:6
10.
Ratio of HA(F):HW(F)
1:6
11.
Average Area covered by a Sub-Centre
12.
Average Area covered by a PHC
—
13.
Average Area covered by a CHC
—
14.
Max. radial distance covered by a
Sub-Centre ( in Km)
2.86 Km
15.
Max-radial distance covered by a
PHC (in km.)
7.18 Km
16.
Max. radial distance covered by a
CHC (in km.)
24.41 Km
1:6.8
25.73 Sq.km.
162.01 Sq.km.
1872.09 Sq.km.
Appendices
APPENDIX 13
Manpower Requirement for Hospital Nursing Services
SI.
No.
1.
Categories
Basic of Calculation
Nursing manpower
requirement
1 : 200 beds
Nursing Suptds.
1986
1991
2001
2500
3051
4955
2.
Dy. Nursing Suptds.
1 : 300 beds
1700
2034
3003
3.
Departmental Nursing
7 : 1000+1
addl. 1000 beds
(991 X 7 - 991)
4080
4880
7928
4.
Ward Nursing
Supervisors/Sisters
8 : 200 — 30% leave reserve
26520
31730
51532
5.
Staff Nurse for wards
1 : 3 (or 1 : 9 for each
shift)-30% leave reserve
221000
264427
429432
6.
For OPD, Blood Bank,
X-ray, Diabetic clinics,
CSR, etc.
1: 100 Opt. (1 : 5 Opt.) +
30% leave reserve
33160
39664
64415
7.
For intensive units
(8 beds ICU/200 beds
1 : 1 (1 : 3 for each shift) +
30% leave reserve)
26520
31730
51530
8.
For specialised deptts & 8 : 200 + 30% leave reserve
clinics, OT, Labour room
26520
31730
51530
Total
342050
.409246
664623
Nursing Manpower Requirements for Community Nursing Services
Projected population
991,479,200 (medium assumption)
Rural population
742,609,400
Infrastructure requirements by 2000 AD
Community Health Centre
Primary Health Services
30,000 population for
plain area
20,000 population for difficult area
Subcentres
163941
5000 population for plain area
3000 population for difficult area
7436
26439
100000
Plain area
Difficult area
21482
4957
Plain area
Difficult area
128892
33049
Manpower requirement by 2000 AD
Primary Health Centres
Community Health Centre
Nurse
Midwives
ANM
26,439
52,052
26.439
78,491
188380
FH
Supervisor
40,485
In addition to the above, 78491 Traditional Birth Attendents will be required.
105
Health for All
As per the norms reccommended, the Nursing Manpower requirement by 2000 AD will be:
Urban Area
(Hospital Nursing Services)—Nurse Midwives 664623
Rural Area
Sub-cetrcs ANM/F.H. Worker
323882
Health Supervisor
107960
Primary Health Centres P.H. Nurse
26439
Community Health Centres Nurse Midwives
26439
Public Health Nursing Supervisor
7,436
Nurse Midwives
52,052
Distric Public Health Nursing Officer
900
Total Nursing personnel for Urban & Rural Nursing Services
Nurse Midwives
P.H.N.
664623
26439
26439
7436
52052
900
743114
34875
’ Health Supervisor AHM/HW
107960
323882
Source: Report of the High Power Commitice on Nursing & Nursing Profession, Govt, of India,
Ministry of Health & Family Welfare, New Delhi, 1989.
106
Appendices
APPENDIX 14
Health Manpower In Rural Areas as on 31.12.89
Category
No. sanctioned
No. in position
% Vacant
1.
Surgeons
624
435
303
2.
Obst. & Gynaecologists
562
337
40.0
3.
Physicians
555
470
153
4.
Paediatricians
444
276
37.8
5.-
Doctors at PHCs
23619
19487
173
6.
Third Medical Officer under VHG
Scheme
4511
2902
35.7
7.
Block Extension Educators
6076
5569
83
8.
Health Assistants (Male)
27297
24400
10.6
9.
Health Workers (Male)
88078
82071
6.8
10.
Health Assistants (Female)/LHV
21773
17316
203
73
11.
Health Workers (Femalc)/ANMs
128166
118555
12.
Pharmacists
21665
19708
9.0
13.
Lab. Technicians
10814
9068
16.1
14.
Nurse Mid-wives
14737
12823
13.0
Actual total of categories (l)-(4)
S = 2801
P = 2158
22.9 % Vacant
Source: Government of India, Rural Health Statistics, Dec.1989, Ministry of Health and Family
Welfare, DGHS, Rural Health Division, Dec. 1989.
107
LIST OF WORK CENTRES
Sl.No.
Name of College
Hospital/Medical College
1.
College ofNursing
B.J.Medical College
New Civil Hospital
Ahmedabad - 3800lt>
2.
College ofNursing
Fort, Bangalore - 560002
3.
College ofNursing
K.L.V. Society
Belgaum
4.
Institute ofNursing Education
J.J. Group of Hospitals
Bombay - 400008
5.
College ofNursing
Armed Forces Medical College
Pune - 411040
6.
College ofNursing
S.S K.M. Hospital
Calcutta -700020
7.
College ofNursing
Medical College Hospital
Guwahati - 781001
8.
College ofNursing
Nizam’s Institute of Medical Sciences,
Hyderabad
9.
College ofNursing
Indore - 452001
10.
College ofNursing
Jaipur - 302004
11.
College ofNursing
G.S.V. Medical College Hospital
Kanpur - 20800.-.
12.
College ofNursing
Christian Medical College
Ludhiana - 141008
13.
College ofNursing
Sri Ramakrishna Instritue of ParaMedical Sciences, Coimbatore
14.
R.A.K. College ofNursing
15.
S.J. Hospital
16.
College ofNursing
17.
College ofNursing
Andrews Gar.j, New Delhi - 110024
Ansari Nagar, New Delhi - 110029
Medical College Hospital
Trivandrum - 695011
Kottyam, Kerala
SOHS-IGNOUP P.O.IT/September 1997 (Reprint)
ISBN-81-7263-554-0
- Media
7865.pdf
Position: 1781 (5 views)