CHAPTER - 2 HEALTHCARE SYSTEMS AND INFRASTRUCTURE IN INDIA

Transcription

1 CHAPTER - 2 HEALTHCARE SYSTEMS AND INFRASTRUCTURE IN INDIA Second chapter discusses Healthcare systems and Infrastructure in India to give better understanding on research area. The chapter starts with concept of health followed by Health and development changes in India, Healthcare systems and infrastructure in India, Rural Healthcare System in India the structure and current scenario. Finally this chapter ends with Rural Health infrastructure a statistical overview. 50

2 2.1. INTRODUCTION: With over one billion people, India is the second most populous country in the world, and accommodates 17 percent of the world s population in 2.4 percent of the world s area. The demographic profile of India s population is changing and the proportion of the elderly is increasing significantly. The female-to-male sex ratio in the age group of 0-6 years has decreased from 945 in 1991 to alarming proportion of 927 as of One of the major challenges to the health sector is to respond to these demographic phenomena. Since India is home to diverse socio-cultural groups, the health needs of the people also vary from region to region. Given the size of India s population, its diversity and the burden of disease, the challenge of attaining good health for the people of India is a daunting one. Since independence, due to focused action by the Government and civil society, India has made substantial progress in controlling communicable diseases and reducing child mortality. While India is being propelled to a position of international eminence, it faces the challenge of dealing effectively with unfinished agendas, strengthening of public health systems, and critical issues of human resources, management, health information and health sector governance on one hand; and new emerging challenges such as globalization and a formidable rising burden of preventable premature morbidity and mortality due to non communicable diseases on the other. 1 Census of India 1991 & 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs, Government of India. 51

3 The spectrum of human resource issues in India is vast and complex and is not limited to health practitioners, but extends to managers, administrative and support staff and allied health personnel. There are issues of quantity, quality, relevance, motivation, utilization and distribution. Shortages of human resources in the health sector are widespread with disproportionate concentration in urban areas. 2.2 CONCEPT OF HEALTH: Health is a common theme in most cultures. In fact, all communities have their concepts of health, as part of their culture. In some cultures health and harmony are considered equal. Modern medicine often acquired for its free occupation with the study of disease and neglected the study of health. Health continues to be a neglected entity despite lip service. However, during the past few decades, there has been a reawakening that health is a fundamental human right. And that it is essential to the satisfaction of basic human needs and to an improved quality of life. Thus, health is to be attained by all people. In 1997, the 30 th World Assembly decided as there is a main social target of governments and World Health Organization (WHO) in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that well permits them to lead a socially and economically productive life. With adoption of health as an integral part of socio-economic development by the United Nations Organization ( U.N.O) in 1979, health while being an end in itself has also become a major instrument of over all socio-economic development and the creation of a new social order. 52

4 Definition of Health: The widely accepted definition of health is that given by W.H.O, 1948 in the preamble to its constitution as below: Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmly In recent years, this statement has been amplified to include the ability to lead a socially and economically productive life 2. The W.H.O definition of health has been criticized as being too broad. Some argue that health cannot be defined as a state at all, but must be seen as a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life. It is a dynamic concept. It helps people live well, work well and enjoy themselves. The W.H.O definition of health is therefore considered by many as an idealistic goal than a realistic proposition. It refers to a situation that may exist in some individuals but not in everyone all the time; it is not usually observed in groups of human beings and in communities HEALTH AND DEVELOPMENT: As health is essential for socio-economic development has gained increasing recognition. It was commonly thought in the 1960s that socio-economic progress was not essential for improving the health status of people in developing countries, and that substantial and rapid progress could be made through introduction of modern public health measures 2 World Health Organization (1978), Declaration of Alma-Ata: Health for All, Series No World Health Organization (1981), Techn. Rep. Sr., No

5 alone. According to this way of thinking, the role of human beings in the developing process was grossly underestimated during the period that witnessed considerable rethinking on this subject 4. This was profound modification of the economic theory. It become increasingly clear that economic development alone cannot solve the major problems of poverty, hunger, malnutrition and disease. In this place, non economic issues have emerged as major objectives in development strategies. The more recent experiences of a few developing countries (ex: Srilanka, Costarica and the state of Kerala in India) illustrate the way in which health forms only a part of development. This was because the efforts in health field were simultaneously reinforced by developments in other sectors such as education, social welfare and land reforms 5. The link between health and development has been clearly established, the one being the starting point for the other and vice-versa. Health and Development changes in India: India is the second most populated country in the world. The demographic outline of India s populace is varying and the proportion of the aged is rising notably. The female to male sex ratio in the age group of 0-6 years has decreased from 945 in 1991 to disturbing proportion of 927 as of India is home to varied socio-cultural groups and the health needs of the people also vary accordingly. India s literacy rate as per 2001 Census was 64.8%. The female literacy rate was 53.7% and male literacy rate 75.9% (Table 1). 4 World Health Organization (1986), Evaluation of the strategy for health for all, SEARO, Seventh Report World Health Situation, Vol World Health Organization (1984), Inter sectorial linkages and health development, WHO Offset Publ.No Census of India 1991 & 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs, Government of India. 54

6 Water plays a vital role and in India, 73% of rural and 90% of urban household have access to safe drinking water 7. At the same time as of 2002, 37.7% of the population has access to better sanitation facilities 8. Table 2.1 Selected Indicators for India Total population (in millions) ,029 Female (%) Urban (%) Population Density (persons per Sq.km) Sex Ratio (Females per 1000 males) Population 0-6 years (%) Decadal population growth rate (%) ( ) Total Literacy Rate (%) Female Literacy Rate (%) Male Literacy Rate (%) Population Below Poverty Line (%) Gross Domestic Product at factor cost at prices (Rs. Millions) ,936,710 Percentage of Households with no toilet/latrine facility ( ) Projected Life Expectancy at Birth (in years) ( ) 64.8 Crude Birth Rate (per thousand population) (2002) Crude Death Rate (per thousand population) (2002) Total Fertility Rate (2003) 13 (children per married woman completing reproductive life span) 3 Infant Mortality Rate (per thousand live births) (2003) Maternal Mortality Ratio (per thousand live births) Number of Disabled persons (in millions) (2001) Percentage of Deliveries Attended by Trained Personnel ( ) Percentage of Eligible population fully immunized ( ) Number of Allopathic Hospitals (2002) 10 15,393 7 Economic Survey , Ministry of Economic Affairs, Government of India. 8 India Water Supply & Sanitation, The World Bank, January Census of India 2001, Provisional Population Totals: India, Registrar General of India, Ministry of Home Affairs, Government of India. 10 Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, MOHFW, Government of India. 11 Economic Survey , Ministry of Economic Affairs, Government of India. 12 National Family Health Survey (NFHS-II), , IIPS and ORC Macro, SRS Bulletin, Registrar General of India, Government of India. 14 Registrar General India,

7 Number of Primary Health Centres Functioning (2004) 15 23,109 Number of Community Health Centres Functioning (2004) 16 3,222 Total Expenditure on Health as a % of GDP ( ) Public Health Expenditure as a % of GDP ( ) Public Expenditure on Health as a % of Total Expenditure on Health ( ) Private Expenditure on Health as a % of Total Expenditure on Health ( ) Ever since India got independence it has practiced a policy of designed economic development led by the public sector. Structural adjustment policies were adopted in 1990s and this gave emphasis to liberalization of hold on economic actions and greater amalgamation with the universal economy. As a result, the Indian economy grew at a rapid rate and 9 th Five-Year Plan ( ) focused more in improving the living conditions of the poor and increasing employment opportunities. India is currently implementing the 11 th Five-Year Plan ( ) which emphasizes human development by promoting quality of life and access to basic social services. India holds 10 th place in world s economy 18. The Gross National Product (GNP) at current prices, per capita stood at around Rs. 25,781 (US$ 572) in The Gross Domestic Product (GDP) per capita annual growth rate has been 3.3% for with the current annual growth rate being 8%. India s economy has been growing progressively in the last few decades and the percentage of poor came down from 47% in 15 Health Information of India 2004 & 2005, Central Bureau of Health Intelligence, MOHFW, Government of India. 16 Annual Report , Ministry of Health and Family Welfare, Government of India. 17 National Health Accounts India, , MOHFW, Government of India Quick Estimates of National Income, Consumption Expenditure, Saving and Capital Formation , Central Statistical Organization, Ministry of Statistics & Programme Implementation, Government of India. 20 World Development Indicators, 2005, World Bank

8 to 26% in the year As the focus was on enhancement in public health and living conditions, a significant improvement in the health status of the people has been witnessed in the last 50 years (Table 3.2). In comparison to economic growth the India s public health sector has not grown considerably (Table 3.3). Table 2.2 Health Indicators Health Indicator Infant Mortality Rate (per 1000 live births) Crude Birth Rate (per thousand population) Crude Death Rate (per thousand population) Total Fertility Rate (children per married woman completing reproductive life span) Life Expectancy (at birth, in years) (1997) 3.0 (2003) 63 (2001) Source: Sample Registration Systems Bulletin, 2004, Provisional Estimates and Census of India, Registrar General of India, Ministry of Home Affairs, Government of India. Table 2.3 Public Health Infrastructure Infrastructure Sub Centres 0 51,405 1,37,311 Community Health Centres ,043 Primary Health Centres 725 5,740 23,109 Dispensaries ,291 Hospitals ,393 Beds(Private & Public 1,17,198 5,69,495 9,14,543 Doctors (Allopathic) 61,800 2,68,700 6,39,729(MCI) Nursing Personnel 18,054 1,43,887 8,39,862 INC) Source: Health Information of India, 2004 & 2005, Central Bureau of Health Intelligence, Ministry of Health and Family Welfare, Government of India HEALTHCARE SYSTEMS AND INFRASTRUCTURE IN INDIA: The Healthcare system is intended to deliver Healthcare services. It constitutes the management sector and involves organizational matters. It operates in the context of the socio economic and political frame work of the country. In India, it is represented by five 21 Tenth Five Year Plan Document, Planning Commission, Government of India. 57

9 major sectors which differ from each other by the health technology applied and by the sources of funds for operation. These are Public Health Sector a. Primary Health Care Primary Health Centres Sub Centres b. Hospitals / Health Centres Community Health Centres Rural Hospitals District Hospitals / Health Centre Specialist Hospitals c. Health Insurance Schemes Employees State Insurance Central Government Health Scheme d. Other agencies Defense services Railways 2. Private Sector a. Private Hospitals, Polyclinics, Nursing Homes and Dispensaries b. General Practitioners and Clinics 3. Indigenous Systems of medicine a. Ayurveda and Siddha b. Unani and Tibbi 22 K. Park (2007), Preventive and Social Medicine, Banarsidas Bhanot publishers, 19 th Edition, pp

10 c. Homeopathy d. Unregistered practitioners 4. Voluntary Health Agencies 5. National Health Programmes PUBLIC HEALTH SECTOR: Government health care services are organised at different levels, generally corresponding to the organisational structure of the administrative machinery. The Primary Health Centre (PHC) is the core of the rural health services infrastructure in India. It has both outpatient and outreach services. These outreach services are provided by Sub-Centres and staffed by multipurpose health workers. Inpatient and more specialised services are provided at the Community Health Centres (CHC). Each sub - centre is expected to cater to a population of 5,000; each PHC to a population of 30,000; and a CHC serves a population of 100,000. District hospitals and medical college teaching hospitals along with specialized institutions provide referral care. Health Insurance Schemes: Employees State Insurance Scheme: The ESI Scheme, introduced by an Act of Parliament in 1948, is a unique piece of social legislation in India. It has introduced for the first time in India the principle of contribution by the employer and employee. The Act provides for medical care in cash and kind, benefits in the contingency of sickness, maternity, employment injury, and pension for dependents on the death of worker because of employment injury. The Act covers employees drawing wages not exceeding Rs. 10,000 per month. 59

11 Table 2.4 The ESI Scheme as on 31 st March, 2006 No. of implemented centres (2005) 718 No. of employers covered (2006) 3lacs No. of insured persons (2006) lacs No. of beneficiaries (2006) 354 lacs No. of Regional Offices / SRO s (2006) 35 No. of ESI hospitals / annexes (2005) 186 No. of ESI dispensaries (2005) 1427 No. of Panel Clinics (2005) 2100 SERVICE PERFORMANCE (Per Year) (2002) OPD attendances 650 lacs No. of hospital admissions 7 lacs No. of cash benefit payments 42 lacs No. of insured persons on the payrolls of permanent disablement benefits 1.68 lacs No. of dependants on the payrolls of family pension Total expenditure on medical benefits Rs. 770 crores Total expenditure on cash benefits Rs. 312 crores Source: Central Government Health Scheme: This was first introduced in New Delhi in 1954 to provide comprehensive medical care to central Government employees. The scheme which was started with 16 Allopathic dispensaries in 1954 covering 2.3 lakh beneficiaries has now 320 dispensaries / hospitals in various systems of medicine and provide service to about lakh beneficiaries. Other Agencies: Also defense services have their own organization for medical care under the banner Armed Forces Medical Services. Likewise the railways provide comprehensive Health care services to the agency of Railway Hospitals. 23 Health Information of India 2005, Ministry of Health and Family Welfare, Government of India New Delhi

12 PRIVATE HEALTH SECTOR: India has a large and unregulated private sector, both in formal and informal sectors. In the formal sector, the private sector accounts for 68 percent of the hospitals and 64 percent of the beds 25. There are large numbers of informal health care providers, most of them being less than fully qualified service providers. Adequate information is not available on the number of informal health care providers. Expenditure data reveals that more than three-fourths of outpatient curative care services are accessed through private health care providers 26. Private non-profit sector: The private non-profit sector includes health services provided by voluntary organizations, charitable institutions, missions, and charitable trusts among others. Till the mid-1960s, voluntary effort in heath care was confined to hospital-based care. Of late, may be enthused by means of the Chinese knowledge at the community level, even the models of community health programmes and decentralized healing services started to get awareness. Even the National Health Policy of 1983 and 2002 described for increasing the exposure of services throughout the non-profit sector to improve accessibility and user-friendliness. The efforts of the non profit organizations in the health sector are classified mainly into a broad variety of actions: The governmental programmes are executed by the organizations. 25 Better Health Systems for India s Poor: Findings, Analysis, and Options, David H. Peters, Abdo S. Yazbeck, et al, World Bank, Morbidity and Treatment of Ailments, NSSO 52 nd Round, 2001, Dept. of Statistics, Government of India, New Delhi. 61

13 For a basic health care delivery and development organizations are running specialized community health integrated programmes. Sponsoring health care for blindness control, polio eradication, management of blood banks, and support during disasters/epidemics by the organizations. Even the health researchers, organizations/individuals, and also the activists who undertake applied research in health service delivery, health economics, and health education play an advocacy role. According to a rough estimate, more than 7000 voluntary organizations in the country work in these areas of health care 27. Although a systematic documentation of NGO contribution is lacking, it is obvious that NGOs and non profit institutions could improve access, quality and equity of services either through direct provision or through advocacy and other action. The potential of non profit institutions in helping to reach public health goals have not been fully realized for several reasons, beginning with their limited size and spatial distribution. The challenge is to find strategies that will facilitate a far more substantial participation in the health sector, particularly in poor performing states and remote areas, and to ensure systems that will keep participation accountable and transparent. INDIGENOUS SYSTEMS OF MEDICINE: As it is a know fact that India is abode for various native system of medication together with Ayurveda and Siddha, Homeopathy, Unani, Naturopathy etc., systems which are also widely practiced. The Government of India and many state governments have taken steps to formalize and initiate standardization of these systems. These include evolving 27 India Health Report, Mishra R. L., Chatterjee R, Rao S, OUP,

14 pharmacopoeia standards for drugs, upgrading educational standards in indigenous medicine and in homeopathy colleges in the country and encouraging research on applicability of these systems to specific diseases. In India, new public health challenges have emerged from demographic and epidemiological transitions, environmental degradation, emerging infectious diseases and anti-microbial resistance. India s public health infrastructure, however, is unable to respond to these new challenges as the delivery system is not functioning optimally and as it is not based on the current needs of the community. The Government in its National Health Policy , advocated the need for ensuring adequate availability of personnel with specialization in public health. There is an urgent need to strengthen public health education in India. The main challenges for public health institutions in India is to reflect social responsiveness and accountability, develop quality assurance systems, keep pace with advancing technology and develop an interface with the community and health care delivery system. VOLUNTARY HEALTH AGENCIES: The Voluntary health agencies occupy an important place in community health programmes. A voluntary health agency may be defined as an organization that is administered by an autonomous board which holds meetings, collects funds for its support chiefly from private sources and expends money, whether with or without paid workers, in conducting a programme directed primarily to furthering the public health by 28 National Health Policy 2002, MOHFW, Government of India,

15 providing health services or health education, or by advancing research or legislation for health, or by a combination of these activities. 29 Voluntary Agencies in India: Indian Red Cross Society: The Indian Red Cross Society was established in It has a network of over 400 branches all over the country it has been executing programs for the promotion of health, prevention of Disease and mitigation of suffering among the people. Its activities include 30 a. Relief work b. Milk and Medical supplies c. Armed forces d. Maternal & Child welfare services e. Family Planning f. Blood Bond & First Aid Hind Kusht Nivaran Sangh: This was founded in 1950 with its head quarters in New Delhi. Its program of work includes rendering of financial assistance various Leprosy homes and clinics, health education, conducting research and field investigations. The Sung has branches all over India and works in close cooperation with the government and other voluntary organizations. Indian Council for Child Welfare: This was established in 1952 and is affiliated with the International Union for Child Welfare. The services of I.C.C.W are devoted to secure 29 Gunn, S.M. and Platt, P.S. (1945), Voluntary Health Agencies, the Ronald Press, New York. 30 Voluntary Health Organizations and India s Health Programmes, Central Health Education Bureau, 1961, Government of India, New Delhi. 64

16 India s children while those opportunities and facilities are guarded by law and other means which would necessarily enable them to develop physically, mentally, morally, spiritually and socially in healthy and normal manner. Tuberculosis Association of India: It was found in The activities of this association comprise organizing a T.B seal campaign every year to raise funds, training of doctors, health visitors and social workers in Anti Tuberculosis work. Bharat Sevak Samaj: It was formed in 1952 to help people to achieve health by their own actions and efforts. Improvement of sanitation in villages is one of its important activities. Central Social welfare board: This was setup in August 1953 comprising activities like surviving the needs and requirements of voluntary welfare organizations, promoting and setting-up of social welfare organizations on a voluntary basis and rendering of financial and to deserve the existing organizations. Kasturba Memorial Fund: The trust has nearly a crore of rupees and is actively engaged in various welfare projects in the country especially in the villages. Family Planning Association of India: It was formed in 1949 with its head quarter at Mumbai. It has done pioneering work in propagating family planning in India. All India Women s Conference: It is the only women s voluntary welfare organization in India which was established in Most of its branches are running M.C.H clinics and Adult education centres, Milk centres and Family planning clinics. 65

17 The All India Blind Relief Society: This was established in 1946 with a view to coordinate different institutions working for the blind. Professional Bodies: The Indian Medical Association, All India Licentiates Association, the All India Dental Association, the Trained Association of India are all voluntary agencies which conduct annual conferences, published journals, arrange scientific sessions and exhibitions and set-up standards of professional education and organize relief camps during periods of natural calamities. International Agencies: The Rockefeller Foundation, Ford Foundation, Cooperative for Assistance and Relief Every Where (A.R.E) are examples of voluntary international health agencies. NATIONAL HEALTH PROGRAMMES: Indian Government has been undertaken several measures to improve the health of the people. Prominent among these measures are the National Health Programmes, which have been launched by the Central Government for the control / eradication of the communicable diseases, improvement of environmental sanitation, raising the standard of nutrition, control of population and improving rural health. Various international agencies like WHO, UNICEF, UNFPA, Red Corss, World Bank, as also a number of foreign agencies like SIDA, DANIDA, NORAD and USAID have been providing technical and material assistance in the implementation of these programmes. Non Government Organizations (NGO) & local bodies based on their objectives provide 66

18 health care services to the needy. Various programmes which are currently in operation are: - National Vector Borne disease control programme -National Anti-Malaria programme -Natiaonal Filaria control programme -Kala-Azar control programme -Japanese encephalitis control programme - National Leprosy eradication programme - National Tuberculosis control programme - National Aids control programme - National programme for control of Blindness - Iodine deficiency disorders (IDD) programme - Universal immunization programme - National Rural Health Mission - Reproductive and Child Health (RCH) programme - National Guinea Worm eradication programme - Yaws eradication programme - National Cancer control programme 67

19 - National Mental Health programme - National Diabetes control programme - National programme for control and treatment of occupational diseases - Nutritional programme - National surveillance programme for communicable diseases - Integrated disease surveillance project - National Family Welfare programme - National water supply and sanitation programme - Minimum needs programme - 20-point programme 68

20 2.5. RURAL HEALTHCARE SYSTEM IN INDIA - THE STRUCTURE AND CURRENT SCENARIO: The healthcare infrastructure in rural areas has been developed as a three tier system (see figure 2.1) and is based on the following population norms 31 (see Table 2.5): Figure 2.1 Health Care system in India RURAL HEALTH CARE SYSTEM IN INDIA COMMUNITY HEALTH CENTRE (CHC) A 30 bedded Hospital / Referral Unit for 4 PHCs with Specialised services PRIMARY HEALTH CENTRE (PHC) A Referral Unit for 6 Sub Centres 4-6 bedded manned with a Medical Officer incharge and 14 Subordinate Paramedical staff SUB CENTRE (SC) Most peripheral contact point between Primary Health Care System & Community Manned with 1HW(F)ANM & 1HW(M) & 1 Voluntary 31 Ministry of Health and Family welfare, Government of India 69

21 Table 2.5 Rural Healthcare system population norms Population Norms Centre Plain Area Hilly/Tribal/Difficult Area Sub-Centre Primary Health Centre 30,000 20,000 Community Health Centre 1,20,000 80,000 Sub-Centres (SCs) The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community. Each Sub-Centre is manned by one Auxiliary Nurse Midwife (ANM) and one Male Health Worker/ MPW (M) (for details of staffing pattern, see Box 1). One Lady Health Worker (LHV) is entrusted with the task of supervision of six Sub-Centres. Sub-Centres are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes. The Sub-Centres are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. The Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-Centres in the country since April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The salary of the Male Worker is borne by the State Governments. Under the Swap Scheme, the Government of India has taken over an additional 39,554 Sub Centres from State Governments / Union Territories since April, 2002 in lieu of 5,434 members of Rural Family Welfare Centres transferred 70

22 to the State Governments / Union Territories. There are 1,45,272 Sub Centres functioning in the country as on March Primary Health Centres (PHCs) PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Programme (MNP)/ Basic Minimum Services Programme (BMS). At present, a PHC is manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 6 beds for patients. The activities of PHC involve curative, preventive, primitive and Family Welfare Services. There are 22,370 PHCs functioning as on March 2007 in the country 32. Community Health Centres (CHCs) CHCs are being established and maintained by the State Government under MNP/BMS programme. It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 indoor beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2007, there are 4,045 CHCs functioning in the country. 32 Ministry of Health and Family welfare, Government of India 71

23 Table 2.6 Staffing pattern A. STAFF FOR SUB - CENTRE: Number of Posts 1. Health Worker (Female)/ANM 1 2. Health Worker (Male) 1 3. Voluntary Worker Rs.100/- p.m. as honorarium) 1 Total: 3 B. STAFF FOR NEW PRIMARY HEALTH CENTRE 1. Medical Officer 1 2. Pharmacist 1 3. Nurse Mid-wife (Staff Nurse) 1 4. Health Worker (Female)/ANM 1 5. Health Educator 1 6. Health Assistant (Male) 1 7. Health Assistant (Female)/LHV 1 8. Upper Division Clerk 1 9. Lower Division Clerk Laboratory Technician Driver (Subject to availability of Vehicle) Class IV 4 Total: 15 C. STAFF FOR COMMUNITY HEALTH CENTRE: 1. Medical Officer * 4 2. Nurse Mid Wife(Staff Nurse) 7 3. Dresser 1 4. Pharmacist/Compounder 1 5. Laboratory Technician 1 6. Radiographer 1 7. Ward Boys 2 8. Dhobi 1 9. Sweepers Mali Chowkidar Aaya Peon 1 Total: 25 * Either qualified or specially trained to work as Surgeon, Obstetrician, Physician and Pediatrician. One of the existing Medical Officers similarly should be either qualified or specially trained in Public Health. 72

24 Table 2.7 Rural Health infrastructure Norms and levels of achievements (All India) NATIONAL S.NO. INDICATOR NORMS ACHIEVEMENTS Tribal / Rural Population (2001) Hilly / 1 covered by a: General Desert Sub Centre Primary Health Centre (PHC) Community Health Centre (CHC) lakhs 2 Number of Sub Centres per PHC Number of PHCs per CHC Rural Population (2001) covered by HW (F) HW (M) Ratio of HA (M) to HW (M) 1:6 1:3 6 Ratio of HA (F) to HW (F) 1:6 1:9 7 Average Rural Area (Sq. Km) covered by Sub Centre PHC CHC

25 8 Average Radial Distance (Kms) covered by Sub Centre PHC CHC Average Number of Villages covered by Sub Centre PHC CHC Source: Ministry of Health and Family welfare, Government of India Table 2.8 Health Infrastructure of Andhra Pradesh 33 : Particulars Required In Position Shortfall Sub-centre Primary Health Centre Community Health Centre Multi purpose health worker (Female)/ANM at Sub Centers & PHCs Health Worker (Male) MPW(M) at Sub Centers Health Assistants (Female)/LHV at PHCs Health Assistants (Male) at PHCs Doctor at PHCs Obstetricians & Gynecologists at CHCs Physicians at CHCs Pediatricians at CHCs Total specialists at CHCs Radiographers Ministry of Health and Family welfare, Govt. of India, 74

26 Pharmacist Laboratory Technicians Nurse/Midwife Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI The other Health Institutions in the state are detailed as under Table 2.9 The other Health Institutions in the State Health Institution Number Medical College 32 District Hospitals 16 Referral Hospitals City Family Welfare Centre Rural Dispensaries Ayurvedic Hospitals 9 Ayurvedic Dispensaries 557 Unani Hospitals 6 Unani Dispensaries 196 Homeopathic Hospitals 6 Homeopathic Dispensary

27 2.6. RURAL HEALTH INFRASTRUCTURE - A STATISTICAL OVERVIEW: The Centres Functioning: The complete family welfare programme is put into practice through Primary Health Care system. For which the Primary Health Care Infrastructure is developed as a three tier system like - Sub Centre, Primary Health Centre (PHC) and Community Health Centre (CHC) which are all well thought -out as the pillars and the support of the Primary Health Care System. One could easily make out that the progress of Sub Centres, in most of them is the marginal contact point amid the Primary Health Care System and the community, which is a requirement for the complete development of the complete system. The graph 3.4 gives data of Sub Centres running over the years disclose that at the end of the Sixth Plan ( ) there were 84,376 Sub Centres. The figure increased to 1, 30,165 at the end of Seventh Plan ( ) and to 1,36,258 at the end of Eighth Plan ( ). At present, as on March, 2007, 1,45,272 Sub Centres are executing in the country. Graph 2.1 Progress of Sub Centres 76

28 Graph 2.2 Progress of Primary Health Centres Graph 2.3 Progress of Community Health Centres Same kind of progress can be seen in the number of PHCs which was 9115 by the end of sixth plan ( ) and the figure approximately doubled to by the end of Seventh Plan ( ) and increased to by the end of Eighth Plan ( ). As on March, 2007, there are PHCs functioning in the country. In accordance with the progress in the number of SCs and PHCs, the numeral of CHCs has also augmented from 761 by the end of Sixth Plan ( ) to 1910 at the end of Seventh Plan ( ) and 2633 by the end of Eighth Plan ( ). As on March, 2007, 4045 CHCs are running. Based on the 2001 Population census the shortfall in the rural health infrastructure comes out to be of Sub Centres, 4883 PHCs and 2525 CHCs. 77

29 Building Status: Almost 76% of PHCs, 50% of Sub Centres and 91% of CHCs are situated in the Government buildings. The others are situated in rented building; rent free Panchayat/ Voluntary Society buildings. As on March, 2007, in case of Sub Centres, overall buildings are needed to construct. Similarly, for PHCs 3618 and for CHCs 199 buildings are needed to construct. Graph 2.4 The % of Sub Centres, PHCs and CHCs functioning in Government buildings Manpower: The on hand manpower is vital requirement for the well-organized performance of the Rural Health Infrastructure. As on March, 2007 the by and large shortfall in the posts of HW (F) / ANM was 12.6% of the whole constraint. Likewise, in case of HW (M), there was a shortage of 55.4% of the obligation. At the same time even the Female Health Assistant has a deficit of 32.8% and that of Health Assistant (Male) which is 28.8%. While the Doctors at PHCs, the shortfall is 7.8% of the total prerequisite. 78

30 Graph 2.5 Shortfall the % of shortfall as compared to requirement based on existing infrastructure Graph 2.6 Vacancy position the % of Sanctioned Post Vacant Even from the authorized posts, a greater % of posts are unoccupied at all the levels. For example, about 8.8% of the authorized posts of HW (Female)/ ANM are unoccupied as put side by side to about 32% of the authorized posts of MPW/Male Health Worker. At PHC, about 13.8% of the authorized posts of Male Health Assistant and 18% of Female Health Assistant/ LHV, 22.1% of the sanctioned posts of doctors are vacant. 79

31 At the Sub Centre level the degree of offered manpower can be used from the actuality that about 37.2% Sub Centres were without a Male Health Worker about 5% of the Sub Centres are carried out without a Female Health Worker / ANM, and about 4.7% Sub Centres are run without both Female Health Worker / ANM as well as Male Health Worker. This shows a greater deficit in Male Health Workers, ensuing in poor male contribution in Family Welfare and other health programmes and is burdening the ANMs. Graph 2.7 The % of Sub Centres functioning without ANMs or / and HW(M) PHC is the foremost contact point amid Medical Officer and the village community. Manpower in PHC consists of a Medical Officer helped by paramedical and other staff. Graph 2.8 The % of PHCs without Doctor, Lab Tech., Pharmacist 80

32 As on March, 2007, about about 40% were without a Lab technician, 5.6% of the PHCs were without a doctor, and about 17% were without a Pharmacist The Community Health Centres provide expert medical care in the form of services of Physicians, Surgeons, Obstetricians & Gynaecologists, and Paediatricians. Graph 2.9 The % of Sanctioned Posts of Specialists Vacant Graph 2.10 The % shortfall of experts as measured up to the obligation based on present infrastructure 81

33 The present position of experts manpower at CHCs disclose that out of the authorized posts, were 59, in which about 51.9% of Paediatricians, 46.4% of Obstetricians & Gynaecologists, 56.6% of Physicians and 2% of Surgeons, were unoccupied. On the whole almost 50% of the authorized posts of experts at CHCs were unoccupied. Furthermore, there was a deficit of 64.8% specialists at the CHCs as put side by side to the prerequisite for existing infrastructure on the basis of on hand norms. Even though the Central and State Governments is accountable in providing Health care, the major importance in this case is on Rural Health care. This is because the Health care s at urban and city level it is cared by private and trust owned hospitals. Nevertheless, the management is also trying to play some role by setting up and working with District Level head quarter s hospitals, Community Health Centres and Area Hospitals. It is considered that the Health care at the rural areas has turned out to be the sole obligation of the governments as the private agencies do not undertake even at a least. Besides all this as India being a rural oriented economy the task of Health care in rural areas is being carried out by the governments as their chief task. 82