NATIONAL HEALTH DELIVERY SYSTEM PRIMARY HEALTH CARE DISTRICT REHABILITATION CENTER NATIONAL INSTITUTES

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NATIONAL HEALTH DELIVERY SYSTEM + PHC, DRC, AND NATIONAL INSTITUTES
INTRODUCTION: Healthcare may be defined as multitude of services rendered to
individual or communities by the agents of the health services or professionals for
the purpose of promoting, restoring and maintaining health
• INPUTS: Represent health needs and demands of the community
• HEALTH CARE SERVICES: Designed to meet the health needs of the community
• HEALTH CARE SYSTEM: Constitutes management sector, and involves organizational matter.
• OUTPUT: Represent the changed or improved health status of the community.
HEALTH CARE PROVIDERS IN INDIA
Departments under State
Government
Departments under Central
Government
Non-Government
• Public Health Department
• Medical Education
Department
• Municipal Administration
Department
• Non-Allopathic systems of
medicine
• Under Ministry of Health
and Family Welfare
(MoHFW)
✓ Central Health Services
Medical Colleges
✓ Corporate Industries
✓ Central Government
Health Services (CGHS)
• Ministry of AYUSH
• Ministries besides MoHFW
✓ Railway Hospitals (Railway
Ministry)
✓ Armed Forces Hospitals
(Ministry of Defence)
• Private Hospitals
• Private Practitioners
• NGO Health Facilities
• Traditional Healers

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ORGANIZATIONAL STRUCTURE IN INDIA: Health system in India has 3 main links
– Central, State, Local or Peripheral.
AT CENTRAL / NATIONAL LEVEL:
THE UNION MINISTRY OF HEALTH AND FAMILY WELFARE
Headed by – Cabinet Minister → Minister of State → Deputy health Minister
THE DIRECTORATE GENERAL OF HEALTH SERVICES
Headed by – DGHS → Additional DGHS → Deputy DGHS → Administrative staff
THE CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE
Headed by – Union Health Minister → State Health Ministers
AT STATE LEVEL:
OFFICIAL ORGANS
THE UNION MINISTRY
OF HEALTH AND
FAMILY WELFARE
THE DIRECTORATE
GENERAL OF HEALTH
SERVICES
THE CENTRAL COUNCIL
OF HEALTH AND
FAMILY WELFARE
STATE LEVEL
STATE MINISTRY OF
HEALTH AND FAMILY
WELFARE
DIRECTORATE OF
HEALTH AND FAMILY
WELFARE SERVICES

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AT DISTRICT LEVEL
PANCHAYAT PANCHAYAT SMITI ZILLA PARISHAD
GRAM PANCHAYAT GRAMSABHA
DISTRICT
SUB-DIVISION
TEHSIL (TALUKA)
COMMUNITY
DEVELOPMENT BLOCKS
VILLAGES
PANCHAYATS
CORPORATIONS
MUNICIPAL BOARDS
TOWN AREA
COMMITTEES
URBANRURAL

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HEALTH CARE SYSTEMS: In India, it is represented by 5 major sectors or agencies
which defer from each other by the health technology applied and by the source of
fund for operation. (Ref: Preventive and Social Medicine – K Park; Textbook of
Community Medicine – Dr. AP Kulkarni et al.)
HEALTH CARE DELIVERY SYSTEM: Health care delivery system in India is three – tier
system. It operates through 3 levels – Primary Health Care, Secondary Health Care
and Tertiary Health Care (Ref: Textbook of Commuity Medicine and Community
Rehabilitation for Physiotherapist – T Bhaskara Rao, Preventive and Social
Medicine – K Park)
HEALTH CARE
SYSTEMS
PUBLIC SECTOR PRIVATE SECTOR
VOLUNTARY
AGENCIES
INDIGINEOUS
SYSTEMS OF
MEDICINE
NATIONAL
HEALTH
PROGRAMS
Primary Health Care
✓ Primary Health
Centres
✓ Sub Centres
Referral Hospital
Services
✓ Community
Health Centres
✓ Rural Hospitals
✓ District Hospitals
✓ Speciality
Hospitals
✓ Teaching
Hospitals
Central Government
Schemes
✓ ESIS
✓ Central Gov.
Health Schemes
Other Agencies
✓ Defence Services
✓ Railways
✓ Private hospitals
✓ Polyclinics
✓ Nursing homes
✓ Dispensaries
✓ General
Practitioners and
clinics
✓ Indian Red Cross
Society
✓ Family Planning
Association of
India
✓ Indian Council
for Child Welfare
✓ Central Social
Welfare Board
✓ TB Association
of India
✓ Professional
Bodies – IMA,
IDA, TNAI etc.
✓ Ayurveda and
Siddha
✓ Unani and Tibbi
✓ Homeopathy
✓ Reproductive and
Child Health
Program
✓ Universal
Immunization
Program
✓ NPCDSCS –
National Program
for Prevention
and Control of
Cancer, Diabetes,
Cardiovascular
Disease and
Stroke

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1) Primary care level:
• It is the first level of contact of individuals, the family and community with the
national health system, where primary (essential) health care is provided.
• Primary health care delivery system in India is at 3 levels.
Village Level (1000 population)
▪ Community Health Guide (CHG)
▪ Trained birth attendant (trained dais) (TBA)
▪ Anganwadi workers (under ICDS scheme)
Subcentre Level (3000 – 5000 population)
▪ Multipurpose Health Assistant (male) (MPHA – M)
▪ Multipurpose Health Assistant (female) (MPHA – F)
Primary Health Center Level (20000 – 30000 population)
▪ 1 – 2 medical officers
2) Secondary Care Level (80, 000 – 1,20,000 population)
• Intermediate health care level ∕ First referral level
• At this level more complex problems are dealt with
• In India, this kind of care is provided by – Community Health Centers and District
Hospitals.
3) Tertiary Care level
• Apex care ∕ Second level referral
• More specialized than secondary care level and requires specific facilities (high-
tech diagnostic and therapeutic equipment) and highly specialized health
workers (medical and paramedical professionals)
• In India, this kind of care is provided by – regional or central level institutions
like Medical college hospitals, All India Institutes, Super-speciality Hospitals,
Regional Hospitals etc.

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PRIMARY HEALTH CARE
Definition: Primary health care is essential health care made universally accessible
to individuals and acceptable to them, through their full participation and at a cost
the community and country can afford.
Elements of Primary Health Care:
• Health Education
• Nutrition
• Immunization
• MCH care
• Family Planning
• Safe water supply
• Basic Sanitation
• Control of endemic diseases
• Treatment of common diseases
• Provision of essential drugs
Principles of Primary Health Care:
• Equitable distribution: Health services – shared equally by all people irrespective
of their ability to pay; all people (rich or poor, urban or rural) must have access
to health services.
• Community Participation: Participation of community essential – during
planning, implementation and maintenance of health services.
• Intersectoral coordination and cooperation: All components of primary health
care cannot be provided by the health sector alone. So, cooperation of other
sectors (education, transportation, communication, food and agriculture) also
needed to improve health status of the people.
• Appropriate technology: Interventions adopted should be appropriate to local
condition and it should be accepted and affordable for the people.
Strategies of Primary Health Care:
• Intersectoral coordination and cooperation
• Development of basic health infrastructure
• Prevention of disease and promotion of health

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• Community participation and IEC (Information, Education, Communication)
activities
• Appropriate technologies
• Training of MPHA, TBA, and CHG.
THREE TIER PRIMARY HEALTH CARE DELIVERY SYSTEM
A) AT VILLAGE LEVEL
DESCRIPTION SELECTION CRITERIA
TRAINING / DUTIES /
SERVICE PROVIDED
COMMUNITY
HEALTH GUIDE
▪ Male / female with an
aptitude to serve
selected by the
community
▪ Should not be full time
government employee
▪ Preference – female
▪ One from each village –
every 1000 population
▪ Permanent resident of
village
▪ Minimum qualification:
6th
class
▪ Acceptable to all sections
of the community
▪ Spare at least 2 – 3 hours
per day for community
health work.
Training – PHC (3 months –
minimum 200 hrs.)
▪ Treatment of minor
ailments
▪ First aid treatment
▪ MCH services
▪ Family planning
▪ Health Education
▪ Basic Sanitation
TRAINED BIRTH
ATTENDANT
Earlier deliveries in rural
area conducted by local dais
(untrained) → delivery
complication → government
decided to train them (clean
and save deliveries) → after
training they are called TBA
▪ One from each village –
every 1000 population
▪ Permanent resident of
village
▪ Acceptable to all sections
of the community
▪ Only females are
selected
Training – PHC or subcentre
or MCH centres (30 days)
emphasis on asepsis – clean
– hands, surface, blade,
thread, stump.)
ANGANWADI
WORKERS
▪ One anganwadi worker
for every 1000
population
▪ Selected under ICDS
Program
▪ Each ICDS block contains
100 anganwadi workers
▪ Selected from the same
community
▪ Part time worker
Training – 4 months in
health, nutrition and mother
& child development
▪ Health check-ups
▪ Health education
▪ Immunization
▪ Supplementary nutrition
▪ Referral services
B) AT SUBCENTRE LEVEL
▪ In India, there is 1 subcentre for every 5000 population. In tribal, hilly, and
backward areas – 1 subcentre for every 3000 population.
▪ Each subcentre manned by – MPHA (M) and MPHA (F)

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JOB RESPONSIBILITIES
MPHA (M)
• Participation in national health programs
• Environmental sanitation
• Immunization
• Family planning
• Health education
• Collecting vital events
• Record keeping
• Treatment of minor ailments
• MTP (Identify & refer to PHC)
MPHA (F)
• Participation in national health programs
• Immunization
• MCH care including family planning
• Health education
• Nutrition
• Collecting vital events
• Record keeping
• Treatment of minor ailments
• Training of dais
• School health
C) AT PRIMARY HEALTH CENTRE LEVEL
• In India, 1 PHC was constructed for every population of 30000 in rural areas
and 20000 in tribal and hilly areas.
• The medical officer – is the administrative head of primary health centre
STAFF NUMBER OF POSTS
Medical Officer 1 / 2
Staff Nurse 1
Pharmacist 1
Health worker (female) 1
Health educator 1
Health assistant (male) 1
Health assistant (female) 1
Upper division clerk 1
Lower division clerk 1
Lab Technician 1
Driver 1
Class IV 4
TOTAL 15

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Functions of Primary Health Centres:
A) Individual Services
▪ Medical care
▪ Maternal care
▪ Child care
▪ Family welfare
▪ School Health
▪ Heath Education
B) Community Services
▪ Prevention and control of endemic diseases
▪ Environmental Sanitation
▪ Vital Statistics
▪ National Health Program
C) Technical / Managerial Services
▪ Referral
▪ Laboratory
▪ Training
▪ Office and Management
Duties of Medical Officer:
A) Preventive and Promotive
• MCH services: Antenatal, perinatal and postnatal care of mothers, infants and
child.
• Nutritional Program: Supervision and implementation – Vit A supplementation
and iron folic acid distribution.
• Immunization Program: Plan, implement and supervision of adequate supply of
vaccines, proper storage and maintenance of cold chain.
• Family Planning Program: Successful implementation – education, motivation,
delivery of services and after care.
• National Health Program: He will look after all national health programs.
• Trained: Tubectomy and Vasectomy – organizes and conduct camps.
• School Health: Visit school at regular interval – medical check-ups, treatment of
minor illness, immunization of children.
• Communicable disease: Ensure steps being taken for control of CDs and proper
sanitation and will take necessary action in case of outbreak of pandemic.
• Early detection/confirmation/treatment: Leprosy, TB, STD

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• Health Education
• Diarrhoeal Disorder: Early detection and provide treatment through ORT,
Referral of serious cases.
B) Curative
• Organize: Dispensaries, outpatient department and will allot duties to ancillary
staff.
• Organize: Laboratory services for cases where necessary.
• Arrangement: Rendering services for treatment of minor ailments at community
level and PHC through subordinate staff.
• Arrangement: Suitable arrangement for work distribution in case of emergency
• Attend: Cases referred by health workers, health assistant, health guides etc.
• Screen: Cases needing specialized attention.
• Guidance: Provide guidance to health assistants, health workers. Health guides,
school teachers – treatment of minor ailments.
• Co-ordinate: Cooperate and coordinate with other institutes providing medical
care.
• Visit: Visit each subcentre in the area at least once in fortnight on a fixed day –
check the work of staff and provide curative services.
C) Administrative
• Supervise work of staff working in PHC.
• Ensure general cleanliness inside and outside premises of PHC.
• Ensure proper maintenance of equipment.
• Ensure to keep up to date stock registers of stores and drugs.
• Will get intends prepared timely for drugs, instruments, vaccines sufficiently in
advance and will submit to appropriate health authorities.
• Check proper maintenance of transport given.
• Display charts in the room – area, location of peripheral units, health statistics.
• Conduct monthly meeting with staff – scrutinize and evaluating progress –
suggestions for improvements.
D) Training
• Organize training programs including continuing education with the assistance
of CHO (Community Health Officer)

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• Provide training to CHGs and TBAs.
• Make arrangements to provide assistance to health assistant (F) and health
workers (F) in organizing training programs for Dais.
• Educate community about important health problems and ways of prevention.
SECONDARY HEALTH CARE (INTERMEDIATE HEALTH CARE)
STAFF PATTERN OF COMMUNITY HEALTH CENTRE
STAFF PATTERN OF DISTRICT HOSPITAL
Specialists in medicine, surgery, obstetrics and gynaecology, ENT, ophthalmology,
orthopaedics, anaesthesia, radiology are present. Pathologist may or may not be
present.
SERVICE PROVIDED
• Medical care
• Surgical care
• Specialized diagnostic services
• Inpatient, outpatient, supervisory services
STAFF NUMBER OF POSTS
Medical Officer 4
Staff Nurse 7
Pharmacist 1
Dresser 1
Lab technician 1
Radiographer 1
Ward boys 2
Dhobi 1
Sweepers 3
Mali 1
Chowkidar 1
Peon 1
Aya 1
TOTAL 25

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TERTIARY HEALTH CARE (APEX CARE)
STAFF PATTERN
• Teacher – speciality wise (specialist in all speciality)
• Super specialist – speciality wise
• Specialised paramedical staff
EQUIPMENT
• High-tech diagnostic and therapeutic equipment
SERVICES
• Emergency care
• Speciality and superspeciality care
• Inpatient survices and Outpatient services
• Clinical training
• High-tech diagnostic and therapeutic services

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REHABILITATION SERVICES IN INDIA
1) District Rehabilitation Center (DRC) Project started in 1985
2) Four Regional Rehabilitation Training Centers (RRTC) have been functioning
under the District Rehabilitation Center (DRC) scheme at Mumbai, Cuttack,
Chennai and Lucknow.
3) National Information Center on Disability and Rehabilitation
4) National Council for Handicapped Welfare
5) National Level Institutes –
o National Institute for Mentally Handicap (NIMH) - Secunderabad
o National Institute for Empowerment of Persons with Intellectual
Disabilities (NIEPID) - Secunderabad
o National Institutes for Hearing Handicap (NIHH) – Mumbai
o Ali Yavar Jung National Institute of Speech and Hearing Disabilities
(AYJNISHD) – Mumbai
o National Institute for the Visually Handicap (NIVH) – Dehradun
o National Institute for Orthopedically Handicap (NIOH) – Kolkata
o National Institute for Locomotor Disabilities (NILD) - Kolkata
o Institute for the Physically Handicap (IPH) – Delhi
o National Institute of Rehabilitation Training and Research (NIRTAR) -
Cuttack, Odhisha.
o National Institute for Empowerment of Persons with Multiple
Disabilities (NIEPMD) - Chennai
o Indian Sign Language Research and Training Center (ISLRTC) - Delhi
6) Ministry of Social Justice and Empowerment has set up Composite Regional
Centers for Skill Development, Rehabilitation and Employment of Persons
with disabilities in various states to provide preventive and promotional
aspects of rehabilitation.
7) The Government of India formulated National Policy for person with
Disabilities, 2006 which deals with physical, educational and economical
aspects of rehabilitation.

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DISTRICT REHABILITATION CENTRE
STAFF MEMBERS:
• Clinical Psychologist
• Sr. Physiotherapist / Occupational Therapist
• Sr. Prosthetist / Orthotist
• Prosthetist Orthotist Technician
• Sr. Speech Therapist / Audiologist
• Hearing Assistant / Jr. Speech Therapist
• Mobility Instructor
• Multipurpose Rehabilitation Worker
• Accountant cum Clerk cum Storekeeper
• Attendant cum Peon cum Messenger
ROLE OF DRC:
• Survey and identification of PWD through camp approaches.
• Awareness generation for encouraging and enhancing prevention of
disabilities.
• Early detection and intervention
• Counseling of PWD, their parents and family members.
• Assessment of need of assistive devices, provision/fitment of assistive devices,
follow up/repair of assistive devices.
• Therapeutic services: Physiotherapy, Occupational therapy, Speech therapy
etc.
• Promotion of barrier free environment.
• Facilitation of disability certificates, bus passes and other concession/facilities
for PWD.
• Referral and arrangement of surgical correction through government and
charitable institutes.
• Arrangement of loans for self-employment, through banks and other financial
institutions.
• To provide supportive and complimentary services to promote education,
vocational training and employment of PWD.
• Providing training to PWD for early motivation and early stimulation for
education, vocational training and employment.

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• Providing orientation training to teachers, community and family.
• Identifying suitable vocations for PWD so as to make them economically
independent, keeping in view local resources and designing.
• Provide referral services for existing educational training, vocational institutes.
NATIONAL INSTITUTES
ROLE OF NATIONAL INSTITUTUES:
• Human resource development in the field of disability.
• Develop trained manpower for rehabilitation – training of personnel such as
doctors, engineers, prosthetists, orthotists, physiotherapists, occupational
therapists, multipurpose rehabilitation therapists, speech therapist etc.
• Providing comprehensive rehabilitation services for PWD through team
approach.
• Undertaking research and development work.
• Provide vocational skill training and placement for PWD.
• Distribution of assistive aids and appliances to PWD.
• Documentation and dissemination of information for PWD.
COMPOSITE REGIONAL CENTRE
Nineteen Composite regional center for skill development, rehabilitation and
empowerment of PWD are working under supervision of National Institutes and
Administrative control of the ministry.
ROLE OF COMPOSITE REGIONAL CENTRE:
• It works as an extended arm of National Institutes.
• Provide human resource development.
• Provide rehabilitation services for catering to multiple and different disabilities
at one place.
• Provide vocational skill training and placement for PWD.
• Undertake research and development work.
• Distribution of assistive aids and appliances to PWD.

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• Undertake public education program for creation of awareness among parents
and community
• To establish linkages with existing medical, educational and employment
services following the principles of CBR
• Offer extension services in rural areas.
REFERENCES:
❖ Preventive and Social Medicine – K Park
❖ Textbook of Community Medicine – Dr. AP Kulkarni et al.
❖ Textbook of Commuity Medicine and Community Rehabilitation for
Physiotherapist – T Bhaskara Rao
❖ Physiotherapy in Community Health and Rehabilitation – Waqar Naqvi
❖ Disabilityaffairs.gov.in