Primary Health Care

presented by
Dr. Neha Agrawal
 Contents

 Introduction
 Health for All
 Primary Health Care
Concepts
Elements
Principles
Existent approaches
 Primary Health Care in India
Changing concepts
Village Level
Sub Centre Level
Primary Health Centre
Community Health Centre
Criticism of primary health care approach
Barriers to primary health care
National rural health mission
 Introduction
HEALTH - fundamental human right.

Health care “ multitude of services provided to

individuals or communities by agents of health
services or professions, for the purpose of
promoting, maintaining, monitoring or restoring
health”

Health systems
 LEVELS OF
PRIMARY HEALTH CARE
PHC, SUBCENTRES

SECONDARY
CHC, DISTRICT HOSPITALS

TERTIARY
AIIMS,
MEDICAL COLLEGES AND HOSPITALS,
SPECIALITY HOSPITALS
Health Care Systems are –

1. Accessible to small part of the population

- lack of services in some areas and
unnecessary duplication in others.

“SOCIAL INJUSTICE”

2. Curative in nature
 HEALTH FOR ALL
30th World Health Assembly resolved in May 1977
“the main social target of governments and 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 will permit them to lead a socially and
economically productive life”

HEALTH FOR ALL by the year 2000 - Social Goal.

Two major themes have evolved :
1. Needs of the entire population.
Preventive, curative and rehabilitative
services.
2. Best way to provide health care - effective
“Primary Health Care Services” supported
by an appropriate referral system.
 BACKGROUND
 WHO, UNICEF and the Govt
of USSR held an
International Conference on
Health Care
 (6-12 Sept, 1978) at Alma
Ata, CAPITAL OF
KHAZAKISTAN.
 134 Govts and 67 UN
members attended.
 PRIMARY HEALTH CARE

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
COUNTRY AND COMMUNITY CAN AFFORD
TO MAINTAIN AT EVERY STAGE OF THEIR
DEVELOPMENT IN THE SPIRIT OF SELF
RELIANCE AND SELF DETERMINATION
What it does

 to reach to the home and family level and not

be limited to health facilities.
 involve a continuing relationship with persons
and families.
 reach everybody, particularly those in
greatest need.
 Principles of primary health
care
Equitable distribution

Community participation

Intersectoral co-ordination

Appropriate technology
 Principles

EQUITABLE DISTRIBUTION
SOCIAL INJUSTICE

AIMS
Shifting the gravity of health care system from cities
( 3/4th of health budget) to rural areas (3/4 the of people
live)

Easily AVAILABLE, ACCESSIBLE, AFFORDABLE

 COMMUNITY PARTICIPATION

By which individuals and families assume

responsibility for health and welfare for themselves as
also for the community in which they live, and develop
the capacity to contribute to their own for own and
community’s development.
Universal coverage requires involvement of local
community.
People should participate in :
1. Decision making
2. Implementation
3. Monitoring and evaluation
4. Sharing the benefits.
Advantages
Helps in achieving results at a lower cost
Long term social development
 FOCUS ON PREVENTION
AND HEALTH PROMOTION

Not only be curative, root causes of disease

Promote Health and Healthy lifestyles
APPROPRIATE TECHNOLOGY

“ Technology that is scientifically sound, adaptable to

local needs and acceptable to those who apply it
and those for whom it is used and that can be
maintained by the people themselves in keeping
with the principle of self-reliance with the resources
the community & country can afford.”
MULTISECTORAL APPROACH

Cannot be provided by health sector alone.

Planning with other sector is important to avoid

unnecessary duplication of activities.
Pre- requisites of primary health care

 Political and social will

 Community participation
 Multisectoral approach
 Appropriate technology
 Referral system
 Elements of primary health care
 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, family planning

 Immunization against major infections diseases

 Prevention and control of locally endemic

diseases

 Appropriate treatment of common diseases and

injuries

 Provision of essential drugs

Principles of Primary Health Care

ACCESSIBILITY ACCEPTABILITY AVAILABILITY

AFFORDABILITY EFFICIENCY SUSTAINABLE

 Primary Health Care in India

Comprehensive Health Care

Bhore Committee, 1946.
• Preventive, curative & promotive health
services
• Be as close to beneficiaries as possible
• Available to all
• Create & maintain healthy environment
Establishment of a network of primary health
centres and subcentres.

But these services did not extend beyond a 2-

5 kms radius.

Moreover,
- understaffed
- poorly supplied with with medicines
& equipment.
Rural Health Scheme

Government of India, 1977.

“placing people’s health in people’s hands”

Alma-Ata Declaration 1978.

As a signatory, Government of India committed

to achieve Health for All through Primary
Health Care approach.
 PRIMARY HEALTH CARE IN INDIA

 National health policy-

1983-3 tier system of
health care
 Village level
1.Village health guide
scheme
2.Training of local dais
3. Anganwadi workers
 Village Health Guides Schemes

2nd October,1977 as
“Community Health Workers Scheme”

1981 - VHG’s Scheme

- Family Welfare programme

Except Kerala, Karnataka, Tamil Nadu, Arunachal

Pradesh & Jammu & Kashmir
Is a person with an aptitude for social services & is not a
full time government functionary

Chosen from the community by Gram Panchayat

 Permanent residents , preferably women
 Minimum education – 6th standard
 Acceptable to all sections of community
 2- 3hrs of community health work
 Reports to village health committee
Training
- 200hrs. over 3 months period
- Rs. 200/ month.
- Certificate, manual and a kit – 17 medicines – vit A
solution, oral rehydration solution packets etc.

Duties
Treatment of simple ailments, activities of first-
aid,mother and child care and family planning,
health education and sanitation.
Drugs : Rs. 600/annum.
1 VHG – 1000 population
3.23 lakh - 2002
 Local Dais
(TBA- traditional birth atttenders)
Rural Health Scheme to train local dais

Training
- 30 working days ; only 2 days / week ; rest 4 days
accompany health worker
- At least 2 deliveries
- Rs. 300/month
- Emphasis – asepsis
- Delivery kit & Certificate
Entitled to receive Rs. 10 / delivery, if case is
registered at health centre / subcentre.

To every infant registered by her, she receives Rs. 3 /

 Anganwadi Workers

Angan – “Courtyard”
Selected from the community.

Training
- 4months period – Health & Nutrition & Child
development
Duties
Health check-up, immunization, supplementary
nutrition, health education & referral services
Part time worker ; Rs.200 – 250 / month.

1 anganwadi worker – 1000 population

 Sub-Centre Level
Peripheral outpost of the existing health delivery
system in rural India.

1 subcentre - 5000 population

- 3000 (hilly,tribal & backward)

1,42,655 sub centres

Rural Health Statistics- 2005

Functions – Limited – drug bank

- proposed – IUD insertion,simple
lab investigations.
Staffing Pattern :
1 Health care worker ( Female) /ANM
1 Health care worker (Male)
1 Voluntary worker.
Supervised – health assistants 1for 6
 Growth of Subcentres

142655
160000 137311
130165 136258
140000
120000
100000 84376
80000
60000
40000
20000
0
VI Plan VII Plan VIII Plan IX Plan X plan
Issues concerning
 Availability- 21983
 50% not having building
 National council for Applied research

- subcenters in rented buildings poorly

furnished, less equipped for working
 Manpower position – 50% male health worker

- 7% ANM
 Effective community linkage missing
 Primary Health Centre
National Health Plan (1983) - HFA
- 1 centre - 30,000 population
- 20,000 (hilly, tribal,backward)
- 28 villages
23109 PHC - 2005
Covers all 8 “essential elements” of Primary Health
Care.
Referral services, training of VHGs & dais, provides
basic health services, National Health Programmes.
 4-6 beds
 Referral units for 6 sub centres
 Proposed to equip – facilities for selected surgical
procedures (vasectomy, MTP & minor surgical
procedures)
 75 essential drugs – antibiotics, bronchodilators,
vaccines etc
 Reorient medical education (ROME)

 Established & maintained by State Governments

Growth of Primary Health Centres

25000 23109
22842
22149
20000 18671

15000

10000 9115

5000

0
VI Plan VII Plan VIII Plan IX Plan X Plan
 Staffing Pattern
Medical Officer (1)
Pharmacist (1)
Nurse mid - wife (1)
Health worker(Female) (1)
block extension Educator (1)
Health Assistant (Male) (1)
Health Assistant (Female) (1)
Upper Divisional Clerk (1)
Lower Divisional Clerk (1)
Lab Technician (1)
Driver (1)
Class IV (4) Total - 15
Criticisms
 Availability of services – 700 PHC without
dentists
- lack basic facilities
- lack of incentives for working in rural areas
 Inadequate - Curative services, emergency
medical care and referral services

4436 – more PHC need to be established

 Community Health Centre
1 CHC – 80,000 – 1,20,000 population - 198 villages
Equipped with 30 beds and specialist in Surgery,
Medicine, OBG, Pediatrics with X-ray & Laboratory
facilities
Community Health Officer – selected from staff at
Primary health centre with minimum of 7 yrs.
experience
Established & maintained by State governments
3222 CHC’s – 2005
Growth Of Community Health Centres

3500 3222
3043
3000
2500 2633

2000 1910
1500
1000 761
500
0
VI Plan VII Plan VIII Plan IX Plan X Plan
Staffing Pattern

Medical Officer (4) Ward boys (2)

Nurses Mid-wives (7) Dhobi (1)
Dresser (1) Sweepers
(3)
Pharmacist / Compounder (1) Mali (1)
Lab Technician (1) Choukidar (1)
X -ray Technician (1) Aya (1)
Peon (1)
Total - 25
Criticisms
 Services of specialists-not provided
 Vacancy – 40-50%
 No anesthetist

3332 more required

Vacant Posts of Medical Personnel

67.00%
70.00%
59.00%
56.00% 56.00%
60.00%

50.00%

40.00%

30.00%

20.00%

10.00% 0.00%

0.00%
Surgeon

Anasthetits
Specialists

Pediatrician
Gynaecologist
Medical
 Primary Health Care - Urban

Urban Revamping Scheme - 1983

Krishnan Committee – West Bengal -1982

- 40% population in slum areas

 primary health care, family welfare and maternal

child health services in urban areas – slums
 871 health posts
Four types of health posts depending upon
the population of the area.
Type A - < 5000
Type B - 5000 - 10,000
Type C - 10,000 - 25,000
Type D - 50,000
Staffing pattern
A B C D
Lady Doctor - - - 1
Public Health
Nurse - - - 1
Nurse Midwife 1 1 2 3-4
Computer cum
Clerk - - - 1
Voluntary women
health worker - - - 1
Barriers to Primary health care in India

 maldistribution
 poor work environments
 low productivity of personnel
 vacant posts, high staff turnover
 loss of personnel to private sector
 migration of health personnel to urban areas
or overseas
 Information on health workforce is sparse
 research is limited
 National rural Health Mission – 2005
 Restructure delivery mechanism
 Public spending – 2-3% of GDP
 Intersectoral co-ordination
 Accredited Social Health Activist (ASHA’s)
1 per 1000- 18 high focus states
resident
education till 8th , 15-45 age
gram sabha
Training
23 days – 12 months
drug kit

 Link between ANM at sub centre, anganwadi worker

and community
 First port of call for any health-related demands
of deprived sections of the population
 Accountable to panchayat

Universal immunization, safe delivery, newborn care,

prevention of water-borne and other diseases and
sanitation.
 National rural Health Mission – 2005

Sub centre level

1 additional ANM

 Primary Health Centre

24 hour – additional 3 staff nurses
out patient services – AYUSH

 Community Health Centre

30 bedded rural hospital
7 specialists, 9 staff nurses
First referral units