02.01.01. The public health system | India
02.01.01. The public health system | India
05 Jul 2022
The provision of health care to the public is enlisted as State subject in the constitution of India. Furthermore, there are references to health in the Union as well as Concurrent Lists (Government of India, n.d.). This means that the States have the opportunity for unique customization of the Union public health initiatives and introduction of state-specific services. The public health network is monitored by the Indian Public Health Standards (Ministry of Health and Family Welfare (MoHFW), 2012).
Traditionally, the public health care system in India has been rural-centric. A three-tiered network of health facilities consisting of sub centres, primary health care centres, and community health centres caters to the primary and secondary health care needs of the population, mostly in rural areas where about 2/3rd of India’s population live.
- A Sub Centre (SC) is the first point of contact between the community and the primary health care system, and it is staffed by nurses and health workers. The minimum requirement of the SC is to have at least one auxiliary nurse midwife (ANM)/female health worker and one male health worker (Ministry of Health and Family Welfare (MoHFW), n.d.-b). SCs provide services in relation to family welfare, maternal and child health (MCH), nutrition, immunization, diarrhoea control, and control of communicable diseases programs (MoHFW, n.d.-b). Existing SCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
- A Primary Health Centre (PHC) is the first point of contact between the village community and a medical officer (MO) — an appointed graduate physician trained in allopathic system of medicine (MBBS; Bachelor of Medicine and Bachelor of Surgery) (MoHFW, n.d.-b). Each PHC is recommended to have at least one MO along with 14 paramedical and other staff. PHCs consist of 4 to 6 beds for in-patients and act as referral units for 6 SCs (MoHFW, n.d.-b). Existing PHCs are being converted to Health and Wellness Centres to provide an expanded range of services at a primary care level as part of the Ayushman Bharat programme (MoHFW, n.d.-b)
- Community Health Centres (CHCs) function as community hospitals. CHCs are required to staff a surgeon, physician, gynaecologist/obstetrician, and paediatrician (4 medical specialists) supported by additional team of 21 paramedical and other staff (MoHFW, n.d.-b). The CHC works as referrals for PHCs within a block (a group of villages), which is the planning and development unit of a district. The CHC also provides specialist obstetric care and specialist consultations facilities across other disciplines (MoHFW, n.d.-b). CHCs are equipped to provide round the clock emergency obstetric care services and thus, they serve as the First Referral Units (FRU) for reproductive health (MoHFW, n.d.-b).
Sub-divisional hospitals, District hospitals, and Government Medical colleges provide comprehensive speciality and super speciality care to referrals, as these may also serve as FRUs (MoHFW, n.d.-b).
Table 2.1. Size of Rural Public Health Network in India (as of March 2020) (Ministry of Health and Family Welfare, n.d.-b).
|Sl. No.||Type||Level of care||Number of centres||Denominator||Function|
|1||Sub centre (SC)
* SCs are being converted to HWCs under Ayushman Bharat
|Primary||155404 in rural areas||1 SC for every 5000 population in the plains, 3000 in Hilly terrains
(Approx. population of 1 village = 1000)
|1st point of contact for the community with the formal health care system. Led by an Auxiliary Nurse Midwife (ANM)/ Multi-purpose Health Worker|
|2||Primary Health Centre (PHC)
*PHCs are being converted to HWCs under Ayushman Bharat.
|Primary||24918 in rural areas||1 PHC per 20000 (tribal)-30000 (plains) population||Each PHC is headed by a graduate physician trained in allopathic medicine. The PHCs provide primary outpatient
services, preventive, curative and emergency care services and implementation of national health programmes.
They have 4-6 beds for in-patient care and provide referral support to 6 sub-centres.
|3||Community Health Centre (CHC)||Primary/ Secondary||5183 in rural areas||1 CHC per 80000-100000 population
|30 bed hospitals.
Staff a surgeon, physician, gynaecologist/ obstetrician, and paediatrician.
Serves as referral centre for 4 PHCs.
|4||Sub-Divisional Hospital||Secondary||1193 in the country. 821 as First Referral Units (FRUs)||Caters to usually 5-6 lakh population||Usually 31-100 bed hospitals. Provide specialized services and may serve as the First Referral Unit (FRU) for obstetric emergencies (hold blood storage facilities, essential laboratory services and provide new-born health services).|
|5||District Hospitals||Secondary||810 in the country. 668 as First Referral Units (FRUs)||At the district level.||Provide comprehensive specialist care at the district level.|
|6||Government Medical Colleges||Tertiary||274 in the country. 118 as First Referral Units (FRUs)||Usually located in urban areas. A district may have no, one or several medical colleges.||Provide speciality and super speciality (provides care and services in one specialism such as neurology/cardiology etc.) care to all referrals|
Source: MoHFW (n.d.-b); Directorate General of Health Services (2012)
Priority health challenges are addressed through an expansive set of health care programs. Traditionally, the focus has been on maternal and child health (MCH) issues and family welfare. In 2005, the National Rural Health Mission (NRHM) brought a paradigm change in the country’s approach (focused attention to ‘weaker’ in terms of infrastructure and/or public health indicators) states, brought programs, and resources under a common banner, decentralised decision making, undertook ‘communitisation’ through a new cadre of community-based health mobilisers (called Accredited Social Health Activists (ASHAs)). Given the success of the NRHM, the approach was extended to both rural and urban areas under the banner of the National Health Mission (NHM) in 2012 with two sub-missions i.e., the NRHM and the National Urban Health Mission (NUHM). Over the years, the focus has expanded beyond MCH to non-communicable diseases, mental health and geriatric care, and a series of state sponsored health insurance schemes (MohFW, n.d.-a)
The NUHM and respective municipal corporations share primary responsibility for providing health services for the urban population. The proposed urban public health infrastructure consists of UPHCs and UCHCs that each cater to approximately 50,000 and 2.5 to 5 lakh population respectively in urban areas to provide equitable and quality care to the urban poor (MoHFW, 2013; MoHFW, n.d.-b).
Table 2.2. Frontline workers in the Public Health System in India
|Sl. No.||Type||Number of Frontline workers|
|1||Accredited Social Health Activists (ASHAs) in Rural Areas||905047 (NHSRC, 2019)|
|2||Accredited Social Health Activists (ASHAs) in Urban Areas||64272 (NHSRC, 2019)|
|3||Auxiliary Nurse Midwives (positioned at both SCs and PHCs)||212593 in position
In 2018, considerable changes were initiated to improve the existing primary health infrastructure as per recommendations of the National Health Policy of 2017 (National Health Portal, 2019). The Ayushman Bharat was introduced to aid in achieving the goal of Universal Health Coverage (UHC). Under Ayushman Bharat, the concept of Health and Wellness Centres (HWCs) was initiated with the aim of providing comprehensive primary care by transforming existing SCs and PHCs (National Health Portal, 2019). Subsequently, a network of HWCs has been rapidly expanded across Indian under the Ayushman Bharat Yojana. By 17th March 2022, 76,633 HWCs had been operationalised across India (MoHFW, 2022). The 13th Common Review Mission (2019) reports that about 1.5 lakh Sub-Centres and PHCs would be transformed to HWCs by 2022 to provide comprehensive and quality primary health care in both urban and rural areas (MoHFW, 2019). A mid-level health officer (Community Health Officer; CHO) manages the HWCs and is supported by two multipurpose workers (one male and one female) and ASHAs. To strengthen HWCs, staff vacancies are being filled-in, and multi-skilling and capacity building efforts are underway. Infrastructure and logistics are being upgraded along with expansion in the range of medicines and diagnostics, adoption of Information Technology (IT) equipment and applications, telemedicine platforms (MoHFW, 2019). Community outreach and information-education-communication (IEC) efforts are being scaled-up through the HWCs with a focus on promotion of health and wellness (MoHFW, 2019).
Proportion that makes use of public sector services:
The percentage of households that use health care in the public sector has increased from 34% to 45% in 2005-2006 and 2015-2016 respectively (International Institute for Population Sciences (IIPS) and ICF, 2017).
Directorate General of Health Services (2012). Indian Public Health Standards. Guidelines for Sub-District/Sub-Divisional Hospitals. Ministry of Health and Family Welfare. Government of India. Available from: http://clinicalestablishments.gov.in/WriteReadData/437.pdf
Government of India (n.d.). Seventh schedule., 1970(5). Retrieved from: https://www.mea.gov.in/Images/pdf1/S7.pdf
International Institute for Population Sciences (IIPS) and ICF (2017). NATIONAL FAMILY HEALTH SURVEY (NFHS-4) 2015-16 INDIA. Mumbai. http://rchiips.org/nfhs/NFHS-4Reports/India.pdf
Ministry of Health and Family Welfare (2013). National Urban Health Mission. Government of India. Available from: https://nhm.gov.in/images/pdf/NUHM/Implementation_Framework_NUHM.pdf
Ministry of Health and Family Welfare (2019). 13th Common Review Mission. National Health Mission, Goverment of India. Available from: https://nhsrcindia.org/sites/default/files/2021-04/13th_common_review_mission-Report_2019_Revise.pdf
Ministry of Health and Family Welfare (2022). Ayushman Bharat-Health and Wellness Centres. Ministry of Health and Family Welfare, Government of India. Retrieved from: http://ab-hwc.nhp.gov.in/
Ministry of Health and Family Welfare (n.d.-a). National Rural Health Mission-Meeting people’s health needs in rural areas: framework for implementation 2005-2012. Government of India. Available from: https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf
Ministry of Health and Family Welfare (n.d.-b). Rural Health Statistics 2019-2020. Statistics Division, Ministry of Health and Family Welfare. Government of India.
Ministry of Health and Family Welfare. (2012). Indian Public Health Standards. Available from https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=971&lid=154
National Health Portal (2019). Ayushman Bharat Yojana. Government of India. Available from: https://www.nhp.gov.in/ayushman-bharat-yojana_pg
National Health Systems Resource Centre (2019). Update on ASHA Programme: July 2019. Ministry of Health and Family Welfare. Available from: https://nhsrcindia.org/sites/default/files/2021-06/ASHA%20Update%20July%202019.pdf