Nidhi Arora

M.Sc Final (DCE)

Health Systems in India

Health
The most widely accepted definition of health is the one given by World Health Organisation
(1984) in the preamble to its constitution. It states “Health is a state of complete physical,
mental and social wellbeing and not merely an absence of disease or infirmity”. Thos
definition has recently been expanded to include the ability to lead a socially and
economically productive life.
Health is a fundamental human right. Thus it becomes imperative for the state to assume
responsibility for the health of its people. There are continuing efforts to improve health
services. Health Care involves much more than just medical care and can be defined as
“multitude of services provided to individuals or communities by agents of the health
services or professions, for the purpose of promoting, maintaining, monitoring, or restoring
health”.
Health System in India
The country is divided into 28 states and union territories for the purpose of administration.
These are further divided into smaller administrative units called the districts, which are 593
in number at present. Within the district are many smaller demarcated units. One of them is
the community development block of which there are about 6000 in the country.
The main links in the health system comprise the centre, state, district, block and the village.
Since health is a state subject in India, the states have a considerable amount of independence
in the delivery of health services to their people. Thus each state has developed its own
system of health care delivery. The centre is responsible for policy making, planning,
guiding, assisting, evaluating and coordinating the work of the State Health Ministries.
State: like the centre, Minister of Health and Family Welfare is head of the State Ministry
and the secretary in the Ministry is the bureaucratic head. All states also have a Family
Planning Bureau which is instrumental in the implementation of the family welfare
programme. In addition there are many specific health programmes which come under the
state health directorate.
District: there are six types of administrative areas, namely-sub divisions, tehsils, community
development blocks, municipalities and corporations, villages and panchayats in a district. A
block is generally the unit of rural planning and development under the charge of a Block
development officer. Panchayats are the institutions of local self government at the village
level. Health being a state subject, there is no uniform “model” of a district health
organisation in India. However, it has been suggested to the states to have an integrated setup
at the district level with a chief medical officer (CMO) assisted by three deputy chiefs totally
in charge of the district for all health, family welfare and maternal and child health
programmes.
The dispensation if the primary health care in India is achieved in the following manner:
A) Village level
There are three functionaries at the village level who are responsible for taking care of the
health needs of the community.
a) Village Health Guide- is not a government functionary, but a volunteer chosen from the
community, preferably a woman, who serves as a link between the community and the formal
health system. She is trained at primary health care at a suitable place and is expected to do
the community health work for 2-3hrs daily in the spare time for which she receives an
honorarium of Rs.50 per month and drugs worth Rs.600 per annum. The village health guide
is capable of taking care of mother and child health including family welfare, health
education and sanitation.
b) Local Dais- an extensive training programme had been undertaken by the government to
train all Traditional Birth Attendants, in the country to improve their knowledge and skills
relating to maternal and child health. Thus, every village should have an access to Trained
Birth Attendants. This will ensure deliveries under safe and hygienic conditions which will
reduce maternal and infant mortality.
c) Anganwadi Worker: under the Integrated Child Development Services Scheme, there is an
Anganwadi worker for a population of 1000. She is selected from the community who is
responsible for a package of services delivered, which include, supplementary nutrition,
health checkups, immunization, preschool education, nutrition and health education and
referral services.
B) Sub-centre Level
It is formal outpost of the existing health delivery system at the periphery in rural areas. A
sub-centre is established for a 5,000 population in general and for a population of 3,000 in
hilly, tribal and backward areas.
C) Primary Health Centre Level
It was established for a population of 30,000 in the rural areas, to provide more effective
outreach of the health care services. The functions of PHC cover both preventive and
promotive aspects of health care.
D) Community Health Centre
It was proposed to provide the specialists services in surgery, medicine, gynaecology and
paediatrics. Another feature is to strengthen the protective and promotive aspects of
health care. This has been achieved by upgrading the existing PHC’s and it is envisaged
that there will be one community health centre per community development block
catering to a population of approximately 1, 00,000.
The health care system in India also includes health insurance schemes and other agencies in
the public sector; the private sector; nursing homes; clinics and general practitioners;
indigenous systems of medicine; voluntary health systems and National Health Programmes.
The private sector contributes a fairly large share of health care to the community, but
primarily in the urban areas and at much higher costs. There is large number of voluntary
health agencies like Red Cross Society, Family Planning Association of India, to name a few
which provide support to the formal health system.

ASHAs. Also you need to give a clear definition of the health system. There are a couple of
other dimensions to the health system.
There is no mention of NRHM.
DEVELOPMENT OF THE HEALTH SYSTEM
Health policies and strategies
The main objective of this policy is to achieve an acceptable standard of good health among the general
population of the country. The approach would be to increase access to the decentralized public health system
by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing
institutions. Overriding importance would be given to ensuring a more equitable access to health services
across the social and geographical expanse of the country. Emphasis will be given to increasing the aggregate
public health investment through a substantially increased contribution by the Central Government.
The public health administration at the State level is to render effective service delivery. The contribution of
the private sector in providing health services would be much enhanced, particularly for the population group,
which can afford to pay for services. Priority will be given to preventive and first-line curative initiatives at the
primary health level through increased sectoral share of allocation.

National health Accounts and Health statistics by 2005 show increase in the expenditure by government as a
percentage of GDP from the existing 0.9 percent to 2 percent by 2010, increase share of central grant to
constitute at least 25 percent of total spending by 2010, increase State sector health spending from 5.5
percent to 7 percent of the budget by 2005 and further increase it by 8 percent by 2010. The policy places
great reliance on the strengthening of primary health structure for the attaining of improved public health
outcomes on an equitable basis.

Organization of the health system

The healthcare services’ organization in the country extends from the national level to village level. From the
total organization structure, we can slice the structure of healthcare system at national, state, district,
community, PHC and sub-centre levels.

National level – The organization at the national level consists of the Union Ministry of Health and Family
Welfare. The Ministry has three departments, viz. – Health, Family Welfare, and Indian System of Medicine
and Homeopathy, headed by two Secretaries, one for Health and Family Welfare and the other for ISM and H.
The department of Health is supported by a technical wing, the Directorate General of Health Services, headed
by Director General of Health Services (DGHS).

State level - The organization at State level is under the State Department of Health and Family Welfare in
each State headed by Minister and with a Secretariat under the charge of Secretary/Commissioner (Health and
Family Welfare) belonging to the cadre of Indian Administrative Service (IAS). By and large, the organizational
Structure adopted by the State is in conformity with the pattern of the Central Government. The State
Directorate of Health Services, as the technical wing, is an attached office of the State Department of Health
and Family Welfare and is headed by a Director of Health Services. However, the organizational structure of
the State Directorate of Health Services is not uniform throughout the country. For example, in some states,
the Programme Officers below the rank of Director of Health Services are called Additional Director of Health
Services, while in other states they are called Joint/Deputy Director, Health Services. But regardless of the job
title, each programme officer below the Director of Health Services deals with one or more subject(s). Every
State Directorate has supportive categories comprising of both technical and administrative staff.

The area of medical education which was integrated with the Directorate of Health Services at the State, has
once again shown a tendency of maintaining a separate identity as Directorate of Medical Education and
Research. This Directorate is under the charge of Director of Medical Education, who is answerable directly to
the Health Secretary/Commissioner of the State. Some states have created the posts of Director (Ayurveda)
and Director (Homeopathy). These officers enjoy a larger autonomy in day-to-day work, although sometimes
they still fall under the Directorate of Health Services of the State.

Regional level – In the state of Bihar, Madhya Pradesh, Uttar Pradesh, Andhra Pradesh, Karnataka and others,
zonal or regional or divisional set-ups have been created between the State Directorate of Health Services and
District Health Administration. Each regional/zonal set-up covers three to five districts and acts under
authority delegated by the State Directorate of Health Services. The status of officers/in-charge of such
regional/zonal organizations differs, but they are known as Additional/Joint/Deputy Directors of Health Services
in different States.

District level - In the recent past, states have reorganized their health services structures in order to bring all
healthcare programmes in a district under unified control. The district level structure of health services is a
middle level management organisation and it is a link between the State as well as regional structure on one
side and the peripheral level structures such as PHC as well as sub-centre on the other side. It receives
information from the State level and transmits the same to the periphery by suitable modifications to meet the
local needs. In doing so, it adopts the functions of a manager and brings out various issues of general,
organizational and administrative types in relation to the management of health services. The district officer
with the overall control is designated as the Chief Medical and Health Officer (CM & HO) or as the District
Medical and Health Officer (DM & HO). These officers are popularly known as DMOs or CMOs, and are overall
in-charge of the health and family welfare programmes in the district. They are responsible for implementing
the programmes according to policies laid down and finalized at higher levels, i.e. State and Centre. These
DMOs/CMOs are assisted by Dy. CMOs and programme officers. The number of such officers, their
specialization, and status in the cadre of State Civil Medical Services differ from the State to State. Due to
this, the span of control and hierarchy of reporting of these programme officers vary from state to state.

Sub-divisional/Taluka level – At the Taluka level, healthcare services are rendered through the office of
Assistant District Health and Family Welfare Officer (ADHO). Some specialties are made available at the taluka
hospital. The ADHO is assisted by Medical Officers of Health, Lady Medical Officers and Medical Officers of
general hospital. These hospitals are being gradually converted into Community Health Centres (CHCs).

Community level – For a successful primary healthcare programme, effective referral support is to be
provided. For this purpose one Community Health Centre (CHC) has been established for every 80,000 to 1,
20,000 population, and this centre provides the basic specialty services in general medicine, pediatrics,
surgery, obstetrics and gynecology. The CHCs are established by upgrading the sub-district/taluka hospitals or
some of the block level Primary Health Centres (PHCs) or by creating a new centre wherever absolutely
needed.

PHC level – At present there is one Primary Health Centre covering about 30,000 (20,000 in hilly, desert and
difficult terrains) or more population. Many rural dispensaries have been upgraded to create these PHCs. Each
PHC has one medical officer, two health assistants – one male and one female, and the health workers and
supporting staff. For strengthening preventive and promotive aspects of healthcare, a post of Community
Health Officer (CHO) was proposed to be provided at each new PHC, but most states did not take it up.

Sub-centre level – The most peripheral health institutional facility is the sub-centre manned by one male and
one female multi-purpose health worker. At present, in most places there is one sub-centre for about 5,000
populations (3,000 in hilly and desert areas and in difficult terrain).

The 73rd and 74th constitutional amendments have given the powers to the local bodies in some states of India.
In the process, different states have adopted different stakeholders for the benefit of health services, with the
help of community participation, which gives stress on safe drinking water and sanitation at village level. The
Panchayats are given the power to look after the welfare of the people.

Community action

A considerable change has happened in the last two decades towards implementation of the government's
action plans through the institutions of civil society and NGOs. It is to be recognized that widespread debate on
various public health issues has, in fact, been initiated and sustained by NGOs and other members of the civil
society. Also, an increasing contribution is being made by such institutions in the delivery of different
components of public health services. Certain disease control programmes require close interaction with the
beneficiaries for regular administration of drugs, periodic carrying out of pathological tests, dissemination of
information regarding disease control, and other general health information.