Village Level – one of the basic tenets of primary health care is universal coverage and equitable

distribution of health resources i.e. health care must penetrate into the farthest reaches of rural
areas and everyone should have access to them. The roles and responsibilities of following health
workers to implement this policy are as follows:

a. Village Health Guide

b. Local Dais/ TBA (Trained Birth Attendant)
c. Anganwadi Worker
d. ASHA (Accredited Social Health Activist)

a. Village Health Guide

 The Village Health Guides Scheme was introduced in 1977 with the idea of securing
people’s participation in the care of their own health.
 The Village Health Guide serves as link between the community and the government
infrastructure.
 They provide the first contact between the individual and the health system.
 The guidelines for the selection of Village Health Guide:
1. They should be permanent residents of the local community, preferably women
2. They should be able to read and write, having minimum formal education at least up to
the VI standard
3. They should be acceptable to all sections of the community
4. They should be able to spare at least 2 to 3 hours every day for community health work
 After selection, the Health Guides undergo a short training of 3 months in primary health
care.
 The duties assigned to health guides include treatment of simple ailments and activities in
first aid, maternal and child health including family planning, health education and
sanitation.
 The national target is to achieve one Health Guide for each village or 1000 rural population.

b. Local Dais

 The World Health Organization defined a Trained Birth Attendant (TBA) as ‘a person who
assists the mother during childbirth and who initially acquired her skills by delivering babies
herself or by working with other TBAs’.
 An extensive programme has been undertaken, under the Rural Health Scheme, to train all
categories of Local Dais/ Traditional Birth Attendants for 30 working days in the country to
improve their knowledge in the elementary concepts of maternal and child health and
sterilization, besides obstetric skills.
 Training is given at PHC/ Sub Centre or MCH centre for 2 days in a week and on the
remaining four days they accompany the health workers to the villages preferably in the dai’s
own area.
 The objectives for the dai training:
a. to decrease maternal and neonatal mortality and morbidity
b. to encourage institutional deliveries
c. to ensure safe delivery for those unwilling or unable to go to health institutions
d. to identify danger signs and promptly refer to a higher health center when necessary
 During the training period, each dai is required to conduct at least 2 deliveries under the
guidance and supervision of the health workers.
 After successful completion of training, each dai is provided with a delivery kit and a
certificate.
 The national target is to train one local dai in each village.
 The services rendered by Local Dai include antenatal care (Registration of pregnant women
at Sub-Centre/PHC, compulsory 3 antenatal check up at pre natal clinic, immunization
against tetanus, administration of folic acid, iron and calcium tablets, report any abnormal
pregnancy), intra natal care, post natal care (reporting of complications, immunization of
infant, supplementary nutrition, health education, promotion of family planning methods),
registration of demographic variables (100% registration of births, deaths, marriages and
pregnancies) and referral services.

c. Anganwadi Worker
 Under the Integrated Child Development Scheme (ICDS), there is an Anganwadi worker for
a population of 1000.
 The Anganwadi worker is selected from the community she is expected to serve.
 The Anganwadi worker undergoes training in various aspects of health, nutrition and child
development for 4 months.
 The services rendered by Anganwadi worker include maintenance of growth chart,
immunization, supplementary nutrition, health education, non-formal preschool education
and referral services.
 The beneficiaries are especially nursing mothers, pregnant women, other women (15-45
years), children below the age of 6 years and adolescent girls.

d. ASHA (Accredited Social Health Activist)

 The main aim of National Rural Health Mission is to provide accessible, affordable,
accountable, effective and reliable primary health care and bridging the gap in rural health
care through creation of a cadre of Accredited Social Health Activist (ASHA).
 The guidelines for the selection of ASHA:
1) must be resident of the village
2) a woman (married/ widow/ divorced) preferably in the age group of 25 to 45 years with
formal education upto 8th standard, having communication skills and leadership
qualities.
 The general norm of selection will be one ASHA for 1000 population.
Responsibilities of ASHA Worker – The ASHA will be a health activist in the community who
will create awareness on health.

Create awareness and provide information to the community on determinants of health

Counsel women on birth preparedness, importance of safe delivery, breast feeding &
complementary feeding , contraception & prevention of sexually transmitted diseases/
reproductive tract diseases and care of the young child

Mobilize the community in accessing health and health related services available at
anganwadi/ sub centre/ PHC

Work with the village health and sanitation committee of the gram panchayat to
develop a comprehensive village health plan
Accompany preganat women and children requiring treatment/ admission to the nearest
pre-identified health facility

Provide primary medical care for minor ailments

Provider of DOTS under Revised National Tuberculosis Control Programme

Act as a depot holder for essential provisions being made available to every habitat like
folic acid tablet, oral rehydration therapy etc.
Inform about the births and deaths and any unusual health problems/ disease outbreaks
in the community to the sub centre/ PHC

Promote construction of household toilets under total sanitation campaign

ORGANIZATION OF SC, PHC, CHC AND DISTRICT HOSPITAL

SUB CENTRE LEVEL
 The Sub-Centre is the peripheral outpost of the existing health delivery system in rural areas.
 Most peripheral and first contact point between the primary health care system and the
community.
 Manned by at least one ANM / Female Health Worker and one Male Health Worker known
as Multi Purpose Worker.
 Provide services in relation to maternal and child health, family welfare, nutrition,
immunization and control of communicable diseases.
 Ministry of Health & Family Welfare are providing 100% Central assistance to all the Sub-
Centre’s.

TYPES OF SUB-CENTRES
Type A Sub-Centre will provide all recommended services except that the facilities for
conducting delivery will not be available. Sub-Centres located in remote, difficult, hilly, desert
or tribal area in such situations, ANMs would be required to conduct deliveries at homes and
ANMs of these Sub-centres should mandatorily be Skilled Birth Attendance (SBA)-trained.
However, the ANMs have been trained in midwifery; they may conduct normal delivery in case
of need.

Type B Sub-centre (MCH) - They have good physical infrastructure preferably with own
buildings, adequate space, residential accommodation and labor room facilities. Centrally or
better located Sub-centres with good connectivity to catchment areas. There are no nearby higher
level delivery facilities. They already have good case load of deliveries from the catchment
areas.

Centre Plain Area Hilly / Tribal / Difficult Area

Community Health Centre 1,20,000 80,000

Primary Health Centre 30,000 20,000

Sub-Centre 5,000 3,000

 According to Indian Public Health Standards for Sub-Centres, the following services are
being prescribed to provide basic promotive, preventive and few curative primary health care
services to the community and achieve an acceptable standard of quality of care:
 Maternal Health Care
Child Health Care
Family Planning and Contraception
Counseling and appropriate referral for Safe Abortion Service
Adolescent Health Care
Assistance to School Health Services
Water Quality Monitroing
Promotion of sanitation including use of toilet and appropriate garbage disposal
Field visits by appropriate health workers for disease surveillance & family welfare
services
Community need assessment
Curative services for minor ailments
Training of traditional birth attendants and ASHA/ community health volunteers
Co-ordinate services of anganwadi workers, ASHA, village health and sanitation
committee etc.
National Health Programmes

PRIMARY HEALTH CARE

 Primary Health Care (PHC) refers to "essential health care" that is based on "scientifically
sound and socially acceptable methods and technology, which make universal health
care accessible to all individuals and families in a community.
 The National Health Policy 2002 accords primacy to preventive and first line curative
initiatives at the primary health level (Government of India, 2002).
 The approach during the Ninth Five Year Plan (1999-2002) was to improve access to and
enhance the quality of Primary Health Care in urban and rural areas by providing an
optimally functioning primary health care system as a part of Basic Minimum Services
(Government of India, 1999).
 The Community Application of Primary Health Care involves the basic requirements as well
as the principles of primary health care for effective implementation of health care system.
 The BASIC REQUIREMENTS for Sound Primary Health Care (the 8 A’s and the 3 C’s) –
 Appropriateness Availability Adequacy Accessibility

Acceptability Affordability Assessbility Accountability

Completeness Comprehensiveness Continuity

PRINCIPLES OF PRIMARY HEALTH CARE

EQUITABLE DISTRIBUTION

APPROPRIATE TECHNOLOGY

COMMUNITY PARTICIPATION

INTERSECTORAL COORDINATION

 Equitable Distribution - first key principle in the primary health care strategy.
 Refers to Equity or Equitable distribution of health services i.e. health services must be
shared equally by all people without any discrimination.
 All must have access to health services.
 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 and country can afford".
 Community Participation – refers to continuing efforts to secure meaningful involvement
of the community in the planning, implementation and maintenance of health services.
 "Health Guides" and “Trained Dais” are an essential feature of primary health care in India.
 Intersectoral Coordination - The Declaration of Alma-Ata states that "primary health
care involves in addition to the health sector, all related sectors and aspects of national
and community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communication and others sectors".

PRIMARY HEALTH CENTRE LEVEL

 Primary Health Care – The Alma-Ata Conference defined “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 the country can afford”.
 ELEMENTS OF PRIMARY HEALTH CARE

Health Education
Nutrition
Water and Sanitation
Maternal and Child Health
Immunization
Prevention of Endemic Diseases
Treatment
Drug Availability

PRINCIPLES OF PRIMARY HEALTH CARE

Equitable Community Appropriate Focus on Mutlisectoral

Distribution Participation Technology Prevention Coordination

 The Bhore Committee in 1946 gave the concept of primary health centre as a basic health
unit, to provide an integrated curative and preventive health care to the rural population with
emphasis on preventive and promotive aspects of health care.
 The National Health Plan (1983) proposed reorganization of primary health centres on the
basis of one PHC for every 30,0000 rural population in the plains, and one PHC for every
20,000 population in hilly, tribal and backward areas for more effective coverage.
 First contact point between village community and the Medical Officer.
 Established and maintained by the State Governments under the Minimum Need Programme.
 Manned by 3 Medical Officers, 1 AYUSH practitioner supported by 20 paramedical and
other staff.
 It acts as a referral unit for 6 Sub Centre’s and has 4 – 6 Beds for patients.

According to Indian Public Health Standards for PHCs, the objectives for PHCs are:
i. To provide comprehensive primary health care to the community through the Primary
Health Centres.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of the community.
According to Indian Public Health Standards for Public Health Centres, the following services
are being prescribed to provide basic promotive, preventive and curative primary health care
services to the community and achieve an acceptable standard of quality of care:

Medical Care
Maternal and Child Health Care
Family Planning and Contraception
Counseling and appropriate referral for Safe Abortion Service
Adolescent Health Care
Assistance to School Health Services
Water Quality Monitroing
Promotion of sanitation including use of toilet and appropriate garbage disposal
Field visits by appropriate health workers for disease surveillance & family welfare
services
Community need assessment
Curative services for minor ailments
Training of traditional birth attendants and ASHA/ community health volunteers
Co-ordinate services of anganwadi workers, ASHA, village health and sanitation
committee etc.
National Health Programmes
Collection and reporting of vital events
Basic Laboratory Services
Monitoring and Supervision
Selected Surgical Procedures
Mainstreaming of AYUSH

COMMUNITY HEALTH CENTRE LEVEL

 Established and maintained by the State Government under Minimum Need Programme.
 Each CHC covers a population of 80,000 to 1.20 lakh.
 As per minimum norms, a CHC is required to be manned by four Medical Specialists i.e.
Surgeon, Physician, Obstetrician & Gynecologist, Pediatrician, Anaesthetist, Public Health
Manager, Eye Surgeon, Dental Surgeon, Medical Officers (General Duty), AYUSH
Specialist and Medical Officer (AYUSH) supported by 64 paramedical and other staff.
 It has 30 in-door beds with one OT, X-ray, Labor Room and Laboratory facilities.
 It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and
specialist consultations.
 According to Indian Public Health Standards for CHCs, the following services are being
prescribed to provide optimal expert care to the community and achieve an acceptable
standard of quality of care:

Care of routine and emergency cases in surgery

Care of routine and emergency cases in medicine
24-hour delivery services including normal and assisted deliveries
Essential and emergency obstetric care
Full range of family planning services
Safe abortion service
Newborn care
Routine and emergency care of sick children
Other management including nasal packing, tracheostomy etc.
National health programmes
Blood storage facility
Essential laboratory services
Referral (transport) services

HOSPITAL
 The World Health Organization (WHO) defines Hospital as: “A hospital is an integral part of
social and medical organization, the function of which is to provide complete healthcare for
the population, both curative and preventive and whose out-patient services reach out to the
family and its home environment. The hospital is also a centre for training of health workers
and for bio-social research”.

DISTRICT HOSPITAL LEVEL

 District Health System is the fundamental basis for implementing various health policies,
delivery of healthcare and management of health services for defined geographic area.
District hospital is an essential component of the district health system and functions as a
secondary level of health care which provides curative, preventive and promotive healthcare
services to the people in the district.
 District Hospital is a hospital at the secondary referral level responsible for a district of a
defined geographical area containing a defined population.
OBJECTIVES OF INDIAN PUBLIC HEALTH STANDARDS (IPHS) FOR DISTRICT
HOSPITALS
 The overall objective of IPHS is to provide health care that is quality oriented and sensitive
to the needs of the people of the district.
 The specific objectives of IPHS for District Hospitals are:
i. To provide comprehensive secondary health care (specialist and referral services) to the
community through the District Hospital.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of the people of the
district and the hospitals/centres from where the cases are referred to the district hospitals

SERVICES DELIVERY
 District Hospital should be in a position to provide all basic speciality services and should
aim to develop super-specialty services gradually.
 District Hospital also needs to be ready for epidemic and disaster management all the times.
In addition, it should provide facilities for skill based trainings for different levels of health
care workers.
 Services that a District Hospital is expected to provide have been grouped as Essential
(Minimum Assured Services) and Desirable (which we should aspire to achieve). The
services include OPD, indoor and Emergency Service.
 Besides the basic specialty Services, due importance has been given to Newborn Care,
Psychiatric services, Physical Medicine and Rehabilitation services, Accident and Trauma
Services, Dialysis services and Anti-retroviral therapy.
 It is desirable that Super-specialties and related diagnostic facilities be made available, in
more than 300 bedded hospitals. Every district hospital should provide facilities of Special
Newborn Care Units (SNCU) with specially trained staff.
 Provisions for Patient Safety, infection control and Health Care workers Safety have been
added.
 It is desirable that every District Hospital should have a Post Partum Unit with dedicated
staff to provide Post natal services, all Family Planning Services, Safe Abortion services and
immunization in an integrated manner.
TEACHING HOSPITAL LEVEL

 A teaching hospital is a hospital that provides clinical education and training to future and
current physicians, nurses and other health professionals, in addition to delivering medical
care to patients.

FUNCTIONS OF TEACHING HOSPITAL

 Investigation, Diagnosis and Care of the Sick and Injured - In modern times, the chief
functions of the hospital; conduct the investigations, for diagnosis, and provide care to the
sick and injured. According to the condition of the patient, they are examined or the
necessary investigations are done of the outpatient or inpatient. According to the type of
disease, he may be admitted in a medical or surgical ward or in any special ward and
according to the income and preference of the patient, he may select a general ward or pay
 ward. Several other departments such as clinical laboratory, kitchen, X-Ray, pharmacy,
operation room, etc. work under the control of the administration for a common goal, the care
of the sick.
 Health Supervision and Prevention of Disease - The prevention aspect of medical work has
been given so much emphasis in all aspects of medical practice, that, hospitals and health
centers are involved in health supervision and preventive therapy. Modern hospitals extend
their services to the community by arranging camps and clinics such as eye camps, detection
of cancer, diabetic clinics, immunization camps, family welfare programme camps, etc. by
specialized doctors and other health supervisors for the health supervision and prevention of
diseases in the community.
 Education of Medical Workers - Doctors, nurses, dieticians, social workers, physical
therapists, technicians, hospital administrators and other medical and paramedical people are
taught the theoretical part of their learning which is conducted in an affiliated institution and
they practice their knowledge in the actual situation of the hospital.
 Medical Research - The modern trend is to establish a close association between the small
rural hospitals, research centers and between all hospitals and other community health
organizations in order that their personnel may have provision for an adequate research and
diagnostic and therapeutic facilities. The statistical side of the research works in the hospital
help to evaluate the occurrence and prevalence of particular disease in locality or society and
the health status of a country.
 Rehabilitation - The rehabilitation in the hospital is a facility to provide additional
help to recover from an injury for stabilized patients who still need inpatient hospital care.
They might require physical, occupational or speech therapy as their injuries improve, and
they might need social work assistance to determine how to live life once they are
discharged.

AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES

Ayushman Bharat (AB) is an attempt to move from a selective approach to health care to deliver
comprehensive range of services spanning preventive, promotive, curative, rehabilitative and
palliative care. It has two components which are complementary to each other. Under its first
component, 1,50,000 Health & Wellness Centres (HWCs) will be created to deliver
Comprehensive Primary Health Care, that is universal and free to users, with a focus on wellness
and the delivery of an expanded range of services closer to the community. The second
component is the Pradhan Mantri Jan Arogya Yojana (PM-JAY) which provides health insurance
cover of Rs. 5 lakhs per year to over 10 crore poor and vulnerable families for seeking secondary
and tertiary care.

HWC are envisaged to deliver expanded range services that go beyond Maternal and child health
care services to include care for non -communicable diseases, palliative and rehabilitative care,
Oral, Eye and ENT care, mental health and first level care for emergencies and trauma, including
free essential drugs and diagnostic services.
EXPANDED RANGE OF SERVICES
The expansion of services has been planned in incremental manner. As a first step, Screening,
Prevention, Control and Management of Non-communicable Diseases and Chronic
Communicable diseases like Tuberculosis and Leprosy has been introduced at HWCs.

1. Care in pregnancy and childbirth.

2. Neonatal and infant health care services
3. Childhood and adolescent health care services.
4. Family planning, Contraceptive services and Other Reproductive Health Care services
5. Management of Communicable diseases: National Health Programs
6. Management of Common Communicable Diseases and General Out-patient care for acute
simple illnesses and minor ailments
7. Screening, Prevention, Control and Management of Non-Communicable diseases and chronic
communicable disease like TB and Leprosy
8. Basic Oral health care
9. Care for Common Ophthalmic and ENT problems
10. Elderly and Palliative health care services
11. Emergency Medical Services
12. Screening and Basic management of Mental health ailment