SEMINAR ON

HEALTH CARE
DELIVERY
OF NATIONAL, STATE
AND
LOCAL LEVELS

Submitted to, Submitted By,

Dr. Vetriselvi, Archana. S

Assistant Professor M.Sc. Nursing II year
College of Nursing College of Nursing
JIPMER. JIPMER.
 HEALTH CARE DELIVERYOF NATIONAL, STATE AND LOCAL LEVELS

INTRODUCTION:
Health has been at the centre of human concern since ancient times. Civilisations developed and perished
due to wars, conflicts and raging diseases, which left none untouched, save those whose health was taken care of
by an organized system. Ancient civilisations that developed in Indus valley, Greece, Rome and Mesopotamia had
fairly advanced health systems for their times and the medical practitioners enjoyed a high status in the society due
to their practice.
Two renowned medical systems developed in India in ancient times; Ayurveda and Siddha, which were
quite similar in concept and practice. Indian systems sought knowledge by which life could be prolonged and
some of the popular medical treatises of those times were the Charaka Samhita and the Sushruta Samhita.
The practice of medicine has come a long way since the time of magic, religion and supernatural thoughts to a
modern science following evidence-based practice with a range of services extending from preventive, promotive,
curative to rehabilitative offered to the individual and community.

HISTORY OF HEALTH CARE SYSTEM

Early history
India is one of the ancient civilizations of the Indus valley. The excavations in the Indus valley especially
Harappa and Mohenjodaro showed planned cities with drainage, house and public baths built of baked bricks
suggesting the practice of environmental sanitation in 3000 B C. The art of Health Care in India can be traced back
nearly 3500 years, when India was invaded by Aryans, Ayurveda and siddha systems of medicine came into
existence.
The hospital system was developed during the rule of Emperor Ashoka (third century BCE), schools of
learning in the healing arts were created. Many valuable herbs and medicinal combinations were created. Even
today many of these continue to be used.
The Emperor Ashoka was the first leader in world history to attempt to give health care to all of his
citizens, thus it was the India of antiquity which was the first state to give its citizens national health care. There
were hospitals not only for people but also for animals.
During the eleventh century The Arabic system known as "Unani" was introduced in India by the Arabs
and Persians.
 Pre independence Era
The British had established their rule in India in 1757. A Royal Commission was appointed to investigate
the causes of the extremely unsatisfactory condition of health in the British army stationed in India. The
commission pointed out the need for the protection of water supplies, construction of drains and prevention of
epidemics in civil population for safeguarding the health of the British army.
An epidemic of plague in 1896 awakened the government to the urgent need of improving public health.
The All India Institute of Hygiene and Public Health, was established in Calcutta with aid from the Rockefeller
foundation. The Health survey and Development Committee (Bhore Committee) was appointed by the government
of India to survey the existing position in regard to health conditions and health organization in the country and to
make recommendations for the future development. In 1946 the Bhore committee recommended a short term and
long-term programme for the attainment of reasonable health services based on concept of modern health practice.

Post-independence Era
India became independent in 1947 with new concept of establishing a welfare state. The burden of
improving the health of people and widening the scope of health measures fell upon the center and states.
Government appointed various committees for health analysis in the country.
The Alma Ata deceleration of 1978 launched concept of "Health for All 2000 A.D." and introduced the
concept of primary health care. It was totally state's responsibility to provide primary health care to the people and
led to the formulation of the first National Health Policy.
In 1983, 1st National Health Policy was introduced. The major goals of the policy was to provide
universal, comprehensive primary health services and articulated the need to encourage private initiative in health
care service delivery.
1980-90 the period of Neoliberal economic and health sector reform that were aimed at increasing the
importance of the private sector and desire to utilize private sector resources for addressing public health goals,
and Liberalization of insurance sector to provide health financing system.
In the year of 2000, the national population policy (NPP) was announced to address the unmet need of
contraception, health care infrastructure, and health personnel, and to provide integrated delivery for basis
reproductive and child care services.
Near 20 years after the first health policy, the 2nd National Health Policy was introduced in 2002. The
NPH was set a new policy framework to achieve public health goals by the increasing access to the decentralized
public health system by establishing new infrastructure indifferent area and upgrading the infrastructure of existing
institutions.
Recently in 2005, The Government of India has launched the National Rural Health Mission with the goal
of improving the availability of and access to quality health care by people, especially for rural areas. NRHM
provide great strength to the rural health care delivery system.
Most recently in 2007, telemedicine and the medical tourism were introduced in the health care system of India.

At present:
India is a union of 29 states and 8 union territories under the constitution of India, the states are largely
independent in matters relating to the delivery of health care to the people
Each state, therefore, has developed its own system of health care delivery, independent of the central
government. The central responsibility consists of mainly policy, planning, guiding, assisting, evaluating and
coordinating the work of state health ministries so that health services cover every part of the country and no state
lags behind for want to these services.
The health care services organization in the country extends from the national level from the total
organization structure, can slice the structure of health care system at National, State, District, community, PHC
and subcenters.

ORGANIZATION AND ADMINISTRATION OF HEALTH SERVICES IN INDIA AT DIFFERENT

LEVELS.

India is a union of 28 states and 7 Union territories. Under the constitution states are largely independent
in matters relating to the delivery of health care to the people. Each State, therefore, as developed its own
system of health care delivery, independent of the Central Government.
Health system in India has 3 links

1. Central level.
2. State level
3. District level
 Synoptic view of the health system in India

National Level

States (28) an Union Territories (7)

District health organisation and basic

specialities hospital/districts

Community Health 1/80,000 – 1,20,000 Sub-district/Taluka

Centres hospital

PHC 1/30,000

Sub-centres 1/3,000 – 5,000

Village health 1/1,000

guide, trained dai

People in the
population

Health administration at the central level

The official organs of the health system at the national level consist of 3 units:
1. Union Ministry of Health and Family Welfare.
2. The Directorate General of Health Services.
3. The Central Council of Health and Family Welfare.
I. Union Ministry of Health and Family Welfare Organisation
The Union Ministry of Health and Family Welfare is headed by a Cabinet Minister, a Minister
of State, and a Deputy Health Minister. These are political appointment and have dual role to serve
political as well as administrative responsibilities for health.
Currently the union health ministry has the following departments:
1. Department of Health
2. Department of Family Welfare
3. Department of Indian System of Medicine and Homoeopathy
a. Department of Health
It is headed by a secretary to the Government of India as its executive head, assisted by
joint secretaries, deputy secretaries, and a large administrative staff.
Functions

Union list
1. International health relations and administration of port-quarantine
2. Administration of central health institutes such as All India Institute of Hygiene and
Public Health, Kolkata; National Institute for Control of Communicable Diseases, Delhi,
etc.
3. Promotion of research through research centres and other bodies.
4. Regulation and development of medical, nursing and other allied health professions.
5. Establishment and maintenance of drug standards.
6. Census, and collection and publication of other statistical data.
7. Immigration and emigration.
8. Regulation of labour in the working of mines and oil fields and

Concurrent list
The functions listed under the concurrent list are the responsibility of both the union and
state governments. The centre and states have simultaneous powers of legislation. They are as
follows:
1. Prevention of extension of communicable diseases from one unit to another.
2. Prevention of adulteration of food stuffs.
3. Control of drugs and poisons.
4. Vital statistics.
 5. Labour welfare.
6. Ports other than major.
7. Economic and social health planning
8. Population control and family planning.
b. Department of Family Welfare
It was created in 1966 within the Ministry of Health and Family Welfare. The secretary
to the Government of India in the Ministry of Health and Family Welfare is in overall charge of
the Department of Family Welfare. He is assisted by an additional secretary and commissioner,
and one joint secretary.
The following divisions are functioning in the department of family welfare.
1. Programme appraisal and special scheme
2. Technical operations: looks after all components of the technical programme viz.
Sterilization/IUD/Nirodh, post partum, maternal and child health, UPI, etc.
3. Maternal and child health
4. Evaluation and intelligence: helps in planning, monitoring and evaluating the programme
performance and coordinates demographic research.
5. Nirodh marketing supply/ distribution
Functions
a. To organize family welfare programme through family welfare centres.
b. To create an atmosphere of social acceptance of the programme and to support all voluntary
organizations interested in the programme.
c. To educate every individual to develop a conviction that a small family size is valuable and to
popularize appropriate and acceptable method of family planning
d. To disseminate the knowledge on the practice of family planning as widely as possible and to
provide service agencies nearest to the community.
 Ministry of Health and Family Welfare

Cabinet Minister

Minister of State

Deputy Ministers

Dept. of Health Dept. of Family WelfareDept. of Indian System of Medicine and Homoeopathy

Secretary
Secretary health
Secretary
Chief Director Joint Secretary
Additional Secretary (1) (3)
Director JS

Ayurveda & Sidha (ISM)

Joint Secretaries (9)

Director General of

Health Services

Addl. Director Generals (4)

c. The department of Indian system of medicine and homeopathy

It was established in March 1995 and had continued to make steady progress. Emphasis
was on implementation of the various schemes introduced such as education, standardization of
drugs, enhancement of availability of raw materials, research and development, information,
education and communication and involvement of ISM and Homeopathy in national health care.
Most of the functions of this ministry are implemented through an autonomous
organization called DGHS.
II. Directorate General of Health Services Organisation
The DGHS is the principal adviser to the Union Government in both medical and public
health matters. He is assisted by a team of deputies and a large administrative staff. The
Directorate comprises of three main units:
i. Medical care and hospitals
ii. Public health
iii. General administration
Functions
1. General functions: The general functions are surveys, planning, coordination,
programming and appraisal of all health matters in the country.
2. Specific functions
a. International health relations and quarantine:
b. Control of drug standards
c. Medical store depots
d. Postgraduate training
e. Medical education
f. Medical research
g. Central Government Health Scheme.
Family welfare services
h. National Health Programmes.
i. Central Health Education Bureau
j. Health intelligence.
k. National Medical Library

III. Central Council of Health

The Central Council of Health was set up by a Presidential Order on August 9, 1952,
under Article 263 of the Constitution of India for promoting coordinated and concerted action
between the centre and the states in the implementation of all the programmes and measures
pertaining to the health of the nation. The Union Health Minister is the chairman and the state
health ministers are the members.
Functions
1. To consider and recommend broad outlines of policy in regard to matters concerning
health in all its aspects such as the provision of remedial and preventive care,
environmental hygiene, nutrition, health education and the promotion of facilities for
training and research.
2. To make proposals for legislation in fields of activity related to medical and public health
matters and to lay down the pattern of development for the country as a whole.
3. To make recommendations to the Central Government regarding distribution of available
grants-in-aid for health purposes to the states and to review periodically the work
accomplished in different areas through the utilisation of these grants-in-aid.
4. To establish any organisation or organisations invested with appropriate functions for
promoting and maintaining cooperation between the Central and State Health
administrations.

AT THE STATE LEVEL

Historically, the first milestone in the state health administration was the year 1919,
when the states (provinces) obtained autonomy, under the Montague-Chelmsford reforms, from
the central Government in matters of public health. By 1921-22, all the states had created some
form of public health organisation. The Government of India Act, 1935 gave further autonomy to
the states. The state is the ultimate authority responsible for health services operating within its
jurisdiction.
State health administration
At present there are 31 states in India, with each state having its own health
administration. In all the states, the management sector comprises the state ministry of Health
and a Directorate of Health.
1. State Ministry of Health
The State Ministry of Health is headed by a Minister of Health and FW and a Deputy
Minister of Health and FW. In some states, the Health Minister is also in charge of other
portfolios. The Health secretariat is the official organ of the State Ministry of Health and is
headed by a Secretary who is assisted by Deputy Secretaries, and a large administrative staff.
 Organisational structure of the health and family welfare services at state level

Minister in charge of health and family welfare portfolio in the state

Secretary or commissioner, Department of Health and Family Welfare

Director
Director FW Services Director Director
Health Services
Medical education ISM and
dditional/deputy joint directors of health services dealing with one or more programmes
Principal/Deans of medical colleges

Divisional set up in some states

Assistant Directors health services dealing with one or
more programmes
District health
organisation

Taluk Health
organisation

Block level health

organisation

Functions: Health services provided at the state level

 Rural health services through minimum needs programme
 Medical development programme
 M.C.H., family welfare & immunization programme
 NMIP (malaria) & NFCP (filarial)
 NLEP, NTCP, NPCB, prevention and control of communicable diseases like
diarrheal disease, KFD, JE,
 School health programme, nutrition programme, and national goitre control
programme
 Laboratory services and vaccine production units
  Health education and training programme, curative services, national Aids control
programme
2. State Health Directorate
The Director of Health Services is the chief technical adviser to the state Government on
all matters relating to medicine and public health. He is also responsible for the organization and
direction of all health activities. The Director of Health and Family Welfare is assisted by a
suitable number of deputies and assistants. The Deputy and Assistant Directors of Health may be
of two types –
Regional
Functional.
The regional directors inspect all the branches of public health within their jurisdiction,
irrespective of their specialty. The functional directors are usually specialists in a particular
branch of public health such as mother and child health, family planning, nutrition, tuberculosis,
leprosy, health education, etc.
AT THE DISTRICT LEVEL
The district is the most crucial level in the administration and implementation of medical
/health services. At the district level there is a district medical and health officer or CMO who is
overall Subdivisions
i. Tehsils (talukas)
ii. Community development blocks
iii. Municipalities and corporations
iv. Villages
v. Panchayaths
Most of the districts in India are divided into two or more subdivisions, each in charge of an
assistant collector or sub-collector. Each division is again divided into tehsils in charge of a
Tehsildar. A tehsil usually comprises between 200 and 600 villages.
Finally, there are the village panchayaths, which are institutions of rural local self- government.
The urban areas of the district are organised into the following local self-government:
 Town area committee – 5,000 – 10,000
 Municipal boards – 10,000 – 2,00,000
 Corporations – population above 2,00,000.
The towns‟ area committees are like panchayaths. They provide sanitary services.
 The municipal boards are headed by a chairman/president, elected usually by the members.
Corporations are headed by mayors. The councilors are elected from different wards of the city.
The executive agency includes the commissioner, the secretary, the engineer, and the health officer.
The activities are similar to those of the municipalities but on a much wider scale.
Primary Healthcare Infrastructure of District Level

T.B.A.
Covers T.B.A. VHG VHG T.B.A. VHG
1,000
population

T.B.A. Sub- Centre T.B.A.

VHG VHG
Covers
5,000
population
Covers Sub- Sub- Centre
30,000 Centre
population Primary Health Centre
Sub- Centre

Sub- Centre Sub- Centre

PHC
Covers 1,00,000 population
Community Health Centre
PHC PHC

District Health and

Zilla
CEO Family Welfare
parishad
PANCHAYATHI RAJ
The panchayath Raj is a 3-tier structure of rural local self-government in India linking the villages
to the district. The three institutions are:
a. Panchayath – at the village level.
b. Panchayath samithi – at the block level.
c. Zilla parishad – at the district level.
The panchayathi Raj institutions are accepted as agencies of public welfare. All development
programmes are channelled through these bodies. The panchayathi Raj institutions strengthen
democracy at its root and ensure more effective and better participation of the people in the
government.
A. At the village level
The panchayathi Raj at the village level consists of:
1. The gram sabha
2. The gram panchayath
3. The nyaya panchayath
B. At the block level
The panchayathi raj agency at the block level is the panchayath samithi. The panchayathi
samithi consists of all sarpanchs of the village panchayaths in the block. The block development
officer is the ex-officio secretary of the panchayath samithi.
The prime function of the panchayat samiti is the execution of the community
development programme in the block.
The block development officer and his staff give technical assistance and guidance to the
village panchayaths engaged in the development work.
C. At the district level
The zilla parishad is the agency of rural local self-government at the district level. The
members of the zilla parishad include all leaders of the panchayath samithis in the district, MPs,
MLAs of the district, representatives of SC, SD and women, and 2 persons of experience in
administration. The collector of the district is a non-voting member. Thus, the membership of the
zilla parishad is fairly large varying from 40 to 70.
The zilla parishad is primarily supervisory and coordinating body. Its functions and
powers vary from state to state. In some states, the zilla parishads are vested with the
administrative functions.
 Direct election @ 1:40,000
(except Uttara Kannada, Coorg
District Zilla Panchayat and Chickmagalore where it is
Level (ZP) 1:30,000). 20 months‘ term for
Adhyakshas and Upadhyakshas
and 5 standing committees.

Direct election @ 1:10,000.

Voting rights to MPs, MLAs,
Taluka Taluka Panchayat
MLCs. One year membership to
Level (TP)
1/5 of Gram Panchayat
Adhyakshas and 5 standing

Village Direct election @ 1:4,000. Ban on

Gram Panchayat
Level political parties. 5 years term.3
(GP)
standing committees.

Minimum of two meetings per

annum, under the chairmanship of
Gram GP Adhyaksha, for approval of
Sabha Budget/accounts, review of
development programme
THEORY APPLICATION:

IMOGENE KING: THEORY OF GOAL ATTAINMENT

The Theory of Goal Attainment was developed by Imogene King in the early 1960s. It describes a
dynamic, interpersonal relationship in which a patient grows and develops to attain certain life goals. The theory
explains that factors which can affect the attainment of goals are roles, stress, space, and time.
The model has three interacting systems: personal, interpersonal, and social. Each of these systems has its
own set of concepts. The concepts for the personal system are perception, self, growth and development, body
image, space, and time. The concepts for the interpersonal system are interaction, communication, transaction,
role, and stress. The concepts for the social system are organization, authority, power, status, and decision-making.

The following propositions are made in the Theory of Goal Attainment:

 If perceptual interaction accuracy is present in nurse-patient interactions, transaction will occur.

 If the nurse and patient make transaction, the goal or goals will be achieved.
 If the goal or goals are achieved, satisfaction will occur.
 If transactions are made in nurse-patient interactions, growth and development will be enhanced.
 If role expectations and role performance as perceived by the nurse and patient are congruent, transaction
will occur.
 If role conflict is experienced by either the nurse or the patient (or both), stress in the nurse-patient
interaction will occur.
 If a nurse with special knowledge communicates appropriate information to the patient, mutual goal-setting
and goal achievement will occur.

There are also assumptions made in the model. They are:

 The focus of nursing is the care of the human being (patient).

 The goal of nursing is the health care of both individuals and groups.
 Human beings are open systems interacting with their environments constantly.
 The nurse and patient communicate information, set goals mutually, and then act to achieve those goals.
This is also the basic assumption of the nursing process.
 Patients perceive the world as a complete person making transactions with individuals and things in the
environment.
  Transaction represents a life situation in which the perceiver and the thing being perceived are
encountered. It also represents a life situation in which a person enters the situation as an active participant.
Each is changed in the process of these experiences.

According to King, a human being refers to a social being who is rational and sentient. He or she has the
ability to perceive, think, feel, choose, set goals, select means to achieve goals, and make decisions. He or she has
three fundamental needs: the need for health information when it is needed and can be used; the need for care that
seeks to prevent illness; and the need for care when he or she is unable to help him or herself.

Health involves dynamic life experiences of a human being, which implies continuous adjustment to
stressors in the internal and external environment through optimum use of resources to achieve maximum potential
for daily living. Environment is the background for human interaction. It involves the internal and external
environments. The internal environment transforms energy to enable a person to adjust to continuous external
environment changes. The external environment involves formal and informal organizations. In this model, the
nurse is part of the patient’s environment.
JOURNAL REFERENCE:

Health systems in India

Author-
M Chokshi, B Patil, R Khanna, S B Neogi, J Sharma, V K Paul and S Zodpey
Journal-
Journal of Perinatology.
Abstract
Health systems and polices have a critical role in determining the manner in which health services are
delivered, utilized and affect health outcomes. ‘Health' being a state subject, despite the issuance of the guidelines
by the central government, the final prerogative on implementation of the initiatives on newborn care lies with the
states. This article briefly describes the public health structure in the country and traces the evolution of the major
health programs and initiatives with a particular focus on newborn health.
CONCLUSION:
The structure of health care service and health care delivery system as provided by the government sector is
impressive. There is continuous striving to attain an adequate delivery system for promotion of HFA goals and
achieve these. The strengthened health care and its adequate delivery surely ensure the progress and prosperity of a
country. The health which is important needs to be delivered at the doorstep of the people and made available to
them by all means to prevent illness, cure it, promote health and rehabilitate the patient as and when required.

BIBLIOGRAPHY:
1. Park. K. Textbook of Preventive and Social Medicine. Bhanot publication. 24th ed., pg no. 674 to 699
2. Bhalwar R. Textbook of Public Health and Community Medicine. 1st ed., Pune: Dept of Community
Medicine, AFMC, 2009.
3. Basavanthappa. B. T. Nursing Administration (2007), Jaypee brothers Publication. New Delhi: 2011
4. Jaiwanti P. TNAI. Nursing Administartion and Management. Dhalta Publication: 2009.
5. Chokshi M, Patil B, Khanna R, Neogi S B, Sharma J, Paul V K and Zodpey S. Health care system in India . J
Perinatol. 2016 Dec;36(s3):S9-S12. doi: 10.1038/jp.2016.184.