‘SAAII COLLEGE OF NURSING KANPUR

SUBJECT:- ADVANCE NURSING PRACTICE

TOPIC:- “NURSING AS A PROFESSION”

SUBMITTED TO SUBMITTED B

SUBMITTED ON

CHAPTER

Health Care Environment

DEFINITION OF HEALTH

According to WHO, ("Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity!" )

The health of an individual as an integrated system within the context of the environment is
termeds as holistic health.

BASIC CONCEPTS

1. Community health: Community health refers to the health status of the members of
community, to the problems affecting

their health and to the totality of health care provided to the community.

2. Health care: The term “health care" is more than medical care. It includes not only the
traditional public health services but also medical, nursing and dental services provided to
individuals or communities for the purpose of promoting, maintaining, monitoring or restoring
health, and the related education and research.

3. Health service: Also known as health infrastructure, the term health service refers to the
permanent countrywide system of established institutions (for example, hospitals, health
centers and subcenters, health laboratories, training and research institutions, etc.), the
objective of which is to copeup with the various health needs and demands of the population
and thereby provideing health care to individuals and the community.

4. Health care revolution: Health care is now regarded as a public right and an important
responsibility of governments to provide this care to all people irrespective of race, religion,
caste, creed, urban or rural, rich or poor.

Environmental Health

Environmental health refers to the state of all substances, forces and conditions in an
individual's surroundings that may exert an influence on health and well-being.

When environmental conditions are favorable, health status is enhanced. However adverse
biological, chemical, physical and sociological forces in the environment, separately or in
combination, may disrupt healthy lifestyle and impede a person's ability to cope with
environmental stimuli.

FLORENCE NIGHTINGALE'S ENVIRONMENTAL THEORY OF NURSING

The core concept that is most reflective of Nightingale's writings is that of environment.
Although she tends to emphasize the physical more than the psychological or social
environment, this needs to be viewed in the context of her time and her activities as a nurse
leader in a war-torn environment.
The environment is viewed as all the external conditions and influences affecting the life and
development of an organism and capable of preventing, suppressing or contributing to
disease or death. Nightingale's writing speaks of providing such things as ventilation, clean
air and water, cleanliness and warmth, so the reparative process that nature has instituted
will not be

hindered.

Medical practice is not viewed as a curative process but as having the function of assisting
nature. nursing is also a noncurative practice in which the patient is put in the best condition
for nature to act. This condition was seen by her as enhanced by providing an environment
conducive to health promotion,

At this point, it is helpful to think of a patient who has had surgery and to relate what
Nightingale proposes . Medicine is as functioning to remove the diseased part , whereas
nursing places the patient in an environment in which nature can postoperative patient to
reach his optimal health condition.

NIGHTINGALE'S ENVIRONMENTAL CONCEPTS

Textbook of Nursing Practice

Major areas of concentration 1. Ventilation Examples Fresh air, which is of primary

importance, can be achieved through open windows. 1. Ventilation GY 2. Light 3. Warmth 4.
Effluvia (smells) be avoided. Second only to the need for fresh air is the value of light. Beds
should be placed in such a position as to allow the patient to see out the window - the sky
and sunlight. Guarding against the loss of vital heat is essential to the patient's recovery.
Chilling is to be avoided. Hot bottles and drinks should be used to restore lost heat. Sewer
air is to be avoided and care is needed to get rid of noxious body odor caused by disease.
Fumigations and disinfectants should not be used but the oftensive substance removed.
Intermittent sudden noise causes greater excitement than continuous noise, especially
during patient's first sleep. Whispering, or discussing a patient's condition just outside his or
her room is cruel. 5. Noise

To Nightingale, the environment of the patient was quite encompassing. Although she did
not specifically distinguish among the physical, social or psychological environments as
such, she speaks of all three in the practice of nursing.

VIEW OF THE THEORY CREATED BY NIGHTINGALE

The key point is diagrammed in the center of the triangle patient condition and nature . Here
the thrust of environment is on the patient and nature functioning together to allow the
reparative process to occur. The three components-physical, social and psychological –
need to be viewed as interrelating rather than a separate distinct part.

Physical Ecrinament Cleanliness Ventilation Air Light Noise Patient condition and nature
Communication advice Mortality data Psychological Environment Social environment
Fig, 9.1: Three Interrelated components

Physical Environment

The basic patient

environmental components are physical in nature and relate to such things as ventilation and
warmth. These basic factors affect one's approach to all other aspects of the environment. A
patient's bed must be clean, airedwarmeidey and free from odor . One should provide an
environment in which can be easily cared for by others or self. The entire room should be
well-ventilated.

Health Care Delivery System

seen assist
Psychological Environment

The effect of mind on the body was fairly well-accepted in Nightingale's time. Nightingale
recognized that a negative environment could cause physical stress thereby affecting the
patient's emotional climate. Therefore emphasis is placed on offering the patient a variety of
activities to keep his or her mind stimulated.

Communication

Communication with the patient is viewed in the context of the total environment.
Communication should not be hurried. When speaking with patients, it is important to sit
down in front of them. The place one communicates with the physician and family about the
patient is in the context of environment of the patient.

Advice

One should not encourage the sick by false hopes and advice about their illness. Rather the
emphasis here is on communicating about the world around them that they miss or about
good news that visitors can share. Again, patients are viewed in the context of their total
environment.

Social Environment

Observation of the social environment, especially as related to specific data collections

relating to illness, is essential to preventing disease. Thus, each nurse must use
observational powers in dealing with specific cases rather than be comfortable with data
addressing the average' patient. The patient's total environment not only includes the
patient's home or hospital room but the total community influencing that specific
environment.

ENVIRONMENTAL HEALTH HAZARDS

The environmental health hazards fall into four general categories: 1. Biological 2. Physical

3. Chemical 4. Psychosocial

Biological

Disease producing infectious agents in the environment that are capable of entering the
human body such as viruses, bacteria or other microorganisms are environmental hazards
of biological nature. Transmission by direct contact, contaminated water, vectors (rodents
and arthropods such as flies, mosquitoes, fleas, ticks, mites).

Chemical

These include toxic agents such as polychlorinated biphenyls (PCBs), asbestos, lead and
pesticides such as insecticides (DDT, hydrocarbons), herbicides and rodenticides, industrial
waste, emissions, from motor vehicles. Results of experimental studies with animals indicate
that these chemicals cause severe chronic health problems, thus posing a serious threat to
human health.

Physical

noise, heat, vibration, radiations, insects, rodents and certain type of equipment fall into the
category of adversely affected in industries that use blast furnaces, laundry equipment

Natural disasters such as earthquakes, volcanoes and accidents , physical hazards.

For example, air temperature and humidity may be contributing to health problems such as
respiratory disorders, dermatitis, GI disturbances and eye inflammation.

Psychosocial

Many of the stressors—violence, stress, substance abuse and dependence are known threat
to health of individuals, families and communities. Additionally, feelings of well-being may be
altered by factors such as high level of noise, overcrowding or isolation, lack of adequate
sources or opportunities for economic
ENVIRONMENTAL INFLUENCES ON HEALTH Toxic Agents It has been linked to diseases
such as lung and GI cancer and mesothelioma. Lead

Air Pollution

Lead biologically interferes with blood formation often resulting in anemia. It can also cause
kidney damage, birth defects, injury to the CNS, poor memory, hair loss, laypertension,
mental retardation, convulsions, coma and death.

Pesticides

Pesticide residues are contact poisons and tend to accumulate in fatty tissues in living
organisms and remain in the body indefinitely.
The effects of air pollution on the health of individuals depend on the chemical properties of
the pollutant and size of particle, which, in turn, affects the site of deposition in the
respiratory tract, adverse health effects from air pollution may range from mild to severe. For
example, mild irritation of respiratory tract can occur when larger particles are entrapped in
the upper respiratory tree. On the other hand, severe respiratory problems and even
asphyxiation may occur as a result of direct absorption of a pollutant such as carbon
monoxide, from the alveoli into the blood. The risk of developing cancer or a chronic
pulmonary disease increases with prolonged exposure to air pollutants.

Water Pollution

The most pressing health problems related to water quality involve contamination of
waterways with the microbial pathogens found in human body wastes, a problem directly
related to lack of or faulty sewage disposal facilities. Swimming facilities such as swimming
pools, hot tubs and natural bathing areas like lakes, rivers and ponds are sometimes
dangerously polluted and provide a medium for vectors to flourish.

Noise Pollution

It can be defined as any unwanted or undesirable sound in the environment. Its effects can
range from mildly annoying to psychologically and physically debilitating. The most severe
health problem resulting from noise pollution is temporary or permanent hearing loss. It also
affects an individuals, psychological and physical health because it disrupts communication,
sleep, leisure and work activities.

Accidents

Asbestoes

Unintentional injuries like due to falls, drowning and fires kill more than 100,000 people each
year and incapacitate millions of others with many lifelong disabilities. Of these, approx.
46,000 deaths are motor vehicle related injuries. Social and Hazardous Wastes

Wastes are being generated at an alarming rate. The amount of solid waste continues to
soar, partly as a result of today's "Throwaway' attitude where many products are used once
and then discarded. In addition to solid wastes, the disposal of hazardous waste is a critical
issue.

EMERGING ENVIRONMENTAL ISSUES

Major Issues Seven major environmental issues which will directly or indirectly affect health
have been identified:

Health Care Delivery

1. Population: There was little change in population growth rates by the year 2000. "The
estimated world population by the end of century will be 6.3 billion.
2. Food production: Worldwide food production was projected to increase by 90% between
1970 & 2000. However, the largest increase of food will occur in richer countries and the
countries of Middle East. Africa and Southern Asia will continue to have inadequate amount
of food for their people.

3. Natural resources: Nonfuel resources appeared sufficient to meet demands through the
year 2000, but discoveries and investments will be needed to maintain reserves.

4. Water: Shortages will become more severe, over-pumping of ground water, poor land use
practices and pollution of existing water supplies will reduce the availability of water at a time
of rising need.

5. Forests: Loss of forests will continue over the next 20 years.

6. Wild life: Rates of extinction will increase sharply resulting in loss of hundreds of
thousands of species, especially in the tropical forest regions.

Natural resources Global Water | Forests Wild life Population Food production Major issues
warming Acid rain Pollution

7. Pollution: Increased emissions of carbon dioxide and chlorofluorocarbons in the

atmosphere are threatening to alter the world's climate and upper atmosphere significantly
by 2050. Acid rain from the burning of fossil fuels is affecting increasingly wider areas with
damage to lakes, soil and crops.

Global Warming

Fig. 9.2: Environmental issues

As a result of increased burning of fossil fuels, deforestation and the production of certain
synthetic chemicals, there is dramatic increase in heat trapping gases in the atmosphere.
Carbon dioxide is the major offender, allowing energy from the sun to pass through, while
absorbing radiation from the earth and creating a planetary hot house.

NASA (National Aeronautics and Space Administration) has reported that the atmospheric
ozone layer, which protects life from harmful ultraviolet radiations, has begun to thin globally.
As ozone layer diminishes in the upper atmosphere, the earth receives more ultraviolet
radiations, which promotes skin cancers and cataracts and depresses the human immune
system.

Acid rain is caused by emission of sulfur dioxide and nitrogen oxides. Nitrogen oxide, formed
when fuel is burnt at high temperature, come principally from motor vehicle exhaust, electric
utilities and industrial boiters that burir coat or oil. Once released into the atmosphere, these
compounds can be carried long distances by prevailing winds until they return to the earth as
acidic rain, snow, fog or dust. Fish and wildlife suffer harm, lakes are contaminated,
buildings and statues deteriorate and people experience health problems such as respiratory
impairment.
Legislation establishing regulations and policy occurs at national level. The EPA is an
independent agency formed to coordinate environmental programs related to air and water
pollution, solid and hazardous waste management, noise, public water supplies, pesticides
and radiation. The agency also administers the municipal sewage treatment construction
grant program authorized by congress in the 1972 Clean Water Act.

Acid Rain

THE ENVIRONMENTAL PROTECTION AGENCY (EPA)

HEALTH ECONOMICS

Economics represents the study of allocating scarce resources among competing needs.
Allocating resources refer to how each good produced is distributed to its consumers. Simply
stated, economics becomes the intellectual liaison between nature and technology on the
supply side and the preferences and desires of consumers and overall society on the
demand side. The economics involved with health care is important on the both sides of the
supply-demand equation. Economics provides a systematic mechanism to obtain information
about the availability, potential and results of health care system. Also, economics can be
used to trace relationships among the health of the population, the size and productivity of
work force, and the demand

for health care.

ECONOMIC INDICATORS OF HEALTH CARE 1. Consumer price index (CPI): CPI
measures the average changes in prices of all types of consumer goods and services
purchased by urban wage earners and clerical workers. This index is computed monthly by
the Federal Government.

2. Hospital status: Admissions, cost per inpatient day, length of stay, outpatient visits,
occupation rates and staffed beds indi

cate consumption and cost of consumption for hospital care.

programs. 3. National health expenditure: It includes both public and private expenditures for
personal health care, medical research, the construction of medical facilities, program
administration, insurance costs and Government sponsored public health

4. Personal consumption expenditure (PCE): PCE represents private payments for medical
care.

5. Personal health care expenditure (PHCE): It indicates expenditures for consumers

whether insured or not. Included are expenses for non-prescribed drugs and medicines,
household supplies and other items not covered by insurance.

6. Professional status:
Office visits - Indicate the number of office calls consumers make to a physician. Physician
fee - Reflects charges for office and other physician visits.

Surgical charges - Indicate the fee for common surgical procedures and emergency medical
procedures. Economic Concepts in Health Care The three basic concepts of supply, demand
and cost are intricately related in economics.

The Supply of health care refers to the amount of resources currently available for delivering
health services. Resources include health care facilities, manpower and financing. Supply
levels are constantly changing because of technological discoveries, costs for services,
consumer demands, and effect of Government regulations.

Introduction Health Delivery System

The Demand for health care refers to the amount and type of health care the consumer
requires and is willing to purchase (Feldstein, 1983). The demand level revolves around
consumer needs and desires, costs of health care, treatment selections ordered by health
care providers, and general societal needs.

The Cost of health care refers to the amount a provider pays to produce health-related
goods and services, as well as the amount a consumer pays to purchase these goods and
services. Factors influencing the cost of health care are numerous, ranging from consumer
demands to advancements in medical technology to the nation's economy. Care

POLICIES

A policy is an established course of action determined to achieve a desired outcome.

Government and institutions create policies to achieve their missions. However, policy
development and implementation are not limited to government and institutions. Any
healthcare providing agency, professional organization, nonprofit organization or family may
make policies for members to follow. Policy formation takes place at many levels in the
society at family, community, institution, state, national and international level. Policies can
be major or minor.

Definitions

Policy is defined as principles that govern actions directed towards given ends; policy
statements set forth a plan, direction or goal for action. Policies may be laws, regulations

or guidelines that govern behavior in the public arena, such as in government or in the
private arena such as in workplaces , schools , organizations and communities. Policies are
formalized procedures that are followed by persons responsible for

delivering governmental or institutional services (Stanhope, 1996). Health policy refers to the
public or private rules, regulations

, laws or guidelines that relate to the pursuit of health and the delivery of health services,
| IMPLIED AND EXPRESSED POLICIES

Implied: Implied policies are neither written nor expressed verbally, have usually developed
overtime and follow a precedent. For example, a hospital may have an implied policy that
employees should be encouraged and supported in their activity in community, regional and
health care organizations.

Expressed: Expressed policies are dineated verbally or in writing. Most organizations have
many written policies that are readily available to all people and promote consistency of
action. It may include a formal dress code, policy for sick leave or vacation time and
disciplinary procedures.

Before any action is taken, an issue should be put on the public agenda. Placing an issue on
the public agenda requires actions that bring a concern to the attention of the policy makers
and the public, people other than those affected by the situation are aware of the issue and
its consequences.

Policy Decisions

According to Mason, Leavitt, Chaffee, 2002: Policy decisions (e.g. laws or regulations)
reflect the values and beliefs of those making the decisions. As the values and beliefs
change, so do policy decisions.

Types of Policies

• Distributive policies: Distributive policies extend goods and services to members of an

organization, as well as distributing the costs of goods or services amongst the members of
organization. Examples include Government policies that impact sending for welfare, public
education, highways and public safety or a professional organization's policy on membership
training

. Regulatory policies: Regulatory policies limit the discretion of individuals and agencies or
otherwise complete certain type of behavior. These policies are generally thought to be best
applied in situations where good behavior can be easily defined and bad behavior can be
easily regulated and punished through fines.

• Constituent policies: These create executive power entities or deal with the laws.

• Miscellaneous policies: Policies are dynamic; they are not just static list of goals or laws.
Policy blueprints have to be implemented, often with unexpected results. Social policies are
what happens on the ground' when they are implemented as well as what happens at the
decision-making or legislative state.

Other Types of Policy

Domestic policy: It presents decisions, laws and programs made by Government which are
directly related to the issues in the country. Economic policy: It refers to the actions that
Governments take in the economic field. It covers the systems for setting interareas of
Government.

est rates and Government deficit as well as the labor market and many other

• Education policy: It refers to the collection of laws or rules that govern the operation of
education system. Education occurs in many forms for many purposes through many
institutions. Education policy can directly affect the education levels.

people engage in at all

• Environmental policy: It is an action deliberately taken to manage human activities with a

view to prevent, reduce or mitigate harmful effects on nature and natural resources and
ensuring that man-made changes to the environment do not have humans.

harmful effects on • Health policy analysis: It is the process of assessing and choosing
among spending and resource alternatives that affect the

health care system and public health system, · Foreign policy: It is also called the
'International relations policy' is a set of goals outlining how the country will interact , socially
and militarily.

with other countries economically, politically Human resource policy: These are systems of
codified decisions, established by an organization, to support administrative management,
employee relations and resource planning.

personnel functions, performance

• Public policy: It is the body of fundamental principles that underpin the operation of legal
systems in each state. This addresses the social, moral and economic values that tie a
society together, values that vary in different cultures and change overtime.

Textbook of Advanced Nursing Practice

Social policy: It relates to guidelines for the changing, maintenance or creation of living
conditions that are conducive to human welfare. Thus social policy is that part of public
policy that has to do with social issues. Social policy aims to improve human welfare and to
meet human needs for education, health, housing and social security.

Impact of Policy on Nursing

• Public policy has significant impact on the practice of nursing, The ability of the individual
nurse to provide care is affected by public policy decisions.

State licensure of a registered nurse (RN) derives from legislation that defines the scope of
nursing practice. The defined scope determines what a nurse legally can and cannot do.
Regulations that are developed to implement legislation also affect practicing nurses and
their work environments. For example, the rules for administering and documenting the
administration of narcotic drugs are promulgated by a regulatory agency of the Federal
Government, the Federal Drug Administration, under the department of Health and Human
Services. The way in which such regulations are written can greatly affect nurse's ability to
practice. If nurses do not actively participate in developing regulations, policy outcomes are
likely to restrict rather than enhance nursing authority for regulated activities.

SPHERES OF NURSING INFLUENCE The nurse has an opportunity to make an impact on

policies in four aspects of influence as identified by Talbott and Mason (1988). These
spheres are: • Government Organizations

• Workplace Community

Since the community encompasses the other three spheres, only Government,
organizations, and workplace will be discussed here.

Government

. services, Delivery Laws, with their accompanying rules and regulations, control nursing
practice and health care. Nurses have been more involved in federal and state
Governments, although local Governments provide many health care

Local Governments control school health programs, local public hospitals and home and
community health care. In general, the nurse first must be a registered voter. Nurses can join
collective actions by working with PACs (Political Action Committees). These committees
support deserving candidates who support nursing and health care issues.

Most states have state nurses association PACs for state and local candidates. Nurse can
even serve on

Workplace: Over 66% of nurses work in hospitals and should be influential in setting hospital
policies, especially regarding patient care. Nurses can influence how quality care is delivered
with controlled costs. Most hospitals currently require that many nonnursing tasks be done
by nurses. Through collective action, nurses serving on committees in the institution can
help eliminate these tasks.

the board of trustees of the institution. Nurses who successfully practice the politics of
change in their place of employment can influence the

type and quality of patient care. . Political Process in Nursing Profession Politics

Organizations: Important influences include professional organizations such as ANA and

many specialty organizations. The organizations work in coalition with other health groups to
support or oppose issues. By joining and being active in a professional organization, an
individual nurse has access to a wider range of tools and information to use in order to
influence health care policies
Merriam Webster's Collegiate Dictionary (1994) defines politics as 'the art or science
concerned with guiding or influencing guiding policy' and 'the art or science of winning and
holding control over a government Policies are the decisions; Politics is the influence of
those decision

..
POLITICS AND NURSING

Broader issues affecting the nursing profession are political in nature. Issues of pay equity,
or equal pay for the work of comparable value are of concern to nurses, because they have
historically been underpaid for their services . One of the earliest case demonstrating the
inequality of nursing salaries involved public health nurses in Colorado. "They were paid
considerably less than city tree trimmers and garbage collectors . The nurses demanded just
compensation for their work by demonstrating that nursing requires more complex
knowledge and is of greater value to society than these

outcomes. other occupations. As a result of this suit, recognition of nurse's low pay was
brought to public attention, this, in turn, mobilized public support for increasing nursing
salaries. This is an example of political action by nurses that resulted in both policy and
professional

More recently, the nursing shortage has caused concern amongst the public that the number
of nurses available to provide care in hospital and other agencies is inadequate. Nurses in
California mobilized the public and other constituency groups to get the first legislation
requiring specific nurse to patient ratios passed in 1999.

Unfortunately nursing profession was not well-organized politically during the time of
expanding health care capacity and access in the early 1960s. Times have changed. Nurses
have increased their political savvy. Through the efforts of American Nurses Association
(ANA), other professional organizations, constituent member associations, political action
committees (PACs), nurses are now participating much more effectively in both
Governmental and Electoral politics.

LEVELS OF POLITICS IN NURSING

Three levels of political involvement in which nurses can participate are as:

Nurse Citizens

A nurse citizen brings the perspectives of health care to the voting booth, to public forums
that advocate for health and human services. Nurses tend to vote for candidates who
advocate for improved health care. Here are some examples of how the nurse citizen can be
politically active:

• Register to vote

Vote in every election

Keep informed about health care issues Speak out when services on working conditions are
inadequate

Join politically active nursing organizations • Join a political party.

Once nurses make a decision to become involved politically, they need to learn how to get
started. One of the best ways is to form a relationship with one or more policymakers. The
nurse activist takes a more active role than the nurse citizen. Nurse activists can make
changes by:

Nurse Activists

Joining politically active nursing organizations Contacting a public official through letters,
emails or phone calls Registering people to vote Contributing money to a political campaign
Writing letters to the editor of local newspapers

Working in a campaign

Inviting legislators to visit the workplace. .

Nurse Politicians

· Once the nurse realizes and experiences the empowerment that can come from political
activism, he or she may choose to run for office. No longer satisfied to help others get
elected, the nurse politician desires to develop the legislation, not just influence it. Nurse
politicians use their knowledge about people, their ability to communicate effectively and
their superb organizational skills in running for office. The nurse politician can: elected office.

Run for an

. CHAPTER

10

Health Care Planning and Organization

“The health care delivery system is cooking with change, predicting the final flavor is
difficult”. According to WHO, 'health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity?

INTRODUCTION
The words “health care delivery system” speak to the coming change in addressing health
and illness needs of clients in the 21st century. It is true that promotion of health is basic to
national progress.

One of the essential parts of an improved health care system will be an emphasis on
prevention and the active participation of clients in their own health choices whereas
scientists will continue to search for and find cures to many illnesses.

CONCEPTS OF HEALTH CARE DELIVERY SYSTEM

The concepts of health has been changing over the years in response to an increase
awareness of health and its relevance to national progress: initially when health care was
equated with patient care, the objective was the achievement of negative health or freedom
from disease through hospital system. This concepts, though inconsistent with the current
awareness of health care, has never been totally eliminated even in this era of “Health for
All".

With the emergence of the concepts of positive health, health care came to be conceived as
an integrated care containing promotive, preventive and curative elements that bear a
longitudinal association with an individual extending from "Womb to health as well as
disease.

tomb” and continuing in the state of

Delivery of health care services is the burning issue of the present time. The concern is to
develop system which ensures need based comprehensive health care service to people at
large especially those living in remote and backward areas using available possible.

resources as effectively as

DEFINITIONS

Health Care

Health care is the preventive, curative, restorative and promotive service provided by the
official and official agencies of a country to its citizens”.

Health Planning Process

According to WHO, health planning process has been defined as the orderly process of
defining community health problem, identifying unmet needs and surveying the resource to
meet these needs, establishing priority goal that are realistic and feasible and projecting
administrative action to accomplish the purpose of the proposed program.

Purpose of Health Care Services

The purposes of health care services are: • To improve the health status of the population in
the light of health for all • The goals to be achieved have been fixed in terms of mortality and
morbidity reduction

Textbook of Advanced Nursing Practice

Increase in expectation of life

Decrease in population growth rate • Improvements in nutritional status • Provision of basic

sanitation • Health manpower requirements and resoures developed and certain other
parameters such as food production, literacy rate, reduced levels of poverty, etc.

CHARACTERISTICS OF HEALTHCARE SERVICES Healthcare is based on:

Morbidity and mortality statistics Demographic profile of the country Environmental

conditions Socioeconomic factors Cultural background Medical and health services available
Other services.

HEALTH PLANNING IN INDIA

Definition

National Health Planning can be defined as, "the orderly process of defining community
health problems, identifying unmet needs and surveying the resources to meet them,
establishing priority goals that are realistic and feasible and projecting administrative action
to accomplish the purpose of the proposed program”.

Purposes or Importance of Planning Process Planning process is very important activity as it

helps in various under mentioned

activities. 1. Predict: Planning helps to foresee about what things and situation would be like
in the future on the basis of analysis of various factor inside the organization and outside the
organization.

2. Reduce uncertainty: Planning brings in rationality and higher degree of certainty in

achieving the objective. Without planning a manager gropes around in the darkness and is
forced to react to the situation. With planning, objective programs and procedures are
chalked out clearly and accordingly efforts of people are channeled. Thus there is no
wastage of effort and resources. 3. Management by objective: The first element in planning
is setting goal and objectives

which give sense of direction. 4. Economy in operation: Planning helps in matching limited
resources to deal with different problems. It also helps in developing the best course of
action to meet the

objectives which are economical in all it

senses. 5. Controlling checking: The planning helps in monitoring the performance of worker
as on the planning basis the job and responsibilities are distributed.

6. Promote innovative and creative thinking in the planners.

Characteristics of Planning

Good planning should focus on the purpose, i.e. any health program should have its own
purpose/objective, e.g. ICDS, RCH, etc. Planning is a continuous process. Health planning
should be according to requirements of the society/community. Planning of the health
program should be precise in its objectives, scope and nature. Planning should be
documented because it serves as a blue - print for the implementation.

Planning Cycle

Planning cycle can be considered in the eight steps as shown in Figure 10.1.

Health Care Delivery

132

. Assessment of environment Evaluation Data collection and anaysis Mid-term appraisal and
correction Planning cycle Target setting Take adoption and implementation Plan formulation
Plan authentication

Fig. 10.1: Planning cycle

The planning cycle consists of the process of analyzing a system, or defining a problem,
assessing the extent to which the problem exists as a need, formulating goals and objectives
to alleviate those identified needs, examining and choosing from among alternative
interventions strategies, initiating the necessary action for its implementation and monitoring
the system to ensure proper implementation of the plan and evaluating the results of
intervention in the light of stated objectives.

Steps of the Health Planning Process

Health

1. Analysis of the health situation. 2. Establishment of the objectives/goals. 3. Assessment of

thr resources. 4. Fixing the priorities. 5. Writing the formulated plan. 6. Implementation. 7.
Evaluation.

History of Health Planning in India

Health planning in India is an integral part of national socioeconomic planning, Planning

Commission (1950)

Planning Commission was set up by Govt of India on 15th March 1950, to raise the standard
of health and living of the people by efficient exploitation of the resources of the country,
increasing production and offering opportunities to all for employment in the service of the
community.

National Development Council (1952) The Prime Minister is the Chairman of the Planning
Commission, which works under the overall guidance of the National Development Council.
The Deputy Chairman and the full time Members of the Commission, as a composite body,
provides

NDC is headed by Prime Minister, constitutes chief ministers and members of the Planning
Commission. Main objective of NDC is to formulate the Five Year plans for the development
of the national economy. Priorities during FYP were fixed based on the individual schemes
and availability of resources.

Planning Process by Planning Commission

advice and guidance to the subject divisions for the formulation of Five-Year Plans, Annual
Plans, State Plans, Monitoring Plan Programs, Projects and Schemes. The Planning
Commission lays down long-term goals, which are approved by the Govt.Five. year goals
are tentatively formulated by Planning Commission. The sector-wise working groups,
headed by Secretary/Add Sec/ Director General/Advisor Planning Commission are set up
and work out detail policies and programs to achieve goals and targets. Planning
Commission prepares a short memorandum of five-year plan in the form of "Approach
paper". This paper is placed before the cabinet and NDC where it is discussed and
approved. The guidelines are sent to the states to develop state plans. The planning
department of each state prepares its plan on the basis of plan of each sector in the state.
Each sector gets input from the districts and blocks. The complete plan is submitted to the
Planning Commission. The Planning Commission discusses and scrutinizes the plans in
detail. The priorities are decided and funds are recommended. The final allocation of funds is
decided in a meeting between the Dy Chairman and the chief minister of the respective
state. The draft Five-Year Plan is prepared which states the objectives, essential resources,
targets and programs. The draft is placed before NDC for approval. It is placed in and
presented before the parliament. Then it becomes an official plan to be implemented by
various departments of central and state governments.

HEALTH CARE DELIVERY SYSTEM IN INDIA

Textbook Practice

Delivery of health care services is the burning issue of the present time. The concern is to
develop a system which ensures needbased comprehensive health care services to the
people at large especially those living in remote and backward areas, using available
resources (manpower, money, material) as effectively as possible.

Determinants

The various factors, which would determine healthcare delivery system are categorized as
under:

Consumers of Health Care

The consumers of health care are the people to whom health care services are to be
rendered. The bulk, extent and nature of services would depend upon the size, demographic
characteristics, physiological and health status of people, their health attitude and health
behavior, morbidity and mortality problems, lifestyle and standard of living, socio-cultural
practices, physical surroundings of people, health awareness and consciousness, health
demands, etc. The distribution of health services will depend upon geographical divisions.

Providers of Health Care

Providers of health care refers to health manpower who are authorized and responsible to
provide health care services to the people. The number and categories of trained personnel
available, their attitude, service conditions, health technology, future scope in development
of manpower, etc. will influence the delivery of health care services.

The Funding Sources

The funding sources can be the government source, private source (direct payment),
voluntary contribution from people, social and private insurance through joint contributions
and through premium respectively.

Other Factors

Other factors which are also very important factors include constitutional obligations, political
system, ideology, agenda, etc. health policies, judiciary obligations and control, executive
machinery, etc. All these factors help in making decision about the healthcare delivery
system in the country.

The Models of Health Care Delivery

Healthcare services mainly delivered by: 1. Public sector. 2. Private sector. 3. Indigenous
system of medicine.

Healt.
Voluntary health agencies. National health programs.

Public Health Sector • Primary Healthcare Hospitals/Health Centers • Health Insurance

Schemes • Other Agencies Private Sector • Private Hospitals, Nursing Homes and
Dispensaries • General Practitioners and Clinics Indigenous Systems of Medicine •
Ayurveda and Siddha • Unani • Homeopathy Unregistered Practitioners Voluntary Health
Agencies National Health Programs .

Fig. 10.2: Health care delivery system in India

PUBLIC HEALTH SECTOR In 1977, the Government of India launched a rural health
scheme, based on the principles of “placing people's health in people's hands”. It is essential
healthcare and accepted as an integral part of country's health system.

According to Alma-Ata, "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 country can afford.” • Education concerning prevailing health problems
and the methods of preventing and controlling them • Promotion of food supply and proper
nutrition

Elements of Primary Health Care

An adequate supply of safe water and basic sanitation

Maternal and child health, including family planning • Immunization against major infectious
diseases • Prevention and control of local endemic diseases • Appropriate treatment of
common diseases and injuries • Provision of essential drugs. There are various principles
regarding operational aspects of primary health care. These are briefly described here: It
means that primary health care service must be shared equally by all the people irrespective
of their ability to pay, belonging to urban and rural areas and to any segment of the
community but giving priority to the unprivileged area of the society.

Principles of Primary Health Care

Equitable Distribution

Coverage and Accessibility

Primary health care aims at providing essential health care to whole population. It implies
providing health care services to all which are required by them, e.g. to children , mother,
adults, elderlies and also which are reachable to them, i.e. geographically , financially,
culturally and functionally.

Community Participation

It is a process by which individual and families assume responsibilities for their own health
and welfare and for those of the community and develop the capacity to contribute to their
and country's development. This process creates awareness among
.

4. 5. Textbook of Advanced Nursing Practice

people about their health situation and resource and motivate them to solve their common
problems. There are many ways in which community can participate in every stage of
primary health care. It can be involved in the assessment of health situation, defining of
health problem, health needs, setting of priorities, planning of alternative action,
implementation of actions by the people, monitoring, evaluation and feedback.

Multisectoral Approach

No sector involved in socioeconomic development can function properly in isolation.

Activities of any one sector have impact on goal of any sector. There is a need for
consultation and coordination of the inter-sectoral activity so also is true with health sector.
The other sectors include agriculture, animal husbandry, housing, water supply, sanitation,
public works, communicationeducation, mass media and panchayats.

Appropriate Health Technology

Appropriate health technology is very important factor for successful primary health care. It
implies use of method, technologies and equipment which are scientifically sound but simple
in accordance to local culture so that these are understood and acceptable to those who use
and to those for whom are used.

Human Resource

Human resource is very important factor for the success of primary health care. Often this
resource is not used effectively and sufficiently for effective implementation of PHC, it is very
essential to make full use of all available resources including the human potential of the
entire community. This is possible through active involvement of people, helping them to
develop their competencies to deal with their problem and become full member of health
care aspect of community as a whole. It is important to ensure availability of adequate
number of appropriate health personnel in PHC.

Services by Community Health Workers and Traditional Health Practitioners

Primary health care is the first level care which is provided by community health workers,
who form a link between community people and health system. They are given short and
simple training to be able to take care of some of simple and basic health needs of people.

Referral System

It is essential the support of higher level health personnel who have specialized technical
knowledge and technology which is useful to servive the life of client. The transportation of
patient to and from referral service has to be properly organized, making most of available
facilities.
Logistic of Supply

Logistic of supply includes planning and budgeting for supplies required, storage, distribution
and control, supplies of the right quality and quantity have to be delivered to primary health
care facilities at the right time to make it possible to provide services on a continuing basis. It
is advisable to have a standard list of drug and equipment which can be adjusted according
to local variation, such as seasonal fluctuation in the incidence of certain disease.

The Physical Facilities

The physical Primary health care, with its supporting service, has to be controlled and
evaluated to ensure that it is functioning in accordance with national policy and strategy and
measures are taken to improve as found necessary. Community can be involved in

facilities for primary health care need to be simple and clean. Already existing facilities can
be used for the purpose. If these are to be specially built, the community people can be
involved to contribute their own labor and materials. It should have spacious waiting area
with toilet facility.

Control and Evaluation

The SC covers the population of 5000 in plain area. This population may be located in 2 to 5
villages and may not be in one village. The subcenter buildings have been built by the
Government under Family Welfare Budget, but 50% of subcenters run in buildings given by
village panchayats.

Delivery huts have been set-up at the level of subcenter to promote institutional deliveries.
Two kits are In addition, a midwifery kit for safe delivery and equipment kit for IUD insertion,
blood pressure apparatus and weighing machine are available at subcenter level. The cost
of these kits is borne by central government. Pressure cookers for autoclaving syringes and
needles are also available.

provided per annum.

Maternal and Child Health Services

Early registration of pregnancies, antenatal care, natal and postnatal care of cases for
referral services Treatment and control of diarrheal diseases Malaria surveillance at
subcenter Organization of Mahlia Swasthya Sanghs and their meetings:

Identification Essential newborn care, immunization, vitamin A prophylaxis, iron and folic
acid and treatment of anemia in pregnant women, children and adolescent girls

Contraceptive services to eligible couple

School health services including immunization Pulse polio immunization and surveillance of
AFP Registration of births, deaths and marriages Dais training Health and nutrition,
education, counseling

Intersectoral coordination with school teachers, anganwadi workers, gramsevikas, and

panchayati rajs institutions Periodical activities like intensive drives for family health
awareness, campaigns, special surveys to prevent infections Preparation of monthly
progress reports and holdings, sector meeting with AWW once a month Record keeping

Subcenter Team

Care The subcenter team consists of health workers (M/F) TBA, AWW, voluntary worker and
one female link worker (ASHA). In addition, village Chowkidar who collects events of birth
and deaths is also helpful to subcenter team.

PRIMARY HEALTH CENTER (PHC)

The primary health center covers 30,000 population in plain rural areas. At this level of
primary health care-services of professionally qualified medical officer (M/F) are available.
These PHCs are established and maintained by the state governments under the minimum
needs program and basic minimum service program. One PHC acts as a referral unit for 6
subcenters. The state government is responsible for buildings of PHCs and most of the
PHCs are found in Panchayats buildings. The medical officer and the staff seldom stay at
PHC hence not available for emergency care and emergency obstetrics care or

deliveries.

Staff of New Primary Health Center

1-2 1 Medical officer Health assistant (male) Health assistant (female) Health educator
Health worker (female) Staff nurse 1 1 1

Health Delivery

Population

1 1 Pharmacist Lab. technician Upper division clerk Lower division clerk Driver Class IV
Total Staff 1 1 4 15

Strengthening of PHCS Under NRHM

. PHCs have been strengthened by regular supplies of essential drugs and equipment
Upgrading single doctor PHC to 2 doctors PHC by posting AYUSH practitioners at PHC level
Observing standard treatment protocols and Indian Public Health Standards • United grant of
725,000 for local health planning and action maintenance grant of £50,000 per to support
essential services and programs

annum have been provided

PHCs are proposed to be transferred to the local elected Panchayati Raj Institutions for
management and control.

Functions of PHCS

• Medical care and referral services for subcenters

Essential obstetrical care and 24 hours delivery services Initial emergency obstetrical care
MTP services Essential newborn care and child health services Maintenance of cold-child
and vaccine storage for one month for effective immunizations services

Services for RTI/STI

Tubectomy/Vasectomy

Services of all National Health Programs • Lab. services, school health services,
environmental sanitation • Health and nutrition education. .

COMMUNITY HEALTH CENTER (CHC) A community health center is responsible for

120,000 populations. Generally, it covers the population of one community developed block
geographical area. The CHCs are established and maintained by the state government
under minimum needs program.

It is manned by four medical specialists, i.e. surgeon, physician, gynecologist and

pediatrician 21 paramedical and other staffs. It has 30 indoor beds with one operation
theater, X-ray, labor room and lab facilities. It serves as a referral center for four PHCs.

No. 1 3 Category Medical officers Nurse midwives Dresser Pharmacist Lab technician
Radiographers Ward boys Staffing pattern of CHC No. Category 4 Dhobi 7 Sweepers 1 Mald
1 Chowkidar 1 Aya 2 Peon 2 1 1 1 1

139

.
. Textbook of Advanced Nursing Practice

The senior-most medical officer (SMO) is responsible to manage the CHC. Each CHC has 4
primary health centers under its control and jurisdiction. Specialist services in medicine,
OBG, surgery and pediatrics are available at the level of CHC and hence it provides high
quality referral services to all PHCs under its control.

STRENGTHENING OF CHCS UNDER NRHM

Operating additional CHCs to meet population norms. • Two specialists namely anesthetist
and public health program manager will be provided.

Provision of limited money for local action. Initial fund of 20 lakhs per CHC has been
provided for its upgradation.

Functions of CHC

• To provide specialist services and referral services

To provide emergency obstetrical care and MTP services • Essential obstetric care and 24
hours delivery services

Essential newborn care Services for national health programs RTI/STI services Cold chain
maintenance through ILR and deep freezers, cold boxes, day carriers Integrated disease
surveillance Training and continuing education of health teams Information, education and
communication activities for specific problems To enhance public private partnership To elicit
community participation.

Lab and X-ray services

HEALTH INSURANCE

Over the last two decades, several health insurance schemes have been introduced. These
are individual, family and group insurance schemes for health care, senior citizens insurance
and insurance for specific diseases. The role of health insurance is much limited in India as
compared to foreign countries. At present, two important health insurance schemes are as
follows:

Employees State Insurance Scheme

It was started in 1948 by an Act passed in the Parliament. This program provides health care
to industrial labers and their familes. This gives safety at the time of delivery disease,
accidents, etc. Similarly if a labor dies in accident, family pension is given. This scheme was
limited to those who get salary below 26500/per month, for this scheme, money is
contributed by the management as well as employees since 1st April 2004, labor ministry
has raised the upper limit of salary to 37500/per month. Employees getting up to 250/per
day, will not have to pay contribution also.
Central Government Health Scheme

The CGHS was started in 1954 with the objective of providing comprehensive medical care
facilities to the central government employees and their family members.

Objectives

1. To give extensive medical facilities to central government employees and their family
members. 2. To save government from heavy expenses on medical refund.

Health Care Delivery System

140

. Outdoor treatment facilities in all medical system

· Emergency services in Allopathy system

Free medicines Facilities for lab. tests and radiological investigation Treatment facility for
serious patients at their own homes Specialist consultation facilities Family welfare service.

Health Care

Facilities

Beneficiaries

. Central government employees and their family members Members of Parliament

Judges of Supreme court and High courts .

Freedom fighter .

• Pensioner of central government, semi-autonomous units Journalists •

Government and ex-vice presidents. .

Other Sectors

Defence Medical Services

• For this, there are separate hospital and health services

. System which provides medical care to military personnel and their family members
Defence health services come under armed forces providing all preventive, curative,
promotional health services They have their own medical college, nursing college and
nursing schools.

Railway Medical Services

Indian railways is a biggest government organization with highest number of railway

employees in world. Railway provides wide range of medical services to its employees
through railway hospitals, clinics and health units, dispensaries to provide primary,
secondary and tertiary level of care.

Autonomous Institutes

Under this category, all such institutes are included which receive central government aid.
But other decisions are made by institute itself. AIIMS, Delhi, NIMHANS, of Banglore are
examples of such central sponsored autonomous health institutes.

NATIONAL HEALTH PROGRAMS IN INDIA

Government of India with the cooperation of state and other institution agencies. In trying to
face the challenge of communicable noncommunicable and services for the fulfillness of this
purpose, the central government is conducting several national health programs. This can be
helpful in bringing down morality and morbidity rates.

National Rural Health Mission (NRHM)

Recognizing the importance of health in the process of economic and social development
and to improve the quality of life of its citizens, the Government of India launched “National
Rural Health Mission (NRHM) on 5th April 2005 for a period of 7 years (2005-2012) the
mission seeks to improve rural health care delivery system. It is operational in the whole
country with special focus on 18 states, viz. 8 empowered action group States (Bihar,
Jharkhand, MP, Chattisgarh, UP, Uttarakhand, Orissa and Rajasthan), 8 North-east States
(Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura),
HP, and Jammu and Kashmir.

. The main aim of NRHM is to provide accessible, affordable , accountable, effective and
reliable primary health care, and bringing the gap in rural health care through creation of
cadre of Accredited Social Health Activist (ASHA).

Creation of a cadre of ASHA

Strengthening sub-center by
- Supply of essential drugs both allopathic and Ayush to the sub-center - Strengthening sub-
centers with united funds of Rs 10,000 per annum in all 18 states

Objectives

In case of additional out-lay, provision of multipurpose worker (male), / additional ANMS

wherever needed, sanction of new sub-centers as per 2001 population norm and upgrading
existing subcenter Strengthening primary health center - for quality preventive, promotive,
curative, supervisory and outreach services

through: - Adequate and regular supply of essential drugs and equipments to PHC's

Provision of 24 hours service in at least 50% PHC by including an AYUSH practitoiners

Following standard treatment guidelines Upgradation of all PHCs for 24 hours referral
services of provision of second doctor at PHC level. Once male and one female) on the
basis of felt needs. Strengthening of ongoing communicable disease control program of new
programs for control of non-communicable

disease. Strengthening of CHC'S for First Referral care.

A key strategy of the mission is

Operationalising 3222 existing community health centers (30-50 beds) as 24 hour First
referral units, including posting of Anesthetists Codification of new Indian public health
standards, setting norms for infrastructure, staff, equipment, management, etc. for Promotion
of stakeholders committees, Rogi Kalyan Samitis for hospital management Developing
standards of services and costs in hospital care CHC's

In case of additional outlays, creation of new community healh centers(30-50 beds) to meet
the population norm as per census 2001

Schedule of implementation of major components of NRHM are as follows

Merger of multiple societies and constitution of District / State mission-June 2005 Provision
of additional generic drugs at SC/PHC/ CHC level—December 2005 Operational program
management units—2005-2006 Preparation of village health plans-2006 ASHA at village
level (with drug kit ) 2005-2008 Upgrading of rural hospitals—2005-2007

Opertationalising district planning—2005-2007 • Mobile medical unit at district level—2005-

08

GOALS

At National Level

Infant mortality rate reduced to 30/1000 live birth

Maternal mortality rate reduced to 100/100,000 • Total fertility rate reduced to 2.1
Malaria mortality rate reduction -50% by 2010, additional 10% by 2012 Kala-azar mortality
rate reduction-100% by 2010, and sustaining elimination until 2012

Health Care Dc.very

Aim of NRHM

Health Care Planning and Organization

Filaria / microfilaria rate reduction—70% by 2010, 80% by 2012 and elimination by 2015
Dengue mortality rate reduction --50% by 2010 and sustaining at that level until 2012
Japanese encephalitis mortality rate reduction–50% by 2010 and sustaining at that level until
2012 Cataract operation-increasing to 46 lakhs per year by 2012 Leprosy prevalence rate-
reduce from 1.8/ 10,000 in 2005 to less than 1/10,000 thereafter Tuberculosis DOTS
services-maintain 85% cure rate through entire mission period Upgrading CHC's to Indian
public health standards Increase utilization of first referral units less than 20% to 75%
Engaging 250,000 female ASHA's in 10 states.

At Community Level

. . Availability of trained community level worked at village level, with drug kit for general
ailments Health day at Anganwadi level on a fixed day/ month for provision of immunization,
ante/ postnatal checkups and services related to mothers and child healthcare, including
nutrition

• Availability of generic drugs for common ailments at subcenter and hospital level

. . Good hospital care through assured availability of doctors, drug and quality services at
PHC/ CHC level Improved access to universal immunization through induction of auto
disabled syringes, alternate vaccine delivery and improved mobilization services under
program

Improved facilities for institutional delivery through provision of referral, transport, escort and
improved hospital care sub

sidized under the Janani Suraksha Yojana for the below poverty line families • Availability of
assured health care at reduced financial risk through pilots of community health insurance
under the mission • Provision of household toilets

Improved outreach service through mobile medical unit at district level.

ACCREDITED SOCIAL HEALTH ACTIVIST (ASHA) to fill this void.

Accredited Social Health Activists ( ASHA) previously Anganwadi workers (AWWs) under
the ICDS are engaged in organizing supplementary nutrition programs and other supportive
activities. They very nature of her job responsibilities (with emphasis on supplementary
feeding and pre school education) does not allow her to take up the responsibility of a
change agent on health in a village. This a new band of community based functionaries,
named as accredited social health activist (ASHA) is proposed

ASHA will be the first port of call for any health related demands of deprived sections of the
population, especially women and children, who find it difficult to access health services.
Every village / large habital (1000 population) will have a female community health chosen
by and accountable to the panchayat to act as the interface between the community and the
public health care system.

Selection

Qualities or Requirements for ASHA

ASHA must be primarily a women resident of the village—married widow/ Divorced and
preferably in the age group of 25 year. She should be a literate women with formal education
up to 8th class.

Training

These ASHA's will be trained , on a pedagogy of and public health developed and monitored
through a national experts group incorporating best practices and implementing through
active involvement of community health resource organization. Various models of training
could be used.

Contract plus distance learning model NGO/ private partnership . .

• ICDS training centers and state health institutes

Comprehensive women's health and empowerment model

143

UNIT II

.
Health Care Delivery System

Textbook of Advanced Nursing Practice

eduention IRC Cont grants are provided by the central government for health education and
publicity compaign to promote the consumption of lodized salt the luc video, ailme posters
and radio/ TV spots are used. For publicity work Doordarshan and Dwectorate of
advertisement and visual publielly are also involved. Government celebrate global iodine
dehidleney disorder prevention day on 21st October.

4. IDD monitoring the growing evidence that hodine deficiency may be reappearing in
countries where it was thought to have been eliminated under cores the need for vigilance in
sustaining current program.

A national reference laboratory for monitoring of IDD has been set up at the biochemistry
division of National Institute of Communicable Disense, Delhi for training medical and
paramedical personnel and monitoring the iodine context of salt and urine training program
is also organized in Chandigarh in 2004 and allocation of Rs 75000 per laboratory has been
provided for estabilishing IDD monitoring laboratories at district level.

Special Nutrition Program

The program was launched in the country in 1970-71. It provides supplementary feeding of
about 300 calories and 10 grams of protein to preschool children and about 500 calories and
25 grams of protein to expectant and nursing mothers for 6 days 4 week. This program was
operated under minimum need program. The program was taken up in the rural areas
inhabited predominantly lwy lower socio-economic groups in tribal and urban slums.

Balwadi Nutrition Program

I II was launched in 1970-71 and fund for supplementary feeding of Balwadi Nutrition
Program was given by the central ywernment. It has

provided 300 calories and 10 grams of protein per child (3-5 years) 1 days for 270 days a
years.

Applied Nutrition Program

ANP was introduced as a pilot scheme in Orissa in 1963 which later on extended to Tamil
Nadu and UP with the objectives of propening production of protective food such as
vegetable and fruits. Ensure consumption by pregnant and nursing mothers and children.
During 1973, it was extended to all the state of the

Uruntry Imograted Child Development Scheme (ICDS) It was launched on 2nd October 1995
(5th five year plan).

Beneficiarios
Children below 6 year Pregant and lactating women in the age group of 15-45 years Adele
centre

Objective of ICDS

. Improve the nutritional and health states of children in the age group of 0-5 years Lay the
foundation for proper prychological, physical and social development of the child Effective
coordination and implementation of policy amongst the various departments Enhance the
capability of the mother to look after the normal health and nutrition need through proper
nutrition and health education . .

Murmional Program for Adolescent Girls 2003

Nutritional prons un for adolescent yela wan proposed by both five year plan and nutritional
policy in which girls who weight leone than 15 ky, and hellern poverty line is entitled to yet
the ration of 6 ky month free of cost in the form of wheat or rice. A chit with tatne in yoven to
the entitled yol or women from the Anganwadi, which help her to get the ration from public
distribution system shem

3. Health
Health Care Planning and Organization

149

Scheme for Adolescent Girls (Kishori Shakti Yojna)

1991 in

It was launched by the Department of Women and Child Development, Ministry of Human
Resource Development in ICDS. All adolescent girls in the age group of 11-18 years (70%)
receive the following common services: Watch over menarche . Immunization

: General health check ups once in every 6 months • Training for minor ailments

Prophylactic measures against anemia, goiter, vitamin deficiency, ctc. Referral to PHC/
District hospital in case of acute need.

Sr. No. Recipients Calories 1. Child upto 6 years 300 2. Adolescent girls 500 3. Pregnant
and nursing mother 500 4. Malnourished childrens Double the daily supplement provided to
the other children (600) or special nutrient on medical recommendation, Grams of protein 8-
10 20-25 20-25

Midday Meal Program

Tamil Nadu was the first state to initiate a massive noon meal program to children. Neither a
child that is hungry, nor a child that is ill can be expected to learn. There are about 150
million children officially enrolled in nearly 8,00,000 schools throughout the country.
Relatively high overhead costs of school coupled with poor school infrastructure, lack of
structure, lack of teachers and teacher absenteeism are most often cited reasons for low
levels of schooling in the country. Realising this need the the national program for nutritional
support to primary education popularly known as mid-day meal programs was formally
launched on 15 august 1995 with the aim of improving in 3 areas. School attendance .

Reduced disopoints A beneficial impact on children's nutrition.

National Nutritional Anemia Prophylaxis Program National Program for Control of Blindness
The national program for control of blindness was launched in the year 1976 as a 100%
centrally sponsored program and incorporates the earlier trachoma control program in the
year 1968. The strategy of the program is as follows:

The program was launched in 1970 to prevent nutritional anemia in mothers and children
under this program. The expected and nursing mothers as well as acceptors of family
planning are given one tablet of iron and folic acid containing 60 mg elementary iron which
was raised to 100 mg elementary iron however (0.5 mg folic acid) and children in the age
group of 1-5 years are given one tablet of iron containing 20 mg elementary iron daily for a
period of 100 days. This program is being taken up by MCH division of ministry of health and
family welfare. Now it is the part of RCH program. The main reason behind this program was
high rate of prevalence of iron deficiency anemia in India.

Strengthening service delivery Developing human resource for eye care

Promoting out reach activities and public awareness • Developing institutional capacity
facilities for every 5 lac persons. .

• To establish eye care Based upon the findings of surveys conducted during 1998-99 and
1999-2000 following measures were included in the program. .

UNIT II

Health Care Delivery System

.
Textbook of Advanced Nursing Practice

1. To make NPCB more comprehensive by strengthening services for other causes of

blindness like corneal blindness, refrac. tive errors in school going children improving follow
up services of cataract operated persons and treating other causes of blindness like
glaucoma.

2. To shift from the eye camp approach to a fixed facility surgical approach.

3. To expand the world bank project activities like construction of dedicated eye operation
theaters, eye wards at district level training of eye surgeons in modern cataract surgery and
other eye surgeries, and supply of ophthalmic equipments, etc. to the whole country.

4. To strengthen participation of voluntary organization in the program and to enhance the

coverage and eye care services in tribal and other underserved areas through identification
of bilateral blind patients, preparation of village-wise blind register and giving preference to
bilateral blind patients for cataract surgery.

NATIONAL MENTAL HEALTH PROGRAM

The Government of India has launched the National Mental Health Program (NMHP) in
1982, keeping in the view the heavy burden of mental illness in the community, and the
absolute inadequate of mental health care infrastructure in the country to deal with it.

Objectives

To ensure availability and accessibility of minimum mental health care for all in the
foreseeable future particularly for the most and under privileged sections of the population

To encourage applications of mental health knowledge in general health care in social

development To promote community participation in the mental health services development
and to stimulate efforts towards self help in the community.

Prevention and treatment of mental and neurological disorders and their associated
disabilities Use of mental health technology to improve general health services Application of
mental health principles in total national developments to improve quality of life.

Approaches

Integration of the mental health care services with the exciting general health services To
utilize the existing infrastructure of health services and also to deliver the minimum mental
health care services To provide appropriate task oriented training to the existing health staff.
To link mental health service with the existing community development program.

Revised Strategies

Strategies

Integrating mental health with primary health care through the NMHP
Provision of tertiary care institutions of treatment of mental disorders • Eradicating
stigmatization of mentally ill patients and protecting their rights through regulatory institution
like the central mental health authority and state mental health authority

• Component: Are prevention, treatment and rehabilitation.

De-Addiction Program

This was started in 1987–88 with establishing center at AllMS first then JIPMER, LHMC,
RML hospital, PGIMER Chandigarh, NIMHANS Bangalore.

150

Aims
Health Care Planning and Organization

151

NATIONAL WATER SUPPLY AND SANITATION PROGRAM

. The national water supply and sanitation program was initiated in 1954 with the objective of
providing safe water supply and adequate drainage facilities for the entire urban and rural
population of the country • In 1972, a special program known as:

Accelerated Rural Water Supply Program

Was started as a supplement to national water supply and sanitation program. The
Government of India launched the International drinking water supply and sanitation decade
program in 1981 targets were set on coverage—100% coverage of water, both rural and
urban 80% of urban sanitation and 25% rural sanitation.

Swajaldhara

Swajaldhara was launched on 25th December 2002. Swajaldhara has certain fundamental
reform principles, which need to be adhered to by the state governments and the impending
agencies. Swajaldhara has 2 components: 1. Swajaldhara 1 (First dhara) is for a gram
panchayat or a group of panchayats (at block/ tehsil level) and 2. Swajaldhara II (Second
dhara) has district as the project area.

Components

NATIONAL FAMILY WELFARE PROGRAM

In 1951, India became the first country in the world to launch a family planning program.
Since then approaches for reducing population growth have taken a variety of forms. In 1974
- 79. It was renamed family planning to family welfare. The family welfare program in India is
recognized as a priority area, and is being implemented as a 100% Centrally sponsored
Reduction in the population growth rate has been recognized as one of the priority objectives
during the 9th plan period • To meet all the felt needs for contraception • To reduce the infant
and maternal mortality so that there is a reduction in the desired level of fertility. • To assess
the needs for reproductive and child health at PHC level and undertake area specific
microplanning. • To provide need-based, demand-driven, high quality, integrated
reproductive and child health care.

The objectives during the 9th plan are:

The strategies during the 9th plan are:

COMMUNICABLE DISEASE PROGRAMS

National Leprosy Eradiction Program (NLEP) world bank supported project was introduced
in 1993.

Govt. of India started national leprosy control program in 1955 based on Dapson domiciliary
treatment, through vertical units implementating survey, education and treatment activities. It
was only in 1970s that a definite cure was identified in the four of multi drug therapy (MDT)
The MDT come into wide use from 1982, following the recommendations by the WHO study
group, Geneva in October 1981. Govt of India established a high power committee under
chairmanship of Dr MS Swaminathan in 1981 for dealing with the problem of leprosy. Based
on its recommendation NLEP was launched in 1983 with the objective to arrest the disease
activity in all the known cases of leprosy. In order to strengthen the process of elimination in
the country, the first

· The Ist pahse of the world bank supported project started from 1993-94 where the project
supported the vertical program structure formulated by Govt. of India for high endemic
districts, while in the moderate and low endemic districts, mobile (MLTV) were established.

leprosy treatment units 2nd phase of world bank project on NLEP started for a period of
3year from 2001-03 this phase was implemented with the objectives towards:

Decentralization of NLEP responsibilities to state/ UT through state / UTs through

state/district leprosy societies

Health Care Delivery System

program.

UNIT II153 Achievement of RNTCP Immediately after the report of a first case of HIV in
1986, the government constituted a higher power committee in 1986 only, subsequently a
national AIDS control program was launched in 1987,

Health Care Planning and Organization

Phase II of RNTCP has been launched in the country from 1st Oct. 2005. The RNTCP
covers the whole country since March 2006. The treatment success rate has more than
trebled from 25% in 1998 to 86% in 2004. Death rate has been brought down 7 folds from
29% to 4%.

National AIDS Control Program

Objectives

Strengthen the management capacity for HIV control Build surveillance and clinical
management capacity Promote public awareness of HIV/ AIDS and community support

Improve blood supply • :

Control the spread of STD's

In 1999-2001, NACP - II was implemented and strategies were 1. Prevention

Condom programming PPP ( Public Private Partnerships) Multisectoral collaboration Safe

blood

Voluntary counseling and HIV testing 2. Care

- Management of HIV - TB co-infection Treatment of opportunistic infection

3. Surveillance

NACP Phase III - 2006-2011

Goals

Prevention of new infection in high risk group and general population through • Saturation of
coverage of high risk group with targeted interventions • Scaled up intervention in the
general population who received care support

Increasing proportion of people living with HIV/ AIDS and treatment Strengthening the
infrastructure human resources in prevention and treatment programs at the district , state
and national levels .

Strengthening a nation wide, strategic information management system National Vector

Borne Disease Control Program

In pursuance of the concept of convergence, the Govt. of India has approved a National
vector brone disease control program (NVBDCP) from the year 2003–04. This program is
going to control 5 disease namely Malaria, Kala azar, Filaria, Japanese encephalitis and
Dengue fever. This program is 100% centrally assisted in northeastern region.

PULSE POLIO IMMUNIZATION PROGRAM

PPI program was launched in the country in the year 1995. Under this program, children
under 5 years of age are given additional oral polio drops in December, January every year
on fixed days.

Health Care Delivery System

UNIT II
153 Achievement of RNTCP Immediately after the report of a first case of HIV in 1986, the
government constituted a higher power committee in 1986 only, subsequently a national
AIDS control program was launched in 1987,

Health Care Planning and Organization

Phase II of RNTCP has been launched in the country from 1st Oct. 2005. The RNTCP
covers the whole country since March 2006. The treatment success rate has more than
trebled from 25% in 1998 to 86% in 2004. Death rate has been brought down 7 folds from
29% to 4%.

National AIDS Control Program

Objectives

Strengthen the management capacity for HIV control Build surveillance and clinical
management capacity Promote public awareness of HIV/ AIDS and community support

Improve blood supply • :

Control the spread of STD's

In 1999-2001, NACP - II was implemented and strategies were 1. Prevention

Condom programming PPP ( Public Private Partnerships) Multisectoral collaboration Safe

blood

Voluntary counseling and HIV testing 2. Care

- Management of HIV - TB co-infection Treatment of opportunistic infection

3. Surveillance
NACP Phase III - 2006-2011

Goals

Prevention of new infection in high risk group and general population through • Saturation of
coverage of high risk group with targeted interventions • Scaled up intervention in the
general population who received care support

Increasing proportion of people living with HIV/ AIDS and treatment Strengthening the
infrastructure human resources in prevention and treatment programs at the district , state
and national levels .

Strengthening a nation wide, strategic information management system National Vector

Borne Disease Control Program

In pursuance of the concept of convergence, the Govt. of India has approved a National
vector brone disease control program (NVBDCP) from the year 2003–04. This program is
going to control 5 disease namely Malaria, Kala azar, Filaria, Japanese encephalitis and
Dengue fever. This program is 100% centrally assisted in northeastern region.

PULSE POLIO IMMUNIZATION PROGRAM

PPI program was launched in the country in the year 1995. Under this program, children
under 5 years of age are given additional oral polio drops in December, January every year
on fixed days.

Health Care Delivery System

UNIT II
Textbook of Advanced Nursing Practice

Accomplish integration of laprosy services with general health care system - Achieve
elimination of leprosy at national level by the end of the project.

India Achieved Elimination of Leprosy in December 2005 • As a result of the

hand work and meticulously planned and executed activities, the country has achieved the
goal of elimi. nation of leprosy as a public health problems, defined as less than I case per
10,000 population at the national level in the month of December 2005. As on 31st
December 2005, prevalence rate recorded in the country was 0.95/10,000 population. The
national leprosy eradication program envisaged the following strategy towards leprosy
elimination in India

from the Decentralization of NLEP to states and districts Integration of leprosy services with
general health care system Surveillance for early diagnosis and prompt MDT, through
routine and special efforts Intensified IEC using local and mass media approaches
Prevention of disability and care.

year 2001

Revised National Tuberculosis Control Program (RNTCP): DOTS Strategy The national TB
control program was started in 1962 with the aim to detect cases at the earliest and treat
them. In 1992, a nationwide review was conducted with the assistance of SIDA and WHO.
With the help of many other evaluation studies it was observed that the program has not
made any improvement in the disease status. Revised National Tuberculosis Control
Program The Govt. of India, WHO and world bank together reviewed the RNTCP in year
1992.

Need for Revised Strategy

Salient Features of RNTCP

. Achievement of at least 85% cure rate of infectious cases through supervised short course
chemotherapy involving peripheral health functionaries Augmentation of case finding
activities through quality sputum microscopy to detect at least 70% estimated cases •
Involvement of NGO, information education and communication.

The revised strategy was introduced in the country as a pilot project since 1993 in a phased
manner as pilot phase I, pilot phase II and pilot phase III. By the end of 1998, only 2% of
total population of India was covered by RNTCP. Large scale implementation began in late
1998 the RNTCP has now entered into IInd phase in which the program aims to consolidate
the gains made to date, to widen services in terms of activities and access and to sustain the
achievements.

Components of DOTS

• Case detection

: Patient wise drugs. Directs observation while patient is getting chemotherapy by the health
worker or community volunteers. Systematic evaluation and monitoring to ensure cure
Political will ensures financial support and sustainability.

Regular and uninterrupted supply of drugs

DOTS - Direct Observed Treatment Short-term DOTS is community based tuberculosis

treatment and care strategy which combines the benefits of supervised treatment, and the
benefits of community based care of support.
152

Health Care Delivery System

Health Care Planning and Organization

8. Pulse polio immunization program 9. Universal immunization program

REPRODUCTIVE AND CHILD HEALTH

PROGRAM - PHASE II

Introduction

Reproductive and child health approach has been defined as “people have the ability to
reproduce and regulate their fertility , women are able to go through pregnancy and child
birth safely, the outcomes of pregnancies is successful in terms of maternal and infant
survival and well-being and couples are able to have sexual relations free of fear of
pregnancy and of contracting disease.

Components of RCH-1

. Family planning

Child survival and safe motherhood component • Client approach to health care • Prevention
/ management of RTI / STD, AIDS. • RCH - Phase II began from 1st April, 2005. The focus
of the program is to reduce maternal and child morbidity and mortal

ity with emphasis on rural health care.

Components of RCH-||

• Population stabilization

Maternal health • Newborn care Child health

treatment and control • Urban health Tribal health.

• Adolescent Health

Other priority areas:

Strengthening service delivery • Infrastructure and maintenance Supply of drugs and

equipments

• Targeting of services

• Strengthening of health care providers. services and

Difference in RCH-I and RCH II

RCH - II is different from RCH - I in its flexible approach, strengthen management capacity,
client based quality convergence with other critical sectors.

Goals of RCH - 11

RTI/ STI

Indicators Population growth IMR MMR Total fertility rate Couple protection rate Goals
16.2% (2001-11) 35/1000 150/100000 2.2 65%

Component of RCH - || (In Detail)

Population Stabilization

• Strategic achieve universal coverage of contraceptive choice TFR of 2.2

UNIT

Health Care Delivery systeme

145
137 managerial control of primary health care. A process of evaluation has to be built in to
assess the relevance, progress, efficiency, effectiveness and impact of services. The
primary health care infrastructure at various levels is depicted in table below:

Health Care Planning and Organization

Level 1000 Subcenter PHC CHC Primary health care Intrastructure Population size
Functionaries Village Health volunteers, Anganwadi workers Trained workers 5000
Mutipurpose health workers MF 30,000 Health professionals (Doctor) 1,20,000 Specialists

The primary health care system infrastructure has been developed as a three-tier system: 1.
Subcenter 2. Primary health care 3. Community health center.

VILLAGE
At village level, we have trained birth attendants, Anganwadi workers and health volunteers
at the rate of 1:1000 population and now Accredited Social Health Activist (ASHA) has been
introduced by National Rural Health Mission over 1,77,924 villages health and sanitation
committees have been established.

Village Health Guide (VHG)

The health guide scheme was started on 2nd October, 1977, in all states except in
Arunachal Pradesh, J&K, Kerala and Tamil Nadu. The scheme was 100% centrally
sponsored scheme in 1981. According to the scheme, the village community selects a
volunteer as village health guide, who after training, acts as link between the community and
government health system. About 3.18 lakhs VHGs were reported to be working in 1985.
Each VHG is paid an honorarium of 50 per months. The purpose of VHG was to elicit
community participation in primary health care and VHG were recruited to mobilize
community for self-reliance in health promotion activities such as village sanitation, safe
water and promotion of nutrition and acceptance of contraception to limit the size of the
family and space children on voluntary basis. They were given medicines for minor ailments
and first aid.

Trained Birth Attendant (TBA)

Trained birth attendants were trained and one trained birth attendant has been provided for
1000 population or for each village. Over 6,00,000 trained birth attendants are in place. They
are voluntary persons and not government servants who work for safe home deliveries, help
in early registration of pregnancy, births, deaths, and help subcenter workers on voluntary
basis.

Anganwadi Workers (AWW)

Anganwadi workers are honorary village-based locally resident workers under integrated
child developed services (ICDS) chosen by village people. One AWW works for 1000
population in the plain area and for 750 in tribal and difficult areas. At present, 79,512 MSS
are working at village level. ASHAs at village level have been introduced under NRHM(2005-
06)–5.40 lakhs ASHAs have been selected and 4.62 lakhs have been trained so far.

Mahila Swasthya Sangh (MSS)

SUBCENTERS (SCS)

It is community based rural institution for primary health care.

The subcenter is the most vital peripheral contact point between the primary health care
system and the community. It is the first formal ladder of primary health care. It is manned by
one multipurpose health worker male or female who is skilled paramedical trained worker,
having undergone one year (MW) and one and half year training (FW),

Health Care Delivery System

UNIT 11
Textbook of Advanced Nursing Practice Seek appointment to a regulatory agency. - Be
appointed to a governing board in the public or private sector. Use nursing expertise as a
frontline policymaker who can enhance health care and the profession.

Florence Nightingale, the founder of modern nursing was the first nurse politician. Current
Political Issues Affecting the Practice of Professional Nursing and Health Care

1. The Patient Safety Act of 1997

It aims to ensure safe patient care in hospital and other health care institutions. Each health
care institution would have to make the following information available to the public: •
Number of RNs and UAP (Unlicensed Assistive Personnel) providing direct patient care •
The mean number of patients per RN who is providing direct patient care • Patients' mortality
rates • Number of adverse patient care incidents • Methods used to determine and adjust
nursing personnel staffing levels according to patient care needs.

2. The Genetic Information Nondiscrimination in Health Insurance Act of 1997

This legislative act would protect American consumers from being denied health care
insurance coverage based on high

risk genetic information • Advances in genetic research provide critical information for
effective screening for diseases for persons at high-risk for

terminal and chronic illnesses, especially cancer. 3.' The HIV Prevention Act of 1997

It includes the following provisions:

Mandatory HIV testing of all sex offenders Mandatory partner notification of persons testing
positive for HIV

Allowing health care professionals to perform HIV testing without informed consent on any
person undergoing an invasive medical procedure.

4. Victims of Abuse Protection Act of 1997

This bill would prohibit the use of information by insurers for refusing to ensure persons or
for charging higher premiums based on previous history of or high-risk for domestic violence.
(Gonzales, 1997). As client advocates, nurses must support any legislation that prohibits
access to, or increases the cost of health care for, any specified population.

5. The Telehealth Bill of 1997

Telehealth is the use of computer technology to link rural and underserved areas to large
medical centers. This bill would provide loan and grant funding to establish telehealth
networks in rural areas and renames the Joint Working Group on Telemedicine as the 'Joint
Working Group on Telehealth.

6. Working Families and Flexibility Act

• It has been introduced to assist parents meet family and work obligations. This bill
proposes that employers compensate hourly rate employees for overtime by offering them a
choice of overtime pay or compensatory time off at a rate of 1.5 times the hourly wage. This
bill would increase the flexibility of hourly waged employees.

BIBLIOGRAPHY

1. BT .

Basavanthappa, "Nursing Administration." New Delhi, Ist edition, Jaypee Brothers Medical
Publishers, p 50-1. 2. Chitty K. "Professional nursing concepts and challenges", 4th edition,
Elsevier, p 580-98. 3. George Julia B. "Nursing Theories: The Basc for Professional Nursing
Practice;" 3rd edition, Appleton and Lange, p 32-6. 4. Joan Creasia L. Barbara Parker.
"Conceptual Foundations of Professional Nursing Practice, Mosby, p 107-25, 225-39. 5.
Susan Leddy, Mae Pepper ), "Conceptual Basis of Professional Nursing", 4th edition,
Lippincott, p 277, 290-2

Health System

130