Hospital management

Ques 1: Describe in detail the healthcare delivery system in India?

Ans: – The Healthcare delivery system broadly consists of the following sectors or agencies:-

Public Health Sector

1. Primary Health Care
   Primary health centres.
   Sub- Centres.
2. Hospitals/Health Centres
   Community Health Centres.
   Rural hospitals.
   District hospitals.
   Teaching hospitals.
   Specialist hospitals.
3. Health Insurance Schemes
   Employees States Insurance Scheme (ESIS).
   Central Government Health Scheme (CGHS).
4. Other agencies
   Defence.
   Railways.

Private Sector

•  Private hospitals, polyclinics, dispensaries and nursing homes.
• General Practitioners and Clinics, Private hospital includes hospitals run on profit basis, no loss- no profit basis and corporate hospitals.

Voluntary Health Agencies

National Health Programmes.

Public Health Sector

Primary health care:

•  Villages level
•  Village Health Guide Scheme. It was introduced on 2nd October,1977 and launches in all states except Kerala, Karnataka, Tamil Nadu, Arunachal Pradesh and Jammu Kashmir. A village health guide is a person with an aptitude for social services and is not a government functionary. The health guides are mostly women now. They are chosen by the community in which they work and serve as links between community and governmental infrastructure.

Guidelines for their selection are:

• Should be permanent residents of the local community.
• Should have a minimum formal education of at least up to VI standard.
•  Should be acceptable to all sections of the community.
• Should be able to spare at least 2-3 hours per day for community health workers.

After selection, they undergo training in the nearest primary health centre for 200 hours spread over a period of 3 months and receive Rs 200/- per month.

Duties assigned include:

• Treatment of simple medical ailments and activities in first aid.
• Mother and child health including family planning.
• Health education.
•  Sanitation.

 Local Dias: Under the Rural Health Scheme, an extensive programme has to be undertaken to train all categories of local Dais (traditional birth attendants) to improve their knowledge in the elementary concepts of maternal and child health and sterilization. Training is at PHC, Subcentres or MCH centres for 2 days a week and the remaining 4 days the accompany the Health Workers to the villages. During training each Dai is required to do 2 deliveries under the guidance of a health worker, the emphasis being on asepsis so that home deliveries are conducted under safe hygiene conditions thereby reducing maternal and infant mortality.

 Anganwadi Workers: Under the integrated Child Development Service Scheme, there is an Anganwadi worker for every 1000 population and one ICDS project has 1000 Anganwadi workers. The Anganwadi worker is selected by the community she is expected to serve and is trained in various aspects of health, nutrition and child development for 4 months. She is paid Rs 200-250/- per month for services rendered which include health check-ups, immunization, supplementary nutrition, health education, non-formal preschool education and referral services.

Sub-centre level: It is the peripheral outpost of the existing health delivery system in rural areas. One sub-centre covers 5000 population in general and one for every 3000 population in hilly, tribal and backward areas. The functions of a sub-centre are limited to mother and child health care, family planning and immunization.

There are 2 functionaries at the level of the Subcentres

1.  Health Care Male.
2. Health Care Female. One health assistant will supervise the work of 6 health workers. Six subcentres are located in each PHC area.

Primary Health Centre level: The Bhore committee in 1946 gave the concept of a Primary Health Centre as a basic health unit, to provide, as close to the people as possible, integrated, curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. One PHC for every 30000 rural populations in the plains and one PHC for every 20000 population in hilly, tribal and backward areas have been proposed for effective coverage.

Functions of PHC are:

• Medical care.
• MCH care includes Family planning.
• Safe water supply and sanitation.
• Prevention and control of locally endemic diseases.
• Collection and reporting of vital statistics.
• Education about health.
• National health programme.
• Referral services.
• Training of health guides, health workers, local dias and health assistants.
• Basic laboratory services.

Hospitals/Health Centres:

Community health centres: Some of the PHCs have been upgraded to function as Community Health Centres, each covering a population of 80,000 to 1.20 lakh. The staff at the CHC includes specialists in surgery, medicine, OBG and paediatrics, 7 nurses mid-wives, dresser, pharmacist, laboratory technician, radiographer, 2 ward boys, dhobi, 3 sweepers, mali, chowkidar, aya and peon.

Health Insurance Scheme:

Employees State Insurance Scheme: This scheme is run by contributions, employers and grants from Central and State Governments. The scheme covers employees drawing wages not exceeding Rs.6500/- per month. There is a provision for medical care in cash and kind, benefits in the contingency of sickness, maternity, employment injury, pension for departments on the death of a worker due to employment injury and also rehabilitation. Medical care is provided by ESI hospitals, ESI dispensaries and Insurance Medical Practitioners.

Central Health Government Schemes: This was started in 1954 to provide comprehensive medical care to Central Government employees. The services include

•  Outpatient care.
• Laboratory and x-ray investigations.
• Domiciliary visits.
•  Hospitalization
• Maternal and child health care.
• Specialist consultation.
•  Supply of optical and dental aids.
•  Emergency treatment.
• Family welfare services. etc The scheme has been gradually extended over the years to cover the employees of the autonomous organizations, retired central govt. servents, widows receiving a family pension, members of parliament, ex-governors and retired judges. The employee and the employer, to the mutual advantage of both, base the CGHS scheme on the principle of cooperative effort.

Other agencies:

Defence Medical Services: Under “Armed Force Medical Services” integrated and comprehensive health care consisting of preventive, promotive and curative services and provided to the defence personnel and their family members free of cost. Outpatient care, hospitalization, drug supply, specialist consultation, laboratory investigation, emergency care including transport facilities, artificial limbs are provided. The services are provided through the outpost health centres, command hospitals at the base and the Armed Force Medical College.

Railways Medical Services: Comprehensive health care is provided to all railway employees and their family members through the agency of railway clinics, Health Units and Hospitals. The lady medical officers, health visitors and mid-wives provide MCH and school health services. At the divisional hospitals, consultation is available.

Private Sector

There is a large number of private medical practitioners providing health care to a large section of the population. General practitioners constitute the majority of the medical profession. Most of the practitioners tend to congregate in urban areas. They provide mainly curative services. There are private clinics, dispensaries, nursing homes and hospitals, functions and activities of these private practitioners are regulated by some statutory bodies like Medical
Council Of India. The services of the private agencies are available to those who can pay.

Voluntary Health Agencies: There are numerous voluntary agencies working in the field of health in India. There are voluntary agencies providing comprehensive care and leprosy services, antituberculosis services, immunization, emergency services, MCH, family planning services, health education etc. They include both national and international health agencies. Some of the agencies working in India are:

1.  Indian Red Cross Society.
2. Hind Kust Nivaran Sangh.
3. Indian Council For Child Welfare.
4. Tuberculosis Association of India.
5. Bharat Sewak Samaj.
6. The Kastueba Memorial Fund.
7. Family Planning Association Of India.
8. The All India Blind Relief Society.
9. Rotary Clubs.
10. Professional Bodies.
11. International Agencies.
12. Health Programmes In India.

National Health Programmes:

Several measures have been undertaken by the National Government to improve the health of the people. List of National Health Programme:

1. National TB Control Programme.
2. National Vector Borne Diseases Control Programme.
3. National Leprosy Eradication Programme.
4.  National AIDS Control Programme.
5. Reproductive and Child Health programme.
6.  National Polio Surveillance Project.
7. National Programme for Control of Blindness.
8.  National Iodine Deficiency Disorders Control Programme.
9. National Diabetes Control Programme.
10. National Cancer Control Programme.
11.  National Mental Health programme.
12. National Programme for Prevention and Control of Deafness.

Ques 2:- Describe the National Health Policy in India. What goals were to be achieved? Ans:- A National Health Policy was last formulated in 1983, and since then there have been marked changes in the determinant factors relating to the health sector. Some of the policy initiatives outlined in the NHP-1983 have yielded results, while, in several other areas, the outcome has not been as expected. The changed circumstances relating to the health sector of the country since 1983 have made it necessary now to review the field and to formulate a new policy framework as the National Health Policy-2002. National Health Policy 2002 attempts to set out a new policy framework for the accelerated achievement of Public Health Goals in the socioeconomic circumstances currently prevailing in the country.

Achievements Through The Year- 1951-2000

In line with the changing health scenario and the overall increasing role of privatisation in the national economy. “National Health Policy 2002” has been brought out by the Ministry of health and family welfare. Among the achievements in the health sector reviewed in NHP2002 is the eradication of smallpox and guinea worm, final steps towards the eradication of polio, increase in life expectancy, decrease in death rate, infant mortality rate, birth rate, reduction in leprosy and malaria and development of health infrastructure. As in NHP 1983, the strategy of primary health care has been adopted as the key strategy in the new NHP2002, with emphasis on increasing access to health services through

• A decentralised Public Health System.
• Equitable access.
• Increasing Public Health Investment, with Greater allocation for Primary Health Level. -Enhanced contribution of the Private and NGO sectors targeted the groups which can afford to pay for services.

Goals Year

1. Eradication of polio and yaws 2005
2. Elimination of Kala Azar and Leprosy 2010
3.  Achieving Zero Growth of HIV/AIDS 2010
4.  Reduction of 50% mortality due to TB,
5. Malaria and Water Borne Diseases 2010
6. Prevalence of Blindness to 0.5% 2010
7. Reduction of IMR to 30/1000 2010
8. Reduction of MMR to 100/1 lakh 2010
9. Reduction of LBW to 10% 2010
10. Increasing health expenditure to 2.0% of GDP 2010 10. Establishing an integrated system of surveillance, National Health and health 2005 statistics.

It is planned, under the policy to increase health sector expenditure to 6 percent of GDP, with 2 percent of GDP being contributed as a public health investment, by the year 2010. The State Governments would also need to increase the commitment to the health sector. In the first phase, by 2005, they would be expected to increase the commitment of their resources to 7 percent of the Budget; In the second phase, by 2010, to increase it to 8 percent of the Budget. With the stepping up of the public health investment, the Central Government’s contribution would rise to 25 percent from the existing 15 percent by 2010.

Ques 3: WHO: World Health Organization.
Ans: The World Health came into being on 7th April 1948, celebrated each year as “World Health Day”. The objective of the WHO is “the attainment by all people of the highest level of health”. In recent years, two major policy developments have influenced the WHO. First, the Alma-Ata conference in 1978 on primary health care and Secondly, the Global Strategy for Health for All by 2000.

Activities of WHO:

1.  Communicable disease control HIV, tuberculosis, malaria, yaws, yellow fever, viral hemorrhagic fevers, leishmaniasis, trypanosomiasis, sexually transmitted disease, zoonoses etc. -WHO aspires to eradicate poliomyelitis, dracunculiasis and to eliminate leprosy in the very near future. -Immunization against common diseases of childhood is now a priority programme.
2. Non- Communicable disease control of cancer, cardiovascular diseases, genetic disorders, mental disorders, drug addiction nutritional disorders and dental diseases.
3.  Family Health:- which includes maternal and child health care, human reproduction, nutritional and health education.
4. Occupational and Environmental Health Problem:- These are the protection of the quality of air, water and food, health conditions of work, radiation protection etc.
5. Health Statistics:- Publishing a wide variety of morbidity and mortality statistics relating to health such as weekly epidemiological Records, World
   Health Statistics, both quarterly and annual, International Classification of Diseases.
6.  Programmes dealing with Bio-Medical Research, education and training of health personnel, information and technology transfer and quality control of biological products and pharmaceutical products.
7. Collaboration with other organizations:- Such as with the UN, U.S centres for Disease Control and Prevention, Public Health Laboratory Services in Uk, the Canadian Addiction Research Foundation and several others.

The headquarters of WHO is in Geneva. There are more than six regional offices of WHO COUNTRY HEADQUARTER

• South-East Asia Region New Delhi, India.
• Eastern Mediterranean Region Alexandria, Egypt.
• Region of the Americas Washington D.C, USA.
• Western Pacific Region Manila, Philippines.
• African Region Brazzaville, Congo.
• European Region Copenhagen, Denmark.

Purpose of WHO:

WHO’s aim is “the attainment by all peoples of the highest possible level of health”.

1. To help governments strengthen their health services.
2. To promote better teaching standards in medicine and its related professions.
3.  To inform, advise and help in the field of health.
4. To promote- in cooperation with other specialized agencies where necessary- the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene.
5.  To promote cooperation among the scientific and professional groups which advance the cause of good health.
6.  To promote maternal and child health and welfare and foster the ability to live harmoniously in a changing environment.
7. To foster activities in the field of mental health, especially those affecting the harmony of human relations.
8. To promote and conduct research in the field of health.
9. To stimulate the eradication of epidemic, endemic and other diseases.
10. To propose international conventions and agreements in health matters.
11. To develop international standards for food, biological and pharmaceutical products.
12. To assist in developing an informed public opinion among all peoples on matter of health.

UNICEF:  United Nations International Children’s

Emergency Fund.

Ans: It was established as one of the specialized UN’s agencies in 1946. Now the agency is known as ‘U.N.Children’s Fund’. Its headquarters is in New York while its regional office for South Central Asia Region is in New Delhi. -UNICEF works in collaboration with WHO and other specialized agencies of the United National like UNDP, FAO and UNESCO. -UNICEF is active in the field of child health, child immunization, child nutrition, family and child welfare, child education etc. Currently, UNICEF is promoting a campaign known as the GOBI campaign to encourage four strategies for “a child health revolution”. G for growth charts to better monitor child development.

•  for oral rehydration to treat all mild and moderate dehydration.
•  for breast feeding and
•  for immunization against diphtheria, pertussis, tetanus, measles, polio and tuberculosis.

Functions of UNICEF:

Child health: Reduction of infant mortality rate to less than 60 percent per 1000 live births and reduction of child mortality to less than 10 by 2000 AD. The objectives are:

• Eradication of poliomyelitis by the year 2000.
• Elimination of neonatal tetanus.
• Reduction by 95% in measles death and reduction by 90% of measles cases compared to preimmunization levels.
• Maintenance of high level of immunization coverage at a level of 100% of infants against Diptheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis and against tetanus for women of childbearing age.
•  Reduction by 50% in death due to diarrhoea in children under the age of 5 years and 25% of diarrhoea in incidence rate.
• Endeavour to reduce mortality rates due to acute respiratory infections among children under 5 BY 40% from the present level.

Maternal Health: Reduction in maternal mortality rate by half. The objectives are:

•  Special attention to the health and nutrition of the female child and to pregnant and lactating women.
• Access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many.
•  Universal access to primary education with special emphasis for girls and accelerated literacy programmes for women.

Nutrition: Reduction in severe and moderate malnutrition among under 5 children by half of the levels in 1990. The objectives are:

• Reduction in the incidence of low birth weight(2.5 kg or less) babies to less than 10%.
• Reduction in iron deficiency anaemia in women by one-third.
•  Control of iodine deficiency disorders.
• Control of vitamin A deficiency and its consequences, including blindness.
• Empowerment of all women to breastfeed their children exclusively for 4-6 months and to continue breastfeeding with complimentary food, well into the second year.
• Growth promotion and its regular monitoring to be institutionalised.
•  Dissemination of knowledge and supporting services to increase food production to ensure household food security.

 Water and Sanitation: Universal access to safe drinking water and improved access to sanitary means of excreta disposal. Eradiation of guinea worm diseases and providing safe water with fluoride content within tolerable limits.

Education: 

Universal involvement, retention, minimum level of learning, reduction of disparities and universalisation of effective access of schooling.

The objective is:

•  Universal enrolment of all children including girls, using both full-time schools and part-time non-formal arrangements.
• Reduction of drop out rate between class I to V and I to VII from the existing 45% and 60% to 20% and 40% respectively.
• Achievement of a minimum level of learning by approximately all children at the primary level.
•  Reduction in disparities by an emphasis on girls education and special measures for children belonging to SC/ST.
•  Expansion of Early Childhood Development activities including appropriate low-cost family and community-based interventions.
• Universalisation of effective access to schooling.

Children in Especially Difficult Circumstances:

Provide improved protection of children in especially difficult circumstances and tackle the root cause leading to such situations.

Advocacy and People’s Participation:

Advocacy for children as everyone’s concern and advocacy with policymakers, planners, programme implementors at national and subnational levels for focus on the child will be integral to the achievement of the goals.

National Vector Borne diseases Control Programme.

Ans:- It was earlier known as National Anti Malarial Programme is the country’s most comprehensive and multi-faceted public health activity. Following are the strategy for the control of these diseases:

1. National Malaria Control Programme: At the time of independence, malaria was responsible for an estimated 75 million cases and 0.8 million deaths annually. Government launches the National Malarial Programme in 1953. The strategy of malaria eradication was highly successful and the cases were reduced to about 100,000 and deaths due to malaria were eliminated by 1965-1966. Subsequently, the programme faced various technical obstacles and financial and administrative constraints, which lead to a countrywide increase in the number of cases. 6.47 million malaria cases were reported in 1976, the
   highest since resurgence.
2. Current Anti-Malaria Control Strategies: The main control strategies under the programme are:

 Early Case Detection and Prompt Treatment (ECDPT) to provide relief to the patient and reduce the reservoir of the infection.

• Selective Vector Control by appropriate insecticidal spray in rural areas and recurrent anti-larval measures including biological methods like use of larvivorous fish.
• Promotion of personal prophylactic measures including the use of Insecticides Treated Mosquito Nets (ITMN) etc. and promotion of bio-environmental control measures.
• Emphasis on Information, Education and Communication (IEC) to promote community participation in the programme and Intersectoral collaboration.
• Capacity building of optimal utilization of the technical manpower for the programme.
• Monitoring and evaluation of Efficient Management Information System (MIS) Under the National Anti Malaria programme, the following schemes/ projects being run in the country:  Enhanced Malaria Control Project(EMCP): in the states of Andhra Pradesh, Chattisgarh, Gujrat, Jharkhand, Madhya Pradesh, Maharashtra, Rajasthan and Orrisa together contribute around 60-70% cases and deaths due to malaria. Urban Malaria Schemes(UMS): in 131 towns in the country. The World Health Organization is giving assistance to the National Anti Malaria Programme.

Dengue:

• Epidemiological Surveillance of Dengue Cases.
• Entomological Surveillance of Aedes aegypti mosquitoes.
• Clinical management of reported cases.
• Control of mosquitoes through Integrated Vector Management including source reduction, use of larvivorous fishes, impregnated bednets and selective fogging with pyrethrum.
• Behaviour changes communication to changes behaviour of the community about prevention of breeding of mosquitoes.

Kala-azar:

•  Early diagnosis and complete treatment through Primary Health Care System.
• Interruption of transmission through Vector control by undertaking residual insecticidal spraying in affected areas.
• Health Education and
• Community participation.

Japanese Encephalitis:

• Vector control by insecticidal spraying with appropriate insecticide for outbreak containment.
• Early diagnosis and prompt clinical management to reduce fatality.
•  Health Education.
• Training of Medical Personnel and Professionals.

Filariasis:

• Annual Mass Drug Administration (MDA) with a single dose of DEC to all eligible populations at risk of Lymphatic Filariasis.
• Home-based management of Lymphodema Cases and
• Hydrocelocotomy.

National AIDS Control Programme:
Ans:- The main regions affected are Tamil Nadu, Maharastra, Andhra Pradesh, Mumbai and Gujarat. It is estimated that about 3.8 million people are infected with the HIV virus in the country. The seropositive rate among the screened general population has reached 27 per 1000. The National AIDS Control Organization (NACO) was established to closely monitor the programme. The overall objective of the programme is to arrest the spread of HIV/AIDS infection in the country with a view to reducing morbidity and mortality, minimizing the socio-economic impact resulting from HIV/AIDS infection. Till 2005, a total of 110856 AIDS cases have been reported from the country. The Programme Strategy:-

Blood Safety: Testing of every unit of blood collected, is made mandatory. Profesional blood donation has been prohibited since January 1998. 154 Zonal Blood Testing Centres and 9 HIV Reference Centres are functioning. HIV kits are supplied up to District Level Blood Banks.

Control of Sexually Transmitted Diseases: 5 Regional STD Reference centres and 504 STD clinics usually located at the district hospitals and the skin and STD departments of medical colleges are strengthened by providing equipment materials, drugs, consumables and training of health personnel. Guidelines have been developed for simplified STD treatment through syndromic management. “Condom Promotion” has been taken up in a big way by NACO with regard to

1. Quality of control of condoms.
2. Social marketing of condoms.
3. Involvement of NGOs.

 HIV Surveillance: A need-based HIV/AIDS surveillance system has been established in the country and modified in response to the changing need and scenario. 62 Surveillance centres and 9 HIV Reference Centres have been set up in the country. In order to know the trend of HIV infection amongst variotion groups, 115 additional sentinel sites were established.

Strenghtening Clinical management

Capabilities and Reduction of Impact: This is accomplished by training of Counselors, setting up of community-based care structure and improving access to health care fcilities for those affected. Health Care Providers are being trained and oriented to provide care to the infected or AIDS patients without discrimination.

Information, Education, Communication and Social Mobilization: The objective is to raise awareness, improve knowledge and understanding among the general public about AIDS infection and STD, routes of transmission and method of prevention. Change in behaviours, condom use. The mass multimedia like television, newspapers have played a big role in this regard.

Ques 5:– Write about National Health Programme for Non-communicable diseases? Ans:- A non-communicable disease, or NCD, is a medical condition or disease which by definition is non-infectious and non-transmissible among people. NCDs may be chronic diseases of long duration and slow progression, or they may result in more rapid death such as some types of a sudden stroke. They include autoimmune diseases, heart disease, stroke, many cancers, asthma, diabetes, chronic kidney disease, osteoporosis, Alzheimer’s disease, cataracts

 National Cancer Control Programme (NCCP):

In India today there are an estimated 2.4 million cases of cancer and 0.7 million new cases are added every year. The initial activities included the purchase of cobalt therapy units. The NCCP was started in 1976 with the following strategy:

• Primary prevention.
• Early diagnosis.
• Upgradation of treatment facilities.

From 1990-91 onwards, the establishment and development of oncology units at medical colleges/ hospitals were taken up. The schemes for district-level projects for preventive, health education, early detection and pain relief measures were initiated; in additional financial assistance to NGOs for the purpose of undertaking health education and early detection activities against cancer was given.

National Diabetes Control Programme:

The prevalence of diabetes today in India in adults is 2.4% in rural and 4.0 -11.6% in the urban population. More than one lakh deaths every year are attributed to diabetes in the country. Considering the importance of the disease, during the seventh five-year plan National Diabetes Control Programme was Started on a pilot basis in some districts of Tamil Nadu, Karnataka and Jammu & Kashmir.

Objectives:

• Identification of high-risk subjects at an early stage.
• Early diagnosis and management of cases of diabetes.
• Prevention, arrest or slowing of acute metabolic as well as chronic cardiovascular- renal complications of diabetes. -Health education.

National Mental Health Programme (NMHP):

Psychiatric symptoms are common in the general population on both sides of the globe. These symptoms

• Worry.
• Tiredness.
• Sleepness nights affect more than half of the adults at some time, while as many as one person in seven experiences some form of diagnosable neurotic
  disorder. The government of India has launched the National Mental Health Programme in 1982.

Aims:

• 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 development to improve quality of life.

Objectives:

1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population.
2. To encourage the application of mental health knowledge in general health care and in social development.
3. To promote community participation in mental health services development and to stimulate efforts towards self-help in the community.

Strategies:

1. Integration of mental health with primary health care through the NMHP.
2. Provision of tertiary care institutions for treatment of mental disorders.
3. Eradicating stigmatisation of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority and State Mental Health Authority.