Public health system of India – an overview (focusing mainly on rural health system)

National Rural Health Mission (NRHM) is the unique initiative of Govt. of India which encompasses all the National Health and Disease Control Programs (except AIDS and Non-Communicable Disease control programs) to provide operational synergy and additional financial, administrative and technical support to those programs. One of the key objectives of NRHM is to strengthen the primary healthcare services at the rural set ups and its referral linkages and decentralization of responsibilities of healthcare management upto the village level.

Village Health and Sanitation Committee (VHSC): A village around 1000 population has a Village Health & Sanitation Committee. The members of the committee are selected from the local villagers like community leaders, teachers, healthcare providers, community health workers and members of the local governance body named Panchayeti Raj Institution (PRI). VHSC is responsible to develop annual health action plan of the village, its implementation & monitoring and overall decision making on the health situation of the village. The committee receives funding support from NRHM on annual basis.

Community Health Workers:  Generally, a village with 1000 population should have the following community health workers:

ASHA (Accredited Social Health Activist) worker: Eligible female volunteer of the village is selected by VHSC of the village to be trained and function as ASHA Worker who is primarily responsible for door-to-door visit, health education, basic health services and linking the community people with the existing public health system through referrals and follow up. There should 1 ASHA worker for 1000 population as per the NRHM norm. NRHM has so far introduced nearly 1 million ASHA workers in the rural health system of India.

 AWW (Anganwadi Worker): AWW works at AWC as health cum education volunteers (Anganwadi Centre) which is the most peripheral rural unit of the Ministry of Women & Child Development under the scheme of Integrated Child Development Service (ICDS) scheme. The key role of AWW is to provide free nutritional supplementation to the children below 6 years and pregnant/lactating mothers, immunization services, ANC & PNC, referral services health education to the women and non-formal preschool education to children below 5 years. There should be 1 AWW per 1000 population. Today in India, about 2 million aanganwadi workers are reaching out to a population of 70 million women, children and sick people, helping them become and stay healthy.

Traditional Birth Attendant (TBA): They are traditional birth attendants in the villages who assist women to deliver at home. Govt. of India has decided to train theis cadre of community health workers to ensure positive outcome of deliveries conducted at home.

Sub-district/block level health services:  India has 640[1] administrative districts within its 28 states and 7 Union Territories and each district is divided into administrative divisions and divisions into several administrative blocks.

1)      Sub Health Centre or Sub Centre: For 5000 population of the block (5 – 6 villages), there is a sub-centre (SC)[2] which is manned by a Multi Purpose Worker/MPW – female or ANM or Auxiliary Nurse Midwife plus a Multi Purpose Worker/MPW – male. In the public sector, a Sub-health Centre is the most peripheral and first contact point between the primary health care system and the community. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. Of particular importance are the packages of services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services and counseling. They also provide elementary drugs for minor ailments such as ARI (Acute Respiratory Tract Infection), diarrhea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the government implements several national health and family welfare programs which again are delivered through these frontline workers like ANM and MPW.

2)      Primary Health Centre (PHC): For every 30,000 – 40,000 population[3] there is one PHC, which acts as a referral point of 4- 5 SCs (30 – 40 villages) and manned by 1-2 Medical Officers and 14/15 para-medical staff like Staff Nurses, Lady Health Visitors, Health Educators, Health Supervisors etc. It has facilities of basic institutional care including delivery with 4 – 6 beds, basic laboratory services and ambulance for referral services. PHCs are the end-point of primary health care.

3)      Community Health Centre or Community Care Centre (CHC/CCC): This is the referral point for 4 PHCs with specialized services, covering a catchment area of 100,000 population (100 villages). The specialized services include emergency medical/surgical/obstetric care, ambulance services for referral, institutional care (30 beds) and laboratory services. CHCs are the starting point of secondary healthcare.

4)      Sub-District/Sub-Divisional hospitals: These are 51 – 100 bedded hospitals to be located in the divisional headquarter of the district.

District health services: Every district is expected to have a district hospital linked with the public hospitals/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centers and Sub-centres. As per the information available, 609 districts in the country at present are having about 615 district hospitals. However, some of the medical college hospitals or a sub-divisional hospital is found to serve as a district hospital where a district hospital as such (particularly the newly created district has not been established. Few districts have also more than one district hospital. These hospitals are 100 – 200 bedded and generally equipped with specialist health and laboratory services. The District Hospitals are actually the end-point of secondary health care.

Tertiary healthcare: The tertiary healthcare referral points are located above district level namely State Hospitals, Regional Medical Centres, Medical Colleges and National level Medical Institutions.

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[1] http://en.wikipedia.org/wiki/List_of_districts_of_India

[2] In hilly and difficult-to-reach area there is one SC for every 30,000 population

[3] In hilly and difficult-to-reach area there is one PHC for every 20,000 population

An unique hot-spot for commercial sex work

Yesterday I visited a Targeted Intervention Project of FSWs after four long years and got a shock of my life after seeing one of the hot-spots of the project in Delhi.

The place is located in one of the filthiest garbage-dumping areas of Delhi with a canal passing by that carries black turry water mixed with all types of biological wastes of the world. We crossed that area in a complete adventurous mode through the mud and garbage and along the edge of the canal with every chance to slip and fall down into the dirty water of the canal. The hot-spot is located at the back portion of garbage area which is actually a large deserted jungle area with almost no visible human movement inside. The FSWs and clients somehow manage to sneak into that area through the heaps of garbage and mud from late morning till evening.

The FSWs generally carry a large plastic sheet with them. The sheet is spread in the convenient location between the bushes and trees for the sexual act. The only witnesses of their activities are some moving stray dog inside the jungle.

We found thousands of used condoms lying almost in all the places between the trees denoting safe sex practice by the FSWs and their clients. The cops have absolutely no idea about these activities as we were reported, so the women who hail mostly from East Delhi and UP don't have to remain worried for administrative vigilance and legal hassles. But there is chance of snake-bite, as I know jungles of Delhi like this have big poisonous snakes (mostly Cobra). When I asked about it, the women agreed, but thankfully, there is no case of snake-bite till now.

The jungle is equally filled with litter that is often brought by gushing wind from the near-by garbage spot. I just failed to understand how those clients (I saw quite a few of them, moving silently in the jungle, mostly young men in their early twenties. The FSWs looked relatively older, in their mid thirties/early forties) grow desire to have sex inside that filthy place with litter lying all-around. Some of the men, I saw were also boozing in the jungle as if they had a picnic over there.

It was truly a queer experience. I visited many hot spots including dingy lanes of Sonagachi, exotic big brothels of Indonesia, massage parlors/night clubs of Thailand and Bali, chaotic GB Road of Delhi, open field brothel of Durgapur, West Bengal, cruising points of MSWs and street-walkers in various places. But this one that I visited yesterday was unique in the sense that the place is damn difficult to reach, and in true sense, with all due respects to those sex workers and their clients, only animals can do sex in those places, not humans.

I gave a big thank to the outreach worker of the project who is responsible for that particular hot-spot, a girl, doing her graduation, who is tremendously enthusiastic and devoted in her work. She has engaged the FSWs strongly with the project activities. She also ensures condoms that have been supplied uninterruptedly to the FSWs by the project are being properly and adequately utilized by them.

We already saw their extensive usage in the jungle through the used ones scattering almost in every nook and corner of the place.

India is gradually overcoming the challenges of HIV with gradual decline of prevalence in many places of the country. The gallant efforts to confine the HIV transmission within the population of so called ‘high risk groups’ through the Targeted Intervention (TI) approaches under the National AIDS Control Program of the country has been showing the good results now.

Sugata M

TB case notification - a remarkable step of Govt. of India

Notification of TB cases is a remarkable decision of Govt. of India and how RNTCP develops the notification system in the coming years is something very interesting to observe.

Presently TB cases outside RNTCP are being reported mainly from the following two sources:

1)      Non-RNTCP govt/public sectors (Public-Public Partnership initiative):  Those sectors have their own health services like Defense, Railways, Para-Military, Mines, Education etc. Some of these sectors are already reporting TB cases detected by them to RNTCP wherever linkages between these sectors and RNTCP have been developed.

The current policy decision of TB case notification is expected to scale up and strengthen those public-public partnership linkages as TB case notification from non-RNTCP public sector should be comparatively an easier job than the same from non-govt. private sector.

2)      Non-govt. sector (Public-Private Mix/PPM initiative): RNTCP is currently linked to Non-govt. sectors through 3 Global Fund supported projects as below:

·         Project Axshya/GFATM Round 9 Civil Society project: Linking chiefly unqualified rural practitioners with RNTCP in 374 districts of 23 states

·         IMA PPM project/RCC project: Linking the qualified private practitioners who are IMA members with RNTCP in 15 states and 1 UT

·         CBCI-CARD project/RCC project: Linking Catholic healthcare facilities with RNTCP in 19 states

·         Besides, there are NGO/Private Practitioners’ Schemes of RNTCP that have been engaging Private Doctors and NGOs with RNTCP on individual basis.

But these linkages are not enough as the non-govt. and private sectors providing health services to the people of the country including TB management and care are so vast. It is estimated that about 45% of the TB cases are treated in the private sector.

 There is an urgent need to expand the PPM (Public-Private Mix) initiative of RNTCP much beyond the above-mentioned projects and on-going NGO/PP schemes to achieve the two main objectives:

1)      To standardize the TB treatment across the country

2)      To enhance TB case reporting from all healthcare providers

The policy decision of making TB a notifiable disease should help in achieving the two objectives, provided the policy will be rolled out with proper strategy and approach with clear and simple operational protocol in place that will be accepted by all stakeholders and implementable.

The role of Civil Society will be immense to help RNTCP to achieve its notification objectives. Other than advocacy, Civil Societies can function as an effective interphase between the National Program and private sector to enable and roll out the notification process.

Currently, the National Program is still finding ways to sustain the communication with private sectors as mere one/two time sensitization of the private providers has been found to be grossly insufficient to engage them with RNTCP. The private practitioners should be kept under constant communication and followed up, where the Civil Societies can play a meaningful role, definitely with some kind of external funding assistance or incentives.

Prioritization of the private practitioners according to the volume of TB cases been provided services by them should be an important strategy that RNTCP may consider in coming future to initiate the process of notification.

At the same time the national program should take proper attention and care of sensitive issues like maintaining confidentiality of the TB patients including their HIV status during the notification process.

Let me wholeheartedly congratulate Central TB Division and Govt. of India for taking such strategic and timely decision, especially at a time when the national program has taken the decision to achieve the targets of Universal Access of TB care in the country.

From: Dr Sugata Mukhopadhyay