Health infrastructure in India

Basic Health Infrastructure : Status as on March, 2009 ASHA : 6.96 lakhs to 8.3 lakhs ( varied figures ) Sub Centres : 145 894 to 146 036 Public Health Centres (PHCs) : 23 391 to 23 458 Community Health Centres (CHCs) : 4276 to 4510 First referral Units (FRUs) : 2463

Basic Health Infrastructure: March, 2009

Villages : 593 731 ASHAs : 696 000 Sub Centres : 146 000 PHCs : 23 400 CHCs : 4300 First referral Units (FRUs) : 2463 1 PHC for 6 Subcentres 1 CHC for 4 PHCs

ANMS : 47 000 MBBS doctors : 8624 Specialists : 2460 AYUSH doctors : 7692 Paramedic staff : 14 490

NRHM for period 2005 to 2010 7.49 lakh AHSA's selected 7.05 lakh AHSA's trained upto first module 5.65 lakh AHSA's trained upto fourth module

5.20 lakh AHSA's with drug kits in villages 7.05 lakh AHSA's trained upto first module 46 690 ANMS appointed on contract 26 793 staff nurses appointed on contract 8624 MBBS doctors appointed on contract 2460 specialists appointed on contract 7692 AYUSH doctors appointed on contract 14 490 paramedic staff appointed on contract

Sub-Centres (SCs) The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community.

Each Sub-Centre is required to be manned by at least one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health Worker. Under NRHM, there is a provision for one additional second ANM on contract basis. One Lady Health Visitor (LHV) is entrusted with the task of supervision of six Sub-Centres. Sub-Centres are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhoea control and control of communicable diseases programmes. The Sub-Centres are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. The Ministry of Health & Family Welfare is providing 100% Central assistance to all the Sub-Centres in the country since April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The salary of the Male Worker is borne by the State Governments. Under the Swap Scheme, the Government of India has taken over an additional 39,554 Sub Centres from State Governments / Union Territories since April, 2002 in lieu of 5,434 Rural Family Welfare Centres transferred to the State Governments / Union Territories. Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee

As on March, 2009 the overall shortfall (difference in requirement for existing infrastructure as compared to manpower in position), in the posts of HW(F) / ANM was 7.3% of the total requirement. The overall shortfall is mainly due to shortfall in States namely, Arunachal Pradesh, Bihar, Chhattisgarh, Gujarat, Himachal Pradesh, Jammu & Kashmir, Karnataka, Orissa, Tamil Nadu, Tripura, Uttarakhand and Uttar Pradesh. The number of ANMs at Sub Centres and PHCs have increased from 133194 in 2005 to 190919 in 2009 There were 1,45,894 Sub Centres functioning in the country as on March 2009.

Primary Health Centres (PHCs) PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Programme (MNP)/ Basic Minimum Services (BMS) Programme.

As per minimum requirement, a PHC is to be manned by a Medical Officer supported by 14 paramedical and other staff. Under NRHM, there is a provision for two additional Staff Nurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centres. It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive, promotive and Family Welfare Services. There were 23,391 PHCs functioning as on March 2009 in the country. The Doctors at PHCs have increased from 20308 in 2005 to 23982 in 2009. ( To get a perspective of how poor is rural doctor penetration, remember that every year about 26000 MBBS graduates pass out of the government and private medical colleges in India. Which means over the last several years, we have not been able to put even one single batch of doctors in rural area ). For Doctors at PHCs, there was a shortfall of 16.2% of the total requirement. This is again mainly due to significant shortfall in Doctors at PHCs in the States of Assam, Bihar, Madhya Pradesh, Orissa, Uttarakhand and Uttar Pradesh

Community Health Centres (CHCs) CHCs are being established and maintained by the State Government under MNP/BMS programme. As per minimum norms, a CHC is required to be manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.

It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2009, there were 4,510 CHCs functioning in the country.

First Referral Units (FRUs) An existing facility (district hospital, sub-divisional hospital, community health centre etc.) can be declared a fully operational First Referral Unit (FRU) only if it is equipped to provide round-the-clock services for Emergency Obstetric and New Born Care, in addition to all emergencies that any hospital is required to provide. It should be noted that there are three critical determinants of a facility being declared as a FRU: i) Emergency Obstetric Care including surgical interventions like Caesarean Sections; ii) Newborn Care; and iii) Blood Storage Facility on a 24-hour basis.

Role of ANM In the rural health care system, the ANM is the key field level functionary who interacts directly with the community and has been the central focus of all the reproductive child health programs. Over the years with changes in program priorities, the role and capacity of the ANM has changed substantially.i Todays multi purpose worker(MPW) is more involved in family planning and preventive services in contrast with ANM of sixties who was providing delivery and basic curative services to the community. In the overall job description of the ANM, the M the role of Midwife has been neglected. This has implications on the implementation and outcomes of health programs in rural India. The overemphasis on family planning targets and the addition of infectious disease control programs in the ANMs already busy schedule has led to neglect of MCH. It is important to understand why the role of ANM changed from primarily a midwife to a preventive health worker with focus on family planning and immunization.

Health Infrastructure in a Typical Indian District

Level of Health Care Institution District Hospital First Referral Unit (FRU) Community Health Center (CHC) Primary Health Center (PHC) (Old Population Norm 2 - 3 Million 300,000 500,000 100,000 300,000 100,000 Human Resource available Obstetrician, Anesthetist, Pathologist, Pediatrician, General doctors, nurses Obstetrician, General doctors, nurses Any specialist, General doctors, nurses General doctors (2), nurses, LHVs, ANMs

or Block level) PHC New Sub-center Village Level Functionaries 30,000 5,000 1000 General doctor, nurse, LHV, ANM ANM ASHA

Average Rural Population covered by Health Infrastructure (2001) Health Infrastructure Sub Centre Primary Health Centre Community Health Centre Plain Area 5 000 30 000 120 000 Hilly /Tribal / Difficult Area 3000 20 000 80 000 Present Status 5 089 31 743 164 632

Present structure Norm : 6 subcentres for one PHC ( Present : 6 ) Norm : 4 PHCs per CHC ( Present : 5 ) The above table indicates that we need to strengthen CHC infrastructure urgently.

Average Rural Area and villages covered

Health Infrastructure
Sub Centre Primary Health Centre Community Health Centre

Avg Villages covered

4 27 142

Avg are covered Sq. Kms

21.37 133.31 691.42

STAFFING PATTERN Staff for sub centre 1 Health Worker (Female)/ANM 1 Additional Second ANM (on contract) 1 Health Worker (Male)

Voluntary Worker (Paid @ Rs.100/- p.m. as honorarium): 1 Total : 3 professionals

Staff for new primary health centre 1 Medical Officer 1 Pharmacist 3. Nurse Mid-wife (Staff Nurse) : 1 + 2 additional Staff Nurses on contract 1 Health Worker (Female)/ANM 1 Health Educator 1 Health Assistant (Male) 1 Health Assistant (Female)/LHV 1 Upper Division Clerk 1 Lower Division Clerk 1 Laboratory Technician 1 Driver (Subject to availability of Vehicle) 4 Class IV Total : 15

Staff for community health centre 4 Medical Officer # 7 Nurse Mid Wife (staff Nurse) 1 Dresser 1 Pharmacist/Compounder 1 Laboratory Technician 1 Radiographer 2 Ward Boys

1 Dhobi 3 Sweepers 1 Mali 1 Chowkidar 1 Aya 1 Peon Total : 25

Status of different states in India: 2009

State / UT : 2009 Status Andaman & Nicobar Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chattisgarh Dadra Nagar Haveli Daman & Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu & Kashmir Jharkhand Karnataka Kerala Sub centre 114 12522 592 4592 8858 16 4776 38 26 41 171 7274 2465 2071 1907 3947 8143 4575 PHC 19 1570 116 844 1776 0 715 6 2 8 19 1084 437 449 375 321 2193 697 CHC 4 167 44 108 70 2 144 1 2 0 5 281 93 73 85 194 324 226

Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Puducherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttarakhand Uttar Pradesh West Bengal Total

14 8869 10579 420 401 370 397 6688 53 2950 10951 147 8706 579 1765 20521 10356 145894

4 1155 1816 72 105 57 123 1279 24 394 1503 24 1277 76 239 3690 922 23391

3 333 376 16 28 9 21 231 3 129 367 0 256 11 55 515 334 4510