ORIENTATION PROGRAMME FOR HEALTH WORKERS

Rural Health Care System in India

Rural Health Care System – the structure and current scenario

Table 1.

Population Norms
Centre Plain Area Hilly/Tribal/Difficult Area
Sub-Centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1,20,000 80,000

Sub-Centres (SCs)

1.2. The Sub-Centre is the most peripheral and first contact point between the primary health
care system and the community. Each Sub-Centre is manned by one Auxiliary Nurse Midwife
(ANM) and one Male Health Worker MPW(M) (for details of staffing pattern, see Box 1). One
Lady Health Worker (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, diarrhea 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 Department of 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 39554 Sub Centres from State Governments /
Union Territories since April, 2002 in lieu of 5434 number of Rural Family Welfare Centres
transferred to the State Governments / Union Territories. There are 146026 Sub Centres
functioning in the country as on September, 2005 as compared to 142655 in September, 2004.

Primary Health Centres (PHCs)

1.3. 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 Programme (BMS). At present, a PHC is manned by a Medical
Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub
Centres. It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive,
primitive and Family Welfare Services. There are 23236 PHCs functioning as on September,
2005 in the country as compared to 23109 in September, 2004.
RURAL HEALTH CARE SYSTEM
IN INDIA
Box 1.
STAFFING PATTERN

A. STAFF FOR SUB - CENTRE: Number of Posts

1. Health Worker (Female)/ANM..................................................................................................1

2. Health Worker (Male)...............................................................................................................1

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

Total............................................................................................................................3

B. STAFF FOR NEW PRIMARY HEALTH CENTRE

1. Medical Officer........................................................................................................................1

2. Pharmacist.............................................................................................................................1

3. Nurse Mid-wife (Staff Nurse).......................................................................................................1

4. Health Worker (Female)/ANM..................................................................................................1

5. Health Educator.......................................................................................................................1

6. Health Assistant (Male)...........................................................................................................1

7. Health Assistant (Female)/LHV................................................................................................1

8. Upper Division Clerk.................................................................................................................1

9. Lower Division Clerk.................................................................................................................1

10. Laboratory Technician..............................................................................................................1

11. Driver (Subject to availability of Vehicle).....................................................................................1

12. Class IV..................................................................................................................................4

Total..........................................................................................................................15

C. S TAFF FOR COMMUNITY HEALTH CENTRE:

1. Medical Officer.......................................................................................................................4

2. Nurse Midwives (staff Nurse)....................................................................................................7

3. Dresser...................................................................................................................................1

4. Pharmacist/Compounder..........................................................................................................1
 5. Laboratory Technician1

6. Radiographer1

7. Ward Boys2

8. Dhobi1

9. Sweepers3

10. Mali1

11. Chowkidar1

12. Aya1

13. Peon1

Total25

Box 2.

RURAL HEALTH INFRASTRUCTURE - NORMS AND LEVEL OF ACHIEVEMENTS (ALL

INDIA)
Indicator National Norms Achievements
S.No.
1 Rural Population (2001) covered by a: General Tribal/Hilly/Desert
Sub Centre 5000 3000 5085
Primary Health Centre (PHC) 30000 20000 31954
Community Health Centre (CHC) 120000 80000 2.21 lakhs

2 Number of Sub Centres per PHC 6 6

3 Number of PHCs per CHC 4 7

4 Rural Population (2001) covered by a:

MPW (F) 5000 3000 5574
MPW (M) 5000 3000 11994

5 Ratio of HA (M) to MPW (M) 1:6.0 1:3

6 Ratio of HA (F) to MPW (F) 1:6.0 1:8

7 Average Rural Area (Sq. Km) covered by a:
Sub Centre -- 21.35
PHC -- 134.20
CHC -- 931.95

Average Radial Distance (Kms) covered by

8 a:
Sub Centre -- 2.61
PHC -- 6.53
CHC -- 17.22

9 Average Number of Villages covered by a:

Sub Centre -- 4
PHC -- 27
CHC -- 191

Community Health Centres (CHCs)

1.4. CHCs are being established and maintained by the State Government under MNP/BMS
programme . It is 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 September, 2005, there
are 3346 CHCs functioning in the country.

1.5. The details of the norms for each level of rural health infrastructure and current status
against these norms are given in Box 2.

2. Strengthening of Rural Health Infrastructure

2.1. With a view of improving facilities in the existing rural health infrastructure under
Reproductive and Child Health Programme, the Government of India is assisting all the States in
improving/ constructing labour room, operation theatre and providing water/ electricity supply in
CHCs/ PHCs etc. so that essential and emergency obstetric services are improved.

Minor Civil Works

2.2. An amount of Rs.10 lakh per district has been released to the States for minor repair and
maintenance of buildings, especially for operation theatres, labour rooms and for carrying out
improvements in water and electric supply.
Major Civil Works

2.3. An amount of Rs. 10 lakh per CHC/ district hospital is available for release to all the
States to improve facilities for essential and emergency obstetric services through providing
water supply and electricity, construction/repair of operation theatre, labour room/ or to
provide/improve facilities for hospitals.

3. Training and Development

Basic Training of Auxiliary Nurse Midwife (ANM) / Lady Health Visitor(LHV)

3.1. ANM/Multipurpose Health Worker (Female) and LHV/Health Assistant (Female) play
vital role in Maternal & Child Health as well as in Family Welfare Service in the rural areas. It
is therefore, essential that the proper training to be given to them so that quality services be
provided to the rural population.

3.2. For this purpose 336 ANM/Multipurpose Health Worker (Female) schools with an
admission capacity of approximately 13,000 & 42 promotional training schools for LHV/ Health
Assistant (Female) with an admission capacity of 2600 established by the Department of Family
Welfare, Government of India. These training institutions are imparting training to prepare
required number of ANMs and LHVs to man the Subcentres, Primary Health Centres, Rural
Family Welfare Centres and other Health centres in the country. The duration of training
programme of ANM is one and half years and minimum qualification for admission to this
course is 10th pass. Senior ANM with five years of experience is given six months promotional
training to become LHV/ Health Assistant (Female). Health Assistant (Female)/LHV provides
supportive supervision and technical guidance to the ANMs in sub-centres.

3.3. The staffing pattern of the school varies according to the no. of annual admission
capacity of the trainees. However, the school with 40 admission capacity is manned by one
nursing officer, two sister tutors, 4 PHN and other supportive staff. Other approved costs besides
salary to staff are stipend to trainee, contingency and rent. The detail of financial norm which is
effected since 7.2.2001 is as follows:

Item Norm

(In Rupees)
1. Salary & allowances of staff As per State Government
2. Stipend for trainees 500/- per month/trainee
3. Contingency 10,000/- per annum / school
4. Rent* 60,000/- per annum /school

* Rent payable in respect of such schools, which are functioning in rented buildings.
Basic Training of Multipurpose Health Worker (Male)

3.4. The Basic Training of Multi Purpose Health Worker (Male) scheme was approved during
th
6 Five-Year Plan and taken up since 1984, as a 100% Centrally Sponsored Scheme. This
training is provided through 56 training centres – through Health & Family Welfare Training
Centres and through basic training schools of Multipurpose Health Workers (Male). Initially, the
schools were sanctioned at the existing Health & Family Welfare Training Centres and later on
expanded to other new basic schools. The training is of one-year duration and on successful
completion of the training, the Male Health Worker is posted at the sub-centre along with an
ANM/Health Worker (Female). The main functions of Male Multi Purpose Health Worker are in
the areas of National Health Programmes like Malaria, Leprosy, T.B. & limited involvement in
U.I.P, Diarrhoea Control Program and in family welfare services.

3.5. The financial norms for this scheme have been revised w.e.f. 7.2.2001. Under the
scheme the salary of the staff, rent for school and hostel, stipend, educational aids and training
material, hiring for bus and contingency are supported. The financial norms has been revised as
follows:

(in Rupees)

Item Norm
1. Salary & allowances As per State Government
2. Rent(for new schools) 10,000/ month
3. Rent for hostel (for new schools) 250 / month / trainee
4. Stipend 300 / month / trainee
5. Educational Aids and Training Material 15,000 / annum
6. Transportation (for hiring bus) 30,000 / annum
7. Contingency 50,000 / annum

Maintenance and Strengthening of Health and Family Welfare Training Centres (HFWTC)

3.6. The HFWTCs are the training centres of DoFW, GOI which provide primarily short-term
in-service training programmes to the doctors, nurses and para-medical personnel in the rural
areas in a defined region. At present these training centres are imparting various in-service
training for RCH programme. Apart from in-service education, 19 centres also responsible for
conducting the basic training of Male Health Worker’s course of one year.

3.7. The training centres have multi-disciplinary staff from biomedicine, social services,
health education, public health and nursing and statistics. Apart from the salary of the staff of the
training centres, other assistance under the scheme includes contingency, rent for training centres
and payment to guest faculty. The financial pattern of assistance for this scheme has been
revised since 7.2.2001. The detail of the financial norms are as follows:

( in Rupees)
 Item Revised norms
1. Salary & allowances of the staff As per State Government
2. Contingency 15,000 / annum
3. Rent* 40,000 / annum
4. Payment to Guest Faculty 50,000 / annum
*Rent payable in respect of such centres that are functioning from rented buildings.

4. Strengthening of Basic Training Schools

This is a new scheme, which is introduced during the 10 th Plan period. This scheme
envisages strengthening basic training schools of ANM/LHV. The main objective of the scheme
is physical strengthening of the training schools for making these schools workable/ suitable,
which have gone into dilapidated condition. The provision under the scheme is maximum of
Rs.21.5 lakhs per ANM/LHV school for following activities.

Activities Rs. in lakhs (maximum)

1. Repair*/up-gradation** for the buildings - 20.00
Trg. Centre, hostel & the field practice area
2. Furniture & Equipment 1.00
3. Books/A.V. Aids 0.50

*Will include replacement/repair of floor/roof, plastering, electric cable, water storage

tanks, wall-cupboard, doors, windows, sanitary fixtures, internal water supply (piping),
septic tank, leakage, painting etc.

** will include minor extension

5. National Rural Health Mission

Under the mandate of National Common Minimum Programme (NCMP) of UPA Government,
health care is one of the seven thrust areas of NCMP, wherein it is proposed to increase the
expenditure in health sector from current 0.9 % of GDP to 2-3% of GDP over the next five years,
with main focus on Primary Health Care. The National Rural Health Mission (NRHM) has been
conceptualized and the same is being operationalised from April, 2005 throughout the country,
with special focus on 18 states which includes 8 Empowered Action Group States (Bihar,
Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan), 8
North East States (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland,
Sikkim and Tripura) Himachal Pradesh and Jammu & Kashmir.

5.2. The main aim of NRHM is to provide accessible, affordable, accountable, effective and
reliable primary health care, especially to poor and vulnerable sections of the population. It also
aims at bridging the gap in Rural Health Care through creation of a cadre of Accredited Social
Health Activists (ASHA) and improve hospital care, decentralization of programme to district
level to improve intra and inter-sectoral convergence and effective utilization of resources. The
NRHM further aims to provide overarching umbrella to the existing programmes of Health and
Family Welfare including RCH-II, Malaria, Blindness, Iodine Deficiency, Filaria, Kala Azar
T.B., Leprosy and Integrated Disease Surveillance. Further, it addresses the issue of health in the
context of sector-wise approach addressing sanitation and hygiene, nutrition and safe drinking
water as basic determinants of good health in order to have greater convergence among the
related social sector Departments i.e. AYUSH, Women & Child Development, Sanitation,
Elementary Education, Panchayati Raj and Rural Development.

5.3. The Mission further seeks to build greater ownership of the programme among the
community through involvement of Panchayati Raj Institutions, NGOs and other stakeholders at
National, State, District and Sub District levels to achieve the goals of National Population
Policy 2000 and National Health Policy.

5.4. Under the strategy of NRHM, in order to fill the gaps in the existing rural health care
infrastructure available in the country, the key components, inter-alia, of the Mission are as given
below:

(i) Creation of a cadre of Accredited Social Health Activists (ASHA) in 2.5

lakh villages in four years – 8 EAG States, J&K and Assam.

(ii) Creation of village health scheme and preparation of village health plan –
18+ states.

(iii) Strengthening sub centres with untied funds of Rs. 10,000/- per annum –
10+8+States.

(iv) Raising 2000+CHCs to the level of IPHS.

(v) Codification of Indian Public health Standards (IPHS) – 18+states.

(vi) Integrating vertical health and family welfare programmes under NRHM at
National, State and District level – all states.
 (vii) Strengthening Programme Management Capacities at National State and
District level – 10+8+states.

(viii) Institutionalising district level management of health – all districts.

(ix) Supply of generic drugs (both Allopathic and AYUSH) – 18+States.

(x) School health check up programme – 18+States

(xi) Promotion of multiple health insurance model – all states.

(xii) Supplementing Vitamin ‘A’ and Iron Folic Acid to deficient children at
Anganwadi level – 18+states.

(xiii) Promotion of private sector for achieving public health goals – all states.

(xiv) Setting up of comprehensive Health and Family Welfare clinics – 5

States+select districts.

(xv) Services of ANM and medical officers, PHCs to be ensured at fixed days at
Anganwadi levels.

(xvi) Mainstreaming ISM. Exploring new Health Financing Mechanism, Policy

reforms in Medical Education and Public Health Management.

(xvii) The mission shall focus on rural areas since bulk of the strategic
interventions are aimed at improvement of primary health care in rural areas.

5.5. Overview of NRHM

(i) The National Rural Health Mission is being launched for a period of seven
years (2005-2012) i.e. 2 years of Tenth Plan and full Eleventh Plan.

(ii) The Mission shall cover entire country, with focus attention on 18 states
having weak demographic indicators/ infrastructure.
 (iii) NRHM is an omni-bus broad band programme, and all other programmes
would be sub-components, retaining the sub-budget heads wherever required
for vertical programmes.

(iv) The emphasis under NRHM is to improve primary health care,

decentralization, intra and inter-sectoral convergence and community
ownership.

(v) NRHM provides broad policy guidelines – states have flexibility to draw
their action plans to attain the goals of NRHM

(vi) RCH-II, including National Family Welfare Programme (NFWP) and

Empowered Action Group (EAG) are subsumed into NRHM.

(vii) Operational phase of the Mission is from April, 2005.

(viii) MOUs being entered into, with the State Governments for RCH-II, will be
broad based for NRHM, to ensure their commitments to the systemic reform
and new financial pattern of performance based funding under NRHM.

5.6. Funding

The budget outlay for National Rural Health Mission for 2005-06 is Rs. 6731.16 Crores.

5.7. Mission Outcome

The following are anticipated Mission outcomes likely to be achieved after its implementation:

 Provision of village level health provider (ASHA) in under served villages

 Strengthening Sub- centers /PHCs

 Raising CHCs to the level of IPHS

 Institutionalizing District level Management of Health (all districts)

 Prevention and control of communicable and non communicable diseases including locally
endemic diseases

 Increase utilization of First Referral Units from less than 20% (2002) to more than 75 % by 2010

 Reduction in communicable diseases, MMR, IMR and would help in attaining population
stabilization.

5.8. NRHM Plan of Action for Infrastructure Strengthening

Component (A): Accredited Social Health Activists

 Every village/large habitat will have a female Accredited Social Health Activist (ASHA)
-chosen by and accountable to the panchayat- to act as the interface between the
community and the public health system. States to choose State specific models.

 ASHA would act as a bridge between the ANM and the village and be accountable to the
Panchayat.

 She will be an honorary volunteer, receiving performance-based compensation for

promoting universal immunisation, referral and escort services for RCH, construction of
household toilets, and other healthcare delivery programmes.

 She will be trained on a pedagogy of public health developed and mentored through a
Standing Mentoring Group at National level incorporating best practices and
implemented through active involvement of community health resource organisations.

 She will facilitate preparation and implementation of the Village Health Plan along with
Anganwadi worker, ANM, functionaries of other Departments, and Self-Help Group
members, under the leadership of the Village Health Committee of the Panchayat.

 She will be promoted all over the country, with special emphasis on the 18 high focus
States. The Government of India will bear the cost of training, incentives and medical
kits. The remaining components will be funded under Financial Envelope given to the
States under the programme.

 She will be given a Drug Kit containing generic AYUSH and allopathic formulations for
common ailments. The drug kit would be replenished from time to time.

 Induction training of ASHA to be of 23 days in all, spread over 12 months. On the job
training would continue throughout the year.
 Prototype training material to be developed at National level subject to State level
modifications.

 Cascade model of training proposed through Training of Trainers including contract plus
distance learning model.

 Training would require partnership with NGOs/ICDS Training Centres and State Health
Institutes.

Component (B): Strengthening Sub-Centres (SC)

 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.

 Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.

 In case of additional Outlays, Multipurpose Workers (Male)/ Additional ANMs wherever

needed, sanction of new Sub-centres as per 2001 population norm, and upgrading
existing Sub-centres, including buildings for Sub-centres functioning in rented premises
will be considered.

Component (C): Strengthening Primary Health Centres (PHCs)

Mission aims at strengthening PHCs for quality preventive, promotive, curative, supervisory
and outreach services, through:

 Adequate and regular supply of essential quality drugs and equipment (including Supply
of Auto Disabled Syringes for immunisation) to PHCs

 Provision of 24 hour service in at least 50% PHCs by addressing shortage of doctors,

especially in high focus States, through mainstreaming AYUSH manpower.

 Observance of Standard treatment guidelines & protocols.

 In case of additional Outlays, intensification of ongoing communicable disease control

programmes, new programmes for control of non-communicable diseases, upgradation of
100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (1
male, 1 female) would be undertaken on the basis of felt need.

Component (D): Strengthening Community Health Centres (CHCs) for First Referral
Care

A key strategy of the Mission is:

  Operationalising 3,222 existing Community Health Centres (30-50 beds) as 24 hour First
Referral Units, including posting of anaesthetists.

 Codification of new Indian Public Health Standards" setting norms for infrastructure,
staff, equipment, management etc. for CHCs.

 Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.

 Developing standards of services and costs in hospital care.

 Develop, display and ensure compliance to Citizen's Charter at CHC/PHC level.

 In case of additional Outlays, creation of new Community Health Centres (30-50 beds) to
meet the population norm as per Census 2001, and bearing their recurring costs for the
Mission period could be considered.

Another important intervention under NRHM is the provision of a Mobile Medical Unit at
District level for improved outreach services.