Health Care System at District Level in India

There are twenty nine states and seven union territories in India which are divided into 597 districts for proper administration. Every district is further divided into sub-divisions or taluka, under which community development blocks are situated. Currently there are 600 community development blocks in the country.

Health Care System at District Level in India

In India, there are six regulatory territories in each region.

• Subdivisions: The districts are divided into two or more subdivisions, each accountable to an Assistant Collector or Sub Collector.
  
  
• Talukas: The subdivision is further divided into taluks which are accountable to a Tehsildar. Each taluk generally has two hundred to six hundred villages.
  
  
• Community Development Blocks: Each block consists of around hundred villages of about 80000 to 200000 population and is the major unit of rural planning and development.

The Local Self-Government has separate units of working in urban and rural areas of the districts.

Divisions in the urban areas

Town area committee

They are set up in the regions with population range of around 5000-10000. These committees work like panchayats and look after the provision and maintenance of sanitary services of that area.

Municipal boards

They are set up in those areas that have population range of about 10000-200000 and are headed either by the chairman or by the president who is generally elected by the members of the board. The members of the board hold office for a term of three to five years.

The functions of municipal boards are:

• Sanitation
• Water supply
• Drainage facilities
• Construction and maintenance of roads
• Birth and death registrations
• Education standards
• Working of hospitals and dispensaries, etc.

Corporation

It is set up in the areas with population more than two lakhs and headed by a mayor. Its members are the counsellors elected from the different wards of the city. Its functions are similar to that of the municipal board but on a wider scale.

Divisions in the rural areas

Let us analyse the divisions in the rural level.

Panchayati Raj

It is a 3-tier structure of the rural local self-government in India that links the villages to the districts. The three tier are:

• Panchayat
• Panchayat Samiti
• Zila Parishad

Panchayat – (at the village level)

The Gram Sabha: It includes all the adults of the village, who at least meet together twice a year. Functions include proposals for taxation policies, discussion about the annual programs and electing the members of the gram panchayat.

The Gram Panchayat: It is an agency that works for planning, management and development at the village level. It covers the population range of five thousand to fifteen thousand and has a strength of 15-30. The term of the members of Gram Panchayat is 3-4 years.

Each panchayat is headed by an elected president who can be a Sarpanch or Mukhiya and also has a vice president and a panchayat secretary. The Panchayat secretary performs numerous functions ranging from civil administration that includes sanitation facilities and public health issues to the economic and social development of the village.

The Nyaya Panchayat: It includes five members from the panchayat and strives to resolve the conflicts between people/societies/groups over different issues.

Panchayat Samiti – (at block level)

The block is comprised of around hundred villages and covers population range of 80000 to 120000. At the block level the executive agency is the ‘Panchayat Samiti’ which consists of all the Sarpanches (mukhiyas) of the village Panchayats in the Block; Member of Legislative Assemblies (MLAs); Member of Parliaments (MPs) who are residing in the block; representatives of women, schedule castes, schedule tribes and the cooperative societies.

The Block development officer (BDO) is its ex-office secretary and he/she along with the staff assist the village panchayats in the developmental programs. It also controls and distributes the funds released by the government.

Zila Parishad – (at the district level)

The members of the Zila Parishad include all heads of Panchayat Samities in the District, Member of Legislative Assemblies (MLAs); Member of Parliaments (MPs) who are residing in the block; representatives of women, schedule castes, schedule tribes and two persons having experience in administration, public health or rural development. Its members ranges from 40-70 and the collector of the district is a non-voting member. It performs different functions in different states. It also performs administrative functions in some states.

At village level

Following schemes are implemented to ensure that healthcare should also reach the remote as well as rural areas:

Village health guides

The village health guide scheme was introduced on 2nd October 1977. The health guides are the first point of contact between the people and healthcare systems and are chosen from the community where they are working.

The guidelines for their selection are:

• The individuals should be the permanent residents of the local community and preferably females.
  
  
• They should be formally educated at least up to sixth standard and able to read and write.
  
  
• They should be willingly accepted by all the sections of their community.
  
  
• They can dedicate at least two to three hours every day to the community welfare health work.

Training

Place/training site – Nearest health Centre or sub-center Training duration – 200 hours for 3 months Stipend during training – `Rs200 per month Responsibilities and duties of health guide:

• Treatment of simple illnesses and performing first aid activities.
  
  
• Awareness about the methods and importance of family planning including Mother and Child health among the people of the village.
  
  
• Providing health education to the people and create awareness about sanitation.

A manual or booklet containing detailed description of clinical care of some of the common and simple ailments with dos and don’ts, is provided to the health guides so that they may understand what to do in emergency situations, how to start the treatment on their own and when to refer the patients to the nearest healthcare center

Local dais

Under rural health scheme, a comprehensive program has been introduced with a goal to provide training to all categories of local dais (TBA) in India to improve and enhance their knowledge about the fundamental concepts of mother and child health, obstetric and sterilization techniques.

Training

Duration of training: Thirty working day Stipend: ` 300 per dias during training.

Place: Primary Health Center (PHC)/subcenter/MCH center for two days/week and they go along with female health workers to the villages for rest four days of the week.

Anganwadi worker

Under the Integrated Child Development (ICDS) Scheme, an anganwadi worker (female) is there for a population of 1000 who is chosen from the community she belongs to and where she is expected to work. They are given training regarding different aspects of child development and nutritional requirements for the mothers. They are part time workers and paid Rs 200-250/month for the services provided.

Detailed description, roles and responsibilities of Anganwadi:

• To obtain the support of community in running health programs and encourage people to participate.
  
  
• To calculate the weight of all the children every month, prepare growth card and graphically document the weight in it, use referral cards to refer mother and child cases to the nearest sub-centers or PHCs etc. and make child cards for the children less than six years of age and show these cards to the medical and para-medical professionals during their visit.
  
  
• To conduct a survey of all mothers, their children and other family members in their working areas once a year.
  
  
• To conduct non-formal play based pre-school activities for the children of three to six years of age in the anganwadis.
  
  
• To plan a menu according to availability of local foods and recipes with a goal to arrange the supplementary healthy nutrition for children of up to six years of age.
  
  
• To council and educate the mothers regarding breastfeeding, nutrition and health.
  
  
• To create awareness about family planning measures among the married woman and to motivate them to adopt these measures.
  
  
• To share the information regarding births and deaths that have occurred in a month with the Registrar of births and deaths in the village who may be Panchayat Secretary or Gram Sabha Sewak or Auxiliary Nurse Midwife.
  
  
• To do home visits in order to educate the parents so that they can play a efficacious role in the growth and development of their children especially the new born infant.
  
  
• To document and maintain all the records properly as prescribed.
  
  
• To help the Primary Healthcare staff in organizing and implementing various immunization programs and anti-natal and post-natal health checkups.
  
  
• To provide all the information that has been collected under Integrated Child Development Scheme to the ANM.
  
  
• To inform the supervisors about the important developments in the village that may need their intervention, especially regarding the work involving the coordination with several departments.
  
  
• To liaison with other organizations like mahila mandals and encourage girl students and women school teachers of primary and middle schools to participate in welfare activities.
  
  
• To provide guidance to the Accredited Social Health Activists regarding the health care service delivery and documentation of records under the Integrated Child Development Scheme.
  
  
• To organize various social awareness programs and help in the implementation and execution of ‘Kishori Shakti Yojana’.
  
  
• To help in the implementation of Nutrition Programme for Adolescent Girls (NPAG) and maintain the records described under the NPAG scheme.
  
  
• To assist in identifying the disabilities among children while conducting home visits and immediately refer the case if any to the nearest Primary Healthcare or District Disability Rehabilitation Centre.
  
  
• To help in organizing and implementing Pulse Polio Immunization programs.
  
  
• To provide information to the ANMs in medical emergency cases such as diarrhea, cholera etc.

Accredited Social Health Activist (ASHA)

National Rural Health Mission (NRHM) was launched by the Government of India in 2005 to cater to the health requirements of the rural population, particularly the vulnerable and deprived sections. An important component of NRHM is to provide a well-trained female Accredited Social Health Activist in every village in India. ASHAs are selected from the villages and are trained so that they can work as an interface between the communities and the public healthcare systems.

The key components of ASHA are:

• ASHA should be a female resident of the village preferably in the age group of 25-45 years and may be married/widow/divorcee.
  
  
• Preference should be given to the woman who is educated up to 10th standard. Relaxation in education may be given only if there is unavailability of the suitable woman with this qualification.
  
  
• ASHA is selected through a rigorous selection process that involves several community groups, Anganwadis, the Block Nodal officers, District Nodal officers, the Village Health Committees and the Gram Sabhas.
  
  
• Training of ASHA workers is an ongoing process. They undergo a number of training sessions to attain the knowledge, competence and confidence required to perform her duties and responsibilities.
  
  
• They are incentivized according to their performance in promoting immunization programs, referral activities and various other healthcare programs.
  
  
• They will act as the first point of contact regarding any demand related to healthcare particularly of vulnerable sections of the society with emphasis on women and children, who feel difficulties in accessing healthcare services.
  
  
• ASHA will work as health activist in the society to create awareness with regard to healthcare and its social determinants and motivate the people to contribute to health planning at the local level and encourage them to utilize the existing healthcare services.

Roles and responsibilities of ASHA

• Creating awareness and providing information to the people in the community regarding the determinants of health like healthy diet, basic sanitation and hygiene practices, good working conditions, proper information with regard to existing healthcare services.
  
  
• Conducting home visits for the pregnant women, lactating mothers and newborns under Home Based Post Natal Care (HBPNC), and counselling the pregnant ladies to prepare them for birth, teaching the significance of safe delivery, breastfeeding practices, immunization programs, contraceptive measures and prevention of different infections.
  
  
• Mobilizing the community people and facilitating them to access public health services that are available at the village/sub-center levels like general immunization, Ante Natal and post natal check-ups and various other services provided by the Government.
  
  
• Working with the Village Health Sanitation Nutrition Committee/Village Level Committee (VHSNC/VLC) of the Gram Panchayat to assist in the village health and development plan along with Auxiliary Nurse Midwives, Anganwadi workers and members of Panchayati Raj Institutions.
  
  
• Encouraging the community people to celebrate Village Health Nutrition Days at least once in a month at their Anganwadi Centers with ANMs, AWWs and members of Village Health Sanitation and Nutrition Committee.
  
  
• Arranging/escorting/accompanying pregnant ladies and children who require treatment to the nearest healthcare facility
  
  
• Providing primary healthcare for simple ailments like diarrhea, fever and minor injuries.
  
  
• Working as Dot Providers of Directly Observed Treatment Short-course (DOTS) under Revised National Tuberculosis Control Programme (RNTCP).
  
  
• Promoting of healthy practices and providing a curative care that is appropriate and feasible for her and making timely referrals.
  
  
• Providing information to the people on determinants of healthcare like nutrition, sanitation and hygiene practices