Healthcare System in India
Introduction: India's health system's governance has been divided between the Union and the state governments. The central government issues guidelines, but the absolute prerogative on implementing the healthcare initiatives lies with the States because 'health' is a state subject.
The Union Ministry of Health & Family Welfare is responsible for the implementation of various programs on a national scale in the areas of health and family welfare, prevention & control of major infectious diseases (Covid-19 pandemic, National AIDS Control Program, Revised National Tuberculosis Program, etc.), and promotion of traditional and indigenous systems of medicines. The Ministry is also responsible for setting standards and guidelines that state governments can adopt. In addition, the Ministry assists states in preventing and controlling the spread of seasonal disease outbreaks and epidemics through technical assistance. On the other hand, public health, hospitals, sanitation and so on come under the purview of the state, making health a state subject. However, areas having wider ramifications at the national level, such as family welfare & population control, medical education, food adulteration, and quality control in the manufacture of drugs, are governed jointly by the Union & the State governments.
Structure of Healthcare: India has a mixed healthcare system, inclusive of public & private healthcare service providers. The public healthcare infrastructure in our country is a three-tier system based on population norms.
The healthcare system is organised into primary, secondary, and tertiary levels. At the primary level are sub-health centres (148,366 SHCs) and primary health centres (24,049 PHCs). At the secondary level, there are smaller Sub-District hospitals. At the tertiary level are Community Health Centres (CHCs), including district hospitals and Medical colleges (722). The private hospitals also contribute to the healthcare infrastructure (increasing total CHCs to 4833). However, most private healthcare providers are concentrated in urban India, providing secondary and tertiary care healthcare services.
Sub-Health Centre: A sub-health centre (SHC) is established in a plain area with a population of 5000 people and in hilly/difficult-to-reach/tribal areas with a population of 3000. SHC is the most peripheral and first contact point between India's primary healthcare system and the general population. Each SHC is required to be staffed by at least one Auxiliary Nurse Midwife (ANM)/female health worker and one male health worker. Under the National Rural Health Mission (NRHM), there is a provision for one additional ANM on a contract basis.
SHCs are assigned tasks to guide and bring about behavioural change and provide services to maternal and child health, family welfare, nutrition, immunisation, diarrhoea control and control of infectious diseases programs. The Ministry of Health & Family Welfare has been providing 100% central assistance to all the SHCs in the country since April 2002 in the form of salaries, rent and contingencies in addition to drugs and equipment.
Primary Health Centre: A primary health centre (PHC) is established in a plain area with a population of 30,000 people and in hilly/difficult-to-reach/tribal areas with a population of 20,000. PHC is the first contact point between the village community and the medical officer. PHCs were envisaged to provide integrated curative and preventive health care to the rural population, emphasising the preventive and promotive aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Program (MNP)/Basic Minimum Services (BMS) Program. As per the minimum requirement, a PHC must be staffed by a medical officer supported by 14 paramedics and other staff. Under NRHM, there is a provision for two additional staff nurses at PHCs on a contract basis. It is a referral unit for 5-6 SHCs and has 4-6 beds.
Community Health Centre: Community health centres (CHCs) are established and maintained by the State Government under the MNP/BMS program in an area with a population of 120,000 people and in hilly/difficult-to-reach/tribal areas with a population of 80,000. As per minimum norms, a CHC is required to be staffed by four medical specialists, that is, surgeon, physician, gynaecologist/obstetrician, and paediatrician, supported by 21 paramedical and other staff. It has 30 beds with an operating theatre, X-ray, labour room and laboratory facilities. It serves as a referral centre for PHCs within the block and also provides facilities for obstetric care and specialist consultations.
First Referral Unit: An existing facility (district hospital, sub-divisional hospital, CHC) 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 newborn 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 an FRU: (i) emergency obstetric care, including surgical interventions such as caesarean sections; (ii) care for small and sick newborns; and (iii) blood storage facility on a 24-hour basis.