nursing

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HEALTH CARE DELIVERY SYSTEM
IN INDIA
INTRODUCTION
Health is the birth right of every individual. Today health is considered more than a
basic human right; it has become a matter of public concern, national priority and political
action. Our health system has traditionally been a disease-oriented system but the current
trend is to emphasize health and its promotion. The nursing profession exists to meet the
health need of the people. Unprecedented changes have occurred in the structure of our
society, in lifestyles, in specific and technological advances.
Health is a multi dimensional with physical, biological, economical, social, cultural
and vocational. Health is not static. A person who is healthy now may not be healthy the next
moment. Public has become more aware and emphasizing on health, health promotion,
wellness and self care. Emphasis has shifted from a focus on cure to a focus on prevention
and health maintenance. This has led to a evolution of a wide range of health promotion
techniques, and programmes including multiphasic screening, life time health monitoring
programs.
Special efforts being made by the health care professionals to reach and motive
members of various cultural and social economic groups concerning life style and health
practices. All efforts are to design a health care system that makes comprehensive health care
available to all the people at an affordable cost.
Selected health care definitions:
 Health: According to WHO, health is defined as “a dynamic state of complete
physical, mental and social well-being not merely an absence of disease or infirmity.”
 Health care services: It is defined as “multitude of services rendered to individuals,
families or communities by the agents of the health services or professions for the
purpose of promoting, maintaining, monitoring or restoring health.”
Definitions of health care delivery:
 Health care delivery system refers to the totality of resources that a population or
society distributes in the organisation and delivery of health population services. It
also includes all personal and public services performed by individuals or institutions
for the purpose of maintaining or restoring health.
Stanhope(2001)
 It implies the organisation, delivery staffing regulation and quality control.
J.C.Pak(2001)
 Health care delivery system is the organisation by which health care is provided.

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Wikipedia(2005)
 A collection of fragmented services provided on free for service basis by numerous
organisations and providers. Laddy Susan
Components of Health System:
 Concepts e.g. health and disease
 Ideas e.g. equity coverage, effectiveness, efficiency, impact.
 Objects e.g. hospitals, health centres, health programms
 Persons e.g. providers and consumers
Philosophy of Health Care Delivery System:
 Every one from birth to death is part of the market potential for health care services.
 The consumer of health care services is a client and not customer.
 Consumers are less informed about health services than anything else they purchase.
 Health care system is unique because it is not a competitive market.
 Restricted entry in to the health care system.
Goals/Objectives of Health Care Delivery System:
1) To improve the health status of population and the clinical outcomes of care.
2) To improve the experience of care of patients families and communities.
3) To reduce the total economic burden of care and illness.
4) To improve social justice equity in the health status of the population.
PRINCIPLES OF HEALTH CARE DELIVERY SYSTEM:
1. Supports a coordinated, cohesive health-care delivery system.
2. Opposes the concept that fee-for-practice.
3. Supports the concept of prepaid group practice.
4. Supports the establishment of community based, community controlled health-care
system.
5. Urges an emphasis be placed on development of primary care
6. Emphasizes on quality assurance of the care
7. Supports health care as basic human right for all people.
8. Opposes the accrual of profits by health-care-related industries.
9. Supports individuals unrestricted access to the provider, clinic or hospital.
10. Urges that in the establishment of priorities for health-care funding, resource be
allocated to maintain services for the economically deprived.

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11. Supports efforts to eliminate unnecessary health care expenditures and voluntary
efforts to limit increase in health care costs.
12. Endorses to provide age old with special health maintenance.
13. Supports public and private funding.
14. Condemns health care fraud.
15. Supports the establishment of a national health care budget.
16. Supports universal health insurance.
FUNCTIONS OF HEALTH CARE DELIVERY SYSTEM:
1) To provide health services.
2) To raise and pool the resources accessible to pay for health care.
3) To generate human and physical sources that makes the delivery service possible.
4) To set and enforce rules of the game and provide strategic direction for all the
different players involved.
CHARACTERS OF HEALTH CARE DELIVERY SYSTEM:
1) Orientation toward health.
2) Population perspective.
3) Intensive use of information.
4) Focus on consumer.
5) Knowledge of treatment outcome.
6) Constrained resources.
7) Coordination of resources.
8) Reconsideration of human values.
9) Expectations of accountability.
10) Growing interdependence.
1. Providers and Consumers
A health care provider or health professional is an organization or person who
delivers proper health care in a systematic way professionally to any individual in need of
health care services. A health care provider could be a government, institution such as a
hospital or laboratory physicians, support staff, nurses, therapists, psychologists,
veterinarians, dentists, pharmacists, or even a health insurance company. Consumers are the
people of the whole world.
Financing
There are generally five primary methods of funding health care systems
1. Direct or Out-of-Pocket payment.

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2. General Taxation,
3. Social Health Insurance,
4. Voluntary or private health insurance, and
Health care systems models
 Purely private enterprise health care systems are comparatively rare. Where they
exist, it is usually for a comparatively well-off subpopulation in a poorer country with
a poorer standard of health care–for instance, private clinics for a small, wealthy
expatriate population in an otherwise poor country. But there are countries with a
majority-private health care system with residual public service eg medicare,
medicaid.
 The other major models are public insurance systems:
o Social security health care model, where workers and their families are
insured by the State.
o Publicly funded health care model, where the residents of the country are
insured by the State.
o Social health insurance, where the whole population or most of the
population is a member of a sickness insurance company.
HEALTH CARE DELIVERY SYSTEM IN INDIA
In India it is represented by five major sectors or agencies which differ from each
other by health technology applied and by the source of fund available. These are:
I. PUBLIC HEALTH SECTOR
A. Primary Health Care
Primary health centres.
Sub- centres.
B. Hospital/Health Centres
Community health centres.
Rural health centres.
District hospitals/health centre.
Specialist hospitals.
Teaching hospitals.
C. Health Insurance Schemes
Employees State Insurance.
Central Govt. Healh Scheme.
D. Other Agencies

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Defence services.
Railways.
II. PRIVATE SECTOR
A. Private hospitals, polyclinics, nursing homes and dispensaries.
B. General practitioners and clinics.
III. INDIGENOUS SYSTEMS OF MEDICINE
 Ayurveda
 Sidda
 Unani
 Homeopathy
 Naturopathy
 Yoga
 Unregistered practioners.

IV. VOLUNTARY HEALTH AGENCIES
V. NATIONAL HEALTH PROGRAMMES
Model of Health Care System In India
The “inputs” are the health status or health problems of the community, they represent
the health needs and health demands of the community. Since resources are always limited to
meet the many health needs, priorities have to be set.
The “health care services” are designed to meet the health needs of the community
through the use of available knowledge and resources. The services provided should be
comprehensive and community based.
The “health care system” is intended to deliver the health care services, it constitutes
the management sector and involves organizational matters.
The “output” is the changed health status or improved health status of the community
which is expressed in terms of lives saved, deaths averted, diseases prevented etc.
ORGANISATION AND ADMINISTRAION OF HEALTH SERVICES IN INDIA AT
DIFFERENT LEVELS
India is a union of 28 states and 7 Union territories. Under the constitution states are
largely independent in matters relating to the delivery of health care to the people. Each State,
therefore , as developed its own system of health care delivery, independent of the Central
Government. Central responsibility consists mainly of policy making, planning, guiding,

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assisting, evaluating and coordinating the work of the State Health Ministries, so that no state
State lags behind in health services.
Health system in India has 3 links
1. Central level.
2. State level
3. District level
CENTRAL LEVEL
Health is a State subject under the constitution of India. The health Centres are mainly
with international, national and interstate health matters. The centre is also responsible for
execution of health programmes in the centrally administered areas. It advises and helps the
States on all health matters.
Official organs of the health system at the National level consists of:
A. The ministry of Health and Family Welfare.
B. The Directorate General of Health Services.
C. The Central Council of Health and Family Welfare.
A. THE MINISTRY OF HEALTH AND FAMILY WELFARE
Functions:
The responsibilities of the central and state governments in the area of health are defined
under Article 246 of the constitution as follows.
a. Union list
1. International obligations such as International Sanitary Regulations regarding port
quarantine.
2. Administration of central institutes such as All India Institute of Hygiene and Public
Health, Kolkota, National Institute of Communicable Diseases, Delhi, National
Institute of Health and Family Welfare, Delhi.
3. Promotion of research through bodies such as the Indian Council of Medical
Research.
4. Regulation and development of medical, dental, pharmaceutical and nursing
education and professionals through their respective councils.
5. Regulation of manufacture and sale of biological products and drugs, including drug
standards.
6. Undertaking census, collecting and publishing health and vital statistics data.
7. Coordination with State in their Health Programs, giving them technical and financial
assistance and procuring for them facilities from international agencies.
8. Coordination with other ministries in matters related to health.

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9. Health regulations regarding labour in general and mines and oil fields in particular.
b. Concurrent List:
Both centre and States have simultaneous power of legislationin relation to subjects in
concurrent list.
1.Interstate spread of disease
2.Prevention of adulteration of foods
3.Control of drugs and poisons
4.Vital statistics
5.Labour welfare
6.Minor ports
7.Population control and family planning
8.Social and economic planning
B. THE DIRECTORATE GENERAL OF HEALTH SERVICES
The main functions of the DGHS
1. Conducting various national health programs.
2. Organising health services in the form of central government health scheme
3. Providing Medical Education through the colleges and institutions under its
control e.g Raj Kumari Amrit Kaur College of Nursing, Delhi, All India Institute
of Hygiene and Public Health, Kolkota, JPMER, Pondicheri etc.
4. Medical research through Indian Council of Medical Research and the institutes
under it, as also other institutions, such as the Central Research Institute, Kasauli.
5. International health and quarantile at major ports and international airports.
6. Drug control
7. Medical stores and supplies
8. Health education through Central Health Education Bureau.
9. Health intelligence, through Central Health Intelligence Bureau.
C. THE CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE
Functions of Central Council of Health and Family Welfare
1. To consider and recommend broad outlines of policy in regard to matters
concerning health in all its aspects such as the provision of remedial and
preventive care, environmental hygiene, nutrition, health education and the
promotion of facilities for training and research.

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2. To make proposals for legislation in fields of activity relating to medical and
public health matters and to lay down patterns of development for the country as a
whole.
3. To make recommendations to the Central Government regarding distribution of
available grants-in-aid for health purposes to the states and to review periodically
the work accomplished in different areas through the utilization of these grants-in-
aid.
4. To establish any organisation or organisations invested with appropriate functions
for promoting and maintaining cooperation between the Central and State Health
administrations.
STATE LEVEL
There are 28 states in the country. Health, as states earlier is a State subject.
Therefore, the pattern of organisation, state of integration, level of health services, public
health laws and scales of pay differ from state to state. The aim, however of all states and
their Public Health Administration is the same- health, happiness and longevity for all the
people.
A. State Ministry of Health
The ministry has a minister and deputy minister of health. The secretary and Joint
secretary, etc. held by the IAS cadre.
B. State Health Directorate
The process of integration has now been completed in most States. The usual pattern
now is that the State Health Directorate is headed by a Director, usually known as
Director of health services, He is assisted by a suitable number of deputies to look
after various health and medical health services. Some states also have a separate
Director Medical Education.
C. District Level:
Each state in Indian union is divided into districts. Total population in each district,
urban as well as rural, varies from one to three million. Just as in case of states, some
autonomy has been given to urban and rural areas in the district as well. The autonomous
bodies or local self government are called Corporation and Muncipal Committees in the
cities, Zilla panchayats or Zilla Parishads in rural districts, Taluka Panchayat or Taluka
Parishats in taluka level and Grama panchayat and Nagara Panchayats in villages and small
towns.
Health organisations in Urban Areas:
There are three types of self-gevernment in urban areas of district, depending upon the
size of population:
1. Town areas committees (5000-100000)
2. Muncipal board or Muncipality (10- 2000000)

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3. Corporation (Above 200000)
Town areas committees: Its functions primarily limited to provision of sanitary services.
Muncipal board or Muncipality: Its functions are more diverse. These include regulation
regarding construction of houses, latrines and urinals, hotels, and markets; provision of water
supply, drainage and disposal of refuse and excreta, disposal of the dead, registration of births
and deaths, keeping of dogs and control of communicable diseases.
Corporation: Corporation provides essentially the same services as the muncilapity, but on a
larger scale. It also maintains hospitals and dispensaries.
Health organisation in Rural areas:
Under panchayat act 1961, the district administration was reorganised in to 3 levels,
self governing autonomous bodies were formed at different levels as follows:
1. For each villages or group of villages with population from 1000 to 10000 there is a
Gram panchayat. If the population os over 10,000 to 30,000 there is a Nagar
Panchayat. The gram panchayat in constituted by 15-30 elected members, who in turn
elect a Sarpanch or president, Vice president, and panchayat secretary is recruited by
government.
2. For each block: There is a Panchayat samiti or taluka panchayat which is a elected
body.
3. For each district: there is a zilla panchayat or parishat which is an autonomous body
for district as well as a whole, responsible to the state assembly. It is constituted by
elected members, MLAs, MPs.
In all above provision has been made for reservation for schedule caste schedule tribes
and women to ensure their active participation in all round development of the village.

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Primary Health Care In India
 In 1977 government of India launched a rural health scheme, based on the
principles of “Placing people’s health in people’s hands’
 As a signatory to Alma-Ata Declaration, the government of India is committed to
achieving the goal of Health care approach which seeks to provide universal
health care at a cost which is affordable.
 Keeping in view the WHO goal of “Health for All” by 2000 AD, the government
of India evolved a National Health Policy in 1983.
 Keeping in view the Millennium Developmental Goals, the government of India
revised the draft of National Health Policy in 2001.
Principles of primary Health Care
1. Equitable distribution
2. Community participation
3. Intersectoral coordination
4. Appropriate technology
5. Preventive in Nature
6. Man power development.
Comparison of infracture in India and Karnakaka
Karnataka India
District Hospitals 24 615
CHC 254 3346
PHC 1681 23236
SUB CENTRES 8143 146026
Primary Health Centre
Primary Health Centers are the cornerstone of rural health services- a first port of call
to a qualified doctor of the public sector in rural areas for the sick and those who directly
report or referred from Sub-centers for curative, preventive and promotive health care.
A typical Primary Health Centre covers a population of 20,000 in hilly, tribal, or
difficult areas and 30,000 populations in plain areas with4-6 indoor/observation beds. It acts
as a referral unit for 6 sub-centers and refer out cases to CHC (30 bedded hospital) and higher
order public hospitals located at sub-district and district level.
In order to provide optimal level of quality health care, a set of standards are

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being recommended for Primary Health Centre to be called Indian Public Health
Standards (IPHS) for PHCs. The launching of National Rural Health Mission
(NRHM) has provided this opportunity.
Assured services or Functions of Primary health centres:
Assured services cover all the essential elements of preventive, promotive, curative
and rehabilitative primary health care.
This implies a wide range of services that include:
1. Medical care:
 OPD services: minimum 4 hours in the morning and 2 hours in the evening.
 24 hours emergency services
 Referral services
 In-patient services (6 beds)
2. Maternal and Child Health Care including family planning:
 Antenatal care: Early diagnosis, minimum three antenatal check up, identification
and management of high risk pregnancies, nutrition and health counseling,
minimum laboratory investigation urin albumin, test ofr syphilis,
chemoprophylaxis for malaria in high endemic area as per NVDCP.
 Intra-natal care. (24-hour delivery services both normal and assisted)
 Postnatal Care.( Janani Suraksha Yojana (JSY)) Minimum 2 postpartum visit,
initiation of breast feeding health education on hygiene, contraception etc,
 New Born care.
 Care of the Child.
 Family Planning
3. Medical Termination of Pregnancies using Manual Vacuum Aspiration
(MVA) technique. (Wherever trained personnel and facility exists)
4. Management of Reproductive Tract Infections / Sexually Transmitted
Infections:
5. Nutrition Services (coordinated with ICDS)
6. School Health
7. Adolescent Health Care
8. Promotion of Safe Drinking Water and Basic Sanitation
9. Prevention and control of locally endemic diseases like malaria, Kalaazar,
Japanese Encephalitis, etc

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10. Disease Surveillance and Control of Epidemics
11. Collection and reporting of vital events
12. Education about health/Behaviour Change Communication (BCC)
13. National Health Programmes including Reproductive and Child HealthProgramme
(RCH), HIV/AIDS control programme, Non communicable
disease control programme etc
14. Referral Services.
15. Training: ASHA, ANM, LHV
16. Basic Laboratory Services
17. Monitoring and Supervision:
18. AYUSH services as per local people’s preference (Mainstreaming of AYUSH)
19. Rehabilitation
20. Selected Surgical Procedures
Man Power in PHC
EXISTING RECOMMENDED
Medical Officer 1 2(one may be from AYUSH
or lady medical officer)
Pharmascist 1 1
Nurse-midwife (staff nurse) 1 3
Health worker(F) 1 1
Health Educator 1 1
Health assistant(M & F)
(LHV and Health Assistant
Male)
2 2
Clercks 2 2
Laboratory Technician 1 1
Driver 1 1
Class IV 4 4

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SUBCENTRE
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. As per the population norms,
one Sub-centre is established for every 5000 population in plain areas and for every 3000
population in hilly/tribal/desert areas. A Sub-centre provides interface with the community at
the grass-root level, providing all the primary health care services. As sub- centres are the
first contact point with the community, the success of any nation wide programme would
depend largely on well functioning sub-centres providing services of acceptable standard to
the people. The current level of functioning of the Subcentres are much below the
expectations.
There is a felt need for quality management and quality assurance in health care
delivery system so as to make the same more effective, economical and accountable. No
concerted effort has been made so far to prepare comprehensive standards for the Sub-
centres. The launching of NRHM has provided the opportunity for framing Indian Public
Health Standards.
Objectives of Sub-centres:
i. To provide basic Primary health care to the community.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of the community.
Assured services or Functions of Primary health centers:
Assured services cover all the essential elements of preventive, promotive, curative
and rehabilitative primary health care. This implies a wide range of services that include:
1. Maternal and Child Health Care including family planning:
 Antenatal care: Early diagnosis, minimum three antenatal check up, identification
and management of high risk pregnancies, nutrition and health counseling,
minimum laboratory investigation urin albumin, test ofr syphilis,
chemoprophylaxis for malaria in high endemic area as per NVDCP.
 Intra-natal care: Promotion of institutional deliveries, skilled reference at home
deliveries. Minimum 2 postpartum visit, initiation of breast feeding health
education on hygiene, contraception etc,
 Others: Provison of facilities under Janani Suraksha Yojna and NRHM.
 Postnatal Care:
 Child health: Essential New born care, promotion of exclusive breast feeding,
immunization of all children, prevention and control of all childhood disease.
2. Family planning and contraception: Education motivation and counseling to adopt
family planning motheds,provision of contraception.
3. Counseling and appropriate referral for safe abortion services for those in need.

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4. Adolescent health care:
5. Assistance to school health services.
6. Control local endemic diseases such as Malaria, filariasis etc.
7. Disease surveillance
8. Water quality monitering: Disinfection of water sources
9. Promotion of sanitation including use of toilets and appropriate garbage disposal.
10. Field visits
11. Community needs assessment
12. Curative services: Provide treatment for minor ailments, referral service, organizing
health day once in month at anganvadi.
13. Training coordination and monitering: Training of traditional birth attendants ASHA
community health volunteers, omonitering of water quality.
14. National Health Programmes
15. Record of Vital Events
Man Power
Manpower Existing Proposed
Health worker(female)
Auxillary Nurse Midwife
1 2
Health worker(male)
Multi Purpose Worker
1 1
Viluntary worker(paid rs
100 per month as
honorarium)
1 1
The staff of the Sub center will have the support of ASHA (Accredited Social
Health Activists) wherever the ASHA scheme is implemented / similar functionaries at
village level in other areas. ASHA is primarily a trained woman volunteer, resident of the
village-married/widow/divorced with formal education up to 8th standard preferably in the
age group of 25-45 years. The general norm is one ASHA per 1000 population. The job
functions of ANM, Male Health worker, ASHA and AWW in the context of coordinated
functions under NRHM.

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HOSPITALS AND HEALTH CENTRES
Community Health Centers
Health care delivery in India has been envisaged at three levels namely primary,
secondary and tertiary. The secondary level of health care essentially includes
Community Health Centers (CHCs), constituting the First Referral Units (FRUs) and the
district hospitals. The CHCs were designed to provide referral health care for cases from the
primary level and for cases in need of specialist care approaching the centre directly. 4 PHCs
are included under each CHC thus catering to approximately 80,000 populations in tribal /
hilly areas and 1, 20,000 population in plain areas. CHC is a 30 bedded hospital providing
specialist care in medicine, Obstetrics and Gynecology, Surgery and Pediatrics. These centers
are however fulfilling the tasks entrusted to them only to a limited extent. The launch of the
National Rural Health Mission (NRHM) gives us the opportunity to have a fresh look at their
functioning.
NRHM envisages bringing up the CHC services to the level of Indian Public Health
Standards. Although there are already existing standards as prescribed by the Bureau of
Indian Standards for 30-bedded hospital, these are at present not achievable as they are very
resource-intensive. Under the NRHM, the Accredited Social Health Activist (ASHA) is being
envisaged in each village to promote the health activities. With ASHA in place, there is
bound to be a groundswell of demands for health services and the system needs to be geared
to face the challenge. Not only does the system require upgradation to handle higher patient
load, but emphasis also needs to be given to quality aspects to increase the level of patient
satisfaction.
Objectives of Indian Public Health Standards (IPHS) for CHCs:
 To provide optimal expert care to the community
 To achieve and maintain an acceptable standard of quality of care
 To make the services more responsive and sensitive to the needs of the community.
Functions of CHCs:
Every CHC has to provide the following services which can be known as the Assured
Services:
1. Care of routine and emergency cases in surgery:
 This includes Incision and drainage, and surgery for Hernia, hydrocele,
Appendicitis, hemorrhoids, fistula, etc.
 Handling of emergencies like intestinal obstruction, hemorrhage, etc.
2. Care of routine and emergency cases in medicine:
 Specific mention is being made of handling of all emergencies in relation to
the National Health Programmes as per guidelines like Dengue Haemorrhagic

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fever, cerebral malaria, etc. Appropriate guidelines are already available under
each programme, which should be compiled in a single manual.
3. 24-hour delivery services including normal and assisted deliveries
4. Essential and Emergency Obstetric Care including surgical interventions like
Caesarean Sections and other medical interventions
5. Full range of family planning services including Laproscopic Services
6. Safe Abortion Services
7. New-born Care
8. Routine and Emergency Care of sick children
9. Other management including nasal packing, tracheostomy, foreign body removal etc.
10. All the National Health Programmes (NHP) should be delivered through the CHCs.
11. Others: Blood storage facility, Essential laboratory services, Referral (transport).
Man power:
Personnel
General Surgeon 1
Physician 1
Obstetrician/Gynacologist 1
Paediatrics 1
Anaesthestist 1(Proposed)
Public Health Programme Manager 1(Proposed)
Opthalmologist 1(proposed)
Nurse-mid wife 9
Dresser (certified by red cross/ St Johns
Ambulance)
1
Pharmascist 1
Lab. Technician 1
Radiographer 1
Opthalmic Assistant 1(optional)

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Ward boys 2
Sweepers 3
Chowkidar 1
OPD attendant 1
Statical Assistant/Data entry operator 1
OT attendant 1
Registration Clerk 1
HOSPITALS
India’s Public Health System has been developed over the years as a 3-tier system,
namely primary, secondary and tertiary level of health care. District Health System is the
fundamental basis for implementing various health policies and delivery of healthcare,
management of health services for defined geographic area. District hospital is an essential
component of the District health system and functions as a secondary level of health care,
which provides curative, preventive and promotive healthcare services to the people in the
district.
Every district is expected to have a district hospital linked with the public
hospital/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.
Objectives for district hospitals:
The overall objective of IPHS is to provide health care that is quality oriented and sensitive to
the needs of the people of the District. The specific objectives of IPHS for DHs are:
i. To provide comprehensive secondary health care (specialist and referral
services) to the community through the District Hospital.
ii. To achieve and maintain an acceptable standard of quality of care.
iii. To make the services more responsive and sensitive to the needs of the people
of the district and the hospitals/centres from which the cases are referred to the
district hospitals

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Definition
The term District Hospital is used here to mean a hospital at the secondary referral
level responsible for a District of a defined geographical area containing a defined
population.
Grading of district hospitals:
The size of a district hospital is a function of the hospital bed requirement, which in
turn is a function of the size of the population it serves. In India the population size of a
district varies from 35,000 to 30,00,000 (Census 2001). Based on the assumptions of the
annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5
days, the number of beds required for a district having a population of 10 lakhs will be
around 300 beds. However, as the population of the district varies a lot, it would be prudent
to prescribe norms by grading the size of the hospital as per the number of beds.
Grade I: District hospitals norms for 500 beds
Grade II: District hospitals norms for 300 beds
Grade III: District hospitals norms for 200 beds
Grade IV: District hospitals norms for 100 beds
The disease prevalence in a district varies widely in type and complexities. It is not
possible to treat all of them at district hospitals. Some may require the intervention of highly
specialist services and use of sophisticated expensive medical equipments. Patients with such
diseases can be transferred to tertiary and other specialized hospitals. A district hospital
should however be able to serve 85-95% of the medical needs in the districts. It is expected
that the hospital bed occupancy rate should be at least 80%. Functions
1. It provides effective, affordable healthcare services (curative including specialist
services, preventive and promotive) for a defined population, with their full
participation and in co-operation with agencies in the district that have similar
concern. It covers both urban population (district headquarter town) and the rural
population in the district.
2. Function as a secondary level referral centre for the public health institutions below
the district level such as Sub-divisional Hospitals, Community Health Centres,
Primary Health Centres and Sub-centres.
3. To provide wide ranging technical and administrative support and education and
training for primary health care.
Essential Services
Services include OPD, indoor, emergency services.
Secondary level health care services regarding following specialties will be assured at
hospital:
Consultation services with following specialists:
 General Medicine

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 General Surgery
 Obg & Gyne
 Paediatrics including Neonatology
 Emergency (Accident & other emergency) (Casualty)
 Critical care (ICU)
 Anaesthesia
 Ophthalmology
 ENT
 Orthopaedics
 Radiology
 Dental care
 Public Health Management
Para clinical services
 Laboratory Services
 X-Ray Facility
 ECG
 Blood transfusion and storage facilities
 Physiotherapy
 Dental Technology (Dental Hygiene)
 Drugs
 Pharmacy
Support Services
 Medico-legal/post-mortem
 Ambulance services
 Dietary services
 Security services.
 Waste management
 Ware housing/central store
 Maintenance and repair
 Electric Supply (power generation and stabilization)
 Water supply (plumbing)

20. 20
 Heating, ventilation and air-conditioning
 Transport
 Communication
 Medical Social Work
 Nursing Services
 Sterilization and Disinfection
HEALTH INSURANCE:
There is no universal health insurance in India. Health Insurance is at present is
limited to industrial workers and their families.
1. Employees State Insurance Scheme: It was introduced by an act of parliament in
1948. It covers employees drawing wages not exceeding Rs. 10,000 per month.
The act provides
o Medical benefits
o Sickness benefits
o Disabled benefits
o Maternity benefits
o Dependent benefits
o Funeral benefits
2. Central Government Health Scheme:
This scheme was introduced in New Delhi in 1954 to provide comprehensive medical
care to Central Government employees. The schemes based on the principles of
cooperative effort by the employee and the mutual advantage of both.
Facilities under the scheme include:
o Outpatient care through a network of dispensaries.
o Supply of necessary drugs.
o Laboratory and x-ray investigation.
o Domiciliary visits.
o Hospitalisation facilities at Govt as well as private hospitals recognized for the
purpose.
o Special consultation.
o Paediatric services including immunization.
o Antenatal, natal and postnatal services.
o Emergency treatment.

21. 21
o Supply of optical and dental aids at reasonable rate.
OTHER AGENCIES:
Defence Medical Services:
Defence services have their own organization for medical care to defence personnel
under the banner “Armed Forces Medical Services”. The services are provided are integrated
and comprehensive.
Health Care of Railway Employees: The Railways provide comprehensive health care
services through the agencies of Railway Hospitals, Health Units and Clinics. Environmental
sanitation is taken care of by Health Inspectors in big stations. Health check-up of employees
is provided at the time of recruitment and thereafter at yearly intervals.
PRIVATE AGENCIES:
In a mixed economy such as India’s, private practice of medicine provides a large
share of the health services available. There has been a rapid expansion in the number of
qualified allopathic physicians to 7.5 lakhs in 2005 and doctor population ration is 1:1428.
Most of them they concentrate in urban areas. They provide mainly curative services. Their
services are available to those who can pay. The private sector of health care services is not
organised.
INDEGINOUS SYSTEMS OF MEDICINE:
The practioners of indigenous system of medicine provide the bulk of medical care to
the rural people. Ayurvedic physicians alone are estimated to be about 4.5lakhs. Nearly 90%
of ayurvedic physicians serve the rural areas. To promote this these indigenous systems
Indian government established Indian Council For Indian Medicine in 1971. AYUSH is the
new approach on this. Which encompasses Ayurveda, Yoga, Unani, Sidda, Homeopathy.
Objectives of AYUSH:
o To upgrade the educational standards in the Indian Systems of Medicines and
Homoeopathy colleges in the country.
o To strengthen existing research institutions and ensure a time-bound research
programme on identified diseases for which these systems have an effective
treatment.
o To draw up schemes for promotion, cultivation and regeneration of medicinal plants
used in these systems.
o To evolve Pharmacopoeial standards for Indian Systems of Medicine and
Homoeopathy drugs.
Voluntary Health Agencies:
A voluntary health agency may be defined as an organization that is administered by
an autonomous board which holds meetings, collects funds for its support, chiefly from
private sources and expands money, whether with or without paid workers, in conducting a
programme directed primarily to furthering the public health by providing health services or

22. 22
health education by advancing research or legislation for health or by a combination of these
activities.
The voluntary health agencies in India are:
o Indian Red Cross Society
o Hind Kusht Nivaran Sangh
o Indian Council for Child Welfare
o Tuberculosis Association of India
o Bharat Sevak Samaj
o Central Social Welfare Board
o The Ksturba Memorial Fund
o Family Planning Association of India
o All India Women’s Conference
o The All- India Blind Relief Society
o Professional Bodies like TNAI, IMA, AIDA etc
o International Agencies like Rockfeller Foundation, CARE, Ford Foundation etc.
NATIONAL HEALTH PROGRAMMES
Since India became free, several measures have been undertaken by National
Government to improve the health of the people. Prominent among these measures are the
National Health Programmes. Which have been launched by the Central Government for
control/eradication of the communicable diseases, improvement of environmental sanitation,
raising the standard of nutrition, control of population and improving rural health. Various
international agencies like WHO, UNICEF, UNFPA etc have been providing technical and
material assistance in the implementation of these programmes.
National Health Programmes are:
 National Vector Borne Disease Control Programme
 National Leprosy Eradication Programme
 Revised National Tuberculosis Control Programme
 National AIDS Control Programme
 National Programme for Control of Blindness
 Iodine Deficiency Disorders Programme
 Universal Immunization Programme
 National Rural Health Mission
 Reproductive and Child Health Programme

23. 23
 Yaws Eradication Programme
 National Cancer Control Programme
 National Guinea- Worm Eradication Programme
 National Cancer Control Programme
 National Mental Health Programme
 National Diabetes Control Programme
 National Programme for Control and Treatment of Occupational Disease
 Nutritional Programme
 National Surveillance Programme for Communicable Disease
 Integrated Disease Surveillance Programme
 National Family Welfare Programme
 National Water Supply and Sanitation Programme
 Minimum Needs Programme
 20-Point Programme
Need For an Alternatenative Health Systems of Health Care:
 The present system is limited to the urban areas.
 It has greater emphasis on curative aspects rather than preventive and promotive
aspects care.
 It is expensive.
 Inadequacy and misdistribution of resources for health services
 There is lack of clear-cut referral system.
 There is lack of intersectoral collaboration and community involvement.
 Over centralization of authority.
 There is insufficient orientation and training of the primary health care staff and there
is also lack of proper job descriptions resulting in poor implementation of the projects.
 The unsuitable working hours of the personnel in the rural areas.
NATIONAL RURAL HEALTH MISSION
The National Rural Health Mission (NRHM) has been launched with a view to
bringing about dramatic improvement in the health system and the health status of the people,
especially those who live in the rural areas of the country. The Mission seeks to provide

24. 24
universal access to equitable, affordable and quality health care which is accountable at the
same time responsive to the needs of the people, reduction of child and maternal deaths as
well as population stabilization, gender and demographic balance. In this process, the
Mission would help achieve goals set under the National Health Policy and the Millennium
Development Goals.
To achieve these goals NRHM will:
 Facilitate increased access and utilization of quality health services by all.
 Forge a partnership between the Central, state and the local governments.
 Set up a platform for involving the Panchayati Raj institutions and community in the
management of primary health programmes and infrastructure.
 Provide an opportunity for promoting equity and social justice.
 Establish a mechanism to provide flexibility to the states and the community to
promote local initiatives.
 Develop a framework for promoting inter-sectoral convergence for promotive and
preventive health care.
The Vision of the Mission
 To provide effective healthcare to rural population throughout the country with
special focus on 18 states, which have weak public health indicators and/or
weak infrastructure.
 18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh,
Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur , Mizoram,
Meghalaya, Madhya Pradesh, Nagaland, Orissa , Rajasthan, Sikkim, Tripura,
Uttaranchal and Uttar Pradesh.
 To raise public spending on health from 0.9% GDP to 2-3% of GDP, with
improved arrangement for community financing and risk pooling.
 To undertake architectural correction of the health system to enable it to
effectively handle increased allocations and promote policies that strengthen
public health management and service delivery in the country.
 To revitalize local health traditions and mainstream AYUSH into the public health
system.
 Effective integration of health concerns through decentralized management at district,
with determinants of health like sanitation and hygiene, nutrition, safe drinking water,
gender and social concerns.
 Address inter State and inter district disparities.

25. 25
 Time bound goals and report publicly on progress.
 To improve access to rural people, especially poor women and children to equitable,
affordable, accountable and effective primary health care.
The Objectives of the Mission
 Reduction in child and maternal mortality.
 Universal access to public services for food and nutrition, sanitation and hygiene and
universal access to public health care services with emphasis on services addressing
women’s and children’s health and universal immunization.
 Prevention and control of communicable and non-communicable diseases, including
locally endemic diseases.
 Access to integrated comprehensive primary health care.
 Population stabilization, gender and demographic balance.
 Revitalize local health traditions & mainstream AYUSH.
 Promotion of healthy life styles.
The core strategies of the Mission
 Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and
manage public health services.
 Promote access to improved healthcare at household level through the female health
activist (ASHA).
 Health Plan for each village through Village Health Committee of the Panchayat.
 Strengthening sub-centre through better human resource development, clear quality
standards, better community support and an untied fund to enable local planning and
action and more Multi Purpose Workers (MPWs).
 Strengthening existing (PHCs) through better staffing and human resource
development policy, clear quality standards, better community support and an
untied fund to enable the local management committee to achieve these
standards.
 Provision of 30-50 bedded CHC per lakh population for improved curative care to a
normative standard. (IPHS defining personnel, equipment and management standards,
its decentralized administration by a hospital management committee and the
provision of adequate funds and powers to enable these committees to reach desired
levels)
 Preparation and implementation of an inter sector District Health Plan prepared by the
District Health Mission, including drinking water, sanitation, hygiene and nutrition.
 Integrating vertical Health and Family Welfare programmes at National, State,

26. 26
District and Block levels.
 Technical support to National, State and District Health Mission, for public health
management Strengthening capacities for data collection, assessment and review for
evidence based planning, monitoring and supervision.
 Formulation of transparent policies for deployment and career development of
human resource for health.
 Developing capacities for preventive health care at all levels for promoting healthy
life style, reduction in consumption of tobacco and alcohol, etc.
 Promoting non-profit sector particularly in underserved areas.
Programmes
 Reproductive and Child Health Programme – II (RCH-II) and the Janani
Suraksha Yojana (JSY) launched.
 Polio eradication programme intensified – cases reduced from 134 in 2004-05 to 63
(up to now).
 Sterilization compensation scheme launched.
 Accelerated implementation of the Routine Immunization programme taken up. Catch
up rounds taken up this year in the States of Bihar, Jharkhand and Orisaa.
 Ground work for introduction of JE vaccine completed.
 Ground work for Hepatitis vaccines to all States completed.
 Auto Disabled Syringes introduced throughout the country.
 State Programme Implementation Plans for RCH II appraised by the National
Programme Coordination Committee set up by the Minstry. Funds to the
extent of 26.14% i.e. Rs. 1811.74 crore have been released under NRHM
Outlay.
Mission on nursing education:
The Mission would support strengthening of Nursing Colleges wherever required, as
the demand for ANMs and Staff Nurses and their development is likely to increase
significantly. This would be done on the basis of need assessment, identification of possible
partners for building capacities in the governmental and non governmental sectors in each of
the States/UTs, and ways of financing such support in a sustainable way. Special attention
would be given to setting up ANM training centres in tribal blocks which are currently para-
medically underserved by linking up with higher secondary schools and existing nursing
institutions

27. 27
HEALTH CARE DELIVERY SYSTEM IN ABROAD
UNITED STATES OF AMERICA
In the United States the health care delivery system in constantly changing.
Implementation and changes are brought according to needs of the citizens. There is a great
division and responsibility.
Health care system is divided in to private and public sector. The public section
includes federal state and local divisions and is cincerned with provision of healthy
environment. Private sector usually care for individuals and families.
Health Care Delivery System Models
Elementary Model of the health care delivery system
Consumers engaged in exchange of relationship with providers. It refelts a strange
blend of public and private enterprises. Mostly private patients are charged. More number of
specialists complicate the entry, there is lot of competetion among providers fee for service.
Public and private sector models:
Public system in composed of public health agencies, both voluntary and official at
federal, state and local levels. The private health care delivery system includes clinic, PPO,
HMO, Hospital based etc, here funding agencies are third party.

28. 28
Health Care Delivery model: public and private sectors
ORGANISATION OF THE HEALTH CARE SYSTEM
PUBLIC SECTOR
Public agencies are financed with tax monies, thus these are accountable to the public. The
public sector includes official(governmental) agencies and voluntary agencies.`
Core Public Health Functions applied to Populations and Peple at Risk

29. 29
Population- Wide Services
Assessment
Health status monitering and disease surveillance
Public Policy
Leadership, policy, planning and administration
Assurance
Investigation and control of diseases and injuries
Protection of environment, workplaces, housing, food, and water
Laboratory services to support diseasecontrol and envirnmental proction.
Health education and information
Community mobilization for health-related issues
Targeted outreach and linkage to personal services
Health services quality assurance and assurance and accountability
Training and education of public health professionals
Personal Services and Home Visits for People at Risk
Primary care for unserved and underserved people
Treating services for targeted conditions
Clinical preventive services
Payments for personal services delivered by others
ORGANISATION OF THE PUBLIC HEALTH SYSTEM
The public health system is organised in to many levels in the
 Federal,
 State,
 Local systems.
THE FEDERAL SYSTEM:
Federal Governmnet has the responsibility for the following aspects of health care.
At the federal level, the primary agencies are concerned with health are organized under the
Department of Health and Human Services(DHHS).

30. 30
 Providing direct care for certain groups such as Native Americans, military personnel,
and veterans.
 Safeguarding the public health by regulating quarrentines and immigration laws and
the marketing food, drugs and products used in medical care.
 Prevents environmental hazzards, gives grantsin aids to states, local areas and
individuals and supports research.
 Administration of social security, social welfare and related programmes
 Public health service administer health functions such as mental health, health
resources, the National Institutes of health (NIH) Centres for Disease Control and
preparation (CDC) and the food and drug administration (FDA)
 The federal government looks in to the Division of Nursing to provide the
competence and expertise for administering nurse education legislation, interpreting
trends and needs of the nursing component of the nations health care delivery system.
STATE SYSTEM:
 Health financing (such as Medicaid) providing mental health and professional
education, establishing health codes, licensingfacilities and personneland regulating
insurance industry.
 Direct assistance to local health departments
 Typical Programs in a State Health Department
o AIDS Services
o Disaster management
o Case management
o Departmental licensing boards
o Division of vital records
o Environmental programmes
o Epidemiology
o Health planning and development
o Health services cost review
o Juveline services
o Legal services
o Media and public relations and educational information
o Medical assistance: policy, compliance operations
o Mental health and addictions
o Mental retardation and developmental disabilities

31. 31
o Preventive medicine and medical affairs
o Quality assurance
o Referral to resources
o Service to chronically ill and ageing
o STD(screening and treatment
 Nurses serve in many capacities in state health departments as consultants, direct
servicce providers, researchers, teachers and supervisors, as well as participating in
programme development planning, and evaluation of health programs. Many
departments have a division or department of nursing.
LOCAL SYSTEM
 Local health department has direct responsibility to the citizens in its community
juridiction.
 Programmes provided by local health departments
o Addiction and alcohol clinics
o Adult health
o Disaster management
o Birth and death records
o Child day care and development
o Child health clinic
o Dental health clinic
o Environmental health
o Epidemiology and disease control
o Family planning
o Health education
o Home health agency
o Hospital discharge planning
o Hypertension clinic
o Immunization clinic
o Information services
o Maternal health
o Medical social work
o Mental health
o Nursing

32. 32
o Nursing home licences
o Nutrition
o Occupational therapy
o School health
 The local level often provides an opportunity for nurses to take on signifacant
leadership roles, with many nurses serving as directors or managers.
PRIVATE SECTOR
The non governmental and voluntary arm of the health care delivery system includes
many types services.
 Privately owned, non profit agencies which includes most hospitals and wlfare
agencies make up one large group.
 Privately owned for profit agencies
 Private professional health care practice, composed largely of physician in solo
practice or group practice.
Private health services are complementary and supplementary to government healh agencies
FINANCING OF HEALTH CARE
Financing and health care significantly affects community health and community
health nursing practice. It influences the type and quality of services offered as well as the
ways in which those services are used. Sources of payment may be clustered in to three
categories
 Third party payments
 Direct consumer payment
 Private or philanthropic support
Third party payments:
These are monetary reimbursements made to providers of health care by some one
other that the consumer who received the care. Organizations that administer these funds are
called third party payers.
Four types of payment sources
 Private insurance companies
 Independent health plans
 Government health programmes
 Claims payment agents

33. 33
Private insurance companies
Private insurance companies market and underwrite policies aimed at decreasing
consumer risk of economic loss because of a need to use health services.
Three types of private insurers
1) Commercial stock companies: These sell health insurances, usually as a side line.
They are private stock hoders corporations that sell insurance nationally e.g Aetna,
Travelers
2) Mutual companies: These insurer that operates in national marketplace are owned by
their policy holders e.g Prudentials,
3) Non profit: These operate under special state enabling laws that give them an
exclusive franchise to whole state and to a specific type of insurance.
E.g Blue cross sells only hospital coverage, Blue Sheild covers only medical
insurance, Delta Dental only dental insurance.
Independent Health Plans
Independent or self health plans underwrite the remaining health insurances in US.
Usually they may only sell health insurances; in some casee they may also provide health
services. They focus on a localized population
Government Health Programs
Government health programs make up the largest source of third party reimbursement
in United States. The governments four major health programme are
 Medicacare,
 Medicaid,
 Federal Health Benefits Plan
 Civilian Health and Medical Program of the Uniformed Services
Medicare:
 Provides mandatory federal health insurance for adults 65 years and older who have
paid in to social securtiy system and for certain disabled persons.
 It is the largest health insurance in US covering about 16% of the population. Among
that 2% are younger than 65 years of age and permanently disabled and chronically
ill.
Medicaid
 Provides medical assistance to children, those who are aged, blind or disabled.
Claims payment Agents:

34. 34
The government contracts with private agents to handle the claims payment process.
More than 80% of the governments third party payments have been handled by these private
contractors.
Direct Consumer Reimbursement:
A second major source of health care financing comes from direct fees paid by
consumers. This refers to individual out-of –pocket payments made for several different
reasons.
Health Maintainance Organisation:
A HMO is a system in which participants prepay a fixed monthly premium to receive
comprehensive health services delievered by a defined network providers to plan
particiapants. HMO are the oldest model of co ordinated or managed care..
Components of HMO:
 They serve a voluntary population
 There is a fixed annual or monthly payment
 The HMO some finaicial risk or gain.
 In contrast with physician in private practice, physician employed by HMO ecieve a
fixed salary.
There is a little co ordination between health care resources. There is variation in
access, quality of care, availability of health services within the state. It is said the US society
in individualistic, materialistic, aggressively competitive and market oriented.
Helath Care Delivery System in United Kingdom
UK has a tax-supported heath system that is owned by the governmnet, services are
available to all its citizens with out cost or for a small fee.
 In 1948, the United Kingdom passed the Acts which created the three separate but co-
operating National Health Services of Scotland, Northern Ireland and England and
Wales that provided free physician and hospital services to all people resident in the
United Kingdom.
 Hospital staff are salaried employees according to nationally agreed contracts,
 whilst primary care is largely provided by independent practices, who are paid, again
via a nationally agreed contract, according to the number of patients registered with
them and the range of additional services offered.
 The National Health Service has been amended from time to time, but is largely
intact. Around 86% of prescriptions are provided free. Prescriptions are provided free
to people who satisfy certain criteria such as low income or permanent disabilities.
People that pay for prescriptions do not pay the full cost.
 Funding comes from a hypothecated health insurance tax and from general taxation.

35. 35
 Private health services are also available. Private health care continued parallel to the
NHS, paid for largely by private insurance, but it is used only by a small percentage
of the population, and generally as a supplement to NHS services
Health Care Delivery System in Canada
 The Canadian health care delivery system is based on a national health insurance
program that is operated by each provincial governmnet.
 Specialists are concentrated in centres, where as primary health care providers are
evenly distributed through out canadian provinces.
 Canada has a federally sponsored, publicly funded Medicare system. Canada's system
is known as a single payer system, where basic services are provided by private
doctors, with the entire fee paid for by the government at the same rate. These rates
are negotiated between the provincial governments and the province's medical
associations, usually on an annual basis. A physician cannot charge a fee for a service
that is higher than the negotiated rate - even to patients who are not covered by the
publicly funded system - unless he opts out of billing the publicly funded system
altogether.
Health Care Delivery System in Australia
 Australia and New Zealand both have publicly funded health care systems, though
under the Conservative government in Australia, there has been new funding and
incentives for people who pay for private health insurance.
 In Australia the current system, known as Medicare, was instituted in 1984. It coexists
with a private health system.
 Medicare is funded partly by a 1.5% income tax levy (with exceptions for low-income
earners), but mostly out of general revenue.
 An additional levy of 1% is imposed on high-income earners without private health
insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme
that heavily subsidises prescription medications
Health Care Delivery System in Cuba
Cuba is an island with an estimated population of 9170000.The climate is subtropical.
Agriculture is the most important economic activity. The world’s biggest producer of sugar.
Principles of health care delivery system in Cuba:
1. Health of a population is government responsibility.
2. Health services should be available to all the population
3. The community should participate actively in health work
4. Preventive and curative health services should be intergraded.

36. 36
 Cuba has a health service system accessible and available to practically 100% of the
population, with a referral system ensuring the approriate level of care for each
patient.
 Preventive curative and rehabilitative services are well planned and integrated and
show excellent result in terms of service indicators and mortality and morbidity data.
 50% or more of the budget is allotted to to health and education.
 Certain factors have helped to make the Cuban health services efficient, such as
extremely high motivation of health services, complete literacy, high proportion of
doctors and other proffessionals staff, good transport facilities, mass mobilization and
full participation of the people.
Health Care Delivery System in Peru
Peru is a poor country that is considered to be transition. There has never been
centrally controlled or equity in availability of health care. People in countryside are treated
by “curanderos” who are traditional healers. The ministry of health of Peru obtained technical
help from Pan American health organisation and the start of a system of organized care for
the poor, and for the rich began to become a reality. The government has began surveillance
of infectious diseases and has omplememented progras to imoprove sanitation.
WHO works closely with other organizations within the United Nation System. It is a
constitutional requirement that WHO should establish and maintain effective collaboration
with the United Nations and provide health services and facilities. UNICEF has been one of
the closest partners. In 1989 WHO and UNICEF jointly launched an initiatives for mothers
and children called “facts of life”
Health system in Africa
 Health care in Africa is usually non existent or highly limited and under resourced.
The outbreak and spread of HIV/AIDS in Africa has crippled many populations and
sent life expectancies plummeting.
 However some countries have been able to tackle the challenges, for instance health
care in Uganda as well as education has reduced HIV/AIDS infections from 13% to
4.1% from 1990 to 2003.
Health system in Nigeriria Health care provision in Nigeria is a concurrent
responsibility of the three tiers of government in the country. However, because Nigeria
operates a mixed economy, private providers of health care have a visible role to play in
health care delivery.
 The federal governments role is mostly limited to coordinating the affairs of the
university teaching hospitals, while the state government manages the various general
hospitals and the local government focus on dispensaries.
 The total expenditure on health care as % of GDP is 4.6, while the percentage of
federal government expenditure on health care is about 1.5%.

37. 37
 National Health Insurance Scheme, the scheme encompasses government employees,
the organized private sector and the informal sector. Scheme also covers children
under five, permanently disabled persons and prison inmates
Health Care Delivery System in Asia
Israel, South Korea, Seychelles and Taiwan have universal health care. Thailand
plans to.In Sri Lanka, drugs are provided by a government owned drug manufcaturer called
the State Pharmaceuticals Corporation of Sri Lanka. In the Philippines, the Department of
Health (Philippines) organises public health for the country, and was established at the
initiative of the American governers, before independence. Saudi Arabia has a publicly
funded health system, although its levels are lower than the regional average.
Health care delivery system in Singapore
Singapore has a dual system of healthcare delivery, comprising of the public and
private systems. Primary healthcare is provided at outpatient polyclinics and private medical
practitioners' clinics. Secondary and tertiary specialist care are provided in the public and
private hospitals.
The private practitioners provide 80% of the primary healthcare services while the
public polyclinics provide the remaining 20%. For hospital care, it is the reverse with 80% of
hospital care being provided by the public sector and the remaining 20% by the private
sector.
In 1999, the public healthcare delivery system was re-organized into two vertically
integrated delivery networks, the National Healthcare Group and the Singapore Health
Services. This was to enable the delivery of more integrated and better quality and healthcare
services through greater cooperation and collaboration among the public sector healthcare
providers. This system also minimises the duplication of services and ensures the optimal
development of clinical capabilities. This public healthcare system is supported by the
Singapore Civil Defence Force's Ambulance Service which provides paramedical support and
transport for accident and trauma victims as well as medical emergencies.
Health System in China
Great advances in public health have been hallmark of the People’s Republic of China
since it was founded in 1949. Examples of public health advances that were made in china
including controlling contagious disease such as cholera, typhoid etc. These accomplishments
in public health were credited to a political system that was and is largely socialistic terms as
collective.
 The collective health care system was owned and controlled by the state and was
characterised by the use of barefoot doctors who were medical practioners trained at
the community level and who could provide a minimal level of health throughout the
country.
 Barefoot doctors combined western medicine with traditional techniques such as
acupuncture, herbal remedies.

38. 38
 Chinas health care system is modified by the introduction of primary health care
system in community health clinics(CHC) based on the health care system in Canada.
With this system, a family practice physician is assigned 500 or more individuals for
whom to provide health care.
A Comparative Study Of Health Care Delivery System
Comparison of Effectiveness of Different Health Care Delivery System through Available
Data
In India
 Life expectancy: 64.4 years(2000)
 Infant mortality rate:70(1999)
 Physicians per 1000 people: 0.4(1998)
 Nurses per 1000 people: 0.45(1998)
 Health care costs as percentage of GDP:6%
 Percentage of public expenditure on health to total health:17.3%
Country
Life
expectancy
Infant
mortality
rate
Physicians
per 1000
people
Nurses
per
1000
people
Per capita
expenditure
on health
(USD)
Healthcare
costs as a
percent of
GDP
% of
government
revenue
spent on
health
% of health
costs paid
by
government
Australia 80.5 5.0 2.47 9.71 2,519 9.5 17.7 67.5
Canada 80.5 5.0 2.14 9.95 2,669 9.9 16.7 69.9
China 31.0 2.0 2.7 24.9
Srilanka 16.00 0.2 1.02 3.0 45.4
Japan 82.5 3.0 1.98 7.79 2,662 7.9 16.8 81.0
Sweden 80.5 3.0 3.28 10.24 3,149 9.4 13.6 85.2
UK 79.5 5.0 2.30 12.12 2,428 8.0 15.8 85.7
USA 77.5 6.0 2.56 9.37 5,711 15.2 18.5 44.6

39. 39
In India technological improvements and increased access to health care have resulted
in a steep fall in mortality, but the disease burden due to communicable and non
communicable disease, environmental pollution and malnutrition problems continued to be
high. In spite of the fact that norms for creation of infrastructure and manpower are similar
through out the country, that remains substantial variation between states and districts with in
the states, in availability and utilization of health care services and health indices of the
population.
CONCLUSION
The health care delivery system is a large complex organisation comprising a variety of
agencies and many health care professionals. Health care can be considered a right of all
people. The idea that health is the responsibility of each individual in society is gaining
greater acceptance. Various providers of health care co-ordinate their skills to assist a client.
Their mutual goal is to restore a clients health and promote wellness.
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