BSC SEM 2 UNIT 2 COMMUNITY HEALTH NURSING

UNIT 2 Health Care Planning and Organization of Health Care at various levels

Health Care Planning

1. Introduction to Health Care Planning

Health Care Planning is a systematic process of identifying health problems, setting priorities, and formulating strategies and policies to improve health status.

Importance in Community Health Nursing:

Helps in achieving equitable, accessible, and affordable healthcare.
Ensures effective utilization of available resources.
Enables planning preventive, promotive, curative, and rehabilitative services.

2. Objectives of Health Care Planning in Community Setting

To reduce morbidity and mortality.
To provide preventive, promotive, curative, and rehabilitative services.
To improve quality of life.
To achieve universal health coverage.
To involve the community in planning and implementation.

3. Levels of Health Care System in India (Based on Three-Tier System)

A. Primary Level (First Contact Care)

Focuses on preventive, promotive, and basic curative care.
Delivered through:
- Sub-Centres (SCs)
  - Staff: ANM, Male Health Worker
  - Population coverage: 5,000 in plain areas, 3,000 in hilly/tribal
  - Services: MCH, immunization, family planning, health education
- Primary Health Centres (PHCs)
  - Staff: Medical Officer, Staff Nurses, Pharmacist, Lab Tech
  - Population coverage: 30,000 in plain, 20,000 in hilly
  - Services: OPD, basic lab tests, ANC/PNC, delivery care, national health programs

B. Secondary Level (First Referral Care)

Provides specialist care, referral support.
Delivered through:
- Community Health Centres (CHCs)
  - Staff: 4 Specialists (Surgeon, Physician, Gynaecologist, Paediatrician), nurses, lab techs, etc.
  - Population coverage: 1,20,000 in plain, 80,000 in hilly
  - Services: 30-bed facility, OPD/IPD care, emergency, surgical services
- Sub-District Hospitals or Taluka Hospitals

C. Tertiary Level (Advanced Care)

Offers super-specialty services.
Institutions:
- District Hospitals
- Medical Colleges
- AIIMS, PGI, Regional Institutes
- Private Super-specialty Hospitals
Services: ICU, surgeries, diagnostics, training, and research.

4. Types of Health Care Services Provided at Each Level

Level	Type of Services
Primary	Immunization, Antenatal care, Health Education, Basic treatment, Nutrition programs, School health
Secondary	Specialist consultations, Inpatient care, Emergency services, Lab investigations
Tertiary	Intensive care, Organ transplant, Cardiac surgery, Oncology, Neuro-care, etc.

5. Health Care Planning Bodies and Schemes

Planning Body/Scheme	Role
Ministry of Health & Family Welfare (MoHFW)	Policy formulation, national health programs
National Health Mission (NHM)	Strengthening public health at all levels
State Health Societies	Implementation of programs at state level
Village Health Sanitation and Nutrition Committees (VHSNC)	Local-level community health planning

6. Role of Community Health Nurse in Health Planning and Organization

Role	Details
Planner	Identifies community health needs, plans interventions.
Care Provider	Offers preventive and basic curative services at SCs/PHCs.
Educator	Conducts health awareness and behavior change communication.
Coordinator	Coordinates with ASHA, Anganwadi, and other health workers.
Evaluator	Assesses effectiveness of health programs, collects data.
Advocate	Mobilizes community participation and empowers local decision-making.

7. Health Programs Supporting Health Care Planning

Reproductive and Child Health (RCH)
National Tuberculosis Elimination Program (NTEP)
National AIDS Control Program (NACP)
National Vector Borne Disease Control Program (NVBDCP)
Ayushman Bharat (PM-JAY, HWCs)
Janani Suraksha Yojana (JSY)
Rashtriya Bal Swasthya Karyakram (RBSK)

8. Challenges in Health Care Planning at Community Level

Inadequate infrastructure in remote areas.
Shortage of trained manpower.
Poor intersectoral coordination.
Low community participation.
Social and cultural barriers.

9. Recommendations

Strengthen sub-centres with equipment and trained staff.
Integrate digital health records and telemedicine.
Promote family and community participation.
Regular training of community health nurses.
Strengthen monitoring and evaluation mechanisms.

📌 Summary

Health care planning ensures rational use of resources and equitable service delivery.
Organization of health care follows a 3-tier system: Primary, Secondary, Tertiary.
Community health nurses play a central role in delivery and planning at grassroots level.
Effective planning, implementation, and evaluation is crucial for achieving Universal Health Coverage.

Steps of Health Planning

Health planning is a logical and systematic process that helps to identify health needs, set goals, and design interventions to improve community health. It is essential for resource allocation, policy development, and program implementation.

Main Steps of Health Planning

Analysis of Health Situation
Setting Objectives and Goals
Assessing Resources
Fixing Priorities
Formulating the Plan
Programming and Implementation
Monitoring
Evaluation

1. Analysis of Health Situation

Also called: Situational Analysis / Situational Assessment

This step involves collecting and analyzing data on the health status of the population.

Data includes:

Demographics (age, sex, literacy)
Morbidity and mortality rates
Disease patterns (communicable/non-communicable)
Nutritional status
Availability and accessibility of health services
Socio-economic and environmental factors

Purpose: To understand the baseline health needs and problems of the community.

2. Setting Objectives and Goals

After identifying problems, goals and objectives are defined.

Objectives should be:

SMART (Specific, Measurable, Achievable, Realistic, Time-bound)
Based on priority health issues

Example:

Reduce IMR from 30/1000 to 20/1000 within 3 years.
Increase institutional deliveries by 40% in rural areas.

3. Assessing Resources

This step identifies available resources to achieve objectives:

Resources include:

Manpower: Doctors, nurses, ANMs, ASHAs
Financial: Government grants, NHM funds
Infrastructure: Buildings, equipment, transport
Material: Medicines, vaccines, consumables
Time: Timeline for implementation

Purpose: To match needs with resources or plan for additional requirements.

4. Fixing Priorities

When resources are limited, priorities must be fixed.

Criteria for prioritization:

Magnitude of the problem
Severity and impact on life
Availability of cost-effective solutions
Community concern
Political will

Example:

Prioritizing immunization over cosmetic surgery in rural health planning.

5. Formulating the Plan

A detailed plan is developed including:

Activities to be done
Personnel involved
Target population
Time frame
Budget estimates
Evaluation indicators

Plan should be: Feasible, Practical, and Inclusive

Example: PHC planning for TB control with X-ray, sputum testing, DOTS services.

6. Programming and Implementation

Plan is converted into operational programs with:

Work plans
Task assignments
Training and orientation
Resource mobilization
Supervision guidelines

Implementation starts through existing health systems — Sub-Centres, PHCs, CHCs, and outreach programs.

7. Monitoring

Ongoing supervision and checking of the program to ensure it is:

On track
Achieving set objectives
Efficiently using resources

Tools used:

Monthly reports
Field visits
Performance indicators (e.g., % immunization coverage)

Community Health Nurse plays a major role in real-time monitoring.

8. Evaluation

Evaluation is the final step to measure:

Effectiveness (Have the objectives been achieved?)
Efficiency (Were resources used wisely?)
Impact (Has the health status improved?)
Sustainability (Can the benefits be maintained long-term?)

Types of Evaluation:

Formative (during the program)
Summative (at the end of the program)
Impact evaluation

📌 Summary Table

Step	Description
1. Situation Analysis	Identify health problems using data
2. Set Objectives	Define SMART goals
3. Resource Assessment	Identify manpower, funds, materials
4. Priority Fixation	Choose most urgent problems
5. Plan Formulation	Design a detailed action plan
6. Implementation	Execute the plan on ground
7. Monitoring	Track the program continuously
8. Evaluation	Assess the success and areas to improve

Role of Community Health Nurse in Health Planning

Participates in community surveys and data collection
Identifies local health needs
Assists in setting realistic objectives
Involves in mobilizing community and resources
Implements and monitors activities
Maintains records and submits reports
Participates in evaluation and feedback

Health Planning in India – Various Committees on Health and Family Welfare

Introduction to Health Planning in India

Health planning in India started after Independence (1947) to develop an organized, equitable, and efficient health care delivery system.
The government appointed several expert committees to evaluate existing services and suggest improvements.
These committees provided the foundation for the structure and functions of the health system in India today.

Major Health Committees in India

1. Bhore Committee (1946)

➡ Official Name: Health Survey and Development Committee

Feature	Description
Chairperson	Sir Joseph Bhore
Year	1946 (pre-independence)
Purpose	To survey the health conditions and recommend future planning

Key Recommendations:

Integration of preventive and curative services at all levels
Primary Health Centres (PHC) to be established for 40,000 population
Long-term goal: Health services for all without financial hardship
Three-tier system: Primary, Secondary, Tertiary care
Emphasis on medical education reform

🎯 Significance: Laid the foundation for modern public health system in India

2. Mudaliar Committee (1962)

➡ Official Name: Health Survey and Planning Committee

Feature	Description
Chairperson	Dr. A. Lakshmanaswamy Mudaliar
Year	1962

Key Recommendations:

Strengthen existing PHCs before opening new ones
One PHC for every 40,000 population
Create district hospitals as referral centers
Improve quality of medical education
Focus on training health workers

🎯 Significance: Emphasis on quality over quantity in health services

3. Chadah Committee (1963)

➡ Related to Family Planning

Feature	Description
Chairperson	Dr. M.S. Chadah
Year	1963

Key Recommendations:

Combine family planning with general health services
Use Basic Health Workers (BHW) to deliver services
Emphasized follow-up services and maintaining family planning records

🎯 Significance: Integration of Family Planning with existing health structure

4. Mukherjee Committee (1965 & 1966)

Year	Purpose
1965	Review family planning implementation
1966	Re-evaluation of urban family planning strategies

Key Recommendations:

Separate staff for Family Planning Services
Establish Family Planning Stores
Appoint a District Family Planning Officer

🎯 Significance: Laid groundwork for independent Family Welfare Programs

5. Jungalwalla Committee (1967)

➡ Focus on Integration of Health Services

| Chairperson | Dr. Jungalwalla |

Key Recommendations:

Unified cadre of health services (no separate cadres)
Common seniority, equal pay for equal work
Eliminate private practice by government doctors
Better service conditions for health workers

🎯 Significance: Proposed integration of preventive, promotive, and curative services

6. Kartar Singh Committee (1973)

Key Recommendations:

Multipurpose workers scheme
Suggested replacing multiple field workers with one Multipurpose Health Worker (MPHW)
Sub-centre for 3,000-5,000 population
Supervisory staff structure with Health Supervisor (Male & Female)

🎯 Significance: Rationalized and simplified field-level staffing in rural health services

7. Srivastava Committee (1975)

➡ Also known as: Group on Medical Education and Support Manpower

Key Recommendations:

Develop Community Health Worker (CHW) at village level
Launch a new cadre of Health Assistants
Medical and nursing education to be restructured towards rural needs
Introduction of Village Health Guides (VHG)

🎯 Significance: Led to concept of community participation in health care delivery

8. Bajaj Committee (1986)

➡ Focus: Health manpower planning and development

| Chairperson | Prof. J.S. Bajaj |

Key Recommendations:

Create national health manpower planning body
Reform medical, nursing, and paramedical education
Strengthen health education and research
Improve career structure of health workers

🎯 Significance: Provided strategies for HR development in health sector

9. Krishnan Committee (1992)

➡ Focus: Voluntary sector participation in health

🔹 Key Recommendations:

Encourage NGOs and private sector to participate in health care
Promote public-private partnerships (PPP)

10. National Health Policy Committees (1983, 2002, 2017)

Year	Focus
1983	Access to primary care and health for all by 2000
2002	Health equity, public-private partnerships
2017	Universal Health Coverage (UHC), wellness centres, digital health

🎯 Significance: Guide long-term national planning and priorities

📌 Summary Table – Health Committees in India

Committee	Year	Focus / Contribution
Bhore	1946	Foundation of Indian health system
Mudaliar	1962	Improve quality of PHCs and education
Chadah	1963	Family planning integration
Mukherjee	1965–66	Dedicated family planning structure
Jungalwalla	1967	Unified health services
Kartar Singh	1973	Multipurpose worker scheme
Srivastava	1975	Community-based workers
Bajaj	1986	Health manpower development
Krishnan	1992	Voluntary sector involvement
NHP Committees	1983–2017	National health policy planning

Role of Community Health Nurse Based on Recommendations

Acts as Multipurpose Worker (MPHW) at sub-centres
Provides maternal, child health, and family welfare services
Works in coordinated team at PHCs/CHCs
Acts as community mobilizer and educator
Maintains health records, immunization registers, and family planning data
Participates in program implementation and evaluation

Health Planning in India – Various Commissions on Health and Family Welfare

While Committees are temporary expert groups formed for specific health planning issues, Commissions are usually more broad-based and permanent or long-term advisory bodies. Several important Health Commissions have influenced India’s health and family welfare planning over time.

1. Bhore Commission (1943–1946)

➡ Official Name: Health Survey and Development Committee
➡ Commissioned by: British Government of India

Details	Description
Chairperson	Sir Joseph Bhore
Year of Report	1946
Purpose	Comprehensive health system development before Indian independence

Major Recommendations:

Integration of preventive and curative services.
Establish Primary Health Centres (PHCs) for 40,000 people.
Emphasized free health services for all.
Development of district hospitals as referral units.
Reforms in medical education, including community-oriented training.

🎯 Impact: Foundation of modern Indian health system and inspiration for post-independence health planning.

2. National Commission on Macroeconomics and Health (NCMH) – 2005

Details	Description
Established by	Ministry of Health and Family Welfare (MoHFW)
Year	2005
Chairperson	Dr. S. Narayan (former Finance Secretary)

Key Focus Areas:

Linking economic growth with health investment.
Evaluate economic impact of diseases like TB, HIV, NCDs.
Recommended increased public health spending up to 2–3% of GDP.
Promote universal access to essential health services.

🎯 Impact: Influenced the framing of National Health Policy 2017 and government health financing strategy.

3. National Commission on Population (NCP)

Details	Description
First Established	2000
Reconstituted	2020
Chairperson	Prime Minister of India
Vice Chair	Union Minister of Health & Family Welfare

Objectives:

Monitor and implement National Population Policy (2000).
Guide population stabilization efforts.
Coordinate family planning programs with state governments.
Support maternal and child health improvements.

🎯 Impact: Ensures long-term planning for population control and demographic management.

4. Law Commission of India (Relevant for Health Law)

Though not a health-specific commission, the Law Commission has periodically submitted reports affecting health and family welfare, such as:

Surrogacy laws
Abortion and reproductive rights
Organ transplantation
Medical negligence laws

🎯 Impact: Influences the legal framework of healthcare in India.

5. Finance Commission of India (Health Grants)

Details	Description
Recent Commission	15th Finance Commission
Chairperson	N. K. Singh

Health-Related Recommendations:

Tied grants for primary health care to urban and rural local bodies.
Emphasis on strengthening infrastructure at the grassroots.
Focus on water, sanitation, nutrition, and immunization.

🎯 Impact: Ensures fiscal support for health sector from the central government to states.

6. NITI Aayog (Previously Planning Commission)

Health Focus:

Published Health Index Reports (state-wise performance).
Promotes public-private partnerships (PPP) in health.
Suggests reforms for Ayushman Bharat, digital health, telemedicine.
Encourages State-level health innovation.

🎯 Impact: Key driver of modern policy-level planning and innovation in health care.

Summary Table – Important Health Commissions in India

Commission	Year	Chairperson	Key Contributions
Bhore Commission	1946	Sir Joseph Bhore	Foundation of Indian health system, PHCs
NCMH	2005	Dr. S. Narayan	Health investment, economic impact of disease
Population Commission	2000 / 2020	PM of India	Population stabilization, family welfare
Law Commission	Ongoing	Varies	Legal framework for health and family welfare
Finance Commission	2021 (15th)	N.K. Singh	Tied grants for health infrastructure
NITI Aayog	2015 onward	PM-led	Health reforms, policy innovation, health index

Role of Community Health Nurse in Implementation of Commission Recommendations

Helps in population stabilization by educating on family planning.
Implements maternal and child health programs.
Coordinates with ASHA, Anganwadi workers for outreach services.
Participates in health surveys, immunization, and nutrition programs.
Assists in collecting data used for health planning and policy evaluation.

Five-Year Plans in India

Introduction

The Five-Year Plans (FYPs) were national level strategies for economic development in India.
Launched in 1951 under the Planning Commission.
Aimed to improve agriculture, industry, education, health, and infrastructure.
Health and Family Welfare was a key component in each plan.
Discontinued in 2017, replaced by NITI Aayog’s strategic planning.

Detailed Overview of Each Five-Year Plan (with Health Focus)

1st Five-Year Plan (1951–1956)

➡ Focus: Agriculture, Community Development

Health Achievements

Strengthening Primary Health Centres (PHCs).
National Malaria Control Programme (1953).
Bhopal Memorial Hospital initiated.
Focus on rural health and nutrition.

2nd Five-Year Plan (1956–1961)

➡ Focus: Industrialization and Health Expansion

Health Achievements

Health Survey & Planning Committee (Mudaliar Committee) formed.
Strengthening District Hospitals and referral services.
Emphasis on medical and nursing education.
Expanded Family Planning Programmes.

3rd Five-Year Plan (1961–1966)

➡ Focus: Self-reliance in economy and health manpower

Health Achievements

Launched National Smallpox Eradication Programme.
Introduction of School Health Services.
Expanded Family Planning and Nutrition Programs.

Plan Holiday (1966–1969)

Due to wars and droughts. Annual Plans instead.

4th Five-Year Plan (1969–1974)

➡ Focus: Growth with Stability

Health Achievements

Expansion of rural health infrastructure.
Launch of Minimum Needs Programme (MNP) – Health, water, housing.
Integrated Maternal & Child Health (MCH) services.

5th Five-Year Plan (1974–1979)

➡ Focus: Poverty Eradication and Self-reliance

Health Achievements

Integrated Child Development Services (ICDS) launched (1975).
Introduction of Multipurpose Health Worker Scheme (Kartar Singh Committee).
Srivastava Committee proposed Village Health Guides (VHGs).

6th Five-Year Plan (1980–1985)

➡ Focus: Health for All by 2000

Health Achievements

Launch of National Health Policy (1983).
Strengthening PHCs and CHCs.
Emphasis on RCH, immunization, sanitation.

7th Five-Year Plan (1985–1990)

➡ Focus: Social Justice and Technology

Health Achievements

Expanded Universal Immunization Programme (UIP).
Focus on AIDS Control, TB, Leprosy.
Strengthened rural health manpower.

Annual Plans (1990–1992)

Transition phase due to political instability.

8th Five-Year Plan (1992–1997)

➡ Focus: Human Development, Health for All

Health Achievements

Launch of Child Survival and Safe Motherhood Programme (CSSM).
Emphasis on women and child health.
Expanded education and training of nurses.

9th Five-Year Plan (1997–2002)

➡ Focus: Quality of Life and Population Control

Health Achievements

Launch of Reproductive and Child Health (RCH).
Emphasis on population stabilization.
Focus on tribal and backward areas.

10th Five-Year Plan (2002–2007)

➡ Focus: Health Indicators – IMR, MMR, TFR

Health Goals

IMR < 45/1000 live births
MMR < 2/1000 live births
TFR = 2.1
Focus on gender equality, access to basic services.

11th Five-Year Plan (2007–2012)

➡ Focus: Inclusive Growth

Health Achievements

Launch of National Rural Health Mission (NRHM).
Focus on maternal and newborn care.
Janani Suraksha Yojana (JSY) for institutional delivery.
Infrastructure strengthening of PHCs, SCs, CHCs.

12th Five-Year Plan (2012–2017)

➡ Focus: Faster, Sustainable, and Inclusive Growth

Health Achievements

NRHM expanded to National Health Mission (NHM).
Emphasis on universal health coverage.
Focus on non-communicable diseases (NCDs).
Launch of Rashtriya Bal Swasthya Karyakram (RBSK).

Discontinuation of Five-Year Plans (2017)

Planning Commission replaced by NITI Aayog (2015).
Five-Year Plans discontinued after 12th Plan.
Now replaced by 3-Year Action Plans, 7-Year Strategy Papers, and 15-Year Vision Documents by NITI Aayog.

📌 Summary Chart – Health Achievements across Five-Year Plans

Plan	Key Health Initiatives
1st	PHCs, Malaria control
2nd	Mudaliar Committee, FP expansion
3rd	Smallpox, School Health
4th	Minimum Needs Programme
5th	ICDS, Multipurpose workers
6th	NHP 1983, HFA by 2000
7th	AIDS control, UIP
8th	CSSM, nursing education
9th	RCH program
10th	IMR/MMR/TFR targets
11th	NRHM, JSY
12th	NHM, RBSK, UHC

Role of Community Health Nurse in Five-Year Plan Implementation

Works in PHCs and SCs under NRHM/NHM.
Implements MCH, immunization, family planning programs.
Participates in health surveys and data collection.
Delivers health education and counseling.
Acts as link between community and health system.

Participation of Community and Stakeholders in Health Planning

What is Participation in Health Planning?

Participation means actively involving the community and other stakeholders in the decision-making, planning, implementation, and evaluation of health services and programs.

This ensures that health plans reflect the real needs of the population and encourages ownership, accountability, and sustainability of health programs.

Importance of Participation

Why It’s Important	Explanation
Need-based planning	Community knows its own problems best
Better acceptance	People support what they help to build
Efficient resource use	Helps mobilize local resources
Transparency and accountability	Builds trust in the health system
Sustainability	People continue the activities even after programs end

Who Are the Stakeholders?

Stakeholders are individuals or groups who have an interest or role in health services.

Types of Stakeholders in Health Planning

Community Members
- Village leaders, women’s groups, adolescents, elderly, etc.
Local Health Workers
- ANM, ASHA, MPHW, Staff Nurses
Government Departments
- Panchayati Raj, Health & Family Welfare, Education, Women & Child Development
Non-Governmental Organizations (NGOs)
- e.g., CARE, UNICEF, CRY
Private Sector Partners
- Local hospitals, doctors, pharmacies
Community-Based Organizations (CBOs)
- Self-help groups (SHGs), youth clubs
Donor Agencies
- WHO, UNDP, World Bank, USAID

Levels of Community Participation (As per WHO)

Level	Description
Information	People are informed of the plan
Consultation	People give suggestions
Involvement	People take part in activities
Collaboration	Shared decision-making
Empowerment	Community has full control

Ways of Community and Stakeholder Participation

Method	Description
Village Health Sanitation and Nutrition Committee (VHSNC)	Local body to plan and monitor health services
Rogi Kalyan Samiti (RKS)	Patient welfare committee at PHC/CHC level
Gram Sabhas	Community meetings for planning and feedback
Participatory Rural Appraisal (PRA)	Mapping and analyzing village health issues with community
Public Hearings (Jan Sunwai)	People give opinions and complaints about health services
Self-Help Groups (SHGs)	Women-led microfinance groups involved in health awareness
ASHA Meetings	Platform to collect feedback and plan health outreach

Examples of Community Participation in India

ASHA workers: Chosen by the community, deliver care at home.
JSY Scheme: Promotes institutional delivery through community mobilization.
RBSK: School-based health check-up program involving teachers and parents.
Swachh Bharat Mission: Community-led total sanitation campaign.

Role of Community Health Nurse in Promoting Participation

Role	Details
Facilitator	Organizes meetings with community and stakeholders
Educator	Raises awareness about health issues and services
Mobilizer	Encourages community involvement in health campaigns
Coordinator	Links health department and local people
Advocate	Voices community needs to higher authorities
Trainer	Trains ASHAs, SHG leaders, youth volunteers

Barriers to Participation

Low literacy or awareness
Cultural or gender bias
Lack of trust in authorities
Dominance of powerful groups
Inadequate incentives or follow-up

Ways to Improve Participation

Conduct health education programs
Encourage inclusive leadership (women, youth, marginalized)
Strengthen local health committees
Provide training and incentives to volunteers
Promote transparency and feedback mechanisms

Conclusion

Community and stakeholder participation in health planning:

Promotes people-centered health services
Improves quality, equity, and accountability
Leads to sustainable health outcomes

It is not just a strategy, but a right and responsibility of every citizen and health worker.

Health Care Delivery System in India

1. Introduction

The health care delivery system in India refers to the organization of people, institutions, and resources to deliver health services to meet the health needs of the population.

It includes public and private sectors, and it operates at primary, secondary, and tertiary levels, supported by health programs, health workers, and community involvement.

2. Objectives of Health Care Delivery System

To provide equitable and accessible health care to all.
To deliver preventive, promotive, curative, and rehabilitative services.
To reduce morbidity and mortality.
To promote community participation and health awareness.
To ensure universal health coverage (UHC).

3. Structure of Health Care System in India

India follows a three-tier health system, particularly in the public sector:

A. Primary Level (First Contact Point)

➡ Delivers basic health services at the grassroots level.

a) Sub-Centre (SC)

Coverage: 5,000 population (3,000 in hilly/tribal)
Staff: 1 ANM (female), 1 MPHW (male), ASHAs
Services:
- Maternal and child health (MCH)
- Immunization
- Family planning
- Home visits and outreach
- Health education

b) Primary Health Centre (PHC)

Coverage: 30,000 population (20,000 in hilly)
Staff: Medical Officer, Nurse, Pharmacist, Lab Tech
Services:
- Outpatient care
- Minor treatments
- Antenatal/Postnatal care
- Disease control programs
- Referral services

B. Secondary Level (Referral Care)

➡ Provides specialist services and handles referrals from PHCs.

a) Community Health Centre (CHC)

Coverage: 1.2 lakh population (80,000 in hilly)
30-bed hospital
Staff: 4 specialists – Surgeon, Physician, Gynecologist, Pediatrician + support staff
Services:
- Emergency care
- Basic surgeries
- Institutional deliveries
- Referral care

b) Sub-District Hospitals / Taluka Hospitals

Act as first-level referral hospitals
Offer specialist and inpatient care

C. Tertiary Level (Advanced/Super-Specialty Care)

➡ Provides advanced diagnostic, therapeutic, and surgical care.

Institutions:

District Hospitals
Medical Colleges
AIIMS, PGIs, Specialty Institutes
Services:
- ICU, NICU, CCU
- Multi-specialty surgeries
- Advanced diagnostics
- Research and training

4. Types of Health Care Providers in India

Sector	Examples
Public Sector	Sub-Centres, PHCs, CHCs, District Hospitals, AIIMS
Private Sector	Private clinics, hospitals, nursing homes
Voluntary Sector	NGOs (e.g., CRY, SEWA), Mission hospitals
Indigenous Systems	AYUSH – Ayurveda, Yoga, Unani, Siddha, Homeopathy
Corporate Sector	Apollo, Fortis, Max Hospitals

5. National Health Programs Supporting the Delivery System

National Health Mission (NHM)
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)
Janani Suraksha Yojana (JSY)
Ayushman Bharat – PMJAY
National TB Elimination Program
Universal Immunization Program (UIP)

6. Human Resources in the Health System

Cadre	Role
ASHA	Bridge between community & health facility
ANM / MPHW	Frontline workers at sub-centre
Staff Nurse	Provides nursing care at PHC, CHC, hospital
Medical Officer	Diagnoses and treats at PHC/CHC level
Specialists	Secondary & tertiary care providers
District Health Officers	Supervise district-level health services

7. Role of Central and State Governments

Authority	Responsibility
Central Government	National health policies, major programs, funding
State Government	Implementation of health programs, infrastructure, HR
Panchayati Raj Institutions (PRIs)	Local-level health planning and monitoring (VHSNC, RKS)

8. Recent Innovations in Health Delivery

Innovation	Description
Health & Wellness Centres (HWCs)	Strengthened SCs/PHCs offering expanded primary care
Telemedicine	Remote consultations and e-health
Digital Health Mission	Health ID, electronic health records
Mobile Medical Units	Reach remote and underserved areas
eSanjeevani	Government’s free teleconsultation platform

9. Role of Community Health Nurse in Health Care Delivery

Provides home-based care and health education
Supports immunization, ANC/PNC, family planning
Maintains records and reports
Acts as link between people and system
Conducts screening and referrals
Promotes community participation and awareness

10. Challenges in Indian Health System

Inadequate infrastructure in rural areas
Shortage of trained health workforce
Unequal access across urban-rural areas
High out-of-pocket expenditure
Poor coordination between sectors

Suggestions for Improvement

Strengthening primary health care
Promoting public-private partnerships
Regular training of health workers
Encouraging community ownership
Ensuring equity and quality in care

Infrastructure and Health Sectors, Delivery of Health Services at Sub-Centre (SC)

(Community Health Nursing Perspective)

1. What is Health Infrastructure?

Health infrastructure refers to the physical and organizational structures, human resources, equipment, and services required to deliver health care effectively.

Components of Health Infrastructure

Component	Includes
Buildings	Sub-centres, PHCs, CHCs, Hospitals
Manpower	ANM, MPHW, Doctors, Specialists
Equipment	BP machine, delivery table, lab kits
Transport	Ambulance, mobile medical units
Drugs and Supplies	Vaccines, contraceptives, essential medicines
ICT	Health Management Information System (HMIS), Telemedicine, eHealth

2. Health Sectors in India

Health services in India are delivered through different sectors:

A. Public Sector

Government Sub-centres, PHCs, CHCs, District hospitals
Funded by: Central and State Governments
Mission: Provide free/affordable services to all

B. Private Sector

Clinics, Nursing homes, Hospitals
Profit-oriented, but important contributor to health services

C. Voluntary Sector

NGOs, Charitable hospitals
Often work in rural, tribal, and underserved areas

D. Indigenous Systems (AYUSH)

Ayurveda, Yoga, Unani, Siddha, Homeopathy
Promoted by Ministry of AYUSH

3. Sub-Centre (SC): The First Contact Point

Definition:

A Sub-Centre is the most peripheral and first contact point between the community and the health system.

Population Coverage

5,000 in plain areas
3,000 in hilly, tribal, or difficult areas

Staffing at Sub-Centre

Staff	Role
ANM (Auxiliary Nurse Midwife) – Female	Provides maternal & child health, immunization, FP services
MPHW (Male)	Disease control, sanitation, health education
ASHA (Accredited Social Health Activist)	Community link, mobilization, home visits
Optional: Second ANM or Health Assistant (under NHM)

4. Delivery of Health Services at Sub-Centre

Sub-Centre provides preventive, promotive, and limited curative services:

A. Maternal Health Services

Antenatal check-ups (ANC)
Iron and folic acid (IFA) tablet distribution
Tetanus toxoid immunization
Identification of high-risk pregnancies
Referral to PHC/CHC
Health education on pregnancy care

B. Child Health Services

Newborn care and home visits
Immunization (as per UIP schedule)
Vitamin A supplementation
Growth monitoring
Management of childhood illnesses (e.g., diarrhea, ARI)

C. Family Planning Services

Counselling for spacing and permanent methods
Distribution of oral pills and condoms
Follow-up of IUCD users
Community-based depot holder (CBD) services

D. Adolescent Health Services

Menstrual hygiene education
Counseling for nutrition, anemia, substance abuse

E. Disease Control Activities

Malaria, TB, Leprosy detection
Distribution of medicines and follow-up
Fever surveillance and sample collection
Vector control activities

F. National Health Programs

Universal Immunization Program (UIP)
Janani Suraksha Yojana (JSY)
Ayushman Bharat (HWC Model)
National Nutrition Mission
COVID-19 vaccination and awareness

G. Environmental Sanitation

Safe water supply
Construction and use of toilets
Promotion of hygiene and cleanliness
School health and sanitation awareness

H. Health Education and Counseling

On nutrition, hygiene, breastfeeding, immunization
Use of IEC (Information, Education, Communication) materials

I. Record Maintenance and Reporting

Eligible couple register
Antenatal/postnatal register
Immunization records
Births and deaths data
Monthly reporting to PHC/Block

Sub-Centre Upgradation – Health & Wellness Centres (HWCs)

Under Ayushman Bharat Mission, SCs are being upgraded into HWCs to provide:

Expanded range of primary care services
Management of non-communicable diseases (NCDs)
Mental health services
Telemedicine and digital health records

Role of Community Health Nurse (ANM) at Sub-Centre

Role	Responsibilities
Service provider	MCH, FP, immunization, first aid
Educator	Health talks, counseling, school health
Coordinator	Coordinates with ASHA, Anganwadi
Recorder	Maintains all SC registers and reports
Referral agent	Identifies danger signs and refers cases
Community mobilizer	Promotes participation in health programs

Challenges at Sub-Centre Level

Inadequate infrastructure or space
Shortage of trained manpower
Irregular supply of medicines and vaccines
Difficult terrain or remote locations
Overburdened ANMs

Suggestions for Improvement

Regular supply of essential drugs and logistics
Training and capacity building for ANMs
Timely salary and incentive for ASHAs
Strengthening HWC model
Community participation through VHSNCs

Primary Health Centre (PHC)

1. What is a Primary Health Centre (PHC)?

A Primary Health Centre (PHC) is the first contact point between a village community and a Medical Officer. It acts as a referral unit for Sub-Centres (SCs) and provides integrated curative and preventive health care to the rural population.

Coverage & Staffing

Criteria	Details
Population Coverage	30,000 in plain areas, 20,000 in hilly/tribal areas
Supervises	5–6 Sub-Centres
Staff (as per IPHS)	1 Medical Officer (MBBS), 1 AYUSH doctor, 3 Staff Nurses, 1 Pharmacist, 1 Lab Technician, 1 Health Educator, 1 Health Assistant (Male & Female), Clerical staff, Class IV

2. Infrastructure of a PHC

6 to 10 bedded facility (for in-patient care)
Outpatient consultation room
Labour room
Minor Operation Theatre (OT)
Laboratory, Pharmacy
Staff quarters
Drinking water and electricity
Waste management system

3. Services Delivered at PHC Level

PHC provides preventive, promotive, curative, and family welfare services.

A. Outpatient Care (OPD Services)

Diagnosis and treatment of common illnesses
Management of minor injuries
Screening for NCDs (diabetes, hypertension)

B. Maternal and Child Health Services

Antenatal and postnatal care (ANC/PNC)
Safe and clean deliveries
Referral of high-risk pregnancies
Immunization of infants and pregnant women

C. Family Planning Services

Counseling on family planning methods
Distribution of condoms, OCPs
IUCD insertion
Referrals for sterilization (tubectomy/vasectomy)

D. National Health Programs Implementation

Tuberculosis (NTEP)
Leprosy (NLEP)
Malaria (NVBDCP)
AIDS (NACP)
Immunization (UIP)
NCDs, Mental health, School health programs

E. Laboratory Services

Blood tests, urine tests, malaria smears
Pregnancy test, hemoglobin estimation

F. Basic In-patient Services

Observation beds for minor ailments
Post-delivery stay and monitoring
Minor surgical procedures

G. Emergency and First Aid

Snake bite, dog bite, poisoning
First aid for injuries, burns, accidents

H. Health Education and Counseling

Nutrition, hygiene, breastfeeding
Substance abuse prevention
Adolescent reproductive health

I. Referral Services

To CHC/District hospital for specialized care
Transport via ambulance (Janani Express, 108)

J. Administrative and Supervisory Role

Supervises Sub-Centres and ASHAs
Reviews performance of ANMs, MPHWs
Monthly meetings and data reporting

PHC as Health & Wellness Centre (HWC-PHC)

Under Ayushman Bharat, PHCs are being upgraded to Health & Wellness Centres offering:

Expanded services (mental health, NCDs, elderly care)
Free essential drugs and diagnostics
Telemedicine facilities
Community outreach via ASHAs and CHOs

Role of Community Health Nurse / Staff Nurse at PHC

Role	Responsibilities
Care Provider	Administers injections, dressings, IV fluids
MCH Services	Assists in deliveries, ANC/PNC care
Immunization	Conducts RI sessions, cold chain maintenance
Health Educator	Conducts group talks, IEC activities
Team Leader	Supervises MPHWs, ANMs, ASHAs
Record Keeper	Maintains registers, reporting formats
Referral Agent	Identifies complications and arranges transport

Challenges at PHC Level

Staff shortages (especially doctors and nurses)
Inadequate infrastructure
Irregular supply of drugs and consumables
Poor transport/referral systems
Low community participation

Suggestions for Improvement

Fill all sanctioned posts
Upgrade PHCs to HWCs with better equipment
Ensure drug supply and lab services
Strengthen referral linkage and transport
Promote use of digital tools (eSanjeevani, HMIS)

Community Health Centre (CHC)

1. What is a CHC (Community Health Centre)?

A Community Health Centre (CHC) is a secondary-level referral health facility. It provides specialist care to patients referred from Primary Health Centres (PHCs) and serves a larger population in rural and semi-urban areas.

Coverage & Role

Criteria	Description
Population Coverage	1,20,000 in plain areas; 80,000 in hilly/tribal areas
Supervises	4 PHCs and their Sub-Centres
Type of Facility	30-bed hospital with specialist services
Role	First referral unit (FRU) for complicated cases from PHCs

2. Infrastructure as per IPHS (Indian Public Health Standards)

30 beds for inpatient care
Separate OPD and IPD wards
Operation Theatre (OT)
Labour Room
Laboratory, X-ray, Ultrasound
Blood Storage Unit
Ambulance Services (108 or Janani Express)
Staff Quarters for Doctors and Nurses
Power backup and sanitation facilities

3. Staffing Pattern of a CHC

Cadre	Numbers (as per IPHS)
Specialists	4 – Surgeon, Physician, Obstetrician/Gynaecologist, Pediatrician
Medical Officers	3–5 (including AYUSH)
Staff Nurses	7–10
Pharmacist, Lab Tech, Radiographer	1 each
ANMs, MPWs, Health Assistants	As per catchment
Support Staff (Ward boys, cleaners, driver)	As needed

4. Services Delivered at CHC Level

CHCs provide both outpatient and inpatient services, with an emphasis on emergency, specialist, and surgical care.

A. Outpatient (OPD) Services

Daily consultation by medical officers and specialists
Management of non-communicable and communicable diseases
Minor ailments and routine follow-up

B. Inpatient (IPD) Services

Admission for illnesses, injuries, and surgical recovery
Bed occupancy for deliveries and postnatal care
Observation of emergency cases

C. Emergency Services

24×7 emergency care for trauma, delivery, poisoning, accidents
First aid for animal bites, burns, and shock
Management of obstetric emergencies (e.g., eclampsia, PPH)

D. Maternal and Child Health Services

Institutional deliveries
Emergency Obstetric Care (EmOC)
Antenatal/Postnatal care
Caesarean sections (if FRU designated)
Newborn care (NBCC, SNCU in some CHCs)

E. Surgical Services

Appendectomy, hernia repair, abscess drainage
Minor and emergency surgeries under general/local anesthesia

F. Family Planning Services

Sterilization procedures (Tubectomy/Vasectomy)
IUCD insertion and contraceptive counseling
Follow-up services

G. National Health Programs

Tuberculosis (DOTS)
Leprosy, HIV/AIDS, Malaria
RCH, NCDs, School Health Program
Immunization, JSY, JSSK implementation

H. Laboratory and Diagnostic Services

Blood tests, urine tests, X-ray
ECG and ultrasonography (if available)
Blood grouping and cross-matching

I. Referral Services

Acts as referral for PHCs
Refers further complicated cases to District Hospital or Medical College

5. CHC as First Referral Unit (FRU)

Many CHCs are upgraded as FRUs (First Referral Units) if they fulfill:

24×7 delivery and caesarean services
Newborn care
Blood storage unit
Emergency care (esp. obstetrics)

6. Role of Community Health Nurse / Staff Nurse at CHC

Role	Responsibilities
Nursing Care	IPD and emergency care
Labour Room Duty	Assisting normal and caesarean deliveries
OT Nurse	Assisting surgeries
Immunization	Coordination with ANMs and ASHAs
Health Education	Conducting sessions for OPD and inpatients
Records & Reports	Documentation of services provided
Supervision	Guides ANMs and field staff during referrals

7. Challenges at CHC Level

Shortage of specialists in rural areas
Inadequate equipment or power backup
Irregular drug and supply chain
Infrastructural limitations (e.g., lack of blood storage or OT)
Poor referral transportation

8. Suggestions for Improvement

Fill specialist posts through incentives and telemedicine
Upgrade all CHCs to fully functional FRUs
Strengthen referral linkages with PHCs and District Hospitals
Provide continuous training and skill upgradation for staff
Community involvement via Rogi Kalyan Samitis (RKS)

District-Level Health Care Delivery System in India

1. Introduction

At the district level, health services form the link between state-level and block-level health care. It is responsible for planning, implementation, monitoring, and supervision of all health programs and services within a district.

Each district has a District Health Society (DHS) under the National Health Mission (NHM) that ensures coordinated functioning of all health institutions.

2. Key Components at the District Level

A. District Hospital (DH)

Criteria	Details
Population Coverage	~10–20 lakh
Bed Strength	100–500 beds
Services Provided	Inpatient & outpatient care, emergency, surgeries, specialist services
Staff	Specialists (Medicine, Surgery, Ob-Gyn, Pediatrics, etc.), Nurses, Lab technicians, Pharmacists

Functions:

Serves as referral center for CHCs and PHCs.
Provides secondary-level health care.
Acts as training center for health personnel.
Handles disaster and emergency preparedness.
Implements national health programs.

B. District Health Office (DHO)

Post	Role
Chief Medical Officer (CMO) / Civil Surgeon	Head of all health services in the district
District Health Officer (DHO)	Supervises rural health services
District Program Officers	Handle specific health programs (e.g., TB, NCD, Immunization)
District RCH Officer	Monitors maternal and child health services

C. District Health Society (DHS)

Under National Health Mission (NHM)

Functions:

Coordinates all public health programs.
Ensures proper fund utilization.
Involves community and PRIs in planning.
Prepares District Health Action Plan (DHAP).

3. Health Facilities at District Level

Facility	Role
District Hospital (DH)	Secondary/tertiary care
Sub-District Hospitals / Civil Hospitals	Intermediate referral
CHCs	First referral unit
PHCs & Sub-Centres	Primary care
Urban Primary Health Centres (UPHCs)	Urban health delivery
Mobile Medical Units (MMUs)	Outreach to remote areas

4. Services Delivered at District Level

Area	Services
Curative	Inpatient care, surgeries, specialist OPDs
Preventive	Immunization, health awareness, disease prevention
Promotive	Nutrition, lifestyle modification programs
Rehabilitative	Disability rehabilitation, physiotherapy
Support Services	Blood banks, diagnostic labs, ambulance

5. National Health Programs Implemented at District Level

National Tuberculosis Elimination Program (NTEP)
Reproductive and Child Health (RCH)
National Vector Borne Disease Control Program (NVBDCP)
National Leprosy Eradication Program (NLEP)
Rashtriya Bal Swasthya Karyakram (RBSK)
National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK)

6. Role of District-Level Nurses / CHNs / Public Health Nurses

Role	Responsibility
Service provider	Hospital and community-based nursing
Trainer	Helps train ANMs, ASHAs, and staff nurses
Supervisory role	Monitors PHC and CHC functioning
Data Management	Health records, reporting to state HQ
Community Engagement	Mobilizing participation through VHNSC, SHGs
Emergency Response	Participates in district disaster management and outbreak control

7. Monitoring and Evaluation

Health Management Information System (HMIS) reporting
District Health Surveys
Review Meetings with PHC/CHC in-charges
Annual District Health Action Plan (DHAP) preparation and review

8. Challenges at District Level

Staff vacancies in specialist and nursing positions
Inadequate infrastructure in sub-district hospitals
Delays in fund release and utilization
Data gaps and poor reporting
Overcrowding in district hospitals

9. Suggestions for Improvement

Strengthen referral linkages and transport
Timely recruitment of specialists and nurses
Upgrade district hospitals as teaching and training centers
Improve data quality and digital systems
Enhance public-private partnerships

State-Level Health Care Delivery System in India

1. Introduction

The State-level health care system plays a critical role in planning, coordinating, financing, and supervising all health activities within the state. It acts as a link between the central government and district/block-level systems.

Every Indian state has its own Department of Health and Family Welfare and associated directorates to ensure implementation of national health programs and state-specific health services.

2. Structure of Health Administration at the State Level

A. State Ministry of Health and Family Welfare

Headed by the State Health Minister
Responsible for policy-making, legislation, budgeting, and coordination with the central ministry.

B. State Health Department (Executive Wing)

Officer	Role
Principal Secretary (Health)	Senior IAS officer overseeing overall administration
Mission Director (NHM)	Supervises implementation of National Health Mission
Director of Health Services (DHS)	Supervises medical and public health services
Director of Medical Education and Research (DMER)	Manages medical, nursing, and paramedical education
Additional / Joint / Deputy Directors	Supervise specific programs like RCH, NCDs, TB, Leprosy etc.

3. Key Responsibilities of State-Level Health System

Function	Description
Planning	Develops State Health Action Plan (SHAP)
Budgeting	Allocates funds to districts and programs
Implementation	Executes national and state-level programs
Supervision	Monitors district performance and quality of services
Training	Organizes pre-service and in-service training
Recruitment	Appoints doctors, nurses, and health workers
Monitoring & Evaluation	Tracks health indicators through HMIS

4. Health Institutions at State Level

Institution	Role
State Hospitals (General Hospitals, Civil Hospitals)	Tertiary care facilities
Medical Colleges	Advanced treatment, education, research
State Health Training Institutes	Training for ANMs, GNMs, LHVs, MPWs
Regional Disease Control Units	Epidemic surveillance and outbreak response
State Drug Warehouses	Procurement and distribution of medicines

5. Key Health Schemes Managed at State Level

Ayushman Bharat – PMJAY
National Health Mission (NHM)
Reproductive, Maternal, Newborn, Child & Adolescent Health (RMNCH+A)
National Tuberculosis Elimination Program (NTEP)
Universal Immunization Programme (UIP)
National Leprosy Eradication Programme (NLEP)
National Mental Health Programme (NMHP)
School Health Programme

6. Role of State in Human Resource Development

Area	Responsibility
Recruitment	Appoints staff nurses, ANMs, doctors, lab techs
Training	Conducts skill upgradation and orientation
Curriculum Approval	For nursing and paramedical education
Monitoring	Evaluates performance of healthcare staff

7. Role of State-Level Nurses / Public Health Nurse / Education Officers

Role	Responsibility
Trainer	Teaches in health training schools or nursing colleges
Supervisor	Monitors district-level nurses and CHNs
Planner	Contributes to state health action plans
Policy Advisor	Assists in nursing policy, HR planning
Program Manager	Supervises maternal-child health, family planning, immunization
Inspector	Ensures quality control in nursing institutions (for INC/State Nursing Council)

8. Monitoring and Evaluation Tools Used at State Level

HMIS (Health Management Information System)
Facility-based Monthly Reports
State Health Dashboards
Supportive Supervision Visits
Annual Review Workshops

9. Challenges at the State Level

Challenge	Description
Manpower shortages	Especially in rural/tribal areas
Uneven fund utilization	Due to delays in planning or implementation
Infrastructure gaps	Need for upgradation of state hospitals
Urban–rural disparity	In service delivery and access
Disease outbreaks	Require timely surveillance and response

10. Suggestions for Strengthening State-Level Health System

Digitalization of health records and program data
Strengthen public-private partnerships (PPP)
Fill staff vacancies quickly
Regular training and capacity building
Improve coordination between medical, nursing, and public health wings
Ensure timely release of funds to districts

National-Level Health Care Delivery System in India

1. Introduction

The National Health Care Delivery System in India is responsible for:

Formulating health policies,
Designing national health programs,
Funding and guiding state and district-level health systems,
Monitoring and evaluating health outcomes across the country.

It is managed mainly by the Central Government, especially the Ministry of Health and Family Welfare (MoHFW).

2. Ministry of Health and Family Welfare (MoHFW)

The MoHFW is the apex body for health-related matters in India. It consists of two major departments:

A. Department of Health and Family Welfare

Handles public health, medical education, and national programs.
Supervises the functioning of:
- Central Government Health Scheme (CGHS)
- National Health Mission (NHM)
- Immunization programs
- Communicable and non-communicable disease programs

B. Department of Health Research

Oversees medical research and policy development.
Coordinates with Indian Council of Medical Research (ICMR).

3. National-Level Health Institutions

Institution	Role
AIIMS (All India Institutes of Medical Sciences)	Tertiary care, education, research
ICMR (Indian Council of Medical Research)	Health research and disease surveillance
NIPCCD, NIHFW	Public health training and research
DGHS (Directorate General of Health Services)	Advises the Ministry, supports implementation
NCDC (National Centre for Disease Control)	Epidemic surveillance and control
NHSRC (National Health Systems Resource Centre)	Technical support for NHM
CBHI (Central Bureau of Health Intelligence)	Health statistics and information
National Health Authority (NHA)	Implements Ayushman Bharat – PMJAY

🧩 4. Major National Health Missions and Programs

The central government runs flagship programs that are implemented at state and district levels:

Program	Focus
National Health Mission (NHM)	Rural and urban health strengthening
Ayushman Bharat – PMJAY	Health insurance for the poor
Universal Immunization Program (UIP)	Free vaccination for children and mothers
Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A)	Comprehensive maternal-child care
National Tuberculosis Elimination Program (NTEP)	TB control
National Leprosy Eradication Program (NLEP)	Leprosy elimination
National Vector Borne Disease Control Program (NVBDCP)	Malaria, Dengue, Kala-azar control
National Mental Health Program (NMHP)	Mental health care at all levels
National Programme for NCDs (NPCDCS)	Diabetes, hypertension, cancer care

🩺 5. Planning and Policy Making at National Level

Institution	Function
NITI Aayog	Replaced Planning Commission; prepares vision and strategy for health
National Population Commission	Population policy and planning
National Health Policy (1983, 2002, 2017)	Guides health sector goals and reforms
15th Finance Commission	Recommends grants for health infrastructure

💰 6. Role of Central Government in Funding

Provides financial assistance to states via Centrally Sponsored Schemes (CSS).
Allocates budget for national programs (like NHM, PMJAY).
Fund disbursal through:
- State Health Societies
- District Health Societies

👩‍⚕️ 7. Role of National-Level Nurses & Nursing Bodies

Role	Institutions
Regulatory	Indian Nursing Council (INC) – Approves nursing curriculum, inspects institutions
Training	NIHFW, RAK College of Nursing, AIIMS – Provide in-service education
Policy	Nurses contribute to policy advisory groups at MoHFW
Representation	Represent India in WHO and global health forums

📊 8. Monitoring and Evaluation at National Level

Health Management Information System (HMIS)
Annual Health Survey (AHS)
National Family Health Survey (NFHS)
Sample Registration System (SRS)
District Health Information Software (DHIS2)

⚠️ 9. Challenges at National Level

Challenge	Description
Inequity	Gaps between urban and rural health care
Underfunding	Health budget below WHO recommendations
HR Shortage	Especially specialists and trained nurses
Disease burden	Rising NCDs along with existing communicable diseases
Coordination issues	Between center and states in implementation

✅ 10. Suggestions for Improvement

Increase health budget to 2.5% of GDP
Strengthen public health education and nursing institutions
Foster digital health innovations (eHealth, Telemedicine)
Empower National Health Authority for smooth implementation of PM-JAY
Enhance multi-sectoral coordination (sanitation, nutrition, environment)

Sustainable Development Goals (SDGs).

🔷 1. Introduction to SDGs

The Sustainable Development Goals (SDGs) are a global blueprint adopted by all United Nations (UN) member states, including India, in 2015.

Part of the 2030 Agenda for Sustainable Development
Total of 17 Goals and 169 targets
Aim to end poverty, protect the planet, and ensure prosperity and peace
Succeed the Millennium Development Goals (MDGs) – 2000–2015

📅 Timeline

Launched: September 25, 2015
Target Year: December 31, 2030
Duration: 15 years

📌 2. List of 17 Sustainable Development Goals (SDGs)

Goal No.	SDG Title
1	No Poverty
2	Zero Hunger
3	Good Health and Well-being
4	Quality Education
5	Gender Equality
6	Clean Water and Sanitation
7	Affordable and Clean Energy
8	Decent Work and Economic Growth
9	Industry, Innovation, and Infrastructure
10	Reduced Inequality
11	Sustainable Cities and Communities
12	Responsible Consumption and Production
13	Climate Action
14	Life Below Water
15	Life on Land
16	Peace, Justice, and Strong Institutions
17	Partnerships for the Goals

🔶 3. Goal 3: Good Health and Well-being (Focus for Health Sector)

🎯 Goal 3: Ensure healthy lives and promote well-being for all at all ages

Key Targets under Goal 3:

Reduce maternal mortality ratio to less than 70 per 100,000 live births
End epidemics of AIDS, TB, Malaria, and neglected tropical diseases
Reduce under-five mortality to 25/1,000 and neonatal mortality to 12/1,000
Ensure universal access to sexual and reproductive health care
Achieve universal health coverage (UHC) including financial risk protection
Reduce deaths from NCDs (like diabetes, cancer, heart disease) by 1/3
Strengthen capacity for emergency preparedness and disease surveillance

🏥 4. SDGs Related to Health & Community Health Nursing

Goal	Relevance to Nursing
Goal 1 (No Poverty)	Poor people are vulnerable to illness and poor access to care
Goal 2 (Zero Hunger)	Nurses address malnutrition, anemia, and infant feeding
Goal 3 (Good Health)	Nurses deliver MCH, immunization, NCD care, etc.
Goal 4 (Education)	Nurse educators train future workforce
Goal 5 (Gender Equality)	Nurses support women’s rights, reproductive health
Goal 6 (Clean Water and Sanitation)	Community nurses promote hygiene and sanitation
Goal 13 (Climate Action)	Nurses respond to health effects of disasters

🌍 5. India’s Commitment to SDGs

India has:

Integrated SDGs into national and state health policies
Established NITI Aayog as the nodal agency for monitoring SDGs
Published the SDG India Index to measure state-wise progress
Introduced health missions like:
- Ayushman Bharat
- POSHAN Abhiyaan
- National Health Mission (NHM)
- Swachh Bharat Abhiyan
- Beti Bachao Beti Padhao

📊 6. Monitoring & Evaluation of SDGs in India

Tool	Description
SDG India Index	Developed by NITI Aayog; scores states/UTs
NFHS (National Family Health Survey)	Tracks health indicators
HMIS (Health Management Information System)	Used for program monitoring
Sample Registration System (SRS)	Monitors birth, death, IMR, MMR

👩‍⚕️ 7. Role of Community Health Nurse in Achieving SDGs

Area	Contribution
Health Promotion	Educates community on nutrition, hygiene, family planning
Service Provider	Provides MCH, immunization, home-based newborn care
Disease Control	Identifies, refers, and follows up on TB, malaria, HIV
Advocate	Promotes gender equality and rights-based health care
Trainer	Trains ASHAs, health workers in community settings
Emergency Response	Participates in disaster relief and outbreak control

⚠️ 8. Challenges in Achieving SDGs in India

High maternal and infant mortality in some regions
Malnutrition and anemia among children and women
Rising burden of non-communicable diseases (NCDs)
Urban-rural and gender disparities in healthcare
Inadequate health infrastructure and workforce

✅ 9. Suggestions to Strengthen SDG Achievement

Strengthen primary health care system
Recruit and retain more trained nurses and health workers
Invest in women’s education and empowerment
Integrate SDG targets into district-level planning
Strengthen digital health records and data collection

Primary Health Care (PHC) and Comprehensive Primary Health Care (CPHC)

1. What is Primary Health Care (PHC)?

Definition (Alma-Ata Declaration, 1978):

“Primary Health Care is essential health care made universally accessible to individuals and acceptable to them through full participation and at a cost the community and country can afford.”

It is the first level of contact between the individual and the health system.

2. Objectives of Primary Health Care

Provide equitable access to essential health services
Promote community participation
Integrate preventive, promotive, curative, and rehabilitative services
Focus on health promotion rather than only treatment
Support intersectoral coordination (e.g., health, water, sanitation)

3. Principles of Primary Health Care

Principle	Description
1. Equitable Distribution	Health services should reach everyone, especially vulnerable and rural populations
2. Community Participation	Involving people in planning and implementation
3. Intersectoral Coordination	Involving sectors like education, agriculture, water, sanitation
4. Appropriate Technology	Simple, cost-effective, and culturally acceptable methods
5. Health Promotion and Disease Prevention	Emphasis on education, immunization, sanitation, and nutrition

4. Elements of Primary Health Care (8 Elements – Alma Ata Declaration)

No.	Element
1️⃣	Health Education – regarding prevailing health problems and methods of prevention/control
2️⃣	Promotion of Food Supply and Proper Nutrition
3️⃣	Adequate Supply of Safe Water and Basic Sanitation
4️⃣	Maternal and Child Health (MCH) care, including family planning
5️⃣	Immunization against major infectious diseases
6️⃣	Prevention and Control of Endemic Diseases
7️⃣	Appropriate Treatment of Common Diseases and Injuries
8️⃣	Provision of Essential Drugs

5. Comprehensive Primary Health Care (CPHC)

Definition:

Comprehensive Primary Health Care (CPHC) is an expanded approach to primary care that ensures universal access to free, equitable, and quality services covering preventive, promotive, curative, rehabilitative, and palliative health care.

Introduced under: Ayushman Bharat – Health & Wellness Centres (HWCs), 2018

Key Features of CPHC:

Feature	Description
Expanded Range of Services	Includes NCDs, mental health, elderly care, oral, eye care
Team-Based Care	CHO, ANM, ASHA working in collaboration
Continuum of Care	From home to facility (Sub-centre to District Hospital)
Use of Technology	Telemedicine, digital health records
Community Empowerment	Health promotion and behavior change

6. Services Delivered Under CPHC (12 Service Packages)

No.	Service Area
1️⃣	Maternal and Child Health
2️⃣	Family Planning and Reproductive Health
3️⃣	Adolescent Health
4️⃣	Neonatal and Infant Health
5️⃣	Communicable Disease Control
6️⃣	Non-Communicable Diseases (NCDs)
7️⃣	Mental Health
8️⃣	Oral Health
9️⃣	ENT and Eye Care
🔟	Elderly Care and Palliative Services
1️⃣1️⃣	Emergency and First Aid
1️⃣2️⃣	Health Promotion and Prevention

7. Health & Wellness Centres (HWCs) – Platform for CPHC

Type	Coverage
SC-HWC	Sub-centre converted to HWC for population ~3,000–5,000
PHC-HWC	PHC upgraded to HWC for population ~30,000

Staffing at HWC:

Community Health Officer (CHO)
ANMs
ASHA workers
MPHW (Male)

8. Role of Community Health Nurse in PHC and CPHC

Role	Responsibilities
Service Provider	Immunization, antenatal/postnatal care, chronic disease care
Educator	Health education on nutrition, hygiene, family planning
Coordinator	Works with ASHA, CHO, and MPHWs
Referral Link	Refers cases to PHC/CHC/District Hospital
Record Keeper	Maintains family records, immunization cards, health registers
Advocate	Promotes health rights and services awareness
Technology User	Uses mobile apps, teleconsultation, HMIS data entry

9. Challenges in Implementation of PHC/CPHC

Shortage of trained staff (especially CHOs)
Inadequate infrastructure and supplies
Difficult terrain and access issues in tribal/rural areas
Lack of community awareness
Digital illiteracy and data management issues

10. Suggestions for Improvement

Ensure regular supply of essential drugs and diagnostics
Recruit and train adequate CHOs and nurses
Strengthen digital infrastructure and telemedicine
Promote community awareness and participation
Provide performance-based incentives to frontline workers

Summary Chart: PHC vs. CPHC

Feature	PHC (Basic)	CPHC (Comprehensive)
Based on	Alma-Ata Declaration (1978)	Ayushman Bharat (2018)
Services	Basic preventive and curative	Expanded services incl. NCDs, elderly care
Focus	Access and essential care	Universal coverage and quality care
Facility	PHC/Sub-centre	Health & Wellness Centres
Staff	MO, Nurse, ANM	CHO, ANM, MPHW, ASHA

Comprehensive Primary Health Care (CPHC) through Sub-Centre / Health & Wellness Centre (HWC)

(As part of Ayushman Bharat – 2018 Initiative)

1. Introduction to CPHC and HWCs

Ayushman Bharat Programme launched in 2018 aims to achieve Universal Health Coverage (UHC) through:
1. Health & Wellness Centres (HWCs) – for Comprehensive Primary Health Care
2. PM-JAY (Pradhan Mantri Jan Arogya Yojana) – for secondary and tertiary hospitalization
Under this, Sub-Centres and PHCs are being transformed into HWCs to deliver expanded primary care services.

2. What is a Health & Wellness Centre (HWC)?

An HWC is a revamped Sub-Centre or PHC that delivers comprehensive primary health care, with free essential medicines, diagnostics, and team-based care.

Types of HWCs:

SC-HWC (converted from Sub-Centre) – for population 3,000–5,000
PHC-HWC (converted from PHC) – for population 30,000

3. Goals of CPHC through HWCs

Provide holistic, preventive, promotive, curative, rehabilitative, and palliative care
Ensure community-based, people-centered care
Strengthen continuum of care and reduce burden on higher facilities
Offer free drugs, diagnostics, and referral linkages

4. Service Packages Delivered at SC-HWC (12 Packages)

No.	Service Package
1️⃣	Maternal and Child Health (ANC, PNC, deliveries, growth monitoring)
2️⃣	Family Planning and Contraceptive Services
3️⃣	Adolescent Health (counseling, menstrual hygiene)
4️⃣	Neonatal and Infant Health (HBNC, immunization)
5️⃣	Communicable Diseases (Malaria, TB, HIV)
6️⃣	Non-Communicable Diseases (diabetes, BP, cancer screening)
7️⃣	Mental Health (stress, depression, counseling)
8️⃣	Oral Health (screening and referral)
9️⃣	ENT and Eye Care
🔟	Elderly Care and Palliative Services
1️⃣1️⃣	Emergency First Aid (minor injuries, burns, snake bite)
1️⃣2️⃣	Health Promotion, Wellness Activities (Yoga, lifestyle education)

5. Human Resources at SC-HWC

Staff	Role
Community Health Officer (CHO)	Team leader, provides clinical care, maintains records
Auxiliary Nurse Midwife (ANM)	MCH services, immunization, family planning
Multipurpose Health Worker (MPHW Male)	Disease control, sanitation, male sterilization counseling
ASHA workers	Community mobilization, follow-up care, home visits

6. Services Available at SC-HWC

Category	Examples
Clinical Services	BP, diabetes, skin problems, infections
Diagnostics	BP monitoring, glucometer, pregnancy test, hemoglobin, malaria
Medicines	IFA tablets, ORS, paracetamol, antibiotics, contraceptives
Referral Services	To PHC/CHC/District Hospital for complications
Telemedicine	For consultation with doctors using eSanjeevani
Wellness Activities	Yoga, health camps, Swasthya Panchayats

7. Digital Tools at SC-HWC

ABHA ID (Ayushman Bharat Health Account)
Teleconsultation App (eSanjeevani)
CPHC IT Platform for service delivery, data entry, drug inventory
HMIS/ANMOL – used by ANMs for real-time reporting

8. Role of CHO, ANM, MPHW, and ASHA in SC-HWC

Cadre	Responsibilities
CHO (BSc Nursing/Post-BSc/CPCH trained)	Clinical care, screening, referrals, data entry
ANM	MCH services, FP counseling, immunization, home visits
MPHW (Male)	Disease surveillance, sanitation, outbreak response
ASHA	Community link, follow-up, birth/death reporting, drug depot holder

9. Health Promotion & Wellness Activities at SC-HWC

Yoga sessions (weekly/monthly)
School health screening
NCD camps and screening days
IEC activities (posters, flipcharts, talks)
Village Health & Nutrition Days (VHNDs)

10. Challenges in Implementing CPHC through SC-HWCs

Shortage of trained CHOs
Infrastructure gaps in Sub-Centres
Inconsistent supply of medicines and diagnostics
Limited awareness among community members
Connectivity issues in remote areas (for teleconsultation)

11. Suggestions for Strengthening SC-HWCs

Fill vacant CHO and ANM posts
Ensure regular supply of essential medicines and test kits
Upgrade buildings and equipment at Sub-Centre level
Conduct community awareness campaigns
Strengthen digital health tools and mobile health platforms

National Health Care Policies and Regulations

1. Introduction

Health policies are strategic documents or plans made by the government to guide health care services, programs, funding, laws, and standards.
Health regulations are the rules and legal frameworks that ensure quality, safety, equity, and accountability in health care delivery.

2. Major National Health Policies in India

A. National Health Policy (NHP)

India has had three official National Health Policies:

1. National Health Policy – 1983

➡ Focused on: “Health for All by 2000”

Key Features:

Emphasized primary health care
Expansion of rural health infrastructure
Community participation
Training of multipurpose health workers
Integration of health services

2. National Health Policy – 2002

➡ Focused on: Improving access and equity

Key Features:

Emphasized decentralization of health services
Encouraged public-private partnerships (PPP)
Increased role of AYUSH systems
Focus on disease surveillance and emergency response

3. National health policy-2017

➡ Focused on: “Universal Health Coverage (UHC)”

Goals:

Reduce out-of-pocket expenditure
Strengthen primary health care
Free drugs, diagnostics, and emergency care
Health and Wellness Centres (HWCs) for Comprehensive Primary Health Care
Digital health records and telemedicine
Address non-communicable diseases (NCDs) and mental health

Targets by 2025:

Reduce IMR to 28/1000
Reduce MMR to 100/100,000
Increase life expectancy to 70 years
Reduce fertility rate to 2.1

3. Other Important National Policies Related to Health

Policy	Year	Purpose
National Population Policy	2000	Population stabilization, FP services
National Nutrition Policy	1993	Address malnutrition in children and women
National Policy on Senior Citizens	2011	Welfare, healthcare, and security of the elderly
National Mental Health Policy	2014	Promote mental health services at all levels
National Education Policy	2020	Includes reforms in nursing and medical education
National Policy for Women Empowerment	2001	Addresses women’s health, rights, and safety

4. Important Health Regulations and Acts in India

Health regulations are legally enforceable rules aimed at ensuring safe, ethical, and standardized healthcare.

A. Constitutional Provisions

Article	Provision
Article 21	Right to Life includes Right to Health
Article 47	Duty of the state to raise nutrition and standard of living
Article 42	Maternity relief and humane working conditions
Concurrent List (List III)	Health is a shared responsibility of Centre and States

B. Key Health Acts in India

Act	Year	Purpose
Drugs and Cosmetics Act	1940	Regulates manufacture and sale of drugs and cosmetics
Indian Nursing Council Act	1947	Governs nursing education and registration
Medical Termination of Pregnancy (MTP) Act	1971 (amended 2021)	Legalizes abortion under conditions
The Epidemic Diseases Act	1897 (used during COVID-19)	Powers to control outbreaks
Transplantation of Human Organs Act	1994	Regulation of organ donation and transplantation
PNDT Act	1994	Prevents female feticide (bans sex determination)
Clinical Establishments Act	2010	Standardizes private health facilities
Mental Healthcare Act	2017	Rights-based mental health care
National Food Security Act	2013	Food and nutrition security to all
Right to Information Act (RTI)	2005	Ensures transparency in health system

5. Role of National Health Agencies in Policy Implementation

Agency	Role
MoHFW	Main health policy-making body
NITI Aayog	Vision documents and SDG monitoring
ICMR	Research to inform policy
NHM	Implements maternal-child health programs
National Health Authority (NHA)	Executes PM-JAY (insurance scheme)
National Medical Commission / INC	Sets standards in medical and nursing education

6. Role of Community Health Nurse in Policy and Regulation Implementation

Area	Role
Health Promotion	Educates community about policies (MTP, vaccination, nutrition)
Service Provider	Implements programs at grassroots (NHM, JSY, immunization)
Record Keeper	Maintains legal and health registers
Law Enforcer	Reports violations (child marriage, PNDT, domestic violence)
Advocate	Promotes rights of women, children, disabled, and elderly
Trainer	Educates ASHAs and health workers about policy updates

7. Challenges in Policy Implementation

Limited awareness among population and health workers
Poor intersectoral coordination
Inadequate infrastructure and HR
Corruption and delays
Gaps in data collection and monitoring

8. Suggestions for Strengthening Policies and Regulations

Increase community participation and awareness
Conduct regular training of nurses and health workers
Strengthen digital health platforms for transparency
Promote collaboration between sectors (education, women development)
Encourage evidence-based policy making using research data

National Health Policy – 1983, 2002, and 2017

What is a National Health Policy?

A National Health Policy (NHP) is a strategic document that provides a vision, priorities, and framework for a country’s health care development. In India, it is issued by the Ministry of Health and Family Welfare to guide health services planning and delivery.

India has had three major health policies:

NHP 1983
NHP 2002
NHP 2017

1. National Health Policy – 1983

📅 Year: 1983

🎯 Goal: “Health for All by 2000” (as per WHO-Alma Ata Declaration)

Key Objectives:

Provide universal, comprehensive, primary health care to all
Reduce IMR, MMR, and control communicable diseases
Increase people’s participation and use of appropriate technology
Train multipurpose health workers
Establish district-level health planning

Focus Areas:

Expand primary health infrastructure in rural areas
Promote indigenous systems of medicine (AYUSH)
Ensure minimum health services for all, especially underprivileged groups

Achievements:

Set the foundation for primary health care (PHC) structure
Led to programs like:
- Universal Immunization Programme (UIP) – 1985
- National Leprosy Elimination Program
- Expansion of Sub-Centres and PHCs

2. National Health Policy – 2002

📅 Year: 2002

🎯 Goal: Improve access, affordability, accountability, and equity in health care.

Key Objectives:

Increase government health spending to 2% of GDP
Reduce IMR to 30/1,000, MMR to 100/100,000, TFR to 2.1
Promote public-private partnerships (PPP)
Expand AYUSH integration
Improve urban health care delivery
Decentralize services through Panchayati Raj Institutions

Focus Areas:

Reproductive and Child Health (RCH)
Disease surveillance and response
Strengthen tertiary care and referral system
Encourage health insurance for the poor

Achievements:

Laid foundation for:
- National Rural Health Mission (NRHM) – 2005
- Disease-specific programs (TB, HIV, Malaria)
- Use of information technology in health care

3. National Health Policy – 2017

📅 Year: 2017

🎯 Goal: “Attainment of the highest possible level of health and well-being for all at all ages” through a preventive and promotive health care orientation.

Vision:

Universal Health Coverage (UHC)
Free, equitable, and quality health care
Financial risk protection
Focus on wellness and prevention

Key Objectives:

Strengthen primary health care through Health & Wellness Centres (HWCs)
Increase government health expenditure to 2.5% of GDP by 2025
Promote digital health and electronic health records (EHR)
Provide free essential drugs, diagnostics, and emergency care
Integrate mental health, palliative care, and NCDs in primary care

Targets by 2025:

Indicator	Target
IMR	≤ 28 per 1,000 live births
MMR	≤ 100 per 100,000 live births
TFR	≤ 2.1
Life Expectancy	≥ 70 years
Reduction in NCDs	25% reduction in premature deaths
Health Expenditure	2.5% of GDP (from ~1.1%)

Comparison Table: NHP 1983 vs. 2002 vs. 2017

Feature	NHP 1983	NHP 2002	NHP 2017
Launch Year	1983	2002	2017
Main Goal	Health for All by 2000	Access & Equity	Universal Health Coverage
Focus	PHC, rural health infra	PPP, decentralization	Wellness, digital health, HWCs
Health Spending Target	Not defined	2% of GDP	2.5% of GDP
TFR Target	–	2.1	2.1
Integration of AYUSH	Promoted	Promoted	Strongly integrated
Programs Initiated	UIP, PHC expansion	NRHM	Ayushman Bharat, HWCs
Emphasis on NCDs	Low	Moderate	High
Digital Health	Not present	Limited	EHR, Telemedicine emphasized

Role of Community Health Nurse in Policy Implementation

Role	Contribution
Service Provider	Implements immunization, ANC/PNC, family planning
Health Educator	Promotes nutrition, hygiene, disease prevention
Referral Agent	Identifies and refers high-risk cases
Record Keeper	Maintains family registers, HMIS
Digital Support	Assists in e-health and teleconsultation (under 2017 policy)
Advocate	Promotes health rights and equity

Conclusion

The evolution of India’s National Health Policies shows a clear shift:

From infrastructure building (1983) →
To system reforms and partnerships (2002) →
To holistic, equitable, digital, and preventive care (2017).

The 2017 policy aligns with Sustainable Development Goals (SDGs) and emphasizes Comprehensive Primary Health Care through HWCs, making community health nurses central players in its implementation.

National Health Mission (NHM)

1. Introduction

The National Health Mission (NHM) is a flagship program of the Government of India, launched to provide accessible, affordable, accountable, and quality health care to all, especially to the vulnerable and poor.

It strengthens the public health system at all levels — from village to district.

📅 Launched On: 12th April 2005

📍 Ministry: Ministry of Health and Family Welfare (MoHFW)

🌐 Website: https://nhm.gov.in

2. Components of NHM

Component	Launched	Focus
A. National Rural Health Mission (NRHM)	2005	Rural health infrastructure
B. National Urban Health Mission (NUHM)	2013	Urban poor and slum population
NRHM + NUHM = NHM	Unified in 2013	Single umbrella mission

3. Vision of NHM

“Attainment of Universal Access to equitable, affordable & quality health care services that are accountable and responsive to people’s needs.”

4. Objectives of NHM

Strengthen health systems in rural and urban areas
Reduce maternal and infant mortality
Control and eliminate communicable and non-communicable diseases
Promote universal access to reproductive, maternal, child and adolescent health (RMNCH+A)
Revitalize local health traditions and mainstream AYUSH
Promote community participation and decentralization

5. Key Strategies under NHM

Strengthening Sub-Centres, PHCs, CHCs & District Hospitals
Establishment of Health & Wellness Centres (HWCs)
Recruitment of ASHA workers
Free essential drugs and diagnostics
Capacity building of healthcare providers
Community-based programs through VHSNCs and Rogi Kalyan Samitis
Performance-based incentives to frontline workers
Telemedicine and digital health platforms

6. Key Programs and Services under NHM

Program Area	Services Provided
RMNCH+A	Reproductive, maternal, newborn, child & adolescent health
JSY	Janani Suraksha Yojana – cash incentive for institutional deliveries
JSSK	Janani Shishu Suraksha Karyakram – free transport, drugs, diagnostics
RBSK	Rashtriya Bal Swasthya Karyakram – child screening and early intervention
RKSK	Rashtriya Kishor Swasthya Karyakram – adolescent health
NCD Control	Screening & treatment for BP, diabetes, cancer
NUHM	Health services for the urban poor
Disease Programs	TB, leprosy, malaria, HIV, vector-borne disease control

7. Service Delivery Innovations under NHM

Initiative	Description
ASHA (Accredited Social Health Activist)	Community link worker
Health & Wellness Centres (HWCs)	Deliver comprehensive primary health care
Mobile Medical Units (MMUs)	Reach underserved and remote areas
eSanjeevani	Free teleconsultation services
Home-Based Newborn and Young Child Care	By ASHA and ANMs
MCTS / RCH Portal	Mother and child tracking system

8. Monitoring & Evaluation under NHM

Health Management Information System (HMIS)
District Level Household Surveys (DLHS)
Annual Common Review Missions (CRM)
Facility-Based Data Collection

9. Role of Community Health Nurse under NHM

Role	Function
Service Provider	ANC, immunization, family planning, newborn care
Trainer	Training ASHAs, ANMs, MPHWs
Health Educator	IEC on nutrition, hygiene, MCH
Program Implementer	Executes JSY, JSSK, RBSK, etc. at grassroots
Data Reporter	Maintains registers and reports to PHC/Block
Team Leader	Leads VHSNCs and coordinates with other health workers
Health Promoter	Encourages institutional deliveries, healthy behaviors

10. Achievements of NHM (as per recent data)

Significant reduction in IMR, MMR, and TFR
Institutional deliveries increased to over 80%
Increased availability of free drugs and diagnostics
85,000+ HWCs operational across India
ASHA workers recognized as Global Health Leaders (by WHO)

11. Challenges in NHM Implementation

Shortage of specialists in CHCs and PHCs
Inadequate infrastructure and drug supply in remote areas
High attrition rate of trained personnel
Monitoring and data reporting issues
Urban health systems still underdeveloped

12. Suggestions for Improvement

Fill staff vacancies, especially doctors and CHOs
Expand digital health records and telemedicine
Strengthen referral transport and emergency services
Increase community participation
Conduct regular training and supervision of frontline workers

Here’s a complete and detailed explanation of the National Rural Health Mission (NRHM) — ideal for Community Health Nursing, nursing students, and competitive exams:

National Rural Health Mission (NRHM)

1. Introduction

The National Rural Health Mission (NRHM) was launched by the Government of India to provide accessible, affordable, and quality health care to the rural population, especially vulnerable groups like women, children, and the poor.

📅 Launched On: 12th April 2005

👩‍⚕️ Target Group: Rural population, especially mothers, infants, children, and adolescents

📍 Ministry: Ministry of Health and Family Welfare (MoHFW)

2. Goals and Objectives

Vision:

“Provide effective health care to the rural population throughout the country with a special focus on 18 high-focus states.”

Main Objectives:

Reduce IMR, MMR, and TFR
Strengthen rural health infrastructure
Promote institutional deliveries
Improve access to maternal and child health services
Integrate AYUSH into the public health system
Enhance community participation and decentralized planning

3. Key Strategies under NRHM

Strategy	Description
Strengthening Health Infrastructure	Upgrade SCs, PHCs, CHCs as per IPHS
Training Human Resources	Recruitment of ANMs, MPHWs, Doctors, ASHAs
ASHA Scheme	Accredited Social Health Activists as community link workers
Untied Funds	Rs. 10,000 at SC level for local health needs
Village Health and Nutrition Days (VHNDs)	Monthly outreach with immunization, ANC/PNC
Janani Suraksha Yojana (JSY)	Cash incentives for institutional deliveries
Janani Shishu Suraksha Karyakram (JSSK)	Free drugs, diagnostics, transport for pregnant women & newborns
Rogi Kalyan Samiti (RKS)	Local hospital management committee
Decentralized Planning	Village, Block, and District Health Plans
Health Management Information System (HMIS)	Improved reporting and monitoring

4. Institutional Strengthening under NRHM

Level	Facility Strengthened
Village	ASHA, Anganwadi, VHSNC
Sub-Centre (SC)	1 per 5,000 people (3,000 in tribal/hilly)
Primary Health Centre (PHC)	1 per 30,000 people (20,000 in hilly areas)
Community Health Centre (CHC)	1 per 1.2 lakh people
District Hospital	First referral unit (FRU)

5. ASHA – Accredited Social Health Activist

1 ASHA per 1,000 population (or per village)
Female health activist from the community
Roles:
- Promotes institutional deliveries
- Accompanies women to health facilities
- Ensures immunization, newborn care, FP
- Community mobilization and awareness

6. Key Indicators Monitored under NRHM

Indicator	Target
IMR (Infant Mortality Rate)	<30 per 1,000
MMR (Maternal Mortality Ratio)	<100 per 1 lakh live births
TFR (Total Fertility Rate)	2.1
Institutional Deliveries	>80%
Child Immunization Coverage	>90%

7. Major Programs Integrated Under NRHM

Program	Focus
Reproductive and Child Health (RCH)	ANC, PNC, deliveries, immunization
National Immunization Program (UIP)	Routine immunization for children & mothers
Disease Control Programs	Malaria, TB, Leprosy, HIV/AIDS
School Health Program	Screening and health education
Adolescent Health Program (RKSK)	Menstrual hygiene, counseling

8. Role of Community Health Nurse under NRHM

Role	Responsibility
Service Delivery	Provides ANC, PNC, immunization, FP
Health Education	IEC on nutrition, hygiene, breastfeeding
Training & Supervision	Trains ASHAs, monitors their work
Referral & Follow-up	Identifies and refers high-risk cases
Data Management	Maintains SC registers and reports
Community Mobilizer	Promotes participation in VHNDs and JSY

9. Monitoring Tools under NRHM

HMIS (Health Management Information System)
Mother and Child Tracking System (MCTS)
Facility and Community Surveys
Annual Common Review Missions (CRM)

10. Achievements of NRHM (2005–2013)

Rise in institutional deliveries
Increase in child immunization coverage
Deployment of 10 lakh+ ASHA workers
Upgradation of rural health facilities
Reduction in IMR and MMR
Introduction of JSSK, RBSK, RKSK

11. Transition from NRHM to NHM

In 2013, NRHM was subsumed under the National Health Mission (NHM) along with the National Urban Health Mission (NUHM) to form a comprehensive mission covering both rural and urban areas.

12. Conclusion

The National Rural Health Mission (NRHM) played a transformative role in strengthening rural health care infrastructure, empowering community health workers (ASHAs), and improving maternal and child health outcomes. It laid the foundation for NHM, moving India toward Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs).

National Urban Health Mission (NUHM)

1. Introduction

The National Urban Health Mission (NUHM) is a sub-mission under the National Health Mission (NHM) that aims to provide quality and equitable health care services to the urban poor and vulnerable populations in towns and cities.

📅 Launched: 20th May 2013

🏛️ By: Ministry of Health and Family Welfare (MoHFW), Government of India

👥 Target Population: Urban poor, slum dwellers, street vendors, homeless, migrants, construction workers

2. Objectives of NUHM

Improve the health status of urban populations, especially urban poor
Provide equitable access to quality health services
Establish a people-centric health care system
Integrate public and private sectors for better urban health delivery

3. Key Features of NUHM

Feature	Description
Focus on Slum Population	Special attention to slum dwellers and vulnerable groups
Urban Primary Health Centres (UPHCs)	One UPHC per 50,000 population
Outreach Services	Mobile Medical Units, Urban Health & Nutrition Days (UHNDs)
Public-Private Partnership (PPP)	Collaborate with NGOs, private providers
City Health Planning	Participatory health plans developed for each city
Community Participation	Mahila Arogya Samitis (MAS), Urban ASHAs, Rogi Kalyan Samitis

4. Urban Health Infrastructure under NUHM

Facility	Coverage	Role
Urban Primary Health Centre (UPHC)	1 per 50,000 population	Provides OPD, basic lab tests, FP, MCH services
Urban Community Health Centre (UCHC)	1 per 2.5–5 lakh population	Secondary care, referrals
Urban Health & Nutrition Day (UHND)	Monthly outreach camp in slums	ANC/PNC, immunization, health education
Mahila Arogya Samiti (MAS)	Women-led community groups	Health promotion, sanitation, behavior change

5. Human Resources under NUHM

Cadre	Role
Urban ASHA	Community mobilization, home visits, follow-up
Medical Officer	Diagnosis and treatment at UPHC
Staff Nurse	OPD care, immunization, wound dressing
ANM/MPHW	MCH, FP, health promotion
Pharmacist, Lab Tech	Dispensing medicines, basic investigations
Community Organizer	Promotes community participation and supports MAS

6. Services Provided under NUHM

Area	Services
Maternal Health	ANC, PNC, institutional delivery support
Child Health	Immunization, newborn care
Family Planning	Counseling, distribution of contraceptives
Communicable Diseases	Screening, treatment, referral
Non-Communicable Diseases	Screening for BP, diabetes, cancer
Adolescent & Geriatric Health	Iron supplementation, counseling, elderly care
Referral Services	To UCHCs, District Hospitals

7. Diagnostics and Free Medicines

Basic lab services at UPHCs (Hb, Blood Sugar, Malaria, Urine test, Pregnancy test)
Free essential drugs for common illnesses
Linkages to diagnostic centers and free drug schemes

8. Community Participation – MAS & ASHA

Mahila Arogya Samiti (MAS):

A group of 10–12 local women from slum areas
Facilitates:
- Health education
- Hygiene and sanitation awareness
- Monitoring of health services
- Participation in UHNDs

Urban ASHA:

One per 2,000 urban population
Promotes institutional delivery, immunization, FP
Conducts home visits and community surveys

9. Monitoring Tools under NUHM

Tool	Use
Health Management Information System (HMIS)	Monthly reporting
Urban Health Card	For families in urban slums
RCH Portal	Tracking mother and child health
Periodic Surveys	NFHS, Urban Health Survey, etc.

10. Role of Community Health Nurse in NUHM

Role	Functions
Service Provider	Provides OPD care, ANC/PNC, immunization
Trainer	Trains ASHAs, MAS members
Health Educator	IEC on nutrition, sanitation, hygiene
Data Manager	Maintains records, reports
Community Mobilizer	Encourages participation in health programs
Referral Coordinator	Connects with UCHCs and higher centers

11. Achievements of NUHM (2013–Present)

More than 5,000 UPHCs established
Over 75 lakh people reached annually in urban areas
Introduction of urban ASHA workforce
Improvement in urban maternal and child health indicators
Integration with Ayushman Bharat – HWCs in Urban Areas

12. Challenges in NUHM Implementation

Slums are often unmapped and scattered
Shortage of staff in UPHCs
Poor sanitation and water in urban slums
Migrant population is mobile and hard to track
Low awareness and utilization of public health facilities

13. Suggestions for Strengthening NUHM

Conduct slum mapping and population enumeration
Recruit and train adequate ASHAs, nurses, and MO
Strengthen referral linkages and transport
Integrate NUHM with urban development departments
Promote urban health literacy campaigns

National Health Protection Mission (NHPM)

Also known as: Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY)

1. Introduction

The National Health Protection Mission (NHPM) was launched as part of Ayushman Bharat, a flagship initiative to achieve Universal Health Coverage (UHC).

It was rebranded as PM-JAY in September 2018 and is now one of the world’s largest government-funded health insurance programs.

📅 Launched On: 23rd September 2018

🏛️ By: Ministry of Health and Family Welfare (MoHFW), Government of India

🌐 Implementing Agency: National Health Authority (NHA)

2. Objectives of NHPM / PM-JAY

Provide financial protection to poor and vulnerable families from catastrophic health expenditure
Ensure access to quality secondary and tertiary hospitalization
Empower beneficiaries with cashless, paperless treatment
Reduce out-of-pocket (OOP) expenses for the poor

3. Target Beneficiaries

Covers over 10.74 crore poor and vulnerable families (~50 crore individuals)
Beneficiaries identified based on Socio-Economic Caste Census (SECC) 2011
No cap on family size, age, or gender
Applicable to rural and urban poor

4. Coverage under NHPM / PM-JAY

Category	Details
Coverage amount	Up to ₹5 lakh per family per year
Type of care	Secondary and tertiary hospitalization (not OPD)
Cashless facility	Yes, at empanelled hospitals
Portability	Yes, usable across India in any empanelled hospital
Pre-existing conditions	Covered from day one

5. Types of Services Covered

Medical and surgical procedures
Day-care procedures
Cost of medicines, diagnostics, room charges, OT charges
3 days pre-hospitalization and 15 days post-hospitalization
Cancer care, heart surgeries, orthopedic surgeries, kidney and liver treatment, neonatal care, etc.

6. How It Works

Step	Process
1️⃣	Beneficiary identified through SECC database or PM-JAY portal
2️⃣	Gets Ayushman Card or ABHA ID
3️⃣	Visits empanelled public or private hospital
4️⃣	Treatment is cashless and paperless
5️⃣	Hospital claims expenses from NHA/State Health Agency

7. Institutional Mechanism

Level	Institution
National Level	National Health Authority (NHA)
State Level	State Health Agency (SHA)
District Level	District Implementation Unit (DIU)

8. Implementation Models

States can choose any of these:

Insurance Model (through insurance companies)
Trust Model (state pays directly to hospitals)
Mixed Model

9. Achievements of NHPM / PM-JAY

Over 6 crore hospital admissions availed by beneficiaries (as of 2024)
More than 26,000 hospitals empanelled (public + private)
Significant reduction in out-of-pocket expenditure
Increased access to specialty care in poor households
Enabled portability of care for migrant workers

10. Role of Community Health Nurse in NHPM

Role	Function
Health Educator	Informs families about PM-JAY eligibility
Facilitator	Helps in registration and Ayushman card generation
Referral Coordinator	Refers patients to empanelled hospitals
Support Staff	Ensures post-hospitalization follow-up
Record Keeping	Maintains household health records and updates ABHA ID
Awareness Creation	Conducts IEC campaigns in villages and slums

11. Challenges in Implementation

Limited awareness among rural and poor populations
Infrastructure gaps in some empanelled hospitals
Claim processing delays in some states
Fraudulent claims by some private hospitals
Lack of specialists in government hospitals

12. Suggestions for Improvement

Strengthen health infrastructure in rural areas
Increase beneficiary awareness through ASHAs and ANMs
Use digital tools (ABHA ID, e-RUPI) for faster service
Ensure timely payment to hospitals
Capacity building of health professionals and program managers

Ayushman Bharat

1. Introduction

Ayushman Bharat is a flagship health initiative launched by the Government of India in 2018 to achieve Universal Health Coverage (UHC) and fulfill the vision of “Healthy India.”

It aims to transform India’s health system through preventive, promotive, curative, and financial protection-based approaches.

📅 Launched On: 14th April 2018 (Ambedkar Jayanti)

🏛️ By: Ministry of Health and Family Welfare (MoHFW), Government of India

🌐 Based On: Recommendations of the National Health Policy 2017

2. Objectives of Ayushman Bharat

Provide comprehensive primary health care at the grassroots
Ensure financial protection through cashless secondary and tertiary care
Improve access to free health care services
Promote wellness and disease prevention
Reduce out-of-pocket expenditure

3. Two Major Components of Ayushman Bharat

Component	Description
1. Health & Wellness Centres (HWCs)	Strengthen primary health care system
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY)	Provide free health insurance of ₹5 lakh per family per year

4. Component 1: Health & Wellness Centres (HWCs)

✅ Aim: Deliver Comprehensive Primary Health Care (CPHC)

Key Features:

Transform existing Sub-Centres and PHCs into HWCs
Provide preventive, promotive, curative, rehabilitative, and palliative care
Deliver 12 health service packages
Run by Community Health Officers (CHOs), ANMs, MPHWs, and ASHAs

Services Provided at HWCs

Maternal and child health
Family planning
Adolescent health
Non-communicable diseases (BP, diabetes, cancer)
Mental health
Oral, eye, and ENT care
Elderly and palliative care
Emergency first aid
Health promotion (yoga, diet, lifestyle)
Teleconsultation via e-Sanjeevani

5. Component 2: PM-JAY (Pradhan Mantri Jan Arogya Yojana)

✅ Aim: Provide financial protection for secondary and tertiary hospitalization

Feature	Details
Coverage	₹5 lakh per family per year
Beneficiaries	~10.74 crore poor and vulnerable families
Mode	Cashless and paperless treatment at empanelled hospitals
Portability	Beneficiaries can access services across India
No restriction	On family size, age, gender
Pre-existing conditions	Covered from day one

Identification of Beneficiaries:

Based on Socio-Economic Caste Census (SECC) 2011
Verified through Ayushman Card / ABHA ID

6. Health Services Covered Under PM-JAY

Cardiac surgeries
Cancer treatment
Dialysis
Orthopedic surgeries
Maternity and neonatal care
ENT, ophthalmology
ICU services, diagnostics, and post-hospitalization follow-up

7. Implementation Mechanism

Level	Agency
National	National Health Authority (NHA)
State	State Health Agencies (SHA)
District	District Implementation Units (DIU)

8. Role of Community Health Nurse in Ayushman Bharat

Role	Functions
At HWCs	Delivers CPHC services, health education, NCD screening
Health Promoter	Educates community on Ayushman card benefits
Facilitator	Helps register families for PM-JAY
Teleconsultation	Coordinates remote consultations via eSanjeevani
Record Keeping	Maintains electronic health records
Trainer	Trains ASHAs and field workers
Referral Agent	Refers complex cases to PM-JAY empanelled hospitals

9. Key Achievements of Ayushman Bharat (till 2024)

1.5+ lakh HWCs operational across India
Over 6 crore hospitalizations under PM-JAY
More than 26,000 empanelled hospitals (public + private)
Enhanced focus on NCDs and mental health screening
Strong digital health ecosystem with ABHA ID and e-Sanjeevani

10. Challenges in Implementation

Low awareness among rural and tribal populations
Limited specialist services in government hospitals
Connectivity issues for telemedicine in remote areas
Fraudulent claims in some private hospitals
Delays in claim reimbursements

11. Suggestions for Improvement

Strengthen infrastructure and staffing at HWCs
Conduct regular IEC/BCC campaigns to increase awareness
Expand empanelment of hospitals in underserved regions
Improve monitoring, audit, and grievance redressal mechanisms
Increase training and capacity building of field-level staff

Universal Health Coverage (UHC)

1. Introduction

Universal Health Coverage (UHC) means that all individuals and communities receive the health services they need — when and where they need them, without financial hardship.

Global Goal:

Declared by World Health Organization (WHO) as part of the Sustainable Development Goals (SDGs) — specifically SDG Goal 3.8.

Goal 3.8: Achieve UHC including financial risk protection, access to quality essential health care services, and access to safe, effective, affordable, and quality medicines and vaccines for all.

2. Objectives of UHC

Access for all to promotive, preventive, curative, rehabilitative, and palliative care
Quality services irrespective of socio-economic background
Financial protection from catastrophic health expenditure
Improve health equity and outcomes

3. Key Components of UHC (The UHC Cube – WHO)

The UHC Cube has 3 dimensions:

Dimension	Meaning
1. Population Coverage	Who is covered? (Aim: Everyone)
2. Services Coverage	What services are covered? (Aim: All essential health services)
3. Financial Coverage	What proportion of costs is covered? (Aim: Full financial protection)

4. Services Covered under UHC

Health promotion (e.g., sanitation, lifestyle education)
Preventive care (e.g., immunization, screening)
Curative care (e.g., treatment of illness and injury)
Rehabilitative care (e.g., physiotherapy, chronic illness care)
Palliative care (e.g., end-of-life care, pain management)

5. UHC in the Indian Context

India is committed to achieving UHC by 2030 through the following key initiatives:

Program	Contribution to UHC
Ayushman Bharat	Combines CPHC through HWCs and financial protection through PM-JAY
National Health Mission (NHM)	Strengthens rural and urban health systems
Janani Suraksha Yojana (JSY)	Promotes institutional deliveries
Janani Shishu Suraksha Karyakram (JSSK)	Free delivery, newborn and maternal care
Free Drugs and Diagnostics Scheme	Reduces out-of-pocket expenses
Digital Health Mission	Enables electronic health records, telemedicine

6. UHC Indicators – WHO & India

Indicator	Target
Service Coverage Index	Aim: 80+% by 2030
Out-of-Pocket Expenditure	Reduce to <20% of total health expenditure
Skilled Birth Attendance	>90%
Immunization Coverage	>90% full immunization
Essential Services	Available in all PHCs and HWCs

7. Role of Nurses and Community Health Workers in UHC

Role	Description
Service Provider	Delivers promotive, preventive, and curative care
Health Educator	Promotes awareness on hygiene, nutrition, NCDs
Screening Agent	Conducts BP, diabetes, cancer, and anemia screening
Referral Connector	Links patients from SC/HWC to higher-level facilities
Data Manager	Updates electronic records, maintains HMIS
Telemedicine Facilitator	Supports remote consultation using e-Sanjeevani

8. Benefits of Achieving UHC

Reduces poverty caused by health expenses
Improves population health outcomes
Builds resilient health systems
Ensures equity and social justice
Empowers communities through health literacy

9. Challenges in Achieving UHC (India)

Inadequate public health funding (only ~1.5% of GDP)
Shortage of health workforce, especially in rural areas
Urban-rural disparity in health infrastructure
High out-of-pocket expenses for diagnostics and medicines
Weak referral systems and low health insurance awareness

10. Suggestions to Strengthen UHC in India

Increase public health investment to at least 2.5% of GDP
Train and deploy more Community Health Officers, Nurses, ASHAs
Expand Health & Wellness Centres (HWCs) for better outreach
Provide free essential medicines and diagnostics
Strengthen digital health systems and teleconsultation platforms
Foster intersectoral collaboration (nutrition, sanitation, education)

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Published March 21, 2025By mynursingapp

Categorized as COMMUNITY HEALTH NURSING-BSC SEM 2, Uncategorised