INDIA's Health System Profile

Organization of the health system

The healthcare services’ organization in the country extends from the national level to village level. From the total organization structure, we can slice the structure of healthcare system at national, state, district, community, PHC and sub-centre levels.

National level – The organization at the national level consists of the Union Ministry of Health and Family Welfare. The Ministry has three departments, viz. – Health, Family Welfare, and Indian System of Medicine and Homeopathy, headed by two Secretaries, one for Health and Family Welfare and the other for ISM and H. The department of Health is supported by a technical wing, the Directorate General of Health Services, headed by Director General of Health Services (DGHS).

State level - The organization at State level is under the State Department of Health and Family Welfare in each State headed by Minister and with a Secretariat under the charge of Secretary/Commissioner (Health and Family Welfare) belonging to the cadre of Indian Administrative Service (IAS). By and large, the organizational Structure adopted by the State is in conformity with the pattern of the Central Government. The State Directorate of Health Services, as the technical wing, is an attached office of the State Department of Health and Family Welfare and is headed by a Director of Health Services. However, the organizational structure of the State Directorate of Health Services is not uniform throughout the country. For example, in some states, the Programme Officers below the rank of Director of Health Services are called Additional Director of Health Services, while in other states they are called Joint/Deputy Director, Health Services. But regardless of the job title, each programme officer below the Director of Health Services deals with one or more subject(s). Every State Directorate has supportive categories comprising of both technical and administrative staff.

The area of medical education which was integrated with the Directorate of Health Services at the State, has once again shown a tendency of maintaining a separate identity as Directorate of Medical Education and Research. This Directorate is under the charge of Director of Medical Education, who is answerable directly to the Health Secretary/Commissioner of the State. Some states have created the posts of Director (Ayurveda) and Director (Homeopathy). These officers enjoy a larger autonomy in day-to-day work, although sometimes they still fall under the Directorate of Health Services of the State.

Regional level – In the state of Bihar, Madhya Pradesh, Uttar Pradesh, Andhra Pradesh, Karnataka and others, zonal or regional or divisional set-ups have been created between the State Directorate of Health Services and District Health Administration. Each regional/zonal set-up covers three to five districts and acts under authority delegated by the State Directorate of Health Services. The status of officers/in-charge of such regional/zonal organizations differs, but they are known as Additional/Joint/Deputy Directors of Health Services in different States.

District level - In the recent past, states have reorganized their health services structures in order to bring all healthcare programmes in a district under unified control. The district level structure of health services is a middle level management organisation and it is a link between the State as well as regional structure on one side and the peripheral level structures such as PHC as well as sub-centre on the other side. It receives information from the State level and transmits the same to the periphery by suitable modifications to meet the local needs. In doing so, it adopts the functions of a manager and brings out various issues of general, organizational and administrative types in relation to the management of health services. The district officer with the overall control is designated as the Chief Medical and Health Officer (CM & HO) or as the District Medical and Health Officer (DM & HO). These officers are popularly known as DMOs or CMOs, and are overall in-charge of the health and family welfare programmes in the district. They are responsible for implementing the programmes according to policies laid down and finalized at higher levels, i.e. State and Centre. These DMOs/CMOs are assisted by Dy. CMOs and programme officers. The number of such officers, their specialization, and status in the cadre of State Civil Medical Services differ from the State to State. Due to this, the span of control and hierarchy of reporting of these programme officers vary from state to state.

Sub-divisional/Taluka level – At the Taluka level, healthcare services are rendered through the office of Assistant District Health and Family Welfare Officer (ADHO). Some specialties are made available at the taluka hospital. The ADHO is assisted by Medical Officers of Health, Lady Medical Officers and Medical Officers of general hospital. These hospitals are being gradually converted into Community Health Centres (CHCs).

Community level – For a successful primary healthcare programme, effective referral support is to be provided. For this purpose one Community Health Centre (CHC) has been established for every 80,000 to 1, 20,000 population, and this centre provides the basic specialty services in general medicine, pediatrics, surgery, obstetrics and gynecology. The CHCs are established by upgrading the sub-district/taluka hospitals or some of the block level Primary Health Centres (PHCs) or by creating a new centre wherever absolutely needed.

PHC level – At present there is one Primary Health Centre covering about 30,000 (20,000 in hilly, desert and difficult terrains) or more population. Many rural dispensaries have been upgraded to create these PHCs. Each PHC has one medical officer, two health assistants – one male and one female, and the health workers and supporting staff. For strengthening preventive and promotive aspects of healthcare, a post of Community Health Officer (CHO) was proposed to be provided at each new PHC, but most states did not take it up.

Sub-centre level – The most peripheral health institutional facility is the sub-centre manned by one male and one female multi-purpose health worker. At present, in most places there is one sub-centre for about 5,000 populations (3,000 in hilly and desert areas and in difficult terrain).

Health information system

Census – The census in India is a decennial activity, which pools tremendous resources, and huge data pertaining to many facets of population is generated. The census in India started on regular basis from the year 1891 and last one was conducted in the year 2001. The data represents the situation as on 1st March (except 1971 census when it was 1st April). It normally provides age and sex structure and spatial distribution of population. In addition, it also provides information on some socio-economic factors. Occasionally some additional information is also obtained like mortality, disability, etc. Among all sources of information, census information reaches maximum accuracy.

Civil Registration System - It is a continuous permanent systematic activity of enlisting vital events countrywide. Considering its utmost importance, this activity is given legal status through a special Act, “Birth and Death Registration Act 1969.” Authorities like local registrar, Registrar General under the act in different areas like rural, urban have been designated from various sectors. Normally, the local registrar is from local self-government or from health department. General apathy leads to gross under-registration from time to time and differs from place to place. There is often a considerable time lag between collection of data and its compilation and publication. The data collected from urban area are comparatively of better quality than from rural area.

Sample Registration System – In 1964-65, Government of India introduced Sample Registration System for improving reliability of data pertaining to vital events and also to have urban and rural break-up. Population covered was 61,12,000 in 1998. Although initiated on pilot basis, it covered 2,235 urban sampling units and 4,436 rural sampling units selected. A Government servant, usually a teacher, is selected and trained to function as enumerator. A baseline survey of sample unit is conducted to obtain information about usual resident population of the same sampling areas. The enumeration of birth and deaths is continuously carried out pertaining to resident population by him for his area. Every six months, an official supervisor makes a visit and independently checks all the households in the area of enumerator. Thus, it functions as a continuous process and which is superimposed by periodic retrospective surveys. Unmatched or partially matched events after verification are added and final estimates are worked out. Sometimes, additional information is also collected through sub samples. Presently, this is supposed to be most accurate data source providing information about birth rate, death rate, age specific death rates, Infant Mortality Rate, age and sex composition, and seasonal and spatial variations in these statistics. It has been decided now to collect data pertaining to causes of deaths on regular basis. Sample Registration System provides information by states and for the country.

National Sample Surveys – National Sample Survey Organisation regularly conducts nation-wide surveys collecting information regarding social, economical, demographic, industrial and agricultural conditions. The organisation has many wings. One wing shoulders responsibilities like designing the sample survey, improving quality of data, etc. Another wing consists of well trained full time personnel who actually conduct surveys. The organisation also obtains support from State statistical organizations. Normally, the surveys collect multi sectoral information. The surveys are conducted in the form of rounds stretched over a specific period, generally one year. The first round was carried in the year 1951 and 55th round in the year 1999-2000. The organisation has published extensive information through 456 reports. Sometimes, special information directly pertaining to health is also collected.

Ministry of Statistics and Program Implementation

Service statistics - Information generated from Sub Centre level and above is also fed into the health information system on specifically designed reporting formats submitted monthly. The health and family welfare information is compiled at district level and submitted to State level from where it goes to central level (GoI).

Ministry of Health and Family Welfare brings out two publications yearly (there is backlog currently) – Family Welfare Yearbook and Health Information Yearbook. These yearbooks compile all information available from various sources and present by districts, states and country. However, most of the information pertains to services provided by public sector.

In addition, all India surveys are also conducted such as National Family Health Survey (1,2 and 3 have been done ), RCH survey, etc.

India has national disease surveillance. The surveillance exists only for polio and HIV/AIDS and it has been effective in getting information. However, there is a need for a strong disease surveillance network in the whole country for better information on diseases and better health initiatives.