2. HEALTH CARE DELIVERY SYSTEM ORGANIZATION AND FUNCTION OF NURSING SERVICES AT NATIONAL, STATE AND DISTRICT AND INSTITUTION HOSPITAL AND COMMUNITY PRESENTED BY MARYSHA DAMS.K M.SC NURSING 2 ND YEAR CON, PIMS

3. GENERAL OBJECTIVES: On completion, the class will have in depth knowledge regarding the health care delivery system and the organization and functions of nursing services at national, state, district, at institutional and community level and develop desirable attitude towards it.

4. SPECIFIC OBJECTIVES: At the end of the teaching, the group will be able to define health care delivery. narrate the philosophy of health care delivery system. state the objectives of health care delivery system discuss the principles of health care delivery system. explain the functions of health care delivery system. list the characters of health care delivery system. elaborate the health care delivery in India in nation, state and district level. discuss in detail about the organization structure and functions of nursing services at national, state, district and community level.

5. INTRODUCTION Health is the birth right of every individual. Today health is considered more than a basic human right; it has become a matter of public concern, national priority and political action. Our health system has traditionally been a disease-oriented system but the current trend is to emphasize health and its promotion.

6. DEFINITIONS OF HEALTH CARE DELIVERY: Health care delivery system refers to the totality of resources that a population or society distributes in the organization and delivery of health population services. It also includes all personal and public services performed by individuals or institutions for the purpose of maintaining or restoring health. Stanhope(2001) It implies the organization, delivery staffing regulation and quality control. J.C.Pak(2001)

7. PHILOSOPHY OF HEALTH CARE DELIVERY SYSTEM: Everyone from birth to death is part of the market potential for health care services. The consumer of health care services is a client and not customer. Consumers are less informed about health services than anything else they purchase. Health care system is unique because it is not a competitive market.

8. GOALS/OBJECTIVES OF HEALTH CARE DELIVERY SYSTEM: 1)To improve the health status of population and the clinical outcomes of care. 2) To improve the experience of care of patients families and communities. 3) To reduce the total economic burden of care and illness. 4) To improve social justice equity in the health status of the population.

9. PRINCIPLES OF HEALTH CARE DELIVERY SYSTEM: 1. Supports a coordinated, cohesive health-care delivery system.2. Opposes the concept that fee-for-practice.3. Supports the concept of prepaid group practice.4. Supports the establishment of community based, community controlled health-care system.5. Urges an emphasis be placed on development of primary care6. Emphasizes on quality assurance of the care7. Supports health care as basic human right for all people.8. Opposes the accrual of profits by health-care-related industries.

10. FUNCTIONS OF HEALTH CARE DELIVERY SYSTEM: 1 ) To provide health services. 2) To raise and pool the resources accessible to pay for health care. 3) To generate human and physical sources that makes the delivery service possible. 4) To set and enforce rules of the game and provide strategic direction for all the different players involved.

11. CHARACTERS OF HEALTH CARE DELIVERY SYSTEM: 1) Orientation toward health. 2) Population perspective. 3) Intensive use of information. 4) Focus on consumer. 5) Knowledge of treatment outcome. 6) Constrained resources.

12. HEALTH CARE DELIVERY IN INDIA

13. HEALTH CARE DELIVERY SYSTEM IN INDIA & ORGANIZATION AND FUNCTIONS OF NURSING SERVICES AND EDUCATION AT NATIONAL, STATE, DISTRICT, AND INSTITUTIONS: HOSPITAL AND COMMUNITY

14. India is a unit of 28 states and 7 union territories. States are largely independent in matter relating to the delivery of health care to the people. Each system has developed its own system of healthcare delivery, independent of the central government. The responsibility consists mainly of Policy making Planning Guiding Assisting Evaluating Coordinating the work of the state health ministers.

15. HEALTH SYSTEM IN INDIA STATE LOCAL OR PERIPHERAL The health system in India has 3 main links CENTRAL

16. CENTRAL LEVEL Health care organization at the center comprised of 3 major organs. They are 1. Union ministry of health and family welfare. 2. The directorate general of health services. 3. The central council of health and family welfare

17. CABINET MINISTER OF STATE DEPUTY HEALTH MINISTER DEPARTMENT OF HEALTH DEPARTMENT OF FAMILY HEALTH SECRETARY TO GOVT. OF INDIA ADMINISTRATION DEPUTY JOINT SECRETARIES JOINT SECRETARIIES ADDITIONAL SECRETARY & COMMISSIONER (F.w) SECRETARY TO THE GOVT

18. FUNCTIONS UNION LIST: International health relations and administration of post quarantine. Administration of central institutions. Promotion of research. Regulation and development of medical, pharmaceutical, dental and nursing professions. Establishment and maintenance of drug standards. Census and collection and publication of other statistical data. Co- ordination with states.  Immigration and emigration  Regulation of labor (mines and oil fields)

19. FUNCTIONS CONCURRENT LIST: Prevention of communicable disease. Prevention of food adulteration. Control of drug and poison. Vital statistics. Labor welfare. Economic and social planning. Population control and family planning.

20. THE DIRECTORATE GENERAL OF HEALTH SERVICE:

21. contd… DGHS DEPUTY DGHS (GENERAL ADMINISTRATION) DEPUTY DGHS (MEDICAL CARE) DEPUTY DGHS (PUBLIC HEALTH ) DEPUTY NURSING ADVISOR NURSING ADVISOR

22. FUNCTIONS OF DGHS: General functions. Specific functions. GENERAL FUNCTIONS: Surveys Planning Co- ordination. Programming and appraisal of all health matters.

23. FUNCTIONS OF DGHS: SPECIFIC FUNCTIONS: International health and quarantine of all major ports in country and international airport. Control of drug standards. Maintain medical store depots. Administration of PG training programs. Administration of certain medical college in India. Conducting medical research through Indian Council of Medical Research (ICMR). Central government health schemes. Implementation of national health programs. Preparation of health education materials creating health awareness through health education bureau. Collection, compilation, analysis, evaluation and dissemination of information. National medical library.

24. THE CENTRAL COUNCIL OF HEALTH AND FAMILY WELFARE: Chairperson : Union Health Minister Members : State Health Ministers. FUNCTIONS: To consider and recommend broad outlines of policy related to matters concerning healthy life environment, hygiene, nutrition and health education. To make proposals for legislation relating to medical and public health matters. To make recommendations to the central government regarding distribution of grants – in- aid.

25. PLACEMENT OF NURSES AT THE CENTRAL LEVEL AT THE CENTRAL LEVEL There is a post of nursing advisor in the medical division of Directorate General of Health Services. The nursing advisor is directly responsible to the Deputy Director General (Medical). The nursing advisor is assisted by nursing officer and support staff for all his/her work. She/he advises the DGHS, Ministry of Health and Family Welfare as well as other ministries and departments.

26. PLACEMENT OF NURSES AT THE CENTRAL LEVEL AT THE CENTRAL LEVEL - contd For example, railways, labor, Delhi Administration, etc. on all matters of nursing services, nursing education, and research. There is a post of deputy nursing advisor at the rank of Assistant Director General (ADGNsg) in the training division of Department of F. W. There is no direct linkage between the nursing advisor and deputy nursing advisor as there are independent posts.

27. NURSING ORGANISATIONAL SET UP AT THE CENTRAL LEVEL

28. DGHS ADDITIONAL DGHS DDG (N) ADG (HOSPITAL) ADG (NRG.EDU&RCH) ADG (COMMUNITY) ANM LHV PHN SUPERVISOR COMMUNITY N.O DADG TUTOR SENIOR TUTOR PRINCIPAL DADG STAFF NNURSE WARD SISTER ANS DNS N.S DADG CLINICAL INSTRUCTOR

29. contd Apart from Governmental actions, Nursing education and services are organized by Indian nursing council and other statutory bodies in national level.

30. STATE LEVEL State ministry of health State health directorate.

31. STATE MINISTRY OF HEALTH MINISTRY OF HEALTH AND FAMILY WELFARE STATE HEALTH MINISTER DEPUTY MINISTER OF HEALTH AND FAMILY WELFARE HEALTH SECRETRIAT HEALTH SECRETARY DEPUTY SECRETARIES ADMIISTRATIVE STAFF

32. STATE HEALTH DIRECTORATE FUNCTIONAL DEPUTY DIRRECTOR ADDITIONAL DIRECTORS REGIONAL DEPUTY DIRECTOR

33. FUNCTIONS: STATE MINISTRY OF HEALTH: Assisting the minister in policy making. Formulating, review and modification of broad policy. Execution of policies. Co- ordination with government of India and other state. Control of smooth and efficient functioning. Budgeting and control over expenditure.

34. FUNCTIONS: STATE HEALTH DIRECTORATE: Provide adequate medical care. Medical education and research. National health program implementation. Provision of health schemes. Food and drug administration. Collection of health information. Control over ESI schemes. Enforcement of professional standards.

35. PLACEMENT OF NURSES AT STATE LEVEL There is no proper and definite pattern of nursing structure in the state directorates except the state of West Bengal. Usually one or two nurses are posted with varying designations, e.g., in Tamilnadu there is one assistant director nursing who is responsible to Director, Medical Services, and Director, Medical Education. In Maharashtra, two nurses work, one each in the office of the Director, Medical Education, and Director, Health Services.

36. RECOMMENDED ORGANIZATION AT STATE LEVEL (UNION TERRITORY LEVEL)

37. SECRETARY (HEALTH) DIRECTOR, NURSING SERVICES JOINT / DEPUTY DIRECTOR, NURSING SERVICES ADNS (COMMUNITY)ADNS ( NRG EDU &RCH) ADNS (HOSPITAL) DADNS DISTRICT N.O PHN PHN @ PHC LHV (HSV) LHV ANM CLINICAL INSTRUCTOR TUTOR SENIOR TUTOR PRINCIPAL DADNS STAFF NURSE WARD SISTER ANS DNS N.S

38. contd The Principal, College of Nursing will be equal to the rank of ADNS and will be eligible for promotion to the post of DDNS/DNS. The salary scales and structure of the staff of colleges of nursing will be as per norms of the Indian Nursing Council and the UGC. Apart from governmental actions it will be organized by state nursing councils and universities Functions of university are Organize the courses Plan for the examinations Setting question papers Planning the examination date Plan the curriculum

39. DISTRICT LEVEL

40. contd FUNCTIONS: Construction and maintenance of roads Sanitation and drainage. Street light. Public health. Maintenance of hospital and dispensaries. Education and registration of birth and death.

41. PANCHAYAT RAJ

42. PANCHAYAT RAJ SYSTEM Panchayati raj system is a local self governing system in rural area which work parallel to official structure of administration. It consists of three –tier structure of rural local self government. Gram sabha- it is comprised of all the adult men and women of the village. This body meets at least twice in a year and discusses important issues and considers proposals pertaining to various developmental aspects including health matters

43. PANCHAYAT RAJ SYSTEM Gram Panchayat- it is the executive organ of the gram sabha. Its main function is overall planning and development of the villages. The Panchayat secretary has been given powers to function for wide areas such as maintenance of sanitation and public health, socio economic development of villages. Panchayat samiti- it is responsible for the block development program. The funds for the development activities are processed through Panchayat samiti. The block development officer and his/her technical staff extend assistance and guidance to gram Panchayats in carrying out developmental activities in their villages.

44. PLACEMENT OF NURSES AT DISTRICT LEVEL Nurses, public health nurses, lady health visitors, auxiliary nurse midwives, etc. have played vital role in providing healthcare services at various levels in both urban and rural areas of the district. They have been the mainstream in providing primary healthcare services in the rural and urban areas from the very beginning.

45. DIRECTOR, NURSING SERVICE DY. DIRECTOR, NURSING SERVICES ASST. DIRECTOR, NURSING SERVICE DY. ASST. DIRECTOR, NURSING SERVICE DMO DIRECTOR N.O DHO ASST. SIST. NRG OFFICER (HOSP.&Nsg Edu) NS/ DNS ANS WARD SISTER STAFF NURSE ASST.DIST.NRG OFFICER (COMMUNITY) Dist P.N.O P.N SUPERVISOR (CHC) P.N (PHC) LHV/HS LHV ANM

46. contd The above recommended organizational set up will need full administrative and financial support of the government. It will look after the overall nursing components, development of nursing standards, norms, policies, ethics, recruitment, selection and placement roles for both hospitals and community health nursing, development in specialty nursing, higher education in nursing, and research. These will promote professional autonomy and accountability.

47. INSTITUTIONAL LEVEL – AT HOSPITAL DIRECTOR (HOSPITAL) SERVICES CHIEF NURSING OFFICER NURSING SUPERINTENDENT STAFF NURSE HEAD NURSE CLINICAL SUPERVISOR/ INCHARGE SISTER ASSISTANT NURSING SUPERINTENDENT DEPUTY NURSING SUPERINTENDENT

48. DIRECTOR NURSING: Nursing must services must function under a senior competent nursing administrator called director of nursing. She is responsible to the hospital administrator for overall program and activities of nursing care of all patients in the hospital. nursing program is administered by her through appropriate planning of services, determining nursing policies in collaboration with hospital management and nursing procedures in collaboration with nursing staff, giving general supervision, delegation of responsibility, coordination of interdepartmental nursing activities and counselling the hospital administration on nursing problems.

49. contd DIRECTOR NURSING: She has a dual role: the first one is the administrative responsibility towards hospital administration, and the second one is the coordinating of all professional activities of nursing staff with those of medical staff.

50. contd CHIEF NURSING OFFICER: The chief nursing officer should have extensive experience as a chief nurse executive in hospital setting, she should be educationally prepared with master degree in nursing and nationally certified as nurse executive with proven track record of achieving goal in highly matrixed organization.

51. Contd… NURSING SUPERINTENDENT: The role of the nursing superintendent starts in a new hospital from helping to establish the overall goals, policies and organization and facilities to accompolish these goals in the most effective and efficient manner. FUNCTIONS: Formation of the aims, objectives and policies of nursing services as an integral part of hospital service. Staffing based on nursing requirements in relation to accepted standards of medical care. Planning and directing nursing services. Maintaining supplies and equipments, budgeting, records and reports. Budgeting. Records and reports.

52. Contd… INCHARGE NURSE/ NURSING SUPERVISOR: Each department or clinical division, e.g medical, surgical, obstetrical, operation theaters, outpatient department, nurseries etc. should have a supervisor. As they may be more than nursing unit in each division or department, supervisors have a general administrative and coordinating function within their respective division. However, supervisors will also have limited clinical functions.

53. Contd… HEAD NURSE: A head nurse is assigned to a nursing unit, or ward, or a section of department. She works under the general direction of the supervisor of the division. STAFF NURSE: Staff nurses are employed at the floor level for carrying out skilled bedside nursing. This is the real work force of the hospital upon whose competency, state of training and dedication depend the success of the nursing department.

54. Contd… FUNCTIONS Of hospital in nursing services and education As a basic function, to assist the individual patient in performance of those activities contributing to his health or recovery that he would otherwise perform unaided has had the strength will, or knowledge. As an extension of the above basic function, to help and encourage the patients to carry out the therapeutic plan initiated by the physician As a member of health team, to assist other members of the team to plan and carryout the total program of care

55. At community level Primary health center (PHC) Community health center (CHC)

56. PRIMARY HEALTH CENTER (PHC) DEFINITION Primary health center is the basic structural and functional unit of public health services for rendering primary health care in peripheral areas. It acts as a referral unit for six sub center and has 4-6 beds. A PHC covers population of 30000 in plain area and 20000 in hilly remote and tribal area. The activities of PHC‘s involve curative, preventive, promotive and family welfare services. The number of PHC‘s functioning in the country is 22975.

57. PRIMARY HEALTH CENTER (PHC) – contd… ELEMENTS OF PHC e- Ensure safe water supply l- Locally endemic disease control E- Education/ expanded program on immunization m- Maternal and child health e- Environmental sanitation n- Nutritional services t- Treatment of minor aliments s- School health services

58. PRIMARY HEALTH CENTER (PHC) – contd… MINIMUM REQUIREMENTS ARE:- The assured services cover all the essentials of preventive, promotive, curative and rehabilitative primary health care. This implies a wider range of services that includes Medical care Maternal and child health care Full rage family planning services including counseling and appropriate referral for couples having infertility MTP services Health education for prevention and management of malnutrition, anemia and vitamin A deficiency and co-ordinates with ICDS School health services Adolescent health care Disease surveillance and control of epidemics Collection and reporting of vital events Promotion of sanitation Testing water quality Nutritional health program Training health workers Training of ASHA

59. PRIMARY HEALTH CENTER (PHC) – contd… STAFFING PATTERN IN PHC:

60. COMMUNITY HEALTH CENTER: DEFINITION Community health centers are the nonprofit community governed health organizations that provide primary health care, health promotion and community development services, using them inter disciplinary terms of health providers

61. COMMUNITY HEALTH CENTER – contd… ELEMENTS Primary care Illness prevention Health promotion Community capacity building Service integration

62. COMMUNITY HEALTH CENTER – contd… MINIMUM REQUIREMENTS: CHCs has to provide the following services like Care of routine and emergency cases in surgery Care of routine and emergency cases in medicine 24 hour delivery services Essentials of emergency obstetric care. Full range of family planning services including laparoscopic services Safe abortion services New born care Routine and emergency care of sick children Other management of medical and accidental conditions All the national health programs should be delivered through CHCs

63. COMMUNITY HEALTH CENTER – contd… STAFFING PATTERN IN CHC: Medical officer -4 Staff nurse - 7 Dresser - 1 Pharmacist/compounder- 1 Laboratory technician- 1 Radiographer - 1 Ward boys - 2 Dhobi - 1 Sweepers - 3 Mali - 1 Chowkidar - 1 Aya - 1 Peon - 1 Total - 25

64. SUMMARY: So far we have seen about the introduction of health care delivery, philosophy, goals, principles, functions, characters of health care system, health care delivery system in India and its organization, functions of nursing services and education at national level, state level, district level and community level.

65. CONCLUSION: Hope you have understood about the health care delivery and health care delivery system at each level and its organization structures and functions at different levels.

66. JOURNAL REFERENCE

67. HEALTH SCHEMES IN INDIA 1. AYUSHMAN BHARAT: The PM-JAY is a health insurance scheme for the poor. It offers a health cover of Rs. 5 lakhs per family on an annual basis, and the payable premium is Rs. 30. 2. AWAZ HEALTH INSURANCE SCHEME: This is a health insurance cover for migrant workers and is initiated by the Government of Kerala. It also offers insurance for death by accident for labourers. The health insurance coverage offered under Awaz Health Insurance is Rs.15000, while the cover for death is Rs.2 lakh. 3) AAM AADMI BIMA YOJANA: The Aam Aadmi Bima Yojana (AABY) is meant for people involved in certain vocations such as Carpentry, Fishing, Handloom weaving, etcAam Aadmi Bima Yojana The premium for Rs.30000 insurance policy is Rs. 200 for a year.

68. HEALTH SCHEMES IN INDIA 4) BHAMASHAH SWASTHYA BIMA YOJANA: Rajasthan Government supports insurance initiatives towards its citizens. This scheme covers hospitalization expenses for general illness as well as critical illnesses as per the terms and conditions. It covers both in-patient as well as out-patient expenses. 5) CENTRAL GOVERNMENT HEALTH SCHEME (CGHS): Central Government employees are eligible for this policy. For example, Supreme Court judges, Certain Railway Board employees, etc. 6) CHIEF MINISTER’S COMPREHENSIVE INSURANCE SCHEME: This is a state government scheme. It is promoted by Tamil Nadu Government in association with United India Insurance Company Ltd One can claim for hospitalization expenses up to Rs. 5 lakhs under this policy.

69. HEALTH SCHEMES IN INDIA 7) EMPLOYEES’ STATE INSURANCE SCHEME: to offer a financial cover in case of illness, disability or death faced by insured workers/employees. 8) KARUNYA HEALTH SCHEME: Kerala Government had launched this initiative. It is a Critical Illness plan for the poor and covers major diseases such as Cancer, Kidney Ailments, Heart-related medical issues, etc. 9) MAHATMA JYOTIBA PHULE JAN AROGYA YOJANA: This policy is initiated by the Government of Maharashtra for the betterment of its downtrodden people

70. HEALTH SCHEMES IN INDIA 10) MUKHYAMANTRI AMRUTUM YOJANA: Lower middle-class families and those living below the poverty line are eligible for this cover. This scheme offers a cover of Rs. 3 lakhs for a year on a family floater basis. Treatment can be availed in different types of hospitals 11) PRADHAN MANTRI SURAKSHA BIMA YOJANA: This scheme came into existence to offer accident insurance to the people of India. People aged 18 to 70 and having a bank account can avail of the benefits of this scheme. This policy offers an annual cover of Rs. 1 lakh for partial disability and Rs. 2 lakhs for total disability/death for a premium of Rs. 12. 12) DR YSR AAROGYASRI HEALTH CARE TRUST ANDHRA PRADESH STATE GOVERNMENT: The Andhra Pradesh Government along with the Dr YSR Aarogyasri Trust, which works for health care,

71. HEALTH SCHEMES IN INDIA 13) TELANGANA STATE GOVERNMENT – EMPLOYEES AND JOURNALISTS HEALTH SCHEME: This health scheme is offered by the Telangana Government for its employees and journalists. 14) RASHTRIYA SWASTHYA BIMA YOJANA: is initiated by the Indian Government’s Ministry of Labour and Employment. Individuals workers in the unorganized sector and below the poverty line are covered under this scheme. 16) YESHASVINI HEALTH INSURANCE SCHEME: The Yeshasvini Health Insurance Scheme is promoted by the Karnataka State Government. It is meant for farmers and peasants associated with a co-operative society. 17) WEST BENGAL HEALTH SCHEME: This scheme was launched by the Government of West Bengal for its employees.

72. BIBLIOGRAPHY 1.Dhaar G.M. & Robbani I. (2006) “Foundations of community medicine”. First Edition, Elsevier publication. PP 923-926. 2.Park K. (2007) “Preventive and social medicine” 19 th edition, Banarsidar Bhanot publication, PP 726-728. 3.Rahim A. (2008), “Principles and Practice of Community Medicine”, 1 st edition, Jaypee Brothers Medical Publishers, pp 47-48 4.Swarnkar K. (2007) “Community Health Nursing “, 2 nd edition, N.R. Brothers, New Delhi, pp 521-523 5.Deepak. K, A Comprehensive Textbook On Nursing Management, EMES Publications, 2 nd Edition, Pg No : 17 – 51. 6.https://www.slideshare.net/mahesh0926/organization-and-functions-of-nursing-srvices-and-educationhttps://www.slideshare.net/mahesh0926/organization-and-functions-of-nursing-srvices-and-education 7.https://www.slideshare.net/deepthyphilipthomas/organizing-nursing-serviceshttps://www.slideshare.net/deepthyphilipthomas/organizing-nursing-services 8.https://www.slideshare.net/SandhyaC6/nursing-services-organisationhttps://www.slideshare.net/SandhyaC6/nursing-services-organisation 9.https://www.slideshare.net/jensensam/management-of-nursing-servicehttps://www.slideshare.net/jensensam/management-of-nursing-service 10.https://www.slideshare.net/bivinjose/nursing-service-administrationhttps://www.slideshare.net/bivinjose/nursing-service-administration 11.https://www.scribd.com/doc/35910778/Steps-in-the-Organization-of-Nursing-Educational-Administrationhttps://www.scribd.com/doc/35910778/Steps-in-the-Organization-of-Nursing-Educational-Administration