Summarised background information on the functioning of the healthcare network we worked across.
The Indian health care system is a mixed system including mostly public and private healthcare providers (Sheikh et al. 2013) as well as other emerging providers such as nonprofit institutions and the traditional medicine system (e.g. AYUSH doctors) (Sheikh et al. 2013). The public healthcare sector in India, marked its milepost in 2005 through the government initiated National health rural mission (later expanded into NHM) to strengthening the rural public health system (Chokshi et al. 2016). It emerged to target one of the biggest public health challenges in India, to reduce maternal and child mortality, aiming to improve the “availability of human resources, program management, physical infrastructure, community participation, financing health care and use of information technology’ (Chokshi et al. 2016).
The public healthcare services are divided in three main levels according to availability of health facilities, namely primary, secondary and tertiary levels. The primary level includes Sub-centers (SC) and Primary health centers (PHC). The subcenter is the first contact point between the primary health care system and the community and often focus on maternal health, disease control and counseling, covering a population of 3000 and 5000 people according to the geographical area (Chokshi et al. 2016). The PHC centers offers curative and preventive health services to the rural population covering a population between 20 and 50 thousand people according to the geographical area. It often serves as a referral for six subcenters and it is the first contact point between the village and one medical officer (Chokshi et al. 2016). The Community health centers (CHC) provide highly specialized healthcare including facilities for obstetric and paediatric care and medical specialists (e.g., obstetricians and gynecologists, physicians and pediatricians), and act as a referral center for PHCs (Chokshi et al. 2016). The secondary level includes the sub-district hospitals with little outpatient services and the third level includes medical colleges, multi-specialty tertiary care hospitals, or district hospitals which are the last referral point and provides emergency facilities for obstetric and newborn care (Chokshi et al. 2016).
The main workforce of the Indian public health infrastructure is the healthcare personnel and thanks to the NHM there are new care providers in place including the Accredited Social Health Activist (ASHA) and Auxiliary Nurse Midwife (ANM, also known as JHAF - Junior Health Assistant Female - in certain regions) who are guided/managed by the Ministry of Health and Family Welfare. Every Sub-center has 2 ANMs allocated (one permanent and other on contractual basis) who are multi-purpose health workers acting as links between the community and health services. ASHAs act as the bridge between the ANM and villages, and collectively work under the ANMs. They together provide services for maternal and child health, family planning, health and nutrition education, environmental sanitization, immunization for control of communicable diseases, treatment of minor injuries and first aid in emergencies and disasters (Chokshi et al. 2016). Adding to their manpower are the Anganwadi (AW) workers sanctioned under the Integrated Child Development Services (ICDS). Every village has an Anganwadi that is the physical place or ‘courtyard’ for rural child care center that provides preschool education/activities. The AWs are aligned to the public health systems to provide nutrition and health education, immunization, health check-up and referral services (Desai 2004; Desai et al. 2012).
Furthermore, the Indian public health care delivery system is supported by ambulance services, toll free-call services (known as Arogya Sahayavani), a Web-based mother and child tracking system (MCTS) and a number of government supported health schemes such as Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA), Thayi Bhagya, Janani Suraksha Yojane, Bhagyalakshmi (Chokshi et al. 2016). While the Indian government has recognized the urgent need to improve the quality of pregnancy and maternity care services through these health schemes, the maternal mortality rate in India is still quite high (i.e., 174 deaths/100000 live births in 20151). The acute shortages of healthcare professionals and resources and uneven distribution of doctors, lack of antenatal care, the low utilization of existing maternal and reproductive healthcare services (Singh et al. 2012; Buehler et al. 2013), the multiplicity of stakeholders (Chawani et al. 2014; Ismail et al. 2018), the increase burden of communicable and non-communicable diseases and sanitation barriers as well as the socio-cultural and economic inequalities (Buehler et al. 2013; Sanneving et al. 2013) help characterize the existing health challenges and needs in India. For instance, the doctor-to-population ratio is 1:16742 in comparison to 1:1000 recommended by the World Health Organization. This influence Indian population to prefer receiving medical attention from private care providers that are often concentrated in urban areas providing secondary and tertiary health services (Chokshi et al. 2016).
Comments