HEALTH CARE OF

COMMUNITY
Levels of health care
 1. Primary care level
• It is the first level of contact of individuals, the family and community with the national
health system, where "primary health care".("essential" health care) is provided.
• As a level of care, it is close to the people, where most of their health problems can be
dealt with and resolved.
• It is at this level that health care will be most effective within the context of the area's
needs and limitations .
• In the Indian context, primary health care is provided by the complex of primary health
centres and their sub centres through the agency of multipurpose health workers, ANM,
ASHA, Anganwadi worker, village health guides and trained dais.
• Besides providing primary health care, the village "health teams" bridge the cultural and
communication gap between the rural people and organised health sector.
• Since India opted for "Health for All" by 2000 AD, the primary health care system has been
reorganized and strengthened to make the primary health care delivery system more
effective
2. Secondary care level
At this level more complex problems are dealt with.
In India, this kind of care is generally provided in district hospitals and community health centres which also serve as the
first referral level .

3. Tertiary care level

The tertiary level is a more specialized level than secondary care level and requires specific facilities and attention of highly
specialized health workers .
This care is provided by the regional or central level institutions,
e.g. ,
Medical College Hospitals, All India Institutes, Regional Hospitals, Specialized Hospitals and other Apex Institutions
Changing concepts
With political independence, there was a national commitment to improve health in developing countries.
Against this background different approaches to providing health care came into existence.
1. Comprehensive health care
The term "comprehensive health care" was first used by the Bhore Committee in 1946.
By comprehensive services, the Bhore committee meant provision of integrated preventive, curative and promotional
health services from "womb to tomb" to every individual residing in a defined geographic area.
The Bhore Committee defined comprehensive health care as having the following criteria :
(a) provide adequate preventive, curative and promotive health services;
(b) be as close to the beneficiaries as possible;
(c) has the widest cooperation between the people, the service and the profession;
(d) is available to all irrespective of their ability to pay;
(e) look after specifically the vulnerable and weaker sections of the community; and
(f) create and maintain a healthy environment both in homes as well as working places.
The Bhore Committee suggested that comprehensive health care should replace the policy of providing more
medical care. This concept formed the basis of national health planning in India and led to the establishment of a
network of primary health centres and subcentres.
The Government of India, during the successive 5 year plans has built up a vast infrastructure of rural health
services based on primary health centres and subcentres.
However, experience during the past 60 years has indicated that the primary health centres were not able to effectively
cover the whole population under their jurisdiction, and their sphere of service did not extend beyond a 2-5 km
radius.
These facilities often did not enjoy the confidence of the people because they were understaffed and poorly
2. Basic health services
In 1965, the term "basic health services" was used by UNICEF/WHO in their joint health policy .
They defined the term as follows '·A basic health service is understood to be a network of coordinated, peripheral and
intermediate health units capable of performing effectively a selected group of functions essential to the health of an area
and assuring the availability of competent professional and auxiliary personnel to perform these functions. "
The change in terminology from comprehensive to basic health services did not affect materially the quality or
content of health services. The handicaps or drawbacks of the basic health services are those shared by the
comprehensive health care services, viz., lack of community participation, lack of inter sectoral coordination and
dissociation from the socio-economic aspects of health.
3. Primary health care
A new approach to health care came into existence in 1978, following an international conference at Alma-Ata
(USSR) . This is known as "primary health care". It has all the hallmarks of a primary health care delivery, first
proposed by the Bhore Committee in 1946 and now espoused worldwide by international agencies and national
governments (8).
Before Alma-Ata, primary health care was regarded as synonymous with "basic health services", "first contact
care", "easily accessible care" , "services provided by generalists", etc. The Alma-Ata international conference
gave primary health care a wider meaning. The Alma-Ata Conference defined primary health care as follows (9) :-
"Primary health care is essential health care made universally accessible to individuals and acceptable to them, through
their full participation and at a cost the community and country can afford".
The primary health care is equally valid for all countries from the most to the least developed, although it takes
varying forms in each of them. The concept of primary health care has been accepted by all countries as the key to
the attainment of Health for All by 2000 AD. It has also been accepted as an integral part of the country's health system.
Elements of primary health care
1. Education concerning prevailing health problems and the
methods of preventing and controlling them.
2. Promotion of food supply and proper nutrition.
3.Adequate supply of safe water and basic sanitation.
4. Maternal and child health care, including family planning.
5. Immunization against major infectious diseases.
6. Prevention and control of locally endemic diseases.
7. Appropriate treatment of common diseases and injuries.
8. provision of essential drugs.
Principles of primary health care
1. Equitable distribution
• The first key principle.
• Health services must be shared equally by all people irrespective of their ability to pay, and all (rich or poor, urban or
rural) must have access to health services.
• The failure to reach the majority of the people is usually due to inaccessibility.
• Primary health care aims to redress this imbalance by shifting the centre of gravity of the health care system from cities
(where three-quarters of the health budget is spent) to the rural areas (where three-quarters of the people live), and
bring these services as near people's homes as possible.

2. Community participation
• Notwithstanding the overall responsibility of the Central and State Governments, the involvement of individuals,
families, and communities in promotion of their own health and welfare, is an essential ingredient of primary health
care.
• There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation
and maintenance of health services, besides maximum reliance on local resources such as manpower, money and
materials.
• In short, primary health care must be built on the principle of community participation (or involvement).
Eg. village health guides and trained dais.
• They are selected by the local community and trained locally in the delivery of primary health care to the community
they belong, free of charge.
• ASHA and Anganwadi workers are an essential feature of primary health care in India.
3. Inter sectoral coordination
• There is an increasing realization of the fact that the components of primary health care cannot be provided by
the health sector alone.
• The Declaration of Alma-Ata states that "primary health care involves in addition to the health sector, all related
sectors and aspects of national and community development, in particular agriculture, animal husbandry, food ,
industry, education, housing, public works, communication and others sectors" .
• To achieve such cooperation, countries may have to review their administrative system, reallocate their resources and
introduce suitable legislation to ensure that coordination can take place.
• This requires strong political will to translate values into action.
• An important element of inter sectoral approach is planning - planning with other sectors to avoid unnecessary
duplication of activities.
4. Appropriate technology
• “Technology that is scientifically sound, adaptable to local needs, and acceptable to those who apply it and those for
whom it is used, and that can be maintained by the people themselves in keeping with the principle of self reliance with
the resources the community and country can afford" .
• The term "appropriate" is emphasized because in some countries, large, luxurious hospitals that are totally
inappropriate to the local needs, are built, which absorb a major part of the national health budget, effectively blocking
any improvement in general health services. This also applies to using costly equipment, procedures and techniques
when cheaper, scientifically valid and acceptable ones are available, viz, oral rehydration fluid, standpipes which are
socially acceptable, and financially more feasible than house-to-house connections, etc.
• It will be seen from the above discussion that primary care is qualitatively a different approach to deal with the
health problems of a community. Unlike the previous approaches (e.g, basic health services, integrated health care,
vertical health services) which depended upon taking health services to the doors of the people, primary health
care approach starts with the people themselves.
• This approach signifies a new dynamism in health care and has been described as Health by the people , placing people's
health in people's hands (11).
• The ends of the primary health care approach are the same as those of earlier approaches (i.e. , attainment of an
acceptable level of health by every individual), but the means adopted are different (12) , that is, more equitable
distribution and nation-wide coverage, more intersectoral coordination and more community involvement in health
related matters. In short, primary health care goes beyond the conventional health services. It forms part of the larger
concept of Human Resources and Development.
 HEALTH FOR ALL
• In 1977, it was decided in the World Health Assembly to launch a movement known as "Health for All by the year 2000".
The fundamental principle of HFA strategy is equity,
that is, an equal health status for people and countries, ensured by an equitable distribution of health resources.
• The Member countries of WHO at the 30th World Health Assembly defined Health for All as :
"attainment of a level of health that will enable every individual to lead a socially and economically productive life."
• In 1978, the Alma-Ata International conference on Primary Health Care reaffirmed Health for All as the major social goal of
governments, and stated that the best approach to achieve the goal of HFA is by providing primary health care, especially to
the vast majority of underserved rural people and urban poor.
• It was envisaged that by the year 2000, at least essential health care should be accessible to all individuals and families in
an acceptable and affordable way, with their full participation.
• The Alma-Ata Conference called on all governments to formulate national policies, strategies and plans of action to
launch and sustain primary health care as part of a national health system. It is left to each country to develop its norms
and indicators for providing primary health care according to its own circumstances.
• In 1981, a global strategy for HFA was evolved by WHO. The global strategy provides a global framework
that is broad enough to apply to all Member States and flexible enough to be adapted to national and regional variations of
conditions and requirements.
• This was followed by individual countries developing their own strategies for achieving HFA, and synthesis of national
strategies for developing regional strategies.
The WHO has established 12 global indicators as the 61 basic point of reference for assessing the progress towards HFA,
for example, a minimum life expectancy of 60 years and maximum IMR of 50 per 1000 live births.
 National strategy for HFA/2000
• As a signatory to the Alma-Ata Declaration in 1978, the Government of India was committed to taking steps to
provide HFA to its citizens by 2000 AD. In pursuance of this objective various attempts were made to evolve suitable
strategies and approaches. In this connection two important reports appeared :
(i) Report of the Study Group on "Health for All - an alternative strategy" , sponsored by ICSSR and ICMR,
(ii) Report of the Working Group on "Health for All by 2000 AD" sponsored by the Ministry of Health and Family Welfare ,
Government of India .
Both the groups considered in great detail the various issues involved in providing primary health care in the Indian
context.
• These reports formed the basis of the National Health Policy formulc;1ted by the Ministry of Health and Family Welfare,
Government of India in 1983 (16) which committed the Government and people of India to the achievement of HFA.
• The National Health Policy echoes the WHO call for HFA and the Alma-Ata Declaration. It had laid down specific
goals in respect of the various health indicators by different dates such as 1990 and 2000 AD. Foremost among the goals
to be achieved by 2000 AD were:
(1) Reduction of infant mortality from the level of 125 (1978) to below 60.
(2) To raise the expectation of life at birth from the level of 52 years to 64.
(3) To reduce the crude death rate from the level of 14 per 1000 population to 9 per 1000.
(4) To reduce the crude birth rate from the level of 33 per 1000 population to 21.
(5) To achieve a net reproduction rate of one.
(6) To provide potable water to the entire rural population.
 THE MILLENNIUM DEVELOPMENT GOALS
• During September 2000, representatives from 189 countries met at the Millennium Summit in New York, to
adopt the United Nations Millennium Declaration.
• The goals in the area of development and poverty eradication are now widely referred to as "Millennium
Development Goals“ (MDGs).
• The MDGs place health at the heart of development and represent commitments by governments throughout the
world to do more to reduce poverty and hunger and to tackle ill-health; gender inequality; lack of education; access to
clean water; and environmental degradation .
• They were an integral part of the road map towards the implementation of the UN Millennium Declaration.
• Three of the 8 goals, 8 of the 18 targets required to achieve them, and 18 of the 48 indicators of progress, are health
related.
• They assist in the development of national policies focussing on poor, and help track the performance of health
programmes and systems.
• Although, the MDGs do not cover the whole range of public health domains, a broad interpretation of the goals
provides an opportunity to tackle important cross cutting issues and key constraints to health and development.
• Governments have set a date of 2015 by which they would meet the MDGs, i.e.
Eradicate extreme poverty and hunger;
Achieve universal primary education;
Promote gender equality;
Improve maternal health;
Combat HIV/AIDS, malaria and other communicable diseases;
Ensure environmental sustainability;
Develop a global partnership for development .
 HEALTH STATUS AND HEALTH PROBLEMS
An assesment of the health status and health problems is the first requisite for any planned effort to develop health
care services. This is also known as Community Diagnosis.
The data required for analyzing the health situation and for defining the health problems comprise the following :
1. Morbidity and mortality statistics.
2. Demographic conditions of the population.
3 . Environmental conditions which have a bearing on health.
4. Socio-economic factors which have a direct effect on health.
5. Cultura l background, attitudes, beliefs, and practices which affect health.
6. Medical and health services available.
7. Other services available .
An analysis of the health situation in the light of the above data will bring out the health problems and health
needs of the community
Health problems
The HEALTH PROBLEMS of India may be conveniently grouped under the following heads:
1. Communicable disease problems;
2. Non-communicable disease problems;
3. Nutritional problems;
4. Environmental sanitation problems;
5. Medical care problems; and
6. Population problems.
1. Communicable disease problems
(a) Malaria (
(b) b) Tuberculosis
(c) (c) Diarrhoeal diseases
(d) (d) ARI
(e) (e) Leprosy
(f) (f) Filaria
(g) (g) AIDS
(h ) Others : Kala-azar, meningitis, viral hepatitis, Japanese encephalitis, dengue fever, enteric fever and helminthic infestations
2 . 2.Non-communicable diseases (NCDs)
diabetes mellitus, CVDs, cancer, stroke, and chronic lung diseases have emerged as major public health problems due to an
ageing population and environmentally-driven changes in behaviour.
3 . Nutritional problems
(a) Protein-energy malnutrition
(b) Nutritional anaemia (
(c) Low birth weight.
(d) Xero phthalmia (nutritional blindness)
(e) Iodine deficiency disorders
(f) Others : lathyrism and endemic fluorosis in certain parts of the country
4 . Environmental sanitation
lack of safe water in many areas of the country and primitive methods of excreta disposal.
population explosion, urbanization and industrialization leading to hazards to human health in the air, in water and in the
food chain.
5. Medical care problems
The existing hospital-based, disease-oriented health care model has provided health benefits mainly to the urban
elite. Approximately 80 per cent of health facilities are
concentrated in urban areas.
Even in urban areas, there is an uneven distribution of doctors
Many villages rely on indigenous systems of medicine.
6. Population problem
The population problem is one of the biggest problems facing the country, with its inevitable consequences on all
aspects of development, especially employment, education, housing, health care, sanitation and environment.
RESOURCES
The basic resources for providing health care are :
(i) Health manpower (ii) Money and material (iii) Time.
1.Health manpower
The term "health manpower" includes both professional and auxiliary health personnel who are needed to provide
the health care.
An auxiliary is defined by WHO as "technical worker in a certain field with less than full professional training".
Health manpower requirements of a country are based on
(i) health needs and demands of the population
(ii) desired outputs.
The health needs in turn are based on the health situation and health problems and aspirations of the people.
Health manpower planning is an important aspect of community health planning.
It is based on a series of accepted ratios such as doctor-population ratio, nurse population ratio, bed-population ratio, etc. 1.
Money and material
• Money is an important resource for providing health services. Scarcity of money affects all parts of the health
delivery system.
• In most developed countries, average government expenditure for health is about 18 per cent of GNP.
• In developing countries it is less than 1 per cent of the GNP and it seldom exceeds 2 per cent of the GNP.
• To achieve Health for All, WHO has set as a goal the expenditure of 5 per cent of each country's GNP on health care.
• At present India is spending about 3 per cent of GNP on health and family welfare development.
• Since deaths from preventable diseases such as whooping cough, measles, tuberculosis. tetanus, diphtheria, malnutrition
frequently occur in developing countries, the case is strong for investing resources on preventing these diseases rather
than spending money on multiplying prestigious medical institutions and other establishments which absorb a large
portion of the national health budget.
• Management techniques such as cost-effectiveness and cost-benefit analysis are now being used for allocation of
resources in the field of community health.
Time
"Time is money", someone said. It is an important dimension of health care services.
Administrative delays in sanctioning health projects imply loss of time.
Proper use of man-hours is also an important time factor.
For example, a survey by WHO has shown that an Auxiliary Nurse Midwife
spends 45 per cent of her time in giving medical care;
40 per cent in travelling;
5 per cent on paper work; and only
10 per cent in performing duties for which she has been trained
What is important is to employ suitable strategies to get the best out of limited resources.
HEALTH CARE SERVICES
The purpose of health care services is to improve the health status of the population.
The goals to be achieved have been fixed in terms of mortality and morbidity reduction , increase in expectation of life,
decrease in population growth rate, improvements in nutritional status,
• provision of basic sanitation,
• health manpower requirements
• food production,
• literacy rate,
• reduced levels of poverty, etc.
There is now broad agreement that health services should be
(a) comprehensive
(b) Accessible
(c) acceptable
(d) provide scope for community participation, and
(e) available at a cost the community and country can afford.
HEALTH CARE SYSTEMS
These are :
1. PUBLIC HEALTH SECTOR 2. PRIVATE SECTOR
(a) Primary Health Care
- Primary health centres (a) Private hospitals, polyclinics, Nursing homes, and dispensaries
(b) General practitioners and clinics

-Sub- centres
b) Hospitals/Health Centres
-Community health centres
-Rural hospitals
-District hospital/health centre
-Specialist hospitals
-Teaching hospitals
(c) Health Insurance Schemes
-Employees State Insurance
-Central Government Health Scheme
(d) Other agencies
-Defence services
-Railways
3. INDIGENOUS SYSTEMS OF MEDICINE 4. VOLUNTARY HEALTH AGENCIES
Ayurveda and Siddha
Unani and Tibbi
Homoeopathy
PRIMARY HEALTH CARE IN INDIA
1. Village level
One of the basic tenets of primary health care is universal coverage and equitable distribution of health resources.
That is, health care must penetrate into the farthest reaches of rural areas, and that everyone should have access to it.
To implement this policy at the village level, the following
schemes are in operation :
a . ASHA Scheme;
b. ICDS Scheme; and
c. Training of Local Dais.
a. ASHA
ASHA must be resident of the village - a woman (married/
widow/divorced) preferably in the age group of 25 to 45
years with formal education upto eight class, having
communication skill and leadership qualities. Adequate
representation from the disadvantaged population group will
ensure to serve such groups better. The general norm of
selection is one ASHA for 1000 population. In tribal, hilly
and desert areas the norm could be relaxed to one ASHA per
habitation.