Indian Public Health Standard Primary Health Centre

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Primary Health Care

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Indian Public Health Standards:

Indian Public Health Standards Primary Health Centers (PHCs)

Synopsis of Service Delivery in a PHC:

Synopsis of Service Delivery in a PHC All “Assured Services” should be available - which includes routine, preventive, promotive, curative and emergency care in addition to all the national health programmes. Appropriate guidelines for each National Programme for management of routine and emergency cases - provided to the PHC. All the support services to fulfil the above objectives will be strengthened

Present Direction:

Present Direction Moving towards setting Health Standards- a dynamic process – Indian Public Health Standards (IPHS) The overall objective of IPHS for PHC is to provide health care – quality oriented and sensitive to the needs of the community. IPHS for P H Cs - prepared keeping in view the resources available with respect to functional requirement for PHCs with minimum standards such as building, manpower, instruments and equipments, drugs and other facilities etc.

Minimum Requirement:

Minimum Requirement Projected based on the basis of 40 patients per doctor per day, the expected number of beneficiaries for maternal and child health care and family planning about 60% utilization of the available indoor/observation beds (6 beds). If the utilization goes up, the standards would be further upgraded. As regards, manpower, one more Medical Officer (may be from AYUSH or a lady doctor) and two more staff nurses are added to the existing total staff strength of 15 in the PHC to make it 24x7 services delivery centre.

Objective of the Institutions :

Objective of the Institutions PHC To provide comprehensive primary health care to the community To achieve and maintain an acceptable standard of quality of care. To make the services more responsive and sensitive to the needs of the community. Bed strength – 2 to 6 CHC To provide optimal expert care to the community To achieve and maintain an acceptable standard of quality of care To make the services more responsive and sensitive to the needs of the community. Bed strength – 30

Basic concept of a PHC :

Basic concept of a PHC Bhore Committee in 1946 suggested: To provide Health Care as close to the people as possible, Integrated curative and preventive health care to the rural population Emphasis on preventive and promotive aspects of health care.

Reorganization of PHCs – ( 6th Five year Plan 83-88):

Reorganization of PHCs – ( 6 th Five year Plan 83-88) One PHC for every 30,000 rural pop in the plains and one PHC for every 20,000 pop - for hilly, tribal and desert coverage; For the sick directly report to PHC or referred from Sub-centres for curative, preventive and promotive health care; Acts as a referral unit for 6 sub -centres and refer out cases to CHCs (30 bedded hospital) and higher order public hospitals at sub -district and district hospitals. It has 4-6 indoor beds for patients. (In TN – Additional PHCs have 2 beds and Block PHCs have 6 beds.) Block level PHCs (100,000 POP) are ultimately going to be upgraded as Community Health Centres with 30 beds for providing specialized services.

Assured Services /Functions at the PHCs:

Assured Services /Functions at the PHCs Medical care: MCH Care including family planning: M T P using MVA technique Management of RTI / STI Nutrition Services School Health Adolescent Health Care Promotion of Safe Drinking Water and Basic Sanitation Prevention & control of locally endemic diseases – Malaria, JE etc. Disease Surveillance and Control of Epidemics: Collection and reporting of vital events Health Education / BCC National Health Programmes - RCH, HIV/AIDS, NCD etc. Referral Services: Training Basic Laboratory Services: Monitoring and Supervision: Functional linkages with Sub-centres ASHA Mainstreaming of AYUSH Rehabilitation: Selected Surgical Procedures: Record of Vital Events and Reporting:

Essential Infrastructure: I:

Essential Infrastructure: I PHC Building - Easily accessible area, Entire necessary infrastructure, including slope for wheelchair, Registration and record room, drug dispensing room, and waiting area for patients. Waiting area a) adequate space and seating arrangements for waiting clients / patients b) The walls should carry posters Proper notice displaying wings

Essential Infrastructure: II:

Essential Infrastructure: II PHC Buildings - plinth area - from 375 to 450 sq. mtrs- minimum) Outpatient Department Wards 5.5x3.5 m each- Separate wards/ areas should be earmarked for males and females with the necessary furniture. Operation Theatre: (Optional) Labour Room (3800x4200mm) Minor OT/Dressing Room/Injection Room/Emergency: Laboratory (3800x2700mm) General store Dispensing cum store area: 3000x3000mm Immunization/FP/counseling area: 3000x4000mm Separate area for baby resuscitation be provided. Infrastructure for AYUSH doctor Dirty utility room for dirty linen and used items Office room 3500x3000mm Auditorium for 30 persons Other amenities: a. Electricity, b. Adequate water supply, c. Telephone, d. garden with involvement of community.

Essential Infrastructure: III:

Essential Infrastructure: III Equipment All equipments necessary to deliver the assured services of the PHC should be available in adequate quantity and also be functional. Equipment maintenance should be given special attention. Periodic stock taking of equipment and preventive/ round the year maintenance will ensure proper functioning equipment. Back up should be made available wherever possible. (A list of suggested equipments and furniture including reagents and diagnostic kits is given in later slides)

Essential Infrastructure: IV:

Essential Infrastructure: IV Man Power Existing Recommended Medical Officer 1 3 (1 Female) AYUSH Practioner Nil 1 Accounts Manager Nil 1 Pharmacist 1 2 Nurse Midwife –(Staff Nurse) 1 5 Health Worker 1 1 Health Educator 1 1 Health Asst (Male & Female) 2 2 Clerk 2 2 Laboratory Technicians 1 2 Driver 1 Optional / if out sourced Class IV Staff 4 4 ---------- ------------ Total 15 24 /25 ---------- ------------ (Job responsibilities to be prescribed)

Consumables - Drugs:

Consumables - Drugs Drugs: a) All the drugs available in the Sub -centre should be available in the PHC. b) In addition - drugs for the National health programmes and emergency management should be available in adequate quantities c) Adequate quantities of all drugs should be maintained through periodic stock-checking, appropriate record maintenance and inventory methods. Facilities for local purchase of drugs in times of epidemics / outbreaks / emergencies should be made available d) Drugs required for the AYUSH doctor should be available in addition to all other facilities. (The list of suggested drugs including AYUSH drugs is given in later slides).

Transport Facilities:

Transport Facilities The PHC should have an ambulance for transport of patients. This may be outsourced . Referral Transport Facility: The PHC should have an ambulance for transportation of emergency patients. Referral transport may be outsourced. Transport for Supervisory and other outreach activities: The vehicle can also be outsourced for this purpose.

Others :

Others Laundry and Dietary facilities for indoor patients - outsourced. Waste Management at PHC level - “Guidelines for Health Care Workers for Waste Management and Infection Control in PHC” -followed. Quality Assurance: Periodic skill development training to ensure quality; Standard Treatment Protocol for all national programmes and locally common disease i) Interaction and Information Exchange, Courtesy extended to patients / clients, All relevant information regards the condition / illness of the client/ patient shared. ii) Change in Attitude of the health care providers iii) Cleanliness should be maintained at all points Monitoring: Internal Mechanism: Record maintenance, checking and supportive supervision External Mechanism: Monitoring through the PRI / VHCommittee Accountability:: the Charter of Patients’ Rights - available in each PHC. Every PHC should have a Rogi Kalyan Samiti / Primary Health Centre’s Management Committee – with the authority to generate its own funds and utilize the same for service improvement of the PHC , including payment of water and electricity bills. The PRI/Village Health Committee / Rogi Kalyan Samiti will also monitor the functioning of the PHCs.

Service Details…….1:

Service Details…….1 Medical care: OPD services: 4 hours in the morning and 2 hours evening. (Minimum OPD attendance should be 40 patients per doctor per day) 24 hours emergency services: injuries and accident, First Aid, Stabilisation of the condition before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions. Sufficient doctors - to attend to 8-hourly shift duties to make 24-hour emergency services available Referral services In-patient services (6 beds)

Service Details…….2:

Maternal and Child Health Care including family planning: a) Antenatal care: i) Early registration; ii) Minimum 3 antenatal checkups; iii)Minimum lab investigations like Hb, urine albumin & sugar, RPR test for syphilis; iv) Nutrition and health counseling; v) Identification of high-risk & management; vi) treating endemic diseases - malaria vii) Referral to FRUs b) Intra-natal care: (24-hour delivery) i) Promotion of institutional deliveries; ii) Conducting of normal deliveries; iii) Assisted vaginal deliveries including forceps / vacuum delivery whenever required; iv) Manual removal of placenta; v) referral for cases; vi) Management of Pregnancy Induced hypertension vii) Pre-referral management (Obstetric first-aid) viii) There should be sufficient number of staff nurses c) Postnatal Care: a) A minimum of 2 postpartum home visits, first within 48 hours of delivery, 2nd within 7 days through Sub-centre staff. b) Initiation of early breast-feeding within half-hour of birth c)Education on nutrition, hygiene, contraception, essential new born Care (As per Guidelines of GOI on Essential new-born care) d) Others: Provision of facilities under Janani Suraksha Yojana (JSY) Service Details…….2

Service Details…….3:

Maternal and Child Health Care including family planning: (Cont…) d) New Born care: i) Facilities and care for neonatal resuscitation ii) Management of neonatal hypothermia / jaundice e) Care of the child: i) Emergency care of sick children -Integrated Management of Neonatal and Childhood Illness (IMNCI) ii) Care of routine childhood illness iii)Essential Newborn Care iv) Promotion of exclusive breast-feeding for 6 months. v) Full Immunization of all infants and children against vaccine preventable diseases. vi) Vitamin A prophylaxis to the children vii) Prevention and control of childhood diseases, infections, etc. f) Family Planning: i. Education, Motivation and counseling to adopt appropriate Family planning methods. ii. Provision of contraceptives such as condoms, oral pills, emergency contraceptives, IUD insertions. iii. Permanent methods like Tubal ligation and vasectomy / NSV. iv. Follow up services to the eligible couples adopting permanent methods (Tubectomy/Vasectomy). v. Counseling and appropriate referral for safe abortion services (MTP) for those in need. vi.Counseling and appropriate referral for couples having infertility. Service Details…….3

Service Details…….4:

MTP using Manual Vacuum Aspiration (MVA) technique. Management of RTI / STI: a) Health education for prevention of RTI/ STIs b) Treatment of RTI/ STIs Nutrition Services (coordinated with ICDS) a) Diagnosis of and nutrition advice to children, pregnant women b) Diagnosis and management of anaemia, and Vit A def. c) Coordination with ICDS. School Health: Regular check ups, appropriate treatment including deworming, referral and follow-ups Adolescent Health Care: Life style education, counseling, appropriate treatment. Promotion of Safe Drinking Water and Basic Sanitation Prevention and control of locally endemic diseases like malaria, Kalaazar, Japanese Encephalitis, etc. Service Details…….4

Service Details…….5:

Disease Surveillance and Control of Epidemics: Alertness to detect unusual health events and take appropriate remedial measures Disinfection of water sources Testing of water quality using H2S- Strip Test (Bacteriological) Promotion of sanitation including use of toilets and appropriate garbage disposal. Weekly collection of information on disease surveillance (by ANM manually). Collection and reporting of vital events Education about health/Behaviour Change Communication (BCC) Service Details…….5

Service Details…….6:

National Health Programmes including RCH Revised National Tuberculosis Control Programme (RNTCP): DOTS Centres to deliver treatment as per RNTCP and through DOTS providers and treatment of common complications of TB and side effects of drugs, Integrated Disease Surveillance Project (IDSP): a) collect, analyse data from sub-centre and report to dist surveillance unit; b) preparedness -first level action in out-break; c)Lab services for Malaria, TB, Typhoid, detection of faecal contamination of water and chlorination level. National Programme for Control of Blindness (NPCB): (a)Diagnosis and treatment of common eye diseases; (b)Refraction Services; (c)Detection of cataract and referral National Vector Borne Disease Control Programme (NVBDCP): Microscopic confirmation and treatment of Malaria ; (b) symptomatic treatment, hospitalization & case management of suspected JE and Dengue; (c) Treatment of Kala-Azar endemic areas; (d) Treatment of microfilaria positive cases with DEC & Mass Drug Administration (MDA) & morbidity management of Lymphoedema cases. Service Details…….6

Service Details…….7:

National Health Programmes including RCH…. Contd… National AIDS Control Programme: ( a) IEC activities & Prevention of Parents to Child Transmission (PPTCT) services. (b) Organizing School Health Education Programme (c) Screening of persons practicing high-risk behaviour & referral to the nearest VCTC at the District Hospital level (d) Risk screening of antenatal mothers with one rapid test for HIV & referral to CHC or District Hospital - in the six high HIV prevalence states (TN, AP, Maharashtra, Karnataka, Manipur and Nagaland) of India. (e) Linkage with Microscopy Centre for HIV -TB coordination. (f) Condom Promotion & distribution to the high risk groups. (g) Help & guide patients with HIV/AIDS receiving ART with focus on adherence. (h) Pre and post-test counseling of AIDS patients by PHC staff in high prevalence states. Service Details…….7

Service Details…….8:

Referral Services: Appropriate and prompt referral of cases needing specialist care including: a) Stabilisation of patient b) Appropriate support for patient during transport c) Providing transport facilities either by PHC vehicle or other available referral transport. The funds should be made available for referral transport as per the provision under NRHM/RCH-II program. Service Details…….8

Service Details…….9:

Essential Laboratory services including: i. Routine urine, stool and blood tests ii. Bleeding time, clotting time, iii. Diagnosis of RTI/STDs with wet mounting, Grams stain, etc. iv. Sputum testing for tuberculosis (if designated as a microscopy center (under RNTCP) v. Blood smear examination for malarial parasite. vi. Rapid tests for pregnancy / malaria vii. RPR test for Syphilis/YAWS surveillance viii. Rapid diagnostic tests for Typhoid (Typhi Dot) ix. Rapid test kit for fecal contamination of water x. Estimation of chlorine level of water using ortho-toludine reagent Service Details…….9

Training::

Training: Health workers and traditional birth attendants ii) Initial & periodic Training of paramedics - minor ailments treatment iii) Training of ASHAs iv) Periodic training of Doctors through CME programmes, skill development training, etc. on emergency obstetric care v) Training of ANM and LHV in AN care and skilled birth attendance. vi) Training under IMNCI vii) Training of pharmacist on AYUSH component with standard modules. viii) Training of AYUSH doctor in imparting health services related to National Health and Family Welfare programme.

Monitoring and Supervision::

Monitoring and Supervision: Monitoring and supervision of activities of sub-centre through regular meetings/periodic visits, etc. (ii) Monitoring of all National Health Programmes (iii) Monitoring activities of ASHAs (iv) MO should visit all Sub-centers at least once in a month (v) Health Assistants Male and LHV should visit Sub-centers once a week.

LINKAGES:

LINKAGES Functional linkages with Sub-centres a monthly review meeting attended by all the ANMs, ASHAs and Anganwadi Workers. Supervisory visits to Sub -centres. Organizing health day at Anganwadi Centres. Specific duties of ASHA - informing PHC about Vital Event and Health occurrence and arranging escort/accompany pregnant women & children requiring treatment/admission Mainstreaming of AYUSH AYUSH doctor at PHC shall attend patients – provide preventive, promotive and curative health care and take up awareness generation about the uses of medicinal plants and local health practices. Local medicinal herbs/plants be grown around the PHC. The signboard of the PHC should mention AYUSH facilities.

Other Functions ….:

Other Functions …. Record of Vital Events and Reporting: a) Recording and reporting of Vital statistics including births and deaths. b) Maintenance of all the relevant records concerning services provided in Rehabilitation Disability prevention, Early detection, Intervention and Referral – Chronic Disease Conditions

Selected Surgical Procedures:

Selected Surgical Procedures The vasectomy, tubectomy (includinglaparoscopic tubectomy), MTP, Hydrocelectomy Cataract surgeries as a camp/fixed day approach have to be carried out in a PHC having facilities of O.T. During all these surgical procedures, universal precautions will be adopted to ensure infection prevention.

OT Infrastructure:

OT Infrastructure a. Changing room, sterilization area, operating area and washing area. b. Separate facilities for storing of sterile and unsterile equipments / instruments c. Patient preparation area and Post-OP area Or well connected to the wards. d. Well-equipped with necessary accessories and equipment Minor OT/Dressing Room/Injection Room/Emergency: located close to the OPD to cater to patients for minor surgeries and emergencies after OPD hours. It should be well equipped with all the emergency drugs and instruments.

Charter of Patients’ Rights for PHCs:

Charter of Patients’ Rights for PHCs Commitments of the Charter · to provide access to available facilities without discrimination, · to provide emergency care, if needed on reaching the PHC · to provide adequate number of notice boards detailing the location of all the facilities and the schedule of field visits.. · to provide written information on diagnosis, treatment being administered. · to record complaints and respond at an appointed time. Grievance redressal · grievances that citizens have will be recorded · aggrieved user after his/her complaint recorded would be allowed to seek a second opinion at CHC.

Responsibilities of the users:

Responsibilities of the users users of PHC would attempt to understand the commitments made in the charter users would not insist on service above the standard set in the charter because it could negatively affect the provision of the minimum acceptable level of service to another user. instruction of the PHC personnel to be followed in case of grievances, the redressal mechanism machinery would be addressed by users without delay. Performance audit and review of the charter · may be conducted through a peer review every two or three years after covering the areas where the standards have been specified

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