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243Introduction to Health Systems
instance, to have good healthcare access, a rural resident
must have:
a. Confidence to communicate with healthcare provi-
ders, particularly if the patient has poor health literacy.
2. Facility to take paid time off from work to use such
services.
3. Faith that they can use services without compromising
privacy.
4. Financial means to pay for services, such as health or
dental insurance that is accepted by the provider.
5. Means of transportation to reach and use services,
which may be located away from their place.
6. No stigma associated with conditions in rural commu-
nities, such as mental health or substance abuse.
7. Trust that they will receive good quality health care.
Rural Healthcare Services
The healthcare services in rural areas are provided at the village
level, subcenter level, and primary health center (PHC) level.
A. Village Level
Primary healthcare is aimed at providing widespread coverage
and equal distribution of health resources so that healthcare
facilities reach all parts of rural areas and that everybody has
equal access to it. We all know that health facilities are
inadequate in the villages and physicians are not available in
each village 24 × 7 days for providing healthcare to the villagers.
At this level, the primary healthcare is provided in villages not
by the medical personnel but by the non-medical personnel
such as village health guide, Dai (traditional birth attendant),
and Anganwadi workers, which constitute the link and bridge
the gap between the health sector and the community. They
are working under the Village Health Guides Scheme (VHG-
Scheme).
a. Village Health Guide
The health guide provides primary healthcare to the people in
the village. They serve as links between the community and
244 Social Pharmacy
the governmental infrastructure. They provide the first contact
between the individual and the health system. Health guides
have an aptitude for social service but they are not full-time
government servants. The government of India issued a circular
in May 1986 that females only would be placed as female health
guides. Accordingly, women’s health guides should be
available in every village. Usually, one VHG is provided for
1000 population (500 in the case of tribal, hilly, or remote areas).
The Village Health Committee consisting of 4 members
selects the health guides from the village where she is going to
work. The guidelines for their selection are:
1. They should be a permanent resident in the village.
2. They should be able to read and write and must have
minimum formal education at least up to the VI
standard.
3. They should be able to spare at least 2 to 3 hours every
day for community health work.
4. They should be acceptable to all sections of the
community.
After selection, the health guides undergo training in the
primary health center, for 3 months on the basic aspects of
health such as basic health concepts including treatment of
minor ailments, first aid, environmental sanitation, family
planning, and personal hygiene. They get a stipend of Rs. 200
per month during the training period. On completion of
training, the health guide receives a certificate, a working
manual describing the detailed information about the medical
care of common illnesses, and a kit of general medicines like
paracetamol tabs, tincture iodine, plaster roll, cotton, bandage
cloth and multivitamins worth Rs. 600 per annum. Broadly,
the duties of health guides include treatment of simple ailments,
first aid, mother and child healthcare, and sanitation. They also
guide the people on healthcare by providing education about
family welfare services, immunization, sanitation, personal
hygiene, etc. The rest of the time she engages in her pursuits.
She is paid an honorarium of Rs. 600 every year. She works in
245Introduction to Health Systems
liaison with other health functionaries. She is answerable to
the village health committee but not to the MO of PHC. The
health guides are free to attend to their normal vocation. The
national target is to achieve one Health Guide for each village
or 1000 rural population.
b. Local Dais (Traditional Birth Attendants)
Local dais or traditional birth attendants (TBAs) are the only
people who are available in the villages to conduct the
deliveries. Because of their illiteracy, ignorance, and
uncleanliness, the deliveries conducted by them under
unhygienic conditions often resulted in high maternal and
infant morbidity and mortality. An extensive dai training
program has now been undertaken to train all categories of
the local dais (one in every village) in the country to improve
their knowledge of the elementary concepts of maternal and
child health, antenatal, natal, and postnatal care, family
planning, asepsis, besides obstetric skills. She is also given
knowledge of the anatomy of the reproductive system,
physiology of pregnancy and labor, and observation of danger
signals. The training is of 1 month duration. Training is given
at the PHC/subcentre or MCH center for 2 days a week and
on the remaining four days of the week dais accompany the
female health worker (HW) to the villages preferably in the
dai’s area. During the training period, each dai is required to
conduct at least 2 deliveries under the guidance and supervision
of the HW female (F), auxiliary nurse midwife (ANM), or health
attendant (HA) female (F). After training, the traditional birth
attendant is designated as a trained birth attendant. She is given
a certificate and a maternity kit (midwifery kit). The kit consists
of sterile gauze, cotton, a clean blade, sterile thread, a bowl,
soap, antiseptic lotion, a plastic sheet, tincture iodine, and an
enema can. The contents are replaced after conducting delivery.
She gets Rs. 10 per delivery, provided the case is registered in
the subcenter or primary health center (PHC), and also receives
Rs. 3 for each newborn registered by her. However, she is free
to charge her fee for conducting delivery. The national target
is to train one local dai in each village.
246 Social Pharmacy
c. Anganwadi Worker (AWW)
‘Angan’ literally means a courtyard. Anganwadi worker is a local
lady selected from within the community she is expected to
serve. She is a part-time worker with qualifications up to 10th
standard. She gets an honorarium of Rs. 1500 per month for
the services she renders. She is assisted by a helper who is also
from the same community. Under the ICDS (integrated child
development services) Scheme, there is one anganwadi worker
for a population of 400–800. There are about 100 such workers
in each ICDS Project. Every AWW undergoes training for
4 months on basic aspects of health, nutrition, and child
development.
The responsibilities of an AWW include:
1. To provide basic health services, health education, and
supplementary nutrition to pregnant and nursing
mothers, other women (15–45 years), children below
the age of 6 years, and adolescent girls.
2. To give non-formal preschool education to children
between 3 and 5 years of age.
3. To act as the community’s primary link that maintains
liaison with other health services and functionaries for
young children present in the village.
4. To assist the PHC staff in the implementation of the
health component of the ICDS Program.
B. Subcentre
A subcenter (sub-health center; SHC) is an infrastructure of
PHC that constitutes the peripheral outpost of the healthcare
delivery system in rural areas. It is the first contact point
between the community and the primary healthcare system.
SHCs are established as per the population norms viz., one
subcenter for every 5000 population in plain areas and one for
every 3000 population in hilly, tribal, and backward areas.
There are about 4 to 6 subcenters under each PHC. A subcenter
provides all primary healthcare services such as immunization,
antenatal, natal, and postnatal care, prevention of malnutrition
and common childhood diseases, family planning services, and
counseling. They carry out community needs assessment and
247Introduction to Health Systems
also supply general drugs for minor ailments such as acute
respiratory infections, diarrhea, fever, worm infestation, etc.,
and help in the implementation of several national health and
family welfare programs.
PHCs are classified as:
1. Type A: SHC in which no deliveries take place.
2. Type B: SHC in which deliveries take place.
Currently, one female ANM and one male Multi Purpose
Worker (MPW) staff are assigned to a subcenter. ANM and
MPW workers have to undergo training for 6 to 8 weeks
(6 weeks for females and 8 weeks for males). One female health
assistant (lady health visitor; LHV) and one male health
assistant at the PHC level are appointed to supervise all the
subcenters under a PHC. Most of the health assistants
appointed for supervision are former health visitors, malaria
inspectors, health inspectors, and sanitary inspectors, who have
undergone 8 to 10 weeks of in-service training. The Ministry
of Health and Family Welfare, Govt. of India has been assisting
all the subcenters in the country since April 2002 in the form of
contingency, a salary of ANMs and LHVs, rent of sub-health
center, and drugs and equipment kits. The salary of male health
workers is borne by the State Governments. In addition, a
voluntary worker is provided at the sub-center level as a helper
to ANM, as and when needed. The ANM pays the voluntary
worker from her contingency fund.
Further, Indian Public Health Standards (IPHS) for sub-
centers are being prescribed to provide an acceptable quality
of basic promotive, preventive, and curative primary health
care services to the community. These standards help to
monitor and improve the functioning of the subcenters.
Subcenters provide the following services that have been
classified as essential (minimum assured services) or desirable
(that all states/UTs should aspire to achieve).
1. Maternal healthcare: Maternal health refers to the health
of women during pregnancy, childbirth, and the postnatal
period. In most cases, maternal health encompasses the
healthcare dimensions of family planning, preconception,
248 Social Pharmacy
Table 5.2: Health services provided in rural areas
Thematic area Sub-centers Primary health centre (PHC) Centre health centre (CHC)
Population 1 centre per 5000 population 1 per 30,000 population in 1 per 120000 population in
in plain areas plain areas plain areas
1 per 3000 population in hilly 1 per 20000 population in 1 per 80000 population in
areas hilly areas hilly areas
Level of healthcare Primary Primary Secondary (first referral
level)
Categorization Type A: No delivery Type A: Less than 20 delive-
ries per month
Type B : Delivery take place Type B: More than 20 delive- No categorization
ries per month
Staff Type A: 3 Type B: 4 Type A: 13–18 Type B: 14–21 46–52
Responsibility Central Government State Govt. State government
for maintenance
No. of villages covered 4 29 158
Staff pattern MPW (male)/ HW (male) 1. Medical officer (essential) 1. MD, medicine
MPW (female)/ HW (female) 2. Ayush officer (desirable) 2. MD, surgery
(Contd.)
249Introduction to Health Systems
Thematic area Sub-centers Primary health centre (PHC) Centre health centre (CHC)
or ANM: 1 in Type A and 3. Health assistant (M) 3. MD: Obs/Gyne
2 in Type 2 SC sweeper 4. Health assistant (F)/LHW 4. MD: Paediatrics
5. Pharmacist:1 5. MD: Anaesthesia
6. Lab Technician: 1 6. Ophthalmologist
7. ENT surgeon
8. Dental surgeon
9. MD, PSM
10. Medical Officer (Ayush)
11. Health supervisor (Male
11. and Female)
12. 10: Staff Nurse
13. Pharmacist:1
14. Lab Technician: 1
15. Ophthalmic assistant
16. Radiographer
17. Registration clerk
250 Social Pharmacy
prenatal, and postnatal care to ensure a positive and
fulfilling experience. Each stage should be a positive
experience, ensuring women and their babies reach their
full potential for health and well-being.
a. Antenatal care: Antenatal care (ANC) essentially
provides monitoring and regular follow-up of
maternal and fetal health during pregnancy. ANC
consists of:
i. Early registration of pregnancy (ideally within the
first trimester).
ii. Minimum four antenatal check-ups.
iii. Recording of a general check-up, height, weight,
blood pressure, abdominal examination, anemia,
routine urine examination for albumin and sugar
and blood group.
iv. Folic acid supplementation from the first trimester
and folic acid and iron supplementation from
12 weeks onwards.
v. Tetanus toxoid (TT) immunization.
vi. Identification and timely referral for HIV/AIDS,
and high-risk pregnancy cases.
vii. Counseling on diet, tobacco cessation, pre-birth pre-
paredness, danger signs, and rest.
b. Intranatal care:
i. Promotion of institutional deliveries.
ii. Skilled attendance at home deliveries.
iii. Appropriate and prompt referral of high-risk cases
in case of complications.
iv. Identification and management of danger signs
during labor; and
v. Identification and basic first aid treatment for
eclampsia, and sepsis, and prompt referral of such
cases.
c. Postnatal care:
i. Minimum of 2 post-partum home visits, first within
48 hours, 2nd within 7 days, and third on 42nd day
of delivery.
251Introduction to Health Systems
ii. Initiation of breastfeeding within an hour of
delivery.
iii. Counseling on diet, rest, hygiene, newborn care,
immunization, and contraception.
iv. Provision of facilities of Janani Suraksha Yojana.
2. Child healthcare:
i. Essential newborn care as per guidelines for antenatal
care.
ii. Counseling on exclusive breastfeeding for 6 months
followed by complimentary feeding from six months
of age.
iii. Full immunization of all infants and children against
vaccine-preventable diseases.
iv. Vitamin A prophylaxis.
v. Assess the growth and development of infants and
under 5 children.
vi. Prevention and control of childhood diseases like
malnutrition, ARI, diarrhea, etc.
3. Family planning and contraception:
i. Education, motivation, and counseling to adopt
appropriate family planning methods. Provision of
contraceptives such as oral pills, condoms, emergency
contraceptives, and IUD insertion
ii. Follow-up services to the eligible couples adopting
permanent methods of tubectomy and vasectomy.
4. Safe abortion services:
i. Counseling and appropriate referral for safe abortion
services/medical termination of pregnancy (MTP).
ii. Follow up for any complication after abortion/MTP
and appropriate referral, if needed.
5. Curative services: Provide treatment for minor ailments
including diarrhea, fever, worm infestation, acute respi-
ratory infections (ARI), and prompt referral, if needed.
6. Adolescent healthcare:
i. Education, counseling, and referral.
ii. Prevention and treatment of anemia.
iii. Counseling on harmful effects of tobacco and its
cessation.
252 Social Pharmacy
7. Assistance to school health services.
8. Water quality monitoring.
9. Promotion of sanitation including the use of toilets and
appropriate garbage disposal.
10. Field visits by appropriate health workers for disease
surveillance, and family welfare services including STI,
and RTI awareness.
11. Community needs assessment.
12. Control and reporting of locally endemic diseases such as
malaria, kala azar, Japanese encephalitis, filariasis, and
dengue, etc.
13. Training of traditional birth attendants and ASHA/
community health volunteers.
14. Co-ordinate services of anganwadi workers (AWW),
ASHA, village health sanitation and nutrition committee,
etc.
15. Implementation of national health programs including (a)
National AIDS Control Programme (NACP); (b) National
Vector Borne Disease Control Programme (NVBDCP); (c)
National Leprosy Eradication Programme (NLEP); (d)
Integrated Disease Surveillance Projects (lDSP); (e)
Revised National Tuberculosis Control Programme
(RNTCP); (f) National Blindness Control Programme
(NBCP); (g) Non-communicable Disease (NCD), and (h)
Cancer Control Programmes (CCP).
C. Primary Health Centre (PHC)
The concept of primary health centre (PHC) is old in India. In
1946, the Bhore Committee proposed the concept of PHC as a
basic health unit to provide integrated curative, promotive,
rehabilitative, and preventive healthcare to rural people. The
health planners in India have envisaged the PHC and its sub-
centres (SCs) as suitable set-ups to provide health facilities to
the rural population.
PHCs are the keystone of rural health services. It is the first
port of call to a qualified doctor of the public sector in rural
areas for the ill and those who directly report or are referred
from subcentres for curative, preventive, and promotive health
care. It has 4–6 beds for indoor patients and acts as a referral