SPECIAL ARTICLE
Year : 2011 | Volume
: 55 | Issue : 4 | Page : 260--266
Assessing Indian public health standards for community health centers: A case study with special reference to essential newborn care services
PR Sodani1, Kalpa Sharma2,
1 Professor and Dean (Training), Institute of Health Management Research, Jaipur, India
2 Research Officer, Institute of Health Management Research, Jaipur, India
Correspondence Address:
P R Sodani
Professor and Dean (Training), Institute of Health Management Research, 1, Prabhu Dayal Marg, Sanganer Airport, Jaipur - 302 011
India
Abstract
The main objective of the study is to identify the availability of infrastructure facility, human resources, investigative services, and facility based newborn care services with respect to Indian Public Health Standards (IPHS) at community health centers (CHC) of Bharatpur District of Rajasthan State. Data were collected from service providers at CHC through well structured questionnaire at thirteen CHCs situated at Bharatpur District of Rajasthan State. It was found that infrastructure facilities were available in almost all the CHCs, but shortage of manpower especially specialists was observed. Availability of investigative services was found quite satisfactory except ECG. It was also observed that none of the CHCs have fully equipped facility based newborn care services (including newborn corner and newborn care stabilization unit). As per IPHS suggested in the revised draft (2010) important deficiencies were revealed in the studied CHCs of Bharatpur district and by additional inputs such as recruiting staff, improving infrastructure facilities, CHCs can be upgraded.
How to cite this article:
Sodani P R, Sharma K. Assessing Indian public health standards for community health centers: A case study with special reference to essential newborn care services.Indian J Public Health 2011;55:260-266
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Sodani P R, Sharma K. Assessing Indian public health standards for community health centers: A case study with special reference to essential newborn care services. Indian J Public Health [serial online] 2011 [cited 2023 Mar 27 ];55:260-266
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Full Text
Introduction
Upgrading public health infrastructure in rural areas to measureable standards of quality is a key strategic intervention under the National Rural Health Mission. [1]
Health care delivery in India has been envisaged at three levels namely primary, secondary and tertiary. The secondary level of health care essentially includes community health centers (CHCs), constituting the First Referral Units (FRUs) and the District Hospitals. CHCs are public health facility, designed to provide referral health care for cases from the primary level and for cases in need of specialist care approaching the CHC directly. A CHC is established for every 1,00,000 population and is expected to provide curative and preventive health services to the people and to control and eradicate communicable diseases. [2] According to Rural Health Statistics Bulletin 2010 of Ministry of Health and Family Welfare, Government of India, there are 4535 CHCs functioning in India. [3]
Hence, standards are being introduced in order to improve the quality of services in these health care centers. Although there are standards as prescribed by the Bureau of Indian Standards (BIS) for 30 bedded hospitals, these are at present not achievable as they are very resource intensive. Hence a less resource intensive standard suited to the requirement of the system has been developed.
Ministry of Health and Family Welfare, Government of India constituted a Task Group under the Chairmanship of Director General of Health Services, Government of India to recommend the Indian Public Health Standards (IPHS) for Community Health Centers. To prepare IPHS for Community Health Centers, inputs were taken from major stakeholders including programme officers of National Health Programmes, consultants from accreditation agencies and apex institutions like All India Institute of Medical Sciences. The Task Group submitted the draft guidelines for "Indian Public Health Standards for Community Health Centers0" in 2006 which was then revised in 2007 as "Indian Public Health Standards (Revised) for Community Health Centers". [4],[5] These standards were further modified by the Task Group in 2010 as "Indian Public Health Standards (Revised Draft) for Community Health Centers0". [2]
During revision, major changes in the IPHS were done in the number of human resources and newborn care facilities in the CHCs. The post of anesthetist and pharmacist/compounder were introduced and the number of nursing staff (staff nurse+ANM) and radiographers were increased. Special focus was given to the newborn care in the revised draft of "Indian Public Health Standards for Community Health Centers" (2010) and the concept of Newborn Corner and Newborn Care Stabilization Unit has been introduced at CHC Level in IPHS.
IPHS are the set of standards formed to provide optimal level of quality health care, with the aim to deliver high quality services which are fair and responsive to client's needs, which should provide equitably and deliver improvements in the health and wellbeing of the population.
IPHS for CHCs are designed to provide optimal expert care to the community; to achieve and maintain an acceptable standard of quality of care; and to ensure that service at CHC are commensurate with universal best practices and are responsive and sensitive to the client needs/expectations.
IPHS is a novel concept to fix benchmarks of infrastructure, including building, manpower, equipments, drugs, quality, through introduction of treatment protocols, and accountability to the public, through the concept of citizen's charter enforced through the hospital management society at the facility level and quality assurance committee at State and District level.
To assess the IPHS at CHC level, little efforts have been made in India. [6],[7] An effort has been made in this paper to assess IPHS at CHC level in an Indian State. The present paper is based on a comprehensive study conducted at CHCs in the Bharatpur District of State of Rajasthan. The main objective of this paper is to study the availability of infrastructure facility, human resources, investigative services and facilities based newborn care services at CHCs and compare these with the IPHS for CHCs.
Materials and Methods
The present paper is based on a study conducted in Bharatpur district of the State of Rajasthan. There are 9 blocks and 13 CHCs in Bharatpur district. As we know, Rajasthan is one of the 18 special focused states identified by the National Rural Health Mission (NRHM) to provide effective healthcare, because of weak public health indicators as well as public health infrastructure. [1] From the State of Rajasthan, Bharatpur district is identified purposively for the present study because of weak health outcomes.
To assess the CHCs in terms of availability of infrastructure facilities, human resources, investigative facilities, essential newborn care services (ENCS) with respect to IPHS, a facility assessment tool was developed referring the " Revised Draft of Indian Public Health Standards (IPHS) for Community Health Centers" (2010) developed by the Ministry of Health and Family Welfare, Government of India. Data were collected from all the 13 CHCs of the study district during the months of September and October 2010. The data were collected by visiting all the CHCs of the study district. Required data were gathered by requesting to the service providers to provide the information, general observation of the study team at the CHCs and records/registers maintained at CHCs.
Results and Discussion
Infrastructure Facilities
According to the IPHS from revised draft (2010), CHC should have operation theater, labor room, cold chain facility and laboratory facility with telephone, email and fax facility. [Table 1] depicts the availability of infrastructure facilities at CHCs in the study district. It was found that all the 13 CHCs have one operation theater, laboratory and cold chain facility, 12 CHCs (92.3%) have labor room and telephone facility, 11 CHCs (84.6%) have availability of e-mail facility and 10 CHCs (76.9%) have fax facility.{Table 1}
Human Resources
In order to provide round-the-clock services, appropriate human resources including both medical and support should be made available at CHCs. Ministry of Health and Family Welfare, Government of India revised the recommended number of human resources at CHC from draft guidelines of IPHS for CHCs to the revised version of IPHS for CHCs. According to the IPHS from revised draft (2010), five specialists - one general surgeon, one physician, one obstetric and gynecologist (OBG), one pediatrician and one anesthetist and six medical officers should be made available at CHC. [Table 2] shows the availability of specialists and medical officers at CHCs in the study district. Data shows poor availability of specialists at CHCs of Bharatpur District. Around 31% general surgeons and pediatricians are available as per the requirement. {Table 2}
The Revised Indian Public Health Standards for Community Health Centers (2007) recommended one anesthetist to strengthen maternal and newborn care, which was not recommended by the earlier draft guidelines of IPHS (2006). The availability of Anesthetist is essential for utilization of the surgical specialities at CHC. However, out of the 13 CHCs in the study district, only one had the availability of anesthetist. [Table 2] shows that as per the IPHS from the revised draft, 13 general surgeons are required for CHCs in the sample district. It was found that only four CHCs have general surgeon in place and at the majority of the CHCs (9), general surgeon was not available. [Table 2] also shows that as per latest IPHS (2010), 13 physicians are required for CHCs; however, only five CHCs have physician in place while the majority of the CHCs (8) functioning without a physician.
To provide maternal health care services at CHC level, the availability of OBG specialist is very critical and important. To see the results on the availability of OBG, [Table 2] depicts that 13 OBG are required in the study district at CHCs as per the latest IPHS (2010); however, only five CHCs were functioning with OBG while the rest eight CHCs were functioning without OBG. To provide newborn and child health care, pediatrics is an essential requirement at CHC level as per the IPHS recommended under revised draft. Data shows that 13 pediatricians are required in the study district at CHCs as per latest IPHS (2010); however, only four CHCs were functioning with pediatricians and rest nine CHCs were functioning without pediatricians. The above finding shows that the availability of specialists to provide various specialist services at CHCs was found to be very poor in the study district.
As far as medical officers are concerned, as per the IPHS from revised draft, six medical officers should be available per CHC. [Table 2] shows that as per the latest IPHS (2010), 78 medical officers (six at each CHC) are required at CHCs in the study district; however, only 32 medical officers are there at the CHC level. There was a scarcity of 46 medical officers at the CHC level in the study district according to IPHS from the revised draft (2010). It was also observed that none of the CHCs have recommended number of medical officers.
According to the draft guideline of IPHS for CHCs, the recommended number of nursing staff were nine which was then increased to 19 in the "Revised Indian Public Health Standards for Community Health Centers" (2007) which then further reduced to 16 in revised draft of IPHS for CHC (2010). According to the latest IPHS (2010), sixteen nursing staff (including ANM and staff nurses), three pharmacists, three laboratory technicians and two radiographers should be available at CHC. [Table 3] shows the availability of support manpower at CHCs in the study district. As per IPHS from the revised draft, 208 nursing staffs are required at all the 13 CHCs in the study district; however, only 163 (78.4%) nursing staff is available at CHCs. {Table 3}
No post of pharmacist/compounder was recommended in the draft guideline of " Indian Public Health Standards Community Health Centers Level". Three post of pharmacist/compounder were introduced in the "Revised Indian Public Health Standards for Community Health Centers" (2007). No further changes were made in the next revised draft of Indian Public Health Standards for Community Health Centers (2010). So, as per latest IPHS (2010), 39 pharmacists/compounders are required at all the 13 CHCs, three per CHC. It was observed that only 12 (30.8%) pharmacists/compounders were available at CHC level in the study district. Regarding laboratory technician, the IPHS from the revised draft suggest that there should be three laboratory technicians at each CHC. Keeping this in mind, 39 laboratory technicians are required at all the 13 CHCs in the study district. It was observed that only 26 (66.7%) laboratory technicians were available at CHC level in the study district.
As per the draft guidelines of IPHS for CHC, one radiographer should be made available at CHC which was then revised in 2007 and increased to two. No further changes were made in the revised draft of Indian Public Health Standards for community health standards (2010). So, latest IPHS (2010) suggest that there should be two radiographers at each CHC. Keeping this in mind, 26 radiographers are required at all the 13 CHCs in the study district. It was observed that only 13 (50%) radiographers were available at CHC level in the study district. It was also observed that only five CHCs have recommended number of nursing staff. None of the CHCs have recommended number of pharmacist/compounder. Only four CHCs showed availability of recommended number of laboratory technician as per the latest IPHS for CHCs. However, two CHCs have recommended number of radiographer.
The above analysis on availability of human resources at CHC, according to the IPHS recommended under revised draft, clearly depicts that the availability of support manpower was found to be better at the participating CHCs compared to the medical professionals, specialists/medical officers. The scarcity of medical professionals can be compensated by applying the resource pooling (block pooling concept) of available medical officers stationed at primary health centers covered under the particular block where a CHC is located. Alternatively, the required medical professionals may be hired 'on-call' basis from the private sector to provide adequate services at the public health facilities.
Investigative Services
As per the latest IPHS for CHCs (2010), the following investigative services should be made available at CHC level: pathological tests, X-ray and ECG. [Table 4] shows that pathological tests were available at all the thirteen CHCs in the study district. Similarly, majority of the CHCs (69.2%) have X-ray facility. However, only three CHCs (23.1%) have facilities for ECG. It was also observed that all necessary reagents, glass ware and facilities for collecting and transport of samples were available. The analysis suggests that efforts should be made to provide ECG services at CHC level. {Table 4}
Essential Newborn Care Services (ENCS)
Newborn was the silent feature in the draft guidelines for " Indian Public Health Standards Community Health Centers" and revised draft of " Indian Public Health Standards for Community Health Centers" (2007), but special focus was given to the newborn care in the revised draft of "Indian Public Health Standards for Community Health Centers" (2010) and the concept of Newborn Corner and Newborn Care Stabilization Unit has been introduced at CHC level.
Newborn corner is a space within the delivery room where immediate care is provided to all newborns. According to the revised draft of IPHS for CHC, the newborn corner provides an acceptable environment for all infants at birth, and is mandatory for all community health centers. The following services should be available at newborn corner: resuscitation including provision of warmth, early initiation of breastfeeding and weighing the neonate.
To provide these newborn care services, IPHS from the revised draft (2010) suggested the availability of the following equipments/items - one radiant warmer, one resuscitator, one weighing scale, one suction pump, two thermometers and one hub cutter at newborn corner at CHC. [Table 5] shows the availability of equipments/items for newborn corner at CHCs in the study district. As per the latest IPHS, 13 radiant warmers are required at all the 13 CHCs in the study district; however, only 3 (23.1%) radiant warmers are available at CHCs. Similarly, as per the IPHS from revised draft (2010), 13 resuscitators are required at all the 13 CHCs, one per CHC. It was observed that only 4 (30.8%) resuscitators were available at CHC level in the study district. Regarding weighing scale, the latest IPHS (2010) suggest that there should be one weighing scale at each CHC. Keeping this in mind, 13 weighing scales are required at all the 13 CHCs in the study district. It was observed that 11 (84.6%) weighing scales were available at CHC level in the study district. Moreover, IPHS from the revised draft (2010) suggest that there should be one suction pump at each CHC. Keeping this in mind, 13 suction pumps are required at all the 13 CHCs in the study district. It was observed that only 9 (69.2%) suction pumps were available at CHC level in the study district. {Table 5}
[Table 5] also shows that as per the latest IPHS (2010), 26 thermometers (two at each CHC) are required at CHCs in the study district; however, only 21 thermometers are there at the CHC level. It was also observed that nine CHCs have recommended number of thermometers as per latest IPHS (2010). Regarding hub cutter, latest IPHS suggest that there should be one hub cutter at each CHC. It was observed that 11 hub cutters were available at CHC level in the study district. There was a scarcity of 2 hub cutters at the CHC level in the study district according to IPHS suggested in the revised draft for community health centers. It was observed that none of the CHCs in the study district have fully equipped newborn corner as per the latest IPHS (2010). Efforts are needed to strengthen the newborn corner at the CHC level to make these units as fully functional to provide newborn care.
The newborn care stabilization unit provides intensive care to a newborn or a sick child, to ensure safe care of the baby prior to appropriate transfer from the maternity ward. It should be located within or in close proximity of the maternity ward at the community health centers. The newborn care stabilization unit should provide the following services - provision of warmth, resuscitation, supportive care including oxygen, drugs, IV fluids, monitoring of vital signs, including blood pressure, care of low birth weight newborns not requiring intensive care, breast feeding/ feeding support and referral. One medical officer skilled in newborn care or pediatrician should be available at stabilization unit for clinical care and oversight.
According to the IPHS from the revised draft (2010), four radiant warmers, two resuscitators, two laryngoscope sets, one weighing scale, one suction pump, four thermometers and one hub cutter should be made available at newborn care stabilization unit at CHC. [Table 6] shows the availability of equipments/items for newborn care stabilization unit at CHCs in the study district. As per the latest IPHS, 52 radiant warmers are required at all the 13 CHCs in the study district; however, only 2 (3.8%) radiant warmers are available at CHCs. Similarly, as per the IPHS from the revised draft, 26 resuscitators are required at all the 13 CHCs, two per CHC. It was observed that only 2 (7.7%) resuscitators were available at CHC level in the study district. Regarding laryngoscope set, the latest IPHS suggest that there should be two laryngoscope set at each CHC. Keeping this in mind, 26 laryngoscope sets are required at all the 13 CHCs in the study district. It was observed that 6 (23.1%) laryngoscope sets were available at CHC level in the study district. As per revised IPHS (2010), 13 weighing scales are required at all the 13 CHCs in the study district; however, only 4 (30.8%) weighing scales are available at CHCs. Moreover, latest revised IPHS (2010) suggest that there should be one suction pump at each CHC. Keeping this in mind, 13 suction pumps are required at all the 13 CHCs in the study district. It was observed that only 5 (38.5%) suction pumps were available at CHC level in the study district. {Table 6}
[Table 6] also shows that as per the IPHS from the revised draft (2010), 52 thermometers (four at each CHC) are required at CHCs in the study district; however, only 24 thermometers are there at the CHC level. Regarding hub cutter, latest IPHS (2010) suggest that there should be one hub cutter at each CHC. It was observed that 4 hub cutters were available at CHC level in the study district. There was a scarcity of hub cutter at the CHC level in the study district according to IPHS from the revised draft of community health centers. It was observed that none of the CHCs have fully equipped newborn care stabilization unit. It was also observed that three CHCs have recommended number of laryngoscope sets. However, six CHCs have recommended number of thermometers as per the latest IPHS (2010). Rest equipments/items were not available as per the IPHS suggested under revised draft for CHC (2010).
Facility-based newborn care services such as newborn corner and newborn care stabilization unit were found to be almost absent in the CHCs of Bharatpur District. Though newborn care has been considered as an essential component under RCH II and additional inputs had also been given under IMNCI. Under this situation, if newborn care services in the CHCs were not strengthened, the challenge of MDG goal 4, reduction in child mortality could not be achieved.
Conclusion
The assessment of CHCs depicted that there is a need to strengthen the CHCs under NRHM to provide quality health care services to the community, especially on providing adequate number of competent human resources, improving communication facilities, strengthening newborn care facilities, and promoting partnership with the private sector in providing human resources. More and concentrated efforts are required to provide human resources support at all CHCs to effectively provide services especially newborn care services in rural areas.
Acknowledgments
Data used for this research paper was gathered from the study "Baseline Studies for Developing Implementation Model for Strengthening Maternal and Newborn Health Services in district Bharatpur, Rajasthan using Health Systems Approach under NRHM" project which was supported by WHO India Country Office. Thanks are due to WHO India Country Office for providing financial support in conducting the study. We also express our gratitude to Directorate of Medical, Health and Family Welfare Services, Government of Rajasthan for facilitating to conduct the study. Thanks are also due to Director, Institute of Health Management Research, Jaipur for providing an opportunity to conduct the study. We also acknowledge the contribution of district/block and facility level officials in providing the required data to complete the assessment.
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