This section presents an overview of the health structure in rural areas.
Topics described here will be explained in more detail in chapter 7.
India started its health care reform in 1952 after the independency from the British Empire, but it was first in 1983, after the Alma-Ata declaration in
1978 (WHO), that the country committed to primary health care and primary health centres. The main stress of this national policy is the provision of preventive and rehabilitative health services to the people, thus representing a change from medical care to health care.
Type of
Sub-centre 5,000 3,000 4,579 4.27
Table 2: Statistical data of primary care institutions. The numbers in the first three columns are people served by the respective health centre.
The primary health care infrastructure in rural areas has been developed as a threetier system and is based on the population norms presented in Table 2.
At the bottom level in the hierarchy, the sub-centre is the peripheral institution available to the rural population, theoretically serving between 3000 and 5000 persons. A sub-centre is according to the government run by one Multipurpose Health Assistant (male) and one field worker as well as one LHV who is in charge of supervising six sub-centres. The field worker core tasks are to capture data about ante natal cases, register births, and give BCG and Measles vaccine. She performs these tasks by going from village to village within her area, usually covering the area within one month (FW 2002).
The primary health centre is the first contact point between the village community and the Medical Officer. A primary health centre acts as a referral unit for six sub-centres, consists of one Medical Officer supported by 14 paramedical and other staff and usually contain between four and six beds for patients. The activities of the primary health centre involve curative, preventive and Family Welfare services in addition to simple daily-based services like vaccinations and blood testing.
From the state, numbers and indicators finally end up at the Department of Health and Family Welfare after being processed at different sub-institutions at the country level.
6.2.1 Andhra Pradesh health information flow
A study of the information flow in Andhra Pradesh performed by the HISP India team exposed a strict separation between the hospitals and the primary health centres. The structure of the health system in Andhra Pradesh is made up of isolated programs that perform vertical reporting, and can broadly be divided into three main areas (Braa et al. 2002b):
• Primary health care: This structure supports mother and child health programs under the Commissioner of Family Welfare.
Collection of various programs is paper based, performed by health workers in the sub-centres, sent through primary health centre to the district and then to the state. All communication between levels is done by post/hand delivery. There is only one computer at the district medical and health office, and no computers in the district health service. Every month the Multipurpose Health Worker (f) fills out the paper forms at the sub-centre and delivers those to the person in charge at the primary health centre, usually the Medical Officer or the Supervisor. Data is then calculated and summarized on paper forms for the primary health centre, and brought to the monthly meeting for all primary health centres in the district. The primary health centre data is then computed manually at the district, and the result is typewritten before sent to the state. Hence, data is aggregated at primary health centres and district level before reaching the state.
• Vertical programs: Several different programs like Malaria, Tuberculosis, Leprosy and Family Planning, have independent structures. Data on these programs is collected by the program officers at the primary health centres and is reported in parallel to the state and district-level programme offices.
• Andhra Pradesh Vaidya Vidhana Parishat (APVVP): As part of World Bank project to strengthen the hospital infrastructure, APVVP was established. APVVP is an independent management and reporting structure that covers all district and area hospitals, and community health centres. Data from all hospitals in the district is entered at the district hospital and submitted electronically to the APVVP head office. Data from APVVP and data under the Commissioner of Family Welfare structure is not integrated, but the same personnel are reporting on the same events into both systems.
The data elements are not following the same standards, i.e. while APVVP reports “number of deliveries”, the other system is reporting
“live births”, “still births” and “deliveries”.
The District Medical & Health Officer deals with the reporting at district level in the first two cases. At district level the Commissioner for Family Welfare or Director of Health is in charge. The APVVP structure is managed by the District Coordinator of Health Services at district level, while the Commissioner APVVP handles it at the state level (Braa et al.
2002b).
Looking at the information flows in Figure 8, the institutional structure of the health sector is identified. The mapping of the HISs is thus a reflection of the hierarchical structures of the health sector down to the lowest institutional level.
APVVP
Vertical programs PHC structure APVVP
Figure 8: Structure and flow of information in the health system of Andhra Pradesh up to 2002.
There are several structural issues that make the information flow problematic. The health structure is an organizational hierarchy consisting of independent, vertical units, which complicates the overall picture in the health status. The most prominent challenges can be outlined as follows (Braa et al. 2002b):
• The fragmented information flows are not integrated, analysed or used at the district level.
• Systematically aggregation of data at each level upwards.
• Poor quality of data.
• Insufficient feedback of data and lack of use to support action.
• Primary health care and hospitals are separate reporting units.
• Data collection tasks consuming a lot of resources.
The above issues will be addressed later in this thesis.