|Year : 2014 | Volume
| Issue : 1 | Page : 12-16
Assessing Indian Public Health Standards for 24 × 7 primary health centers: A case study with special reference to newborn care services
Prahlad Rai Sodani1, Kalpa Sharma2
1 Professor & Dean (Training), Institute of Health Management Research, Jaipur, Rajasthan, India
2 Knowledge Management Officer, Save the Children, Jaipur, Rajasthan, India
|Date of Web Publication||21-May-2014|
A-16/A, Hari Om Marg, Sohan Nagar A, Manyawas, New Sanganer Road, Opposite Mansarovar, Jaipur-302020, Rajasthan
Source of Support: None, Conflict of Interest: None
Objectives: The main objective of the present study is to identify the existing gap with respect to Indian Public Health Standards (IPHS) for availability of infrastructure, human resources, investigative services and essential newborn care services at 24 × 7 primary health centers (PHCs) of Bharatpur district of Rajasthan state.
Materials and Methods: Data were collected from medical officer in-charge from the study 24 × 7 PHCs to provide required data on infrastructure, human resources, investigative services and newborn health care services through the well-structured questionnaire.
Results: It was found that the availability of operation theater, telephone and E-mail facility were not satisfactory. Labor room was available at almost all the 24 × 7 PHCs while nearly 75% of the 24 × 7 PHCs have laboratory and cold chain facility. Shortage of human resources, especially laboratory technician and pharmacist were observed. It was also observed that none of the 24 × 7 PHCs have fully equipped newborn corner. Conclusion: The study depicted that the availability of human resources, infrastructure and facilities for newborn care services at the 24 × 7 PHCs were not satisfactory as per the prescribed IPHS. Efforts are required on priority to strengthen OT, investigative facilities and communication facilities at the 24 × 7 PHCs.
Recommendations: It is recommended that availability of pharmacist/compounder shall be as per IPHS norms at the 24 × 7 PHCs. New born care corners established at 24 × 7 PHCs should be provided adequate equipment/items as recommended by the IPHS so as to become effective and functional to provide new born care services in the rural areas.
Keywords: 24 × 7 primary health centers, essential newborn care services, Indian Public Health Standard
|How to cite this article:|
Sodani PR, Sharma K. Assessing Indian Public Health Standards for 24 × 7 primary health centers: A case study with special reference to newborn care services. J Nat Accred Board Hosp Healthcare Providers 2014;1:12-6
|How to cite this URL:|
Sodani PR, Sharma K. Assessing Indian Public Health Standards for 24 × 7 primary health centers: A case study with special reference to newborn care services. J Nat Accred Board Hosp Healthcare Providers [serial online] 2014 [cited 2020 Sep 26];1:12-6. Available from: http://www.nabh.ind.in/text.asp?2014/1/1/12/132919
| Introduction|| |
There is widespread and growing demand for primary health care in developing countries especially in India. This demand in turn displays a growing eagerness among policymakers and program managers for knowledge related to how health systems can become more equitable, inclusive and fair. The declaration of Alma-Ata on primary health care in 1978 guided and directed path for establishing effective primary health care in member countries and especially in India.  Further, the Bhore Committee (1946) strongly proposed the primary health care approach for effective and equitable health care services in India.  Yet, despite enormous progress in health service delivery in terms of infrastructure, human resources and service provision, failures to deliver in line with the primary health care values deserve most consideration. In rural areas, mothers were suffering complications of labor without access to qualified support and children missing out on essential vaccinations required serious efforts to rectify the problems associated with these health outcomes. In moving forward, it is important to learn from the past and in looking back, it is clear that we can do better in the future. Recognizing the importance of health in the process of economic and social development of India, the Government of India has launched the National Rural Health Mission (NRHM) to carry out necessary architectural correction in the basic health care delivery system in India. The Plan of Action of NRHM included apart from many other sector reforms, upgrading primary health centers (PHCs) as per the Indian Public Health Standards (IPHS) developed by the Ministry of Health and Family Welfare, Government of India, to strengthen primary health care services. 
PHCs are the cornerstone of rural health services-a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from sub-centers for curative, preventive and promotive health care. A typical PHCs covers a population of 20,000 in hilly, tribal, or difficult areas and 30,000 populations in plain areas with six indoor/observation beds.  It acts as a referral unit for six sub-centers and refer out cases to community health centers (CHC) (30 bedded hospital) and higher order public hospitals located at sub-district and district level. However, as the population density in the country is not uniform, the number of PHCs would depend upon the case load. PHCs should become a 24 h facility with nursing facilities. Select PHCs, especially in large blocks where the CHC/first referral unit is over 1 h of journey time away, may be upgraded to provide 24 h emergency hospital care for a number of conditions by increasing number of Medical Officers, preferably such PHCs should have the same IPHS norms as for a CHC.
There are 23,673 PHCs are functioning according to Rural Health Statistics Bulletin 2010 of Ministry of Health and Family Welfare, Government of India and out of them 8409 are functioning as 24 × 7.  PHCs have been categorized into three types, one without 24 by 7 services, second with 24 by 7 nursing facilities and third with 24 by 7 emergency hospital care facilities and the IPHS are defined for each of them accordingly.
The IPHS for PHCs are designed to provide comprehensive primary health care to the community through the PHCs, 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. Draft guidelines for IPHS for PHCs were published in 2006, which were then modified as "IPHS (revised draft) for PHCs" (2010). , During revision, major changes in the IPHS for PHCs were made in terms of the number of human resource and newborn care facilities in the 24 × 7 PHCs. The number of human resource was increased and particular emphasis was given to newborn care in the revised draft of IPHS for PHCs (2010).
There are very few studies to assess the PHCs with respect to IPHS particularly for infrastructure, human resources and service provision. In one of the study, IPHS for PHCs were assessed for service provision, human resources, infrastructure facilities and laboratory facilities, in an Empowered Action Group (EAG) and non-EAG state in India.  Another study paid attention to assess the PHCs with respect to availability of services, infrastructure, human resources, equipment and drugs in Bihar state. 
The objective of the present paper is to study the availability of infrastructure, human resources, investigative services and essential newborn care services (ENCS) at 24 × 7 PHCs with respect to IPHS for 24 × 7 PHCs.
| Materials and Methods|| |
The present paper is based on a study conducted in Bharatpur district of the State of Rajasthan. There are nine blocks, 57 PHCs and 19 24 × 7 PHCs in Bharatpur district. As we know, Rajasthan is one of the 18 special focused states identified by the NRHM to provide effective health care, because of weak public health indicators as well as public health infrastructure.  From the State of Rajasthan, Bharatpur district is identified purposively for the present study because of weak health outcomes as seen from the District Level Household and Facility Survey-3 (DLHS-3) Rajasthan, Bharatpur district. According to DLHS-3, Bharatpur district has (a) the lowest coverage of ante natal check-up (27.8%) compared with 56.6% of state average; (b) 43.8% institutional deliveries compared with 45.5% of state average; and (c) 20.2% full immunization coverage of children aged 12-23 months which is far less than state average (48.7%). 
To assess the 24 × 7 PHCs in terms of availability of infrastructure facilities, human resources, investigative facilities, ENCS with respect to IPHS, a facility assessment tool was developed referring the revised draft of IPHS for PHCs developed by the Ministry of Health and Family Welfare, Government of India. The study tool thus developed was pre-tested and validated before administering for actual assessment of the study sites. The pre-tested tool was used for data collection. To collect data from 24 × 7 PHCs, a competent and committed team of ten investigators were hired. The field investigators were postgraduate in social sciences and had adequate experience of conducting health and demographic surveys and health facility surveys. The field investigators had undergone training to collect data with the help of the pre-tested study tool from the 24 × 7 PHCs. Data were collected from all the 19 24 × 7 PHCs of the study district during the months of September and October 2010. The field investigators were divided into four teams, each consisting of 2 members. The field work and data collection work was monitored and supervised by two field supervisors, each was responsible for two field teams. All the 19 24 × 7 PHCs were distributed among the four teams, thus three teams visited five centers each while the fourth team visited only four centers. The data were collected by all the four teams by visiting the 24 × 7 PHCs. The field investigators requested medical officer in-charge at the 24 × 7 PHCs to provide the required data on infrastructure, human resources, laboratory services and newborn health care services. To avoid any bias in the information gathered, the field investigators reviewed the respective records as well as made observations at the 24 × 7 PHCs.
| Results|| |
As per the recommendations of the revised draft of the IPHS for PHCs (2010), 24 × 7 PHCs should have functional operation theatre (OT), labor room, cold chain facility and laboratory facility with telephone and E-mail facility. [Table 1] depicts the availability of infrastructure facilities at 24 × 7 PHCs in the study district. The study depicted that that out of 19 24 × 7 PHCs, 18 had labor room, 14 (73.7%) had laboratory facility and cold chain facility; while only six had functional OT. Regarding communication facilities eleven 24 × 7 PHCs (57.9%) had telephone facility while only one 24 × 7 PHC (5.3%) had E-mail facility.
|Table 1: Availability of infrastructure facilities and investigative services at 24 × 7 PHCs in Bharatpur district, Rajasthan|
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As per the recommendations of the revised draft of IPHS for PHCs (2010), 24 × 7 PHCs should have facilities for laboratory tests, X-ray and electrocardiogram (ECG). [Table 1] depicts that out of 19 24 × 7 PHCs 12 (63.2%) had availability of laboratory tests facilities, only two 24 × 7 PHCs (10.5%) had availability of ECG facility, while only one 24 × 7 PHC (5.3%) had availability of X-ray facility.
According to the revised draft of the IPHS for PHCs (2010), 24 × 7 PHC should have two medical officers, five staff nurses, two pharmacists/compounders and two laboratory technicians in order to ensure round-the-clock access to public health facilities. Accordingly, 38 medical officers (2/24 × 7 PHC); 95 staff nurses (5/24 × 7 PHC); 38 pharmacists/compounders (2/24 × 7 PHC); and 38 laboratory technicians (2/24 × 7 PHC) should be available at all the 19 24 × 7 PHCs of the study district. [Table 2] shows the availability of human resources at 24 × 7 PHC in the study district. Data depicted that only 23 medical officers, 79 staff nurses, 4 pharmacists/compounders and 18 laboratory technicians were available at the 19 24 × 7 PHCs in the study district
|Table 2: Availability of human resources at 24 × 7 PHCs in Bharatpur district, Rajasthan|
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It was also observed that out of 19 24 × 7 PHCs only five had the recommended number of medical officers, whereas the majority of 24 × 7 PHCs (i.e., 14 out of 19) did not had the availability of the recommended number of medical officers. Results also depicted that out of 19 24 × 7 PHCs, only ten had the recommended number of staff nurses. Similarly, it was also found that the recommended number of pharmacists/compounders as well as the laboratory technician made available only at one 24 × 7 PHC in the study district
According to the revised draft of the IPHS for PHCs (2010), the newborn corner, is mandatory for all 24 × 7 PHCs. Newborn corner is a space within the delivery room where immediate care is provided to all newborns. Delivery rooms in OT and in Labor rooms are required to have separate resuscitation space and outlets for newborns. Some term infants and most preterm infants are at greater thermal risk and often require additional personnel, equipment and time to optimize resuscitation. An appropriate resuscitation/stabilization environment should be provided as provision of appropriate temperature for delivery room resuscitation of high-risk preterm infants is vital to their stabilization.
The newborn corner provides an acceptable environment for most uncomplicated term infants, but may not support the optimal management of newborns who may require referral to special newborn care unit. Services provided in the newborn corner are - care at birth, resuscitation, provision of warmth, early initiation of breastfeeding, and weighing the neonate. To provide these newborn care services, the following equipments/items - one radiant warmer, one resuscitator, one weighing scale, one suction pump, two thermometers and one hub cutter should be made available at newborn corner. 
[Table 3] shows the availability of equipment/items in newborn corner at the 19 24 × 7 PHCs in the study district. According to the IPHS, 19 radiant warmers, 19 resuscitators 19 weighing scale, 19 suction pump, 38 thermometers and 19 hub cutter should be made available at the 19 newborn corner at 24 × 7 PHCs in the study district. It was found that only three radiant warmers, five resuscitators, 11 weighing scales, 10 suction pumps, 29 thermometers, 16 hub cutters were available in the newborn corners located at the 19 24 × 7 PHCs in the study district. The study also found that none of the 24 × 7 PHCs in the study district had fully equipped newborn corner as per the IPHS
|Table 3: Availability of equipments/items of newborn corner at 24 × 7 PHCs in Bharatpur district, Rajasthan|
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According to the revised draft of the IPHS for PHCs (2010), the configuration of the newborn corner include:
- Clear floor area shall be provided for in the room for new born corner. It is a space within the labor room, 20-30 sq. ft. in size, where a radiant warmer will be kept;
- Oxygen, suction machine and simultaneously-accessible electrical outlets shall be provided for the newborn infant in addition to the facilities required for the mother;
- Clinical procedures : a0 dministration of oxygen, airway suctioning;
- Resuscitation kit should be placed in the radiant warmer;
- Provision of hand washing and containment of infection control if it is not a part of the delivery room; and
- The area should be away from draught of air, and should have power connection for plugging in the radiant warmer.
| Discussion|| |
The present study assessed the availability of human resources, infrastructure, investigative facilities and facilities for new born care services at the 24 × 7 PHCs with respect to IPHS. The study found that the 24 × 7 PHCs in the study districts are lacking in terms of human resources, infrastructure, investigative services and new born care services There are very few studies to assess the availability of infrastructure, human resources, investigative services and new born care services at the PHCs and therefore efforts are required to conduct more such studies in other states to better understand the situation of 24 × 7 PHCs in terms of IPHS norms prescribed by the Government of India and how far we need to go to achieve these norms.
The study findings revealed that new born care corners established at the 24 × 7 PHCs should be provided adequate equipment/items as recommended by the IPHS so as to become effective and functional to provide new born care services in the rural areas. One of the major reasons for the poor quality of new born health services is the lack of capital investment for strengthening new born health services especially at 24 × 7 PHCs for a prolonged period of time. The NRHM made some efforts to strengthen the necessary infrastructure for the same, however, much remains to be done. Efforts are required to complete the basic infrastructure needed for good new born health services delivery in rural areas. Investigative services at public health facilities need to be strengthened at the 24 × 7 PHCs levels. This would require not only infrastructural strengthening, but also adequate human resource support.
| Recommendations and Way Forward|| |
It is recommended that public health facilities, particularly 24 × 7 PHCs, which have more number of new born cases and which are more utilized because of central location need to be prioritized for better infrastructure and human resources as per IPHS norms for providing newborn health services.
Further, one of the central issues of human resource planning is the challenge of getting skilled professionals to join in public health systems in rural areas and agree to stay and work in rural and remote areas. Since most doctors come from urban middle class backgrounds, the economic loss and professional and social isolation of rural service, deters them from public health service. NRHM has initiated multiple strategies for attracting and retaining the skilled providers in the rural and remote areas and the initial results have been very encouraging. It is recommended that to deal the issue of human resources at 24 × 7 PHCs, various measures need to be considered. These measures are as follows: Financial incentives such as pay-for-performance linked to the health outcomes and non-financial incentives such as preference for postgraduation, promotion, nomination in training programs, for working at remote 24 × 7 PHCs. States like West Bengal and Chhattisgarh have introduced group housing for health workers living in remote areas. The problems of professional isolation should be addressed by special continuing education programs and telemedicine or even short duration training/internship opportunities at national/international level and by special conferences and workshops that interest them to enhance their professional competencies. Their social isolation should be addressed by more opportunities to interact both with peers and with the community they serve.
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[Table 1], [Table 2], [Table 3]