INTRODUCTION TO NURSING MANAGEMENT

Health care is an expression of concern for fellow human beings. It is defined as ‘multitude
of services rendered to individuals, families or communities by the agents of the health
services or professions, for the purpose of promoting good health. Such services may be
staffed, organized, administered and financed in every imaginable way, but they all have one
thing in common: people are being “Served”, i.e., diagnosed, helped, cured, educated and
rehabilitated by health personnel.

The vital aspect of health did not receive proper care and attention during the pre
independence period as the British rulers were concerned more with the expansion,
consolidation and concentration of their rule, rather than to attend to the alarming, awful and
pressing unsanitary, unhygienic conditions rampant in the country as a whole. Negligence of
these areas, absence of medical and health services and large-scale prevalence of poverty and
ignorance, created conditions conducive for breeding and spreading of all types of diseases
among the Indian masses. In the light of these circumstances, certain measures were taken by
the British rulers for the systematisation of health services in India. Commissioners of public
health were appointed in the major provinces. The Birth and Death Registration Act in
1873, the Vaccination Act in 1880,Epipdemicdoseas Act in 1887 were introduced. The
Government of India Act was introduced for granting larger autonomy to the provinces in
1935. The Drugs Act was enacted as a Central legislation in 1940. In spite of taking these
steps by the British rules, the health conditions and administration could not be recovered on
account of outbreak of Second World War and subsequent partition of the country. Health
Survey and Development Committee popularly known as Bhore Committee was appointed in
1943 to survey the then existing health conditions and health organisation in the country and
to make recommendations for further development. The committee submitted its report in
1947 which. had a powerful impact on evolution of health policy in independent India. This
report still continue to be an important document in the field of health administration in the
country

The overall scenario of health care in India is a mixture of remarkable achievements and
failures. Over the last 60 years a vast network of healthcare services and infrastructure has
been built up. Health care in India is basically urban area oriented, twothirds of the hospitals
are located in urban areas, and accounting for nearly four-fifths of the beds available, serving
about 30 per cent of the total population. An estimated number of hospitals in the country is
13,692 with 5,96,203 beds available; of which, about 68 per cent hospitals with 80 per cent
beds are located in the urban areas.

With the concept of healthcare going beyond hospitals, the health care industry in India has
witnessed remarkable growth in the past few years. According to India Brand Equity
Foundation (IBEF,) the Indian health care sector, which consists of hospitals, medical devices
and equipment and health insurance, is expected to reach U.S. $160 billion by 2017. Major
factors driving this growth could be increasing demand of superior health care facilities,
rising health awareness and health policies.
At all levels of health care delivery system, nurses play an important role in effective
management of health care services and provision of holistic health care. With the recent
emphasis and priority set by the Government of India for improving the quality of health
services provided, the nursing professionals have a major responsibility. It is mandatory for
them to have management skills for ensuring good working condition, smooth day to day
operations and overall improvement in the health care delivery.

INDIAN CONSTITUTION

CONSTITUTION

A Constitution is a set of rules by which the people of a country are governed. It says how the
Government should work and what its power and duties are. It guarantees the people about
their rights like justice & freedom. It also tells the people what their rights are and what they
can and cannot do. The Constitution is highest than all other laws in the country. All laws
passed by a country in the line with its Constitution.

INDIAN CONSTITUTION

The Constitution of India is the supreme law of India. It lays down the framework defining
fundamental political principles, establishes the structure, procedures, powers and duties of
government institutions and sets out fundamental rights, directive principles and the duties of
citizens. Dr. B. R. Ambedkar is regarded as the chief architect of the Indian . The
Constitution of India is the world's lengthiest written constitution with 395 articles and 8
schedules. It contains the good points taken from the constitution's of many countries in the
world.

EVOLUTION OF THE CONSTITUTION

a. Acts of British Parliament before 1935

After the Indian Rebellion of 1857, the British Parliament took over the reign of India from
the British East India Company, and British India came under the direct rule of the Crown.
The British Parliament passed the Government of India Act of 1858 to this effect, which set
up the structure of British government in India.

b. Government of India Act 1935

The provisions of the Government of India Act of 1935, though never implemented fully, had
a great impact on the constitution of India. The federal structure of government, provincial
autonomy, bicameral legislature consisting of a federal assembly and a Council of States,
separation of legislative powers between center and provinces are some of the provisions of
the Act which are present in the Indian constitution.

c. The Cabinet Mission Plan

In 1946, at the initiative of British Prime Minister Clement Attlee, a cabinet mission to India
was formulated to discuss and finalize plans for the transfer of power from the British Raj to
Indian leadership and providing India with independence under Dominion status in the
Commonwealth of Nations. The Mission discussed the framework of the constitution and laid
down in some detail the procedure to be followed by the constitution drafting body. Elections
for the 296 seats assigned to the British Indian provinces were completed by August 1946.
The Constituent Assembly first met and began work on 9 December 1946.

d. Indian Independence Act 1947

The Indian Independence Act, which came into force on 18 July 1947, divided the British
Indian territory into two new states of India and Pakistan, which were to be dominions under
the Commonwealth of Nations until their constitutions were in effect.

e. Constituent Assembly

The Constitution was drafted by the Constituent Assembly, which was elected by the elected
members of the provincial assemblies. Jawaharlal Nehru, C. Rajagopalachari, Rajendra
Prasad, Sardar Vallabh bhai Patel, Maulana Abul Kalam Azad, Shyama Prasad Mukherjee
and Nalini Ranjan Ghosh were some important figures in the Assembly.

In the 14 August 1947 meeting of the Assembly, a proposal for forming various committees
was presented. Such committees included a Committee on Fundamental Rights, the Union
Powers Committee and Union Constitution Committee. On 29 August 1947, the Drafting
Committee was appointed, with Dr Ambedkar as the Chairman along with six other
members. A Draft Constitution was prepared by the committee and submitted to the
Assembly on 4 November 1947.

It was passed on 26 Nov 1949 by the 'The Constituent Assembly' and is fully applicable since
26 Jan 1950. The Constituent Assembly had been elected for undivided India and held its first
sitting on 9th Dec.1946, re-assembled on the 14th August 1947, as The Sovereign Constituent
Assembly for the dominion of India. In regard to its composition the members were elected
by indirect election by the members of The Provisional Legislative Assemblies (lower house
only). At the time of signing 284 out of 299 members of the Assembly were present. The
constitution of India imparts constitutional supremacy and not parliamentary supremacy .
India celebrates the coming into force of the constitution on 26 January each year as Republic
Day .

The Constitution declares India a sovereign, socialist, secular, democratic, republic assuring
its citizens of justice, equality, and liberty and endeavours to promote fraternity among them.
The Indian constitution is one of the most frequently amended constitutions in the world.
The constitution has provision for Schedules to be added to the constitution by amendment.
A review of the constitution needs at least two-thirds of the Lok Sabha and Rajya Sabha to
pass it.

We, The people of India, having solemnly resolved to constitute India into a SOVEREIGN
SOCIALIST SECULAR DEMOCRATIC REPUBLIC and to secure to all its citizens:

 JUSTICE, social, economic and political;

  LIBERTY of thought, expression, belief, faith and worship;
 EQUALITY of status and of opportunity and to promote among them all
 FRATERNITY assuring the dignity of the individual and the unity and integrity of
the Nation
 IN OUR CONSTITUENT ASSEMBLY this twenty sixth day of November, 1949,
do hereby Adopt, Enact and give ourselves this Constitution.
ARTICLES OF THE CONSTITUTION

Part Article Deals with

Part I Articles 1-4 Territory of India, admission, establishment or
formation of new states Citizenship
Part II Articles 5-11 Fundamental Rights
Part Ill Articles 12-35 Directive Principles of State Policy
Part IV Articles 36-51 Duties of a citizen of India. It was added by the 42nd
Amendment in 1976
Part IV A Article 51-A Government at the Union level
Government at the State level
Part V Articles 52-151 Deals with states in Part B of the First Schedule. it
Part VI Articles 152-237 was repealed by 7th Amendment in 1956
Part VII Article 238 Administration of Union Territories Territories in
Part VIII Articles 239-241 Part D of the First Schedule and other territories, It
was repealed by 7th Amendment in 1956 Scheduled
and tribal areas Relations between the Union and
States Finance, property, contracts and suits Trade,
commerce and travel within the territory of India
Part IX Article 242-243 Services under the Union and States Added by the
Part X Articles 244-244 A 42nd Amendment in 1976 and deals with
administrative tribunals to hear disputes and other
complaints
Part Xl Articles 245-263 Election and Election Commission
Part XII Articles 264-300 Special provision to certain classes ST/SC and Anglo
Part XIII Articles 301-307 Indians
Part XIV Articles 308-323 Official language
Part XIV A Articles323A-323B Emergency provisions
Part XV Articles 324-329 Miscellaneous provision regarding exemption of the
Part XVI Articles 330-342 President and governors from criminal proceedings
Part XVII Articles 343-351 Amendment of Constitution
Part XVIII Articles 352-360
Part XIX Articles 361-367 Temporary, transitional and special provisions
Part XX Article 368 Short title, commencement and repeal of the
Part XXI Articles 369-392 Constitution
Part XXII Articles 393-395
CITIZENSHIP

The Constitution of India provides for a single citizenship for the whole of India. Every
person who was at the commencement of the Constitution (26 January 1950) domiciled in the
territory of India and
(a) who was born in India; or

(b) either of whose parents was born in India; or

(c) who has been ordinarily resident in India for not less than five years became a citizen of
India. The Citizenship Act, 1955, deals with matters relating to acquisition, determination and
termination of Indian citizenship after the commencement of the Constitution.

FUNDAMENTAL RIGHTS

1. Right to Equality-The right to equality includes equality before law, prohibition of

discrimination on grounds of religion, race, caste, sex or place of birth and equality of
opportunity in matters of employment and abolition of untouchability.

2. Right to Freedom-The right to freedom includes freedom of speech and expression; right
to assemble peacefully and without arms, formation, association or union; free movement
throughout the territory of India; residence and the right to practice any profession or
occupation; control and disposal of property.

3. Right against Exploitation-The right against exploitation all forms of forced labour,
prohibits child labour and traffic in human beings.

4. Right to Freedom of Religion -The right to freedom of religion contains religious

freedom to all. All persons are entitled to freedom of conscience and the right to profess,
practice and propagate religion freely.

5. Cultural and Educational Rights-It includes right of any section of the citizens to
conserve their culture, language or script and right of minorities to establish and administer
educational institutions of their choice.

6. Right to Constitutional Remedies- This right guarantees the right to constitutional

remedies to the citizens for enforcement of their Fundamental Rights.

[The right to property was also one of the fundamental rights, according to the original
Constitution. This right was omitted by the 44th Amendment Act in December, 1978. It is
now only a legal right.]

FUNDAMENTAL DUTIES : Duties of a citizen of India were not included in the original
constitution. These have been added by the 42nd Amendment in 1976. There are ten
Fundamental Duties:

1) To abide by the Constitution and respect its ideals and Institutions, the National Flag
and the National Anthem;
2) To cherish and follow the noble ideals which inspired our national struggle for
freedom;
3) To uphold and protect the sovereignty, unity and integrity of India;
4) To defend the country and render national service when called upon to do so;
 5) To promote harmony and the spirit of common brotherhood amongst all the people of
India transcending religious, linguistic and regional diversities; to renounce practices
derogatory to the dignity of women;
6) To value and preserve the rich heritage of our composite culture;
7) To protect and improve the natural environment including forests, lakes, rivers and
wildlife, and to have compassion for living creatures;
8) To develop the scientific temper, humanism and the spirit of inquiry and reform;
9) To safeguard public property and to abjure violence; and
10) To strive towards excellence in all spheres of individual and collective activity so that
the nation constantly rises to higher level of endeavour and achievement.

DIRECTIVE PRINCIPLES OF STATE POLICY :

A. To secure the right of all men and women to an adequate means of livelihood;
B. To ensure equal pay for equal work;
C. To make effective provision for securing the right to work, education and to public
assistance in the event of unemployment old age, sickness and disablement;
D. To secure to workers a living wage, humane conditions of work, a decent standard of
life, etc;
E. To ensure the operation of the economic system does not result in the concentration of
wealth;
F. To provide opportunities and facilities for children to develop in a healthy manner;
G. To provide free and compulsory education for all children up to 14 years of age;
H. To promote educational and economic interest of scheduled castes, scheduled tribes
and other weaker sections;
I. To organize village panchayats ;
J. To separate judiciary from the executive;
K. To promulgate a uniform civil code for the whole country;
L. To protect national monuments ;
M. To promote justice on a basis of equal opportunity;
N. To provide free legal aid;
O. To protect and improve environment and forests and wildlife;
P. To promote international peace and security;
Q. To promulgate a uniform civil code for the whole country;
R. To settle international disputes by arbitration.
FEDERAL STRUCTURE

The constitution provides for distribution of powers between the Union and the States. It
enumerates the powers of the Parliament and State Legislatures in three lists, namely Union
list, State list and Concurrent list. Subjects like national defence, foreign policy, issuance of
currency are reserved to the Union list. Public order, local governments, certain taxes are
examples of subjects of the State List, on which the Parliament has no power to enact laws in
those regards, barring exceptional conditions. Education, transportation, criminal laws are a
few subjects of the Concurrent list, where both the State Legislature as well as the Parliament
has powers to enact laws.

Changing the constitution

In 2000 the National Commission to Review the Working of the Constitution (NCRWC) was
setup to look into updating the constitution of India.

Judicial review of laws

This section requires expansion.

Judicial review is actually adopted in the Indian constitution from the constitution of the
United States of America. In the Indian constitution, Judicial Review is dealt under Article
13. Judicial Review actually refers that the Constitution is the supreme power of the nation
and all laws are under its supremacy.

Article 13 deals that

1. All pre-constitutional laws, after the coming into force of constitution, if in conflict with it
in all or some of its provisions then the provisions of constitution will prevail. If it is
compatible with the constitution as amended. This is called the Theory of Eclipse.

2. In a similar manner, laws made after adoption of the Constitution by the Constituent
Assembly must be compatible with the constitution, otherwise the laws and amendments will
be deemed to be void-ab-initio.

In such situations, the Supreme Court or High Court interprets the laws as if they are in
conformity with the constitution.

HEALTHCARE IN INDIAN CONSTITUTION

Right to Health is not included as an explicit fundamental right in the Indian Constitution.
Most provisions related to health are in Part-IV {Directive Principles}. These are:

 Article 38 says that the state will secure a social order for the promotion of
welfare of the people. Providing affordable healthcare is one of the ways to
promote welfare.
 Article 39(e) calls the state to make sure that health and strength of workers,
men and women, and the tender age of children are not abused.
 Article 41 imposes duty on state to provide public assistance in cases of
unemployment, old age, sickness and disablement etc.
 Article 42 makes provision to protect the health of infant and mother by
maternity benefit.
 Article 47 make it duty of the state to improve public health, securing of
justice, human condition of works, extension of sickness, old age, disablement
and maternity benefits and also contemplated. Further, State’s duty includes
 prohibition of consumption of intoxicating drinking and drugs are injurious to
health.
 Article 48A ensures that State shall Endeavour to protect and impose the
pollution free environment for good health.
 Apart from DPSP, some other provisions related to health fall in 11th schedule
and 12th schedule as subjects of Panchayats and Municipalities respectively.
These include drinking water, health and sanitation, family welfare, women
and child development, social welfare etc.
 The above description makes it clear that most provisions related to health fall
in DPSP in the constitution. They are non-justifiable and no person can claim
for non-fulfilling of these directives. However, Judiciary has widely
interpreted the scope of Right to Health under Article 21 (right to life ) and has
thus established right to health as an implied fundamental right. Not only
article 21 but also other articles under Part-III have been linked. For example,
Article 23(1) prohibits traffic in human beings. Since trafficking of women
leads to prostitution, which in turn is to major factor in spread of AIDS, this
article has been linked to Right to Health.
 Similarly, Article 24 says that No child below the age of 14 years shall be
employed to work in any factory or mine or engaged in any other hazardous
employment. It is directly related to Child health.

Further, in relation to the serious medical cases, the supreme court has provided certain
directions such as:

 Provision of adequate health facilities at public health centers.

 Upgradation of sub-divisional level hospitals to make them capable of treating serious
patients.
 To ensure availability of bed in any emergency at State level hospitals, there should
be a centralized communication system so that the patient can be sent immediately to
the hospital where bed is available in respect of the treatment, which is required.
 Proper arrangement of ambulances adequately provided with necessary equipments
and personnel.

Further, the Supreme Court in Paramanand Katara v Union of India case gave a landmark
judgement that a every doctor at government hospital or otherwise has the professional
obligation to extend his services with due expertise for protecting life of a patient.

HEALTH CARE DELIVERY SYSTEM IN INDIA

DEFINITION OF HEALTH:

According to W.H.O., “Health is a state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity.”
 The health of an individual as an integrated system within the context of the environment is
termed holistic health. Environmental Health refers to the state of all substances, forces and
conditions in an individual's surroundings that may exert an influence on health and
wellbeing. When environmental conditions are favorable, health status is enhanced. However
adverse biological, chemical, physical and sociological forces in the environment, separately
or in combination may disrupts healthy life-style and impede a person's ability to cope with
environmental stimuli.

The amendments to the Indian Health Care Improvement Act set forth a “declaration of
national policy,” in fulfillment of the special trust responsibilities and legal obligations to
Indians “to assure the highest possible health status for and raise the health status of Indians
and urban Indians through the provision of health services and to provide all resources
necessary to effect that policy.”

CHARACTERISTICS OF HEALTH CARE SYSTEM IN INDIA:

With the World Health Organization’s 2000 World Health Report ranking India’s healthcare
system at 112 out of 190 countries .For those living in urban areas, healthcare is merely a
political issue. They argue that the country faces bigger challenges such as economic
development, infrastructure, jobs, and border disputes with Pakistan.

1. Rural Versus Urban Divide: While the opportunity to enter the market is very ripe, India
still spends only around 4.2% of its national GDP towards healthcare goods and services
(compared to 18% by the US) . Additionally, there are wide gaps between the rural and urban
populations in its healthcare system which worsen the problem. A staggering 70% of the
population still lives in rural areas and has no or limited access to hospitals and clinics .
Consequently, the rural population mostly relies on alternative medicine and government
programmes in rural health clinics. One such government programme is the National Urban
Health Mission which pays individuals for healthcare premiums, in partnership with various
local private partners, which have proven ineffective to date.

In contrast, the urban centres have numerous private hospitals and clinics which provide
quality healthcare. These centres have better doctors, access to preventive medicine, and
quality clinics which are a result of better profitability for investors compared to the not-so-
profitable rural areas.

2. Need for Effective Payment Mechanisms: Besides the rural-urban divide, another key
driver of India’s healthcare landscape is the high out-of-pocket expenditure (roughly 70%).
This means that most Indian patients pay for their hospital visits and doctors’ appointments
with straight up cash after care with no payment arrangements. According to the World Bank
and National Commission's report on Macroeconomics, only 5% of Indians are covered by
health insurance policies . Such a low figure has resulted in a nascent health insurance market
which is only available for the urban, middle and high income populations. The good news is
that the penetration of the health insurance market has been increasing over the years; it has
been one of the fastest-growing segments of business in India.

Coming to the regulatory side, the Indian government plays an important role in running
several safety net health insurance programmes for the high-risk population and actively
regulates the private insurance markets. Currently there are a handful of such programmes
including the Community Health Insurance programme for the population below poverty line
(like Medicaid in the US) and Life Insurance Company (LIC) policy for senior citizens (like
Medicare in the US). All these plans are monitored and controlled by the government-run
General Insurance Corporation, which is designed for people to pay upfront cash and then get
reimbursed by filing a claim. There are additional plans offered to government employees,
and a handful of private companies sell private health insurance to the public .

3. Demand for Basic Primary Healthcare and Infrastructure: India faces a growing need
to fix its basic health concerns in the areas of HIV, malaria, tuberculosis, and diarrhea .
Additionally, children under five are born underweight and roughly 7% (compared to 0.8% in
the US) of them die before their fifth birthday. Sadly, only a small percentage of the
population has access to quality sanitation.

For primary healthcare, the Indian government spends only about 30% of the country’s total
healthcare budget . This is just a fraction of what the US and the UK spend every year. One
way to solve this problem is to address the infrastructure issue by standardizing diagnostic
procedures, building rural clinics, and developing streamlined health IT systems, and
improving efficiency. The need for skilled medical graduates continues to grow, especially in
rural areas which fail to attract new graduates because of financial reasons. A sizeable
percentage of the graduates also go abroad to pursue higher studies and employment.

4. Growing Pharmaceutical Sector: According to the Indian Brand Equity Foundation

(IBEF), India is the third-largest exporter of pharmaceutical products in terms of volume.
Around 80% of the market is composed of generic low-cost drugs which seem to be the
major driver of this industry .

The increase in the ageing population, rising incomes of the middle class, and the
development of primary care facilities are expected to shape the pharmaceutical industry in
future. The government has already taken some liberal measures by allowing foreign direct
investment in this area which has been a key driving force behind the growth of Indian
pharmacy .

5. Underdeveloped Medical Devices Sector: The medical devices sector is the smallest
piece of India’s healthcare pie. However, it is one of the fastest-growing sectors in the
country like the health insurance marketplace. Till date, the industry has faced a number of
regulatory challenges which has prevented its growth and development.

Recently, the government has been positive on clearing regulatory hurdles related to the
import-export of medical devices, and has set a few standards around clinical trials.
According to The Economic Times, the medical devices sector is seen as the most promising
area for future development by foreign and regional investors; they are highly profitable and
always in demand in other countries

“Health is a state of complete Physical, Mental and Social well being and not merely an
absence of disease or infirmity which allows a person to live a socio-economically productive
life.”

“Illness is a state in which a person’s physical, emotional, intellectual, social or spiritual

functioning is diminished or impaired.”
“Health care is multitude of services rendered to individuals or communities by the agents of
health services or professional for the purpose of – Promoting, Restoring and Maintaining
health. It embraces all the goods and services designed for “prevention, promotion and
rehabilitation interventions” includes Medical Care.”

Health Care provider:

A person or organization that provides services and/or health care personnel to deliver proper
health care in a systematic way to any individual in need of health care services. It could be a
government or the health care industry, a health care equipment company, an institution such
as a hospital or laboratory. Health care professionals may include physicians, dentists, and
other support staff.

Health services:

Permanent countrywide system of established institutions with the objective of coping with
the various health needs and demands of population thereby provide health care to
individuals and community with preventive and curative activities utilizing health care
workers. These forms a system interacting with each other, supporting and controlling each
other.

Components of healthcare delivery system

1. Structure of health system

Aspects of the design of health services that influences the way in which they are
delivered Includes :

 Number and type of personnel and staff

 Way of these personnel organized to work
 Nature and extend of facility and equipment
 Range of services offered
 System of management and amenities
 Financing
 Enumeration and determination of the eligible population for these services
 Governance and decision making

2. Process of health care delivery

 Behavior of professionals
 Recognition of the problem i.e. diagnosis
 Diagnostic procedure
 Recommendation of treatment or management
 Appropriate follow up
 Participation of people
 Utilization of services
 Understanding the recommendations
 Satisfaction with the services
 Participation in decision making

3. Outcomes of health care: It includes aspects of health that results from interventions
provided by the health system

4. Flow of patients in health care system: It varies from country to country . India harbors a
multistage (three tier) system, where majority of health care is delivered by community health
care worker . Indian system is more cost effective if health workers are skilled and effectively
supervised . Such system could one of the reason to reduced cost of health care in developing
countries

CONSTRAINTS IN HEALTH CARE DELIVERY SYSTEM:

In India though Central and State governments are spending huge sum on healthcare but what
we do not get reciprocal results on ground, malnourishment and spreading of seasonal
diseases like malaria, small pox, dengue, etc. are still uncontrollable. It is really shameful that
hospitals all over our land are not being kept clean. Roaming dogs and dirty side drains and
hospital waste can be found everywhere near the hospital. Clean hospitals will definitely give
better results in healing and controlling of diseases.

Thus we find that medical facilities are available but cost wise they are not affordable for the poor
people therefore government and medical corporate sector must devise the means to reduce the cost of
diagnosis and treatment by providing low cost medicines and medical instrument and profiting in
medical profession must be discouraged by exercising better control on pharmaceutical productions.
The ultimate aim of this should be to provide the medicines and healthcare at the cheapest level and
be affordable to the poor. Secondly in small cities and villages better medical facilities should be
made available by maintaining good hospitals and not only doctors but all government employees
should be encouraged for staying in small cities and performing their duties properly.

Here are seven charts that sum up these key challenges.

1) A weak primary healthcare sector

India has made strides in the expansion of public services. For instance, in 2015, there was
one government hospital bed for every 1,833 people compared with 2,336 persons a decade
earlier. However, as Lancet points out, this has been inequitably distributed. For instance,
there is one government hospital bed for every 614 people in Goa compared with one every
8,789 people in Bihar. The care provided in these facilities is also not up to the mark. For
example, in 2011, six out of every 10 hospitals in the less developed states did not provide
intensive care and a quarter of them struggle with issues like sanitation and drainage.

2) Unequally distributed skilled human resources:

There aren’t enough skilled healthcare professionals in India despite recent increases in
MBBS programmes and nursing courses. Lancet says this shortage is compounded by
inequitable distribution of these resources. In community health centres in rural areas of
many states, ranging from Gujarat to West Bengal, the shortfall of specialists exceeds 80%.
“India does not have an overarching national policy for human resources for health. The
dominance of medical lobbies such as the Medical Council of India has hindered adequate
task sharing and, consequently, development of nurses and other health cadres, even in a state
like Kerala that has historically encouraged nurse education and has been providing trained
nurses to other parts of India and other countries,” said the Lancet study.

3) Large unregulated private sector

Given the quality of care available, few frequent public sector hospitals. The National Sample
Survey Office (NSSO) numbers show a decrease in the use of public hospitals over the past
two decades—only 32% of urban Indians use them now, compared with 43% in 1995-96.
However, a significant portion of these private practitioners may not be qualified or are
under-qualified, Lancet said. For instance, a study in rural Madhya Pradesh found that only
11% of the sampled healthcare providers had a medical degree, and only 53% had completed
high school. Moreover, “the many new institutions set up in the past decade... encouraged by
commercial incentives, have often fuelled corrupt practices and failed to offer quality
education”, the study said.

4) Low public spending on health

Public health expenditure remains very low in India. Even though real state expenditure on
health has increased by 7% annually in recent years, central government expenditure has
plateaued. Economically weaker states are particularly susceptible to low public health
investments. Many state governments also fail to use allocated funds, but this “might simply
reflect structural weaknesses in the system and that need to be addressed with more resources
and a different approach to provision and delivery of care”, said Lancet. The 14th finance
commission recommendations, which will transfer a greater share of central taxes to states,
offers an opportunity for the latter to increase investments in health.

5) Fragmented health information systems

Like in most facets of life in modern India, getting quality, clean, up-to-date data is difficult
in the health sector as well. This is despite the presence of many agencies ranging from
NSSO to the Registrar General of India to disease-specific programme-based systems to
survey malaria to HIV. Data is incomplete (in many cases it excludes the private sector) and
many a time, it’s duplicated. Worse, the agencies don’t talk to each other. Further, its usage is
limited because of an inadequate focus on outputs and outcomes.

6) Irrational use and spiraling cost of drugs

Costs of medical treatment have increased so much that they are one of the primary reasons
driving people into poverty, as Mint has pointed out previously. Yes, there have been
schemes such as the Jan Aushadhi campaign to provide 361 generic drugs at affordable prices
and different price regulation policies, but their implementation has been patchy and varied in
different states, said Lancet. Corruption also increases irrational use of drugs and technology.
For instance, kickbacks from referrals to other doctors or from pharmaceutical and device
companies lead to unnecessary procedures such as CT scans, stent insertions and caesarean
sections, the study said.
7) Weak governance and accountability

“In the past 5 years, the government has introduced several new laws to strengthen
governance of the health system, but many of these laws have not been widely implemented,”
said Lancet. In some instances, the “scope of (some) regulations is still unclear, and there are
fears that these laws have hindered public health trials led by non-commercial entities”, it
added.

The Lancet study identified inadequate public investment in health, the missing trust and
engagement between various healthcare sectors and poor coordination between state and
central governments as the main constraints why universal healthcare is not assured in India.

“At the heart of these constraints is the apparent unwillingness on the part of the state to
prioritize health as a fundamental public good, central to India’s developmental aspirations,
on par with education. Put simply, there is no clear ownership of the idea of universal health
coverage within the government,” it said.

Health Care Delivery System in India

India is a union of 28 states and 7 union territories.
States are largely independent in matters relating to the delivery of health care to the
people.
Each state has developed its own system of health care delivery, independent of the
Central Government.
The Central Government’s responsibility consists mainly of policy making , planning
, guiding, assisting, evaluating and coordinating the work of the State Health
Ministries.
The health system in India has 3 main links
1. Central
2. State and
3. Local or peripheral
The official “organs” of the health system at the national level consist of
1. Ministry of Health and Family Welfare
2. The Directorate General of Health Services
3. The Central Council of Health and Family Welfare
 (2) Concurrent list :The functions listed under the concurrent list are the responsibility of
both the union and state governments.

 Prevention and extension of communicable diseases

 Prevention of adulteration of food stuffs
 Control of drugs and poisons
 Vital statistics
 Labor welfare
 Ports other than major
 Economic and social planning
 Population control and Family Planning
 Preparation of health education material for creating health awareness through
Central Health Education Bureau.
 Collection, compilation, analysis, evaluation and dissemination of information
through the Central Bureau of Health Intelligence
 National Medical Library

2. Directorate General of Health Services

Organization Pattern

Directorate General of health services ↓

Director General of health services ↓

Additional Director General of health service ↓

Deputy Directorate General of health services

Administrative staff

Functions:

 International health relations and quarantine of all major ports in country and
International airport
 Control of drug standards
 Maintain medical store depots
 Administration of post graduate training programmes
 Administration of certain medical colleges in India
 Conducting medical research through Indian Council of Medical Research
 Central Government Health Schemes.
 Implementation of national health programmes
 Preparation of health education material for creating health awareness through Central
Health Education Bureau.
 Collection, compilation, analysis, evaluation and dissemination of information
through the Central Bureau of Health Intelligence
 National Medical Library

3. Central Council of Health

Organization Pattern

Chairman (Union health Minister)

Members (State health Minister)

Functions 1. To consider and recommend broad outlines of policy regard to matters

Concerning health like environment hygiene, nutrition and health education.

2. To make proposals for legislation relating to medical and public health matters.

3. To make recommendations to the Central Government regarding distribution of Grants-in-

aid

II. At the State level :The health subjects are divided into three groups: federal, concurrent
and state. The state list is the responsibility of the state, including provision of medical care,
preventive health services and pilgrimage within the state.

State health administration :At present there are 28 states in India, each state having its
own health administration
 Organization Pattern
State Ministry of Health & family welfare ↓

Deputy Minister of Health and Family Welfare ↓

Health Secretary ↓

Deputy Secretaries ↓

Administrative staff

(2) State Director of health

Director of Medical Education Director of Health Services

Dean of medical college Additional Director of Health Services
State nursing superintendent Deputy Director of Health
Services

Functions of state health Director:

(1) Studies in depth the health problem and needs in the state and plans scheme to Solve
them

(2) Providing curative & preventive services

(3) Provision for control of milk and food sanitation

(4) Prevention of any outbreak of communicable diseases

(5) Promotion of health education

(6) Promotion of health programmes such as school health, family planning,

Occupational health

(7) Supervision of PHC

(8) Establishing training courses for health personnel

(9) Co-ordination of all health services with other minister of state such as minister of
education, central health minister &voluntary agency

III. At the district level There are 593 ( year 2001 ) districts in India. Within each district,
there are 6 types of administrative areas.

 Sub –division
 Tehsils( Taluks )
 Community Development Blocks
 Municipalities and Corporations
 Villages and
 Panchayats
  Most district in India are divided into two or more subdivision, each incharge of an
Assistant Collector or Sub Collector
 Each division is again divided into taluks, incharge of a Thasildhar. A taluk usually
comprises between 200 to 600 villages
 The community development block comprises approximately 100 villages and about
80000 to 1,20,000 population, in charge of a Block Development Officer. Finally,
there are the village panchayats, which are institutions of rural local self-government.
 The urban areas of the district are organized into Town Area Committees (in areas
with population ranging between 5,000 to10,000 Municipal Boards (in areas with
population ranging between 10,000 and2,00,000)
 Corporations(with population above 2,00,000) The Town Area Committees are like
panchayats. They provide sanitary services. The Municipal Boards are headed by
Chairmen /President, elected by members.

The functions of Municipal Board:

1. Construction and maintenance of roads

2. Sanitation and drainage
3. Street lighting
4. Water supply
5. Maintenance of hospitals and dispensaries
6. Education and Registration of births and deaths etc.

The Corporations are headed by Mayors, elected by councilors, who are elected from
different wards of the city. The executive agency includes the commissioner, the secretary,
the engineer and the health officer. The activities are similar to those of municipalities, on a
much wider scale.

Panchayat Raj - The panchayat raj is a 3-tier structure of rural local self-government
in India linking the village to the district. It includes Panchayat (at the village level)
,Panchayat Samiti ( at the block level), Zila Parishad(at the district level)
(1) Panchayat (at the village level): The Panchayat Raj at the village level consists of
The Gram Sabha
The Gram Panchayat

The Gram Sabha: It is the assembly of all the adults of the village, which meets at least
twice a year. The gram Sabha considers proposals for taxation, and elect members of The
Gram Panchayat.

The Gram Panchayat :It is the executive organ of the gram sabha and an agency for
planning and development at the village level. The population covered varies from 5000 to
15000 or more. The members of panchayat hold offices for a period of 3to4 years. Every
panchayat has an elected president (Sarpanch or Sabhapati or Mukhia), a vice president and
panchayat secretary. It covers the civic administration including sanitation and public health
and work for the social and economic development of the village
 (2) Panchayat Samiti (at the block level): The block consists of about 100 villages and a
population of about 80,000 to 1,20,000. The panchayat samiti consists of Sarpanch, MLAs,
MPs residing in block area, representative of women, SC, ST and cooperative societies. The
primary function of the Panchayat Samiti is the execute the community development
programme in the block. The Block development Officer and his staff give technical
assistance and guidance in development work.

(3) Zila Parishad (at the district level): The Zila Parishad is the agency of rural local self
government at the district level . The members of Zila parishad include all heads of panchayat
samiti in the district, MPs, MLAs, representative of SC, ST and women and 2 persons of
experience in administration, public life or rural development. Its functions and powers vary
from state to state.

Health care system:

o At village level
o At sub center level
o At PHC level
o At CHC level

(1) At village level: At the village level, elementary services are rendered by

(a) Village health guides

(b) Local dais

(c) Anganwadi workers

(d) ASHA
 (a) Village health guides: Village health guide is a person with an aptitude for social service
and is not full time govt. functionary. Village health guides scheme was introduced on 2nd
oct. 1977. Guidelines for their selection:

o They should be permanent resident of the local community, preferably women

o They should be able to read and write, having minimum formal education at
least up to the VI std.
o They should be acceptable to all sections of community
o They should be able spare at least 2 to 3 hours every day for community health
work.
o After selection the health guide undergo a short training in primary health
care. The training is arranged in the nearest PHC, sub Centre or other suitable
place for the duration of 200 hours, spread over a period of 3 months. During
the training period they receive a stipend of Rs. 200 per month.

Functions of Village health guides:

(1) Provide treatment for common minor ailments (2) First aid during accidents and
emergency (3) MCH care (4) Family planning (5) Health education

(2) Local dais: Most deliveries in rural areas are handled by untrained dais. The training for
dais given for 30 working days. Each dai is paid stipend of Rs. 300 during the training period.
The training is given at PHC, sub centers or MCH center for 2 days in a week and on the
remaining four days of the week they accompany the health worker(female) to the village.
During her training each dai is required to conduct at least 2 deliveries under the supervision
and guidance of health worker (female), ANM, health assistant (female).

Functions of dais: (1) MCH care (2) Family planning (3) Immunization (4) Education
about health (5) Referral services (6) Safe water and basic sanitation (7) Nutrition

(3) Anganwadi worker: Under the ICDS scheme there is an anganwadi worker for a
population of 1000.There are about 100 such workers in each ICDS project. The anganwadi
worker is selected from the community and she undergoes training in various aspect of
health, nutrition and child development for 4 months. She is a part time worker and paid an
honorarium of Rs.200-250 per month for the services.

Functions of anganwadi worker: (1) MCH care (2) Family planning (3) Immunization
(4) Education about health (5) Referral services (6) Safe water and basic sanitation (7)
Supplementary nutrition (8) Non formal education of children

4) Accredited Social Health Activist (ASHA) :One of the key components of the National
Rural Health Mission is to provide every village in the country with a trained female
community health activist – ‘ASHA’ or Accredited Social Health Activist. Selected from the
village itself and accountable to it, the ASHA will be trained to work as an interface between
the community and the public health system. Following are the key components of ASHA:

SELECTION OF ASHA
The general norm will be ‘One ASHA per 1000 population’. In tribal, hilly, desert areas the
norm could be relaxed to one ASHA per habitation, dependent on workload etc. The States
will also need to work out the district and block-wise coverage/phasing for selection of
ASHAs.

It is envisaged that the selection and training process of ASHA will be given due attention by
the concerned State to ensure that at least 40 percent of the ASHAs in the State are selected
and given induction training in the first year as per the norms given in the guidelines. Rest of
the ASHAs can subsequently be selected and trained during second and third year.

Criteria for Selection: ASHA must be primarily a woman resident of the village
‘Married/Widow/Divorced’ and preferably in the age group of 25 to 45 yrs. ASHA should
have effective communication skills, leadership qualities and be able to reach out to the
community. She should be a literate woman with formal education up to Eighth Class. This
may be relaxed only if no suitable person with this qualification is available. Adequate
representation from disadvantaged population groups should be ensured to serve such groups
better.

Roles and responsibilities of ASHA:

1. ASHA will take steps to create awareness and provide information to the community
on determinants of health such as nutrition, basic sanitation & hygienic practices,
healthy living and working conditions, information on existing health services and
the need for timely utilization of health & family welfare services.
2. She will counsel women on birth preparedness, importance of safe delivery, breast-
feeding and complementary feeding, immunization, contraception and prevention of
common infections including Reproductive Tract Infection/Sexually Transmitted
Infection (RTIs/STIs) and care of the young child.
3. ASHA will mobilize the community and facilitate them in accessing health and health
related services available at the village/sub-center/primary health centers, such as
Immunization, Ante Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS,
sanitation and other services being provided by the government.
4. She will work with the Village Health & Sanitation Committee of the Gram
Panchayat to develop a comprehensive village health plan.
5. She will arrange escort/accompany pregnant women & children requiring treatment/
admission to the nearest pre-identified health facility i.e. Primary Health Centre/
Community Health Centre/ First Referral Unit (PHC/CHC /FRU).
6. ASHA will provide primary medical care for minor ailments such as diarrhea, fevers,
and first aid for minor injuries. She will be a provider of Directly Observed Treatment
Short-course (DOTS) under Revised National Tuberculosis Control Programmed.
7. She will also act as a depot holder for essential provisions being made available to
every habitation like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA),
chloroquine , Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug
Kit will be provided to each ASHA. Contents of the kit will be based on the
 recommendations of the expert/technical advisory group set up by the Government of
India.
8. Her role as a provider can be enhanced subsequently. States can explore the
possibility of graded training to her for providing newborn care and management of a
range of common ailments particularly childhood illnesses.
9. She will inform about the births and deaths in her village and any unusual health
problems/disease outbreaks in the community to the Sub-Centers/Primary Health
Centre.
10. She will promote construction of household toilets under Total Sanitation Campaign.
11. Fulfillment of all these roles by ASHA is envisaged through continuous training and
up gradation of her skills, spread over two years or more

Rural Health care system in India:The health care infrastructure in rural areas has been
developed as a three tier system and is based on the above population norms.

Sub Center:
The most peripheral and first contact point between the primary health care system and
the community. The Ministry of Health Family Welfare is providing 100% Central
assistance. They are established on the basis of

II. Primary Health Center: The first contact b/w village and community and the
Medical Officer. The PHCs were envisaged to provide an integrated curative and
preventive health care to the rural population with emphasis on preventive and
promotive aspects of health care. The PHCs are established and maintained by the State
Governments. At present, a PHC is manned by a Medical Officer supported by 14
paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 - 6 beds for
patients. The activities of PHC involve curative, preventive, primitive and Family
Welfare Services.

Medical care
Health programmes
MCH care and family planning
Health education and training
Referral services
Safe water supply and basic sanitation
Prevention and control of locally endemic diseases
Collection and reporting of vital events
Basic laboratory services
Community Health Center (CHC):These were established by upgrading the primary
health centers. CHCs are being established and maintained by the State Government.
centers,each community health center should cover population of 80000 to 1.2 lakh

FUNCTIONS

Care of Routine and Emergency Cases in Surgery

Dressings, I&D, and surgery for Hernia, Hydrocele, Appendicitis etc.Emergencies

like Intestinal Obstruction, Haemorrhage, etc.

Other management including nasal packing, tracheostomy,foreign body removal etc.

Fracture reduction and putting splints/plaster cast.Conducting daily OPD.

 Care of Routine and Emergency Cases in Medicine,Daily OPD

Handling all the emergency and routine cases

Maternal Health

 Minimum 4 ANC check ups including Registration &associated services

 1st visit: Within 12 weeks—preferably as soon as pregnancy

 2nd visit: Between 14 and 26 weeks

 3rd visit: Between 28 and 34 weeks

 4th visit: Between 36 weeks and term

 24 hr delivery services including normal and assisted delivery and

cesareansection

 Managing labour using Partograph.

 Minimum 48 hours of stay after delivery, 3-7 days stay post delivery for managing
Complications Newborn Care and Child Health

 Essential Newborn Care and Resuscitation

 Counseling on Infant and young child feeding

 Routine and emergency care of sick children

 Full Immunization of infants and children against VPDs

 Management of Malnutrition cases.

 Family Planning

 Counseling, provision of Contraceptives, NSV,

 Laparoscopic Sterilization Services and their follow up.

 Safe Abortion Services All National Health Programmes delivered through CHCs

 School health services

 Others

 Blood storage facility

 Essential laboratory services

 Referral (transport) services

 Maternal Death review (MDR)

Patterns of Nursing care delivery in India
INTRODUCTION :As nursing has evolved over a period, nursing is still focused on caring.
Rapid technologic advances, knowledge explosion, emphasis on quality –cost effectiveness-
accessibility of health care and increased demand by the patients for advanced alternative
health care modalities present many challenges for nursing profession.

How are nurses responding to these challenges? .So how can we best utilize professional
nurses across various practice settings? The answer for this question is that it is possible by
reshaping organizational (administrative) policies and developing such system of nursing care
delivery as best suited to client needs.

MEANING OF NURSING CARE DELIVERY SYSTEM

A system may be defined as a whole made up of integrated or joined and interrelated

parts. Although each component of the system has its specific function, yet all of
them work harmoniously for common out come.
The nursing care delivery system means ‘the process of delivering care to the client
by combining various aspects of nursing service which will fit to various patient care
settings to produce a common outcome of delivering quality care and meeting the
needs of clients.’
There are various types of nursing care delivery system include case method,
functional method, team nursing, primary nursing, modular nursing, nursing care
management, patient focused care.

PRINCIPLES OF NURSING CARE DELIVERY

 Holistic approach is used to identify nursing care needs:

 physical needs
 mental and social needs
 spiritual needs
 Nursing care is based on a helping relationship
 It is the unique function of the nurse to provide nursing care according to client’s
needs
 The aspect of patient care has to be initiated and controlled by nurse
 There should be justification for selecting each delivery system
 Before planning care organizational policies to be considered

Factors influencing nursing care delivery system

 Availability of adequate staff in wards or units

 Patient census
 Extend of staff deficiency
 Organizational policies regarding it’s practice
 Patient’s preferences for care
 Availability of skilled staff
 Opportunities for continuing and in-service education to the staffs
 Budget of the organization
  Socio economical condition of the patient
 The organization’s mission
 Patient and community needs

1. CASE METHOD: The case method or total patient care method of nursing care delivery
is the oldest method of providing care to a patient. The premise of the case method is that one
nurse provides total care to one patient during her entire work period of one shift. This
method was used in the era of Florence nightingale when patient received total care in the
home. That time nurses were ‘hired’ and they lived with in the family of the patient provided
24 hrs care to patient and even family. But the case method developed over the years to the
specialty of private duty nursing especially in critical care nursing where one nurse cared one
or two clients. During an 8-12 hour shift the patient receives consistent care from one nurse.
The nurse , patient , family share mutual trust and work together toward specific goals.
Usually the care is patient centered, comprehensive, holistic and continuous.

Nurse Manager’ role:

The nurse manager must consider the expense of the system before arranging the staff.
Arrange skilled and qualified nurse so that she could manage all the care of the person. The
manager also need to identify the level of education and communication skills of all .Arrange
for continuing education and in service education for the personnel.

Staff nurse’s role: Provide holistic care to assigned patient during a defined work period.
Assessment and teaching the patient and family

Merits:

o Nurse can see better and attend to the total needs of the patient
o Continuity of care can be facilitated
o Client or nurse interaction and rapport can be developed
o Client may feel more secure
o Family friends become more known by nurse and get more involved
o Equal work load

Demerits:

1. Many clients do not require the inherent care

2. Must be modified if non professional health workers are used
3. Great disadvantage when nurse is inadequately trained
4. Cost –effectiveness

2. FUNCTIONAL NURSING : This system emerged in 1930’s in USA

Meaning: Individual care givers are assigned to specific tasks rather than being assigned to
certain patients or clients . It is based on a division of labour similar to an assembly line. This
model is also referred to as task method . Functional nursing evolved during the depression
when RNs went from being private practitioners to becoming employees for the job security
Origin: Once world war II was broke out resulted in severe shortage of nurses in US. Many
nurses entered the military to care for the soldiers. To accommodate this shortage, hospitals
increased their usage of auxiliary personnel. Functional nursing is a method of providing
patient care by which each licensed and unlicensed staff members perform specific tasks for a
large group of patients. For example RN may administer all intravenous medications one
LPN /LVN may give treatments another LPN /LVN may give all oral medications , One
assistant may do all hygienic tasks, and another assistant may take all vital signs. The nurse
become expert in the particular task she is performing.

A charge nurse co-ordinates care and assignments and may ultimately be the only person
familiar with all the needs of any individual patient. ‘The key idea was nurses to be assigned
for tasks not to the patient’

Nurse managers role:

The nurse manager must be sensitive to the quality of patient care delivered and the
institution’s budgetary constraints. Achieving patient outcome is her responsibility. Improve
the staff’s perception of their lack of independence. Rotate assignments among staff , to
alleviate boredom with repetition. Conduct staff meeting frequently to encourage staff to
communicate about care And unit functions.

Staff nurse’s role: They are skilled at the task which is assigned. Complete the task in an
efficient and economical manner

Merits:

1. Person can become particularly skilled in performing assigned tasks

2. The best utilization of personnel can be done
3. Less equipment is needed
4. Saves time
5. Potential for development of technical skills is amplified
6. There is a sense of productivity for the task oriented nurse
7. It is easy to organize the work of the unit and staff
8. Task oriented and time saving
9. Reduced work load to the registered nurses.

Demerits: Client care become impersonal .Diminishing continuity of care. Staff may become
bored and have little motivation to develop self and others. Work may become monotonous.
Less accountability for the nurse. Lack of professional development. Client may tend to feel
insecure and inconvenient. Only parts of the nursing care plan are known to personal. Where
the model is commonly used;

3. TEAM NURSING: Team nursing is the delivery of nursing care by a designated group of
staff members including both professional nurses and non-professional staff .This method of
nursing care was introduced in early 1950’s. Several elements are considered necessary:
Team leader is the delegated authority to make assignments for team members and guide the
work of the team. The leader of the team should be a registered nurse, not a practical nurse
The leader is expected to use a democratic or participative style in interactions with team
members. The team is responsible for the total care given to an assigned group of patients or
clients. Communication among team members is essential to its success, and includes written
patient care assignments , nursing care plans, reports to and from the team leader, team
conferences in which patient care problems and team concerns are discussed, and frequent
informal feedback among team members.

Responsibilities of team leader:

1) Team leader assign team members to patients by matching patient’s needs and staff
knowledge and skill.
2) Knowing condition and needs of all assigned patients
3) Duty vary according to work load, i.e. assisting the members and giving direct care to
patients.
4) Planning and conducting the conference.

Advantages:

 Improved patient satisfaction

 Cost effectiveness for the agency
 Care is less fragmented because of the increased communication and extensive
ordination efforts of team leader
 Allows comprehensive, holistic nursing care when the team function best.
 Good interpersonal relationships among staffs and with the patients
 Satisfaction to the patient and the nurses

Disadvantages:

1) Continuity of care is not given

2) Changing team membership makes it difficult for the team leader to assign the patient.
3) Team nursing requires a great deal of co-operation communication from all staff
members
4) The large number of people attending the same is causing some discomfort to the patient.
5. MODULAR NURSING

It is a modification of team nursing In modular nursing, staff are geographically assigned to

patients for whom they co-ordinate and provide comprehensive care. It focuses on geographic
location of patient rooms and assignment of staff members. It was developed by Magargal in
1987

Delivery model: The total unit is divided in to modules or districts and the same team of staff
is assigned consistently to the module. Modular nursing is enhanced when nursing units are
physically designed and built with this nursing delivery system in mind but it can also be
used in nursing units that are not so designed. Each module has a modular, or team leader
RN, who assigns the patient to module staff. Each module ideally consists of at least one RN,
one LPN/LVN and one nursing assistant. A charge nurse will co-ordinate the work of all the
modules in a unit. She expects the module leaders to be accountable for patient care but assist
in problem solving when necessary. Staff nurses work independently or together, depending
on the size of a modular districts . Modules may have same or different number of patients

Responsibilities of charge nurse / head nurse:

1) Assign patients to different modules

2) Co-ordinate the work schedule and supervises all care on the
3) Make patient care assignments, and there by maintain continuity of care.
4) Assist in problem solving when necessary

Responsibilities of modular or team leader:

 Assigns patient to module staff

 Co-ordinate the module activity
 Accountable for the care and to the charge nurse
 Communicate with other modules

Advantages:

1) Increased continuity of care

2) Geographic closeness of the modular system saved nursing time
3) Better communication and co-operation among staff
4) Easier for less experienced nurses because they have other nurses directly available to
them for support
5) Patients are more secured

Disadvantages:

1) Less accountability
2) Less direct nurse-to-nurse communication and accountability
3) If patient changes room, he will also change nurses, so patient satisfaction may be less
4) It’s a costly method as it should have a redesign of the work environment to allow
medication cart, supplies and charts to be located in each module.

5. Primary nursing: Primary nursing developed by Manthey Et al in 1970 as a method for

organizing patient care delivery in which one RN functions autonomously as the patient’s
primary nurse throughout the hospital stay. This method is based on the concept of ‘my
patient-my nurse” In this nursing care delivery system, each registered nurse is assigned to
the care of group of patient for which she plans complete 24 hrs. care and writes the nursing
care plan.

The primary nurse cares for her patients every time she works for as long as the patient stay
on her unit. (ideally from admission to discharge). When she is not there, an associate nurse
who will follow the primary nurse’s care plan is assigned to the care of primary nurse’s
patient. The primary nurse is intensively involved with the patients. Licensed practical nurses
function as associate nurse sand are supervised by the head nurse. When nursing assistants
are used in primary nursing system, they are generally assigned to assist primary and
associate nurses by doing specific tasks for each nurse they assist.

Advantages:

 Satisfaction for both patients and nurses

 The relationship between nurses and patient is intimate
 Autonomy for the nurses
 Nurse is the person who is planning and providing complete care
 She communicates with all other health team members involved in client care
 Other health team members including physician tend to view her more knowledgeable
and responsible
 Patient receives quality and continuity of care
 Reduces the number of errors than can result from a relay of orders
 Increased satisfaction both to patients and nurses
 Nurse can identify patient outcome as a result of their work

Demerits:

1. Nurse may be isolated from colleagues

2. Nurses talent to a limited number of patients
3. Nursing care plan can be changed only with the permission of primary nurse
4. Creates separation anxiety in patients when nurse
5. Nurses should be well educated and trained in all area of patient care, most of the
time which may lack

6. CASE MANAGEMENT: Case management is considered as the newest type of nursing

care delivery system developed in 1985 as an outgrowth of primary care, nursing case
management is a model used to co-ordinate the care, maintain quality, and contain cost while
focusing on the outcomes of care .“Nursing case management is a collaborative activity that
focuses on comprehensive assessment and intervention and holistic care planning with
appropriate referrals to meet the health care needs of the patient and family”. The success of
nursing case management models has been demonstrated in all health care settings including
acute, sub-acute or ambulatory settings long term care facilities, in health insurance
companies and in community.

Role of nurse case manager:

Delivers client focused and outcome oriented care

 Cost effective care through integration of clinical services in combination with

financial services
 Serves as an advocate for patient and family
 More patient and nurse satisfaction is achieved through intensive care
 They attend to a specific high risk population

Advantages:
 o Patient receives high standard care
o Nurse is highly qualified and skilled in the particular area,
o More satisfaction to the patient
o Increased professional standards can be developed by the nurses

Disadvantages:

1. Sometimes discomfort to clients

2. Continuity care is difficult
3. Long time nurse patient relationships are difficult to arrange
4. Costly
5. Time consuming
6. No proper attachment between nurses and patients

Research Input

A systematic review of several models of care has been undertaken with a predominance of
team nursing within the comparisons, suggestive of its popularity or longevity. Nurse
satisfaction, absenteeism and role clarity/confusion predominantly did not differ across model
comparisons although the need for clear definition of the role or tasks and accountability of
specific nurses remains necessary. Similarly, communication remains a key aspect of good
patient care and nursing care delivery and should be fundamental to any implementation of a
new model of care. Surprisingly, little benefit was found within primary nursing comparisons
and the cost effectiveness of team nursing over other models remains debatable. Nonetheless,
team nursing does present a better model for inexperienced staff to develop, a key aspect in
units where skill mix or experience is diverse. Contexts such as day surgery may have
relevance in the choice of model and should be considered. This review has provided the best
available evidence relating to various models of nursing care on nurse sensitive indicators
such as fall incidents, medication errors and infection, with several studies showing no
significant difference. These outcome measures are important indicators of care and further
studies should include these data.

Planning and organizing nursing service at various levels – local,

regional, national, and international
Placement of nurses in the healthcare organization A high power committee on nursing and
nursing profession was set up by the Government of India in July 1987 under the
chairmanship of Smt. Sarojini Vasadapan, an eminent social worker and former chairperson
of Central Social Welfare Board with Smt. Rajkumari Sood, Nursing Advisor to Government
of India, as the member secretary. The terms of reference of the committee were as follows:

a. Looking into the existing working conditions of nurses with particular reference to the
status of the nursing care services both in rural and urban areas.

b. To study and recommend the staffing norms necessary for providing adequate nursing
personnel to give the best possible care, both in the hospitals and community.
c. To look into the training of all categories and levels of nursing, midwifery personnel to
meet the nursing manpower needs at all levels of health service and education.

d. To study and clarify the role of nursing personnel in the healthcare delivery system
including their interaction with other members of the health team at every level of health
services management.

e. To examine the need for organisation of the nursing services at the national, state, district,
and lower levels with particular reference to the need for planning and implementing the
comprehensive nursing care services with the overall healthcare system of the country at their
respective levels.

f. To look into all other aspects which the committee may consider relevant with reference to
their terms of reference.

g. While considering the various issues under the above norms of reference, the committee
will hold consultations with the state governments. The findings of this committee give a
grim picture of the existing working condition of nurses, staffing norms for providing
adequate nursing personnel, education of nursing personnel to meet the nursing manpower
needs at all levels and the role of nursing personnel in the healthcare delivery system.

Their recommendations on the organisation of nursing services at central, state and district
levels, and the norms of nursing service and education are given below.

Placement of nurses at the central level

At the central level there is a post of nursing advisor in the medical division of Directorate
General of Health Services. The nursing advisor is directly responsible to the Deputy Director
General (Medical). The nursing advisor is assisted by nursing officer and support staff for all
his/her work. She/he advises the DGHS, Ministry of Health and Family Welfare as well as
other ministries and departments, for example, railways, labour, Delhi Administration, etc. on
all matters of nursing services, nursing education, and research. The nursing advisor also
takes care of administration aspects of Raj Kumari Amrit Kaur College of Nursing and Lady
Hardinge Health School, Delhi. There is a post of deputy nursing advisor at the rank of
Assistant Director General (ADGNsg) in the training division of Department of F. W.
Presently the deputy nursing advisor deals with training of ANMs, dais, health supervisor,
etc. There is no direct linkage between the nursing advisor and deputy nursing advisor as
there are independent posts.
Placement of nurses at state level : There is no proper and definite pattern of nursing
structure in the state directorates except the state of West Bengal. Usually one or two nurses
are posted with varying designations, e.g., in Tamilnadu there is one assistant director nursing
who is responsible to Director, Medical Services, and Director, Medical Education. In
Maharashtra, two nurses work, one each in the office of the Director, Medical Education, and
Director, Health Services.
Placement of nurses at district level : Nurses, public health nurses, lady health visitors,
auxiliary nurse midwives, etc. have played vital role in providing healthcare services at
various levels in both urban and rural areas of the district. They have been the mainstream in
providing primary healthcare services in the rural and urban areas from the very beginning.
INSTITUTIONAL LEVEL –

AT HOSPITAL

Organization of nursing services and education

Director of nursing

Nursing services must function under a senior competent nursing administrator – variously
called as director of nursing, nursing superintendent, principal matron, or matron-inchief. She
is responsible to the hospital administrator for overall programme and activities of nursing
care of all patients in the hospital. Nursing programme is administered by her through
appropriate planning of services, determining nursing policies in collaboration with hospital
management and nursing procedures in collaboration with nursing staff, giving general
supervision, delegation of responsibility, coordination of interdepartmental nursing
activities‘, and counseling the hospital administration on nursing problems.
 She has a dual role: the first one is the administrative responsibility towards hospital
administration, and the second one is the coordinating of all professional activities of nursing
staff with those of medical staff.

The role of the nursing superintendent starts in a new hospital from helping to establish the
overall goals, policies and organization, and facilities to accomplish these goals in the most
effective and efficient manner. The functional elements of the role of nursing superintendent
includes the following

 Formation of the aims, objectives and policies of nursing services as an integral part
of hospital service
 Staffing based on nursing requirements in relation to accepted standard of medical
care
 Planning and directing nursing services
 Maintaining supplies and equipments
 Budgeting
 Records and reports
 Nursing supervisor
 Each department or clinical division, e.g. Medical, surgical, obstetrical, operation
theatres, outpatient department, nurseries, etc. should have a supervisor. As they may
be more than one nursing unit in each division or department, supervisors have a
general administrative and coordinating function within their respective division.
However, supervisors will also have limited clinical functions
 Head nurse / nursing tutor
 A head nurse is assigned to a nursing unit, or ward, or a section of department. She
works under the general direction of the supervisor of the division.
 Staff nurse / clinical instructor
 Staff nurses are employed at the ‗floor‘ level for carrying out skilled bedside nursing.
This is the real work force of the hospital upon whose competency, state of training
and dedication depend the success of the nursing department.
 Student nurse
 Students nurse cannot be employed on nursing duties except under supervision of
fully qualified staff nurses.

FIVE YEAR PLANS

Healthcare During Five Year Plans
The health of the nation is an essential component of development, vital to the
nation’s economic growth and internal stability. Assuring a minimum level of health care
to the population is a critical constituent of the development process. Recognising this
fact, the Planning Commission gave considerable importance to health programmes in Five
Year Plans. For purposes of planning, the health sector has been divided into the following
sub-sectors.
(1) Water supply and sanitation
(2) Control of communicable diseases
(3) Medical education, training and research
(4) Medical care including hospitals, dispensaries and primary health centres
(5) Public health services
(6) Family planning, and
(7) Indigenous systems of medicine.
a. The First Five Year Plan (1951-56) was a modest beginning towards development
of different health programmes. A seven-point public health programme such as provision
of water supply and sanitation, control of malaria, health services for mothers and children,
education and training in healthcare etc. formed the basis for the plan.
b. In the Second Five Year Plan (1956-61) the government aimed to expand the
existing health services to bring them within the reach of the people.
c. In the Third Five Year Plan (1961-66) importance was given to expand health
services to bring progressive improvement in health by ensuring a minimum of physical
well-being.
d. In the Fourth Five Year Plan (1969-74) efforts were made to provide effective base
for health services in rural areas for undertaking preventive and curative health services.
e.In the Fifth Five Year Plan (1947-79) an attempt was made to provide minimum
public health facilities integrated with family planning and nutrition for vulnerable groups.
f. In the Sixth Five Year Plan (1980-90) providing qualitative medical education and
training to the people was emphasised.
g. In the Seventh Five Year Plan (1985-90) efforts were made to correct imbalances to
improve quality and establishment of Universities of Health Sciences with an objective of
linking training centres. Encouragement was given to states to participate fully in their
own manpower development activities.
h. During the Eighth Five-Year Plan (1992-97) Plan period efforts were initiated to
expand education facilities for those categories of healthcare providers. The incorporation
of health related courses was pursued vigorously. Interest was shown in bridging the gap
between supply and demand of paramedical staff and nursing staff.
i. During the Ninth Plan, efforts were made to explore the health status of the
population by optimising coverage and quality of care by:
(a) identifying and rectifying the critical gaps in infrastructure, manpower, equipment,
essential diagnostic reagents and
drugs, and
(b) enhancing the efficiency of the health system. The focus during the Tenth Five Year Plan
was on restructuring the existing government heal care system, Development of appropriate
two-way referral systems, Building up an efficient logistics system, Improvement in the
quality of care at all levels and Building up Health Management Information using IT tools.
j. The Eleventh Five Year Plan (2007-12) will provide an opportunity to restructure
policies to achieve a New Vision for Health based on faster, broad-based and inclusive
growth. This plan gives special attention to the health of marginalised groups like
adolescent girls, women of all ages, children below the age of three, older persons,
disabled and primitive tribal groups. To achieve these objectives, aggregate spending on
health by the Central and States will be increased significantly.
The Eleventh Five Year Plan will aim for inclusive growth by introducing National Urban
Health Mission (NUHM) which, along with National Rural Health Mission (NRHM), will
form SURVA SWASTHYA ABHIYAN. National Urban Health Mission will meet the
health needs of the urban poor, particularly the slum-dwellers, by making available to them
essential primary health services. This will be done by investing in high caliber health
professionals, appropriate technology through Public Private Partnership (PPP) and health
insurance for urban poor, while National Rural Health Mission will address infirmities and
problems across primary health care and bring about improvement in the health system and
the health status of those who live in the rural areas.
k. Twelfth five year plan (2012-17): The Twelfth Five-Year Plan of the Government of
India has been decided to achieve a growth rate of 8.2% but the National Development
Council (NDC) on 27 December 2012 approved a growth rate of 8% for the Twelfth
Five-Year Plan.
With the deteriorating global situation, the Deputy Chairman of the Planning Commission
Montek Singh Ahluwalia has said that achieving an average growth rate of 9 percent in the
next five years is not possible. The Final growth target has been set at 8% by the endorsement
of the plan at the National Development Council meeting held in New Delhi.
he objectives of the Twelfth Five-Year Plan were:

 To create 50 million new work opportunities in the non farm sector.

 To remove gender and social gap in school enrolment.
 To enhance access to higher education.
 To reduce malnutrition among children aged 0-3 years.
 To provide electricity to all villages.
 To ensure that 50% of the rural population have accesses to proper drinking water.
 To increase green cover by 1 million hectare every year.
 To provide access to banking services to 90% of households.

l. 13th five year plan : The ten objectives for the 13th five-year plan includes
"maintaining economic growth, transforming patterns of economic development,
optimizing the industrial structure, promoting innovation-driven development,
accelerating agricultural modernization, reforming institutional mechanisms, promoting
coordinated .

REPORTS OF HEALTH COMMITTEES

In 1940, the resolution adopted by the National Planning Committee based on the Sokheys
Committee’s recommendations recommended integration of preventive and curative
functions and the training of a large number of health workers. Bhore committee constituted
in 1943 laid the framework on which the health care was eventually built in the independent
India. The health care in India has since moved from bureaucratic government based top
down approach to decentralized community based bottom- up system after the Panchayati Raj
came into being. This model was long ago propagated by the Father of the nation “Mahatma
Gandhi”.
A. Bhore Committee (1943-1946): During pre independence era, to improve the
preventive, promotive and curative heath services of country, a National Planning
Commission was set up by the Indian National Congress in 1938. The rulers of that
time, the British Empire realised the importance of Public Health and instituted the
‘Health Survey and Development Committee,’ in the year 1943 under the
chairmanship of Sir Joseph Bhore. The committee was tasked to survey the then
health conditions and health organisations in the country, and to make
recommendations for future development. The committee submitted its report in
1946. The integration of preventive, promotive and curative health services and
establishment of Primary Health Centres in rural areas were the major
recommendations made by this committee:
 Integration of Preventive, Promotive and Curative services at all
administrative levels.
 The development of Primary Health Centres for the delivery of comprehensive
health services to the rural India. Each PHC should cater to a population of 40,
000 with a Secondry Health Centre (now called Community Health Centre) to
serve as a supervisory, coordinating and referral institution.
 In the long term (3 million plan), the PHC would have a 75 bedded hospital
for a population of 10,000 to 20,000.
 It also reviewed the system of medical education and research and included
compulsory 3 months training in Community Medicine.
 Committee proposed the development of National Programmes of health
services for the country.
B. Mudaliar committee (1962) : During second five year plan, Government decided to
relook at the health needs and resources of the country to provide necessary
guidelines to national health planning. Also to review the progress made since
submission of Bhore committee report, Government appointed “Health Survey and
Planning Committee” under the chairmanship of Dr A Lakshman swami Mudaliar in
1959 to make future recommendations for development and expansion of health
services. It admitted that the basic health facilities had not reached at least half the
 nation and there was gross mal distribution of hospitals and beds in favour of urban
areas. The committee found that the quality of services provided by PHCs were
grossly inadequate with poor functioning, lack of referral system, and gross under
staffing due to insufficient resources. Important recommendations of the Mudaliar
committee are:
 Strengthening of existing PHCs and development of referral centres before
new centres were established.
 Strengthening of subdivisional and district hospitals.
 Integration of medical and health services.
 It also suggested constitution of an All India Health Service in the pattern of
Indian Administrative service.
C. Chadah Committee (1963) : Dr MS Chadha, the then DGHS, was appointed to study
the details of the necessary requirements related to PHCs and maintenance of National
Malaria Eradication Program. Important recommendations of the Chadah committee
are:
● Strict monitoring and vigilance of implementation of NMEP is responsibility of
general health services at all levels i.e. health workers of PHC, CHC, ZP.
● One basic health worker (now called Multi Purpose worker) for every 10, 000
population was recommended.
● Basic health workers should visit house to house once in a month to implement
malaria activities.
● Basic Health worker should take additional duties of collection of vital statistics,
family planning etc.
D. Mukerji Committee, 1965 : By recommending basic health workers to take on additional
responsibilities and work as multi purpose worker, both NMEP and family planning
programme got a major set back. A committee under the chairmanship of Shri Mukerji, then
Health Secretary to GOI was appointed to review the health system at different levels from
the point of manpower and financial planning. Important recommendations of the Mukerji
committee are:

 Strengthening of the administrative set up at different levels from PHC to state health
services.
 Separate staff was recommended for family planning program.
 Basic health worker to be utilised for all duties except for family planning.
e. Jungalwalla Committee, 1967 : In 1967, Central Council of Health appointed
“Committee on integration of Health Services” headed by Dr N. Jungalwalla, then
Director, National Institute of Health Administration and Education. Important
recommendations of the Jungalwalla committee are represented:
● Integrated health services with :
- Unified cadre
- Common seniority
- Recognition of extra qualifications
- Equal pay for equal work
- No private practise
- Special pay for specialised service
- Improvement in their service conditions
 ● Medical care of the sick and conventional public health programmes functioning under
single administrator.
f. Kartar Singh Committee, 1973: The Committee headed by then additional secretary,
MOH and Family planning, Shri Kartar Singh, was constituted to study and make
recommendations on the structure for integrated health services at peripheral and
supervisory levels. It was to study the feasibility of bi purpose and multipurpose workers
in the field. Important recommendations of the Kartar Singh committee are:

 It recommended “Female Health Worker” in place of ANM and “Male Health

Worker” in place of malaria surveillance worker, vaccinators, health education
assistants and family planning health assistants.
 The committee proposed a PHC per 50, 000 population with 16 subcentres, each
covering a population of 3000- 3500. (4)
 Each subcentre to have one male and one female health worker.
 There should be one male and one female health supervisor at PHC to monitor and
supervise the activities of staffs of 3-4 sub centres.
 The MO i/c PHC will be the overall in charge of all peripheral staff.
 Training for all workers engaged in the field of health, family planning and
nutrition should be integrated.
g. Shrivastav Committee (1974-75) : This is known as “Group on Medical Education and
Support Manpower” constituted in 1974 by the Government. The concept of community
participation in the health sector originated which has given concept of “people’s health in
people’s hand”. Convened under the chairmanship of Dr J B Shrivastav, Director General
Health Services, this committee made the recommendations as:
● Creation of Village Health Guide (VHG) or community health volunteers from the
community itself like teachers, postmasters, gram sevaks who can provide comprehensive
health services as paraprofessionals.
● Primary health care be provided within the community itself through specially trained
workers so that the health of the people is placed in the hands of people themselves.
● Creation of MPW and Health Assistants (HA) in between the VHG and MO i/c PHC.
h. Shivaraman Committee health report: A Committee on Basic Rural Doctors was
framed under the guidance of Shri Shivaraman, then member of planning commission. The
committee recommended establishment of countrywide cadre of basic rural doctors
consisting of trained paraprofessionals to extend comprehensive health care delivery to rural
community.
i. Ramalingaswamy Committee Health Report : This committee under the chairmanship of
Dr V Ramalingaswamy, then DGHS, recommended as:
● Involvement of community for health planning and health programme implementation
● 30 bedded hospital for every 1 lakh population
● Integration of health services at all levels
● Redefined the role of doctor in the community
● Recommended that PHC and District health centres should be under the control of three
tier Panchayati Raj System.
j. Bajaj Committee health report 1986 : A expert committee for ‘health manpower
planning, production and management’ was constituted under the chairmanship of Dr JS
Bajaj, then member of planning commission, to tackle the problem of health manpower
planning, production and management. Important recommendations of the Bajaj committee
are:
● Recommended for Formulation of National Health Manpower planning based on realistic
survey.
● Educational Commission for health sciences should be developed on the lines of UGC.
● Recommended for National and Medical education policy in which teachers are trained in
health education science technology.
● Uniform standard of medical and health science education by establishing universities of
health sciences in all states.
● Establishment of health manpower cells both at state and central level.
● Vocational courses in paramedical sciences to get more health manpower.
k. Krishnan Committee Health Report 1992 : The committee under the chairmanship of Dr
Krishnan reviewed the achievements and progress of previous health committee reports and
also made comments on shortfalls. The committee address the problems of urban health and
devised the health post scheme for urban slum areas. The committee had recommended one
voluntary health worker (VHW) per 2, 000 population with an honorarium of Rs 100. Its
report specifically outlines which services have to be provided by the health post. These
services have been divided into outreach, preventive, family planning, curative, support
(referral) services and reporting and record keeping. Outreach services include population
education, motivation for family planning, and health education. In the present context, very
few outreach services are being provided to urban slums.

HEALTH POLICY
It refers to the public or private rules, regulations, laws or guidelines that relate to the pursuit
of health and the delivery of health services.

Implied And Expressed Policies:

1. Implied: Implied policies are neither written nor expressed verbally, have
usually developed over time and follow a precedent. For example a hospital
may have an implied policy that employees should be encouraged and
supported in their activity in community, regional and health care
organizations.
2. Expressed: Expressed policies are donated verbally or in writing. Most
organizations have many written policies that are readily available to all
people and promote consistency of action. It may include a formal dress code,
policy for sick leave or vacation time and disciplinary procedures. Before any
 action is taken, an issue should be put on the public agenda. Placing an issue
on the public agenda requires actions that bring a concern to the attention of
the policy makers and the public, people other than those affected by the
situation are aware of the issue and its consequences.
Policy Decisions: According to Mason, Leavitt, Chaffee, 2002 Policy decisions (e.g.
laws or regulations) reflect the values and beliefs of those making the decisions. As
the values and beliefs change, so do policy decisions.

TYPES OF POLICIES:

 Distributive Policies: Distributive policies extend goods and services to

members of an organization, as well as distributing the costs of goods or
services amongst the members of organization. Examples include Government
policies that impact sending for welfare, public education, highways and
public safety or a professional organization‘s policy on membership training.
 Regulatory Policies: Regulatory policies limit the discretion of individuals
and agencies or otherwise complete certain types of behavior. These policies
are generally thought to be best applied in situations where good behavior can
be easily defined and bad behavior can be easily regulated and punished
through fines.
 Constituent Policies: These create executive power entities or deal with laws.
 Miscellaneous Policies: Policies are dynamic; they are not just static list of
goals or laws. Policy blueprints have to be implemented, often with
unexpected results.
 Social Policies are what happens ‗on the ground‘ when they are implemented
as well as what happens at the decision making or legislative state.

Other Types Of Policy:

 Domestic Policy: It presents decisions, laws and programs made by

Government which are directly related to issues in the country.
 Economic Policy: It refers to the actions that Governments take in the
economic field. It covers the systems for setting interest rates and Government
deficit as well as the labor market and many other areas of Government.
 Education Policy: It refers to the collection of laws or rules that govern the
operation of education system. Education occurs in many forms for many
purposes through many institutions. Education policy can directly affect the
education people engage in at all levels.
 Environmental Policy: It is an action deliberately taken to manage human
activities with a view to prevent, reduce or mitigate harmful effects on nature
and natural resources and ensuring that man made changes to the environment
do not have harmful effects on humans.
 Health Policy Analysis: It is the process of assessing and choosing among
spending and resource alternatives that affect the health care system, public
health system.
  Foreign Policy: It is also called the INTERNATIONAL RELATIONS
POLICY‘ is a set of goals outlining how the country will interact with other
countries economically, politically, socially and military.
 Human Resource Policy: These are systems of codified decisions, established
by an organization, to support administrative personnel functions, performance
management, employee relations and resource planning.
 Public Policy: It is the body of fundamental principles that underpin the
operation of legal systems in each state. This addresses the social, moral and
economic values that tie a society together, values that vary in different
cultures and change overtime.
 Social Policy: It relates to guidelines for the changing, maintenance or
creation of living conditions that are conducive to human welfare. Thus social
policy is that part of public policy that has to do with social issues. Social
policy aims to improve human welfare and to meet human needs for
education, health, housing and social security.

Impact of Policy on Nursing:

 Public policy has significant impact on the practice of nursing. The ability of
the individual nurse to provide care is affected by public policy decisions.
 State licensure of a registered nurse (RN) derives from legislation that defines
the scope of nursing practice. The defined scope determines what a nurse
legally can and cannot do. Regulations that are developed to implement
legislation also affect practicing nurses and their work environments. For e.g.,
the rules for administering and documenting the administration of narcotic
drugs are promulgated by a regulatory agency of the Federal Government, the
Federal Drug Administration, under the department of Health and Human
Services.
 The way in which such regulations are written can greatly affect nurse's
ability to practice. If nurses do not actively participate in developing
regulations, policy outcomes are likely to restrict rather than enhance nursing
authority for regulated activities.

Spheres of Nursing Influence: The nurse has an opportunity to make an impact on policies
in four aspects of influence as identified by Talbot and Mason (1988). These spheres are:-

 Government.
 Organizations.
 Workplace.
 Community.
Since the community encompasses the other three spheres, only Government,
organizations, and workplace .
Government: Laws, with their accompanying rules and regulations, control nursing
practice and health care. Nurses have been more involved in federal and state
Governments, although local governments provide many health care services.
 Local governments control school health programs, local public hospitals and home
and community health care. In general, the nurse first must be a registered voter.
Nurses can join collective actions by working with PACs (Political Action
Committees). These committees support deserving candidates who support nursing
and health care issues.
Most states have state nurses association PACs for state and local candidates.
Workplace – Over 66% of nurses work in hospitals and should be influential in setting
hospital policies, especially regarding patient care.
Nurses can influence how quality care is delivered with controlled costs. Most
hospitals currently require that many non nursing tasks be done by nurses. Through
collective action, nurses serving on committees in the institution can help eliminate
these tasks. Nurse can even serve on the board of trustees of the institution. Nurses
who successfully practice the politics of change in their place of employment can
influence the type and quality of patient care.
Organizations: Important influences include professional organizations such as ANA
and many specialty organizations. The organizations work in coalitions with other
health groups to support or oppose issues. By joining and being active in a
professional organization, an individual nurse has access to a wider range of tools and
information to use in order to influence health care policies.

The National Health Policy, 2002:

The National Health Policy, 2002 gives prime importance to ensure a more equitable access
to health services across the social and geographical expanse of the country. It calls for a
strong primary health network in rural India. Emphasis has been given to increase the
aggregate public health investment through a substantially increased contribution by the
Central Government. Priority has been given to preventive and curative initiatives at the
primary health level through increased sectoral share of allocation. The highlights of the
policy are:

(1) Increase health sector expenditure to 6 percent of GDP, with 2 percent of GDP being
contributed as public health investment, by the year 2010. With the stepping up of the public
health investment, the Central Government's contribution would rise to 25 percent from the
existing 15 percent by 2010. An increased allocation of 55 percent of the total public health
investment for the primary health sector. The secondary and tertiary health sectors being
targeted for 35 percent and 10 percent respectively.

(2) The plan envisaged gradual convergence of all health programmes under a single field
administration . Vertical programmes for control of major diseases like TB, Malaria,
HIV/AIDS, as also the Reproductive and Child Health and Universal Immunization
Programmes, would need to be continued till moderate levels of prevalence are reached.

(3) It was proposed that the programme implementation be effected through autonomous
bodies at State and district level. The interventions of State Health Departments may be
limited to the overall monitoring of the achievement of programme targets and other
technical aspects. The presence of State Government officials, social activists, private health
professionals and MLAs/MPs on the management boards on the autonomous bodies will
facilitate well-informed decision-making. All rural health staff should be available for the
entire gamut of public health activities at the decentralized level, irrespective of whether
these activities relate to national programmes or other public health initiatives.

(4) The policy envisages kick starting the revival of the Primary Health System by
providing some essential drugs under Central Government funding through the
decentralised health system. It recognises the practical need for levying reasonable user-
charges for certain secondary and tertiary public health care services, for those who can
afford to pay.

(5) The policy also recommended a mandatory two-year rural posting before the awarding
of the graduates degree. This would not only make trained medical manpower available in
the underserved areas, but would offer valuable clinical experience to the graduating doctors.

(6) The policy envisages the setting up of a Medical Grants Commission for funding new
Government Medical and Dental Colleges in different parts of the country. It also
recommended the need to modify the existing curriculum to enable fresh graduates to
contribute effectively to the providing of primary health services as the physician of first
contact.

(7) This policy also recommends a periodic skill updating of working health professional
through a system of Continuing Medical Education. The policy also envisages the creation of
additional seats for post-graduate courses.

(8) Panchayat bodies to be involved more in health care programmes. All State Governments
to consider decentralising the implementation of the programmes to such institutions by
2005. In order to achieve this, financial incentives, over and above the resources normatively
allocated for disease control programmes, will be provided by the Central Government.

(9) The policy emphasizes the need for an improvement in the ratio of nurses visa-vis
doctors/beds.

(10) The policy proposed setting up of an organised two-tiered urban primary health care
structure: the primary centre as the first-tier, covering a population of one lakh, and a second
tier at the level of public general hospital. The funding for the urban primary health system
will be jointly borne by the local self-government institutions and state and central
governments.

(11) The policy proposed establishment of fully equipped 'hub-spoke' trauma care networks
in large urban agglomerations to reduce accident mortality.

(12) It also recommended the upgrading of the physical infrastructure of mental

hospital/institutions at Central Government expense so as to secure the human rights of this
vulnerable segment of society.
(13) The policy emphasized on giving priority to school health programmes which aim at
preventive health education, providing regular health check-ups, and promotion of health-
seeking behaviour among children.

(14) The policy proposed an increase in Government funded health research to a level of 1
percent to the total health spending by 2005, and thereafter up to 2 percent by 2010.

(15) The policy also proposed a social health insurance scheme, funded by the Government,
and with service delivery through the private sector. As a first step, this policy envisages the
introduction of a pilot scheme in a limited number of representative districts, to determine the
administrative features of such an arrangement as also the requirement of resources for it.

(16) It stressed involvement of non-governmental practitioners in the national diseases

control programmes so as to ensure that standard treatment protocols are followed in their
day-to-day practice.

(17) The policy recognised the significant contribution made by the NGOs and other
institution of the civil society in making available health services to the community. The
disease control programmes would earmark not less than 10% of the budget in respect of
identified programme components, to be exclusively implemented through these institutions.

(18) The policy expected to fully operationalization an integrated disease control network
from the lowest rung of public health administration to the Central Government. The
programme for setting up this network will include the installation of data-base handling
hardware. IT inter-connectivity between different tiers of the network and in-house training
for data collection and interpretation for undertaking timely and effective response.

(19) It also expected that the baseline estimates for the incidence of the common diseases
such as TB, Malaria, and Blindness would be done by 2005.

Baseline estimates for non-communicable diseases, like CVD, Cancer, Diabetes and
accidental injuries and communicable diseases like Hepatitis and JE would also be compiled.

(20) The policy notified a comprehensive code of ethics which is to be rigorously

implemented by the Medical Council of India. It proposed the establishment of statutory
professional councils for paramedical disciplines to register practitioners, maintain standards
of training and monitor performance.

(21) It made mandatory periodic screening of the health conditions of the workers,
particularly for high-risk health disorders associated with their occupation.

(22) The policy envisaged to provide such health services on a payment basis to service
seekers from overseas – Medical Tourism. All fiscal incentives, including the status of
"deemed exports", available to exporters of goods and services, would be extended for
payment received in foreign exchange.
(23) It also proposed a national patent regime for the future, which, while being consistent
with TRIPS, avails of all opportunities to secure for the country, under its patent laws,
affordable access to the latest medical and other therapeutic discoveries.

POLICY ON AYUSH
The Indian Systems of Medicine and Homoeopathy (External website that opens in a new
window) (ISM&H) were given an independent identity in the Ministry of Health and Family
Welfare in 1995 by creating a separate Department of Ayurveda, Yoga and Naturopathy,
Unani, Siddha and Homoeopathy (External website that opens in a new window) (AYUSH)
in November 2003.

The Indian Government is in the process of creating a national policy for AYUSH
(Ayurveda, Unani, Siddha, and Homeopathy). One of the major proposals of this national
policy is to include these traditional forms of Indian treatment in the universal health
insurance scheme. It is expected that this decision will help in making these domains of
treatment a bigger part of public health system in the country. Such inclusion will also mean
that there is a need to create infrastructural facilities, regulations, and research setups that will
streamline AYUSH in the proper sense of the word.

Circulation of Final Draft

It is expected that the final version of the draft policy will be distributed to various states and
ministries by June and only after that will the same be presented to the central cabinet. The
central ministry for AYUSH is looking to introduce the final policy by October. The process
of getting suggestions from other members of the central administration has been initiated
Why is the AYUSH policy important?
Most importantly, it shows that Indian Government is committed to develop the AYUSH
system and also make it a part of a mechanism for delivering healthcare to the people of
India. In fact, even Narendra Modi has stated time and again that he wishes this programme
to succeed. Another reason as to why the policy is so important is a simple fact that AYUSH,
as a form of treatment, is capable of improving the preventive and primary healthcare
scenario in India.
A global destination for AYUSH
Apart from making AYUSH healthcare available to more people in India in a structured and
methodical way, the Indian Government is looking for its own place on the world map by
promoting itself as a destination for such forms of treatment. This is one more reason why it
is so focused on making this idea work and doing so big time.
Benefits of proposed national policy for AYUSH
It is expected that the said policy will be setting certain time-bound targets to be achieved.
This means that research and education related to AYUSH will become more regulated.
There will also be a definite standard that will have to be followed in case of AYUSH
treatment and medicines. All this will mean more benefits for the common patients – the
intended beneficiaries of the programme.
AYUSH policy objective
As has been said already, the Indian Government is looking to make AYUSH a preferred
choice in the domain of primary healthcare. The policy is expected to play a major role in
bridging the gap between demand for doctors and the supply, especially in the rural areas. As
part of the policy, AYUSH practitioners will be trained to deal with primary healthcare
requirements of patients.
Research tie-up with WHO
India is supposed to enter into a collaborative agreement with the United States and the
World Health Organisation (WHO) in order to further develop the aforementioned methods
of treatment. It is also expected that this association will help India take its traditional forms
of treatment to the global stage and thus, gain more exposure. WHO has supposedly
expressed significant interest in AYUSH treatment and an agreement for the purpose is
supposed to be signed soon in Geneva.
Ayurveda, Yoga and Naturopathy
This is indeed one positive development for all concerned. If the Indian government is
successful in making AYUSH work, it will enable the rural population to access primary
healthcare at lower costs. People will also have more choices for treatment. Now that the
central government is backing them, these treatments – otherwise derided so regularly by
allopathic healthcare professionals and common people – will find some much-needed
credibility that will help them thrive in the long run.
Secondly, India has a wealth of practitioners who are well-versed in traditional medicine that
are part of the AYUSH programme. This programme can help them take part in the training
and realise their true potential.
Kerala is known for its Ayurvedic treatments and therapies. However, one feels that it is not
the only part of India where such treatments are afforded. With more people around the
world, hopefully, coming to know of them, there will always be a greater chance of more
influx of patients willing to get treated at those places. One also feels that systems of
treatment like Siddha and Unani, which are not as famous as Ayurveda, will now gain the
popularity that they deserve within India and outside as well.
The Indian Government will do well to bring other traditional forms of treatment such as
yoga and naturopathy in the fold of AYUSH. Yoga is perhaps the most ancient science
maintaining well-being and now, thanks to the efforts of various masters practising and
teaching abroad, and with the endorsement of Narendra Modi, it is a globally-recognized
wellness and holistic treatment. The same can be said about Naturopathy, considering the fact
that it has been a success in the US and across Europe.

STATE HEALTH POLICY (PUNJAB)

The constitution of India envisages the establishment of new social order based on equality,
freedom, justice and dignity of the individual. It aims at the elimination of poverty, ignorance
and ill-health and directs the State with regard to raising the level of nutrition and the
standard of living of the people, securing the health and strength of workers, men and
women, and especially ensuring that children are given opportunities to develop in a healthy
manner.
Strictly to the tune of constitutional directives and sincerely to the commitment for "Health
for All", the main functions of the department may be precisely summed up as curative,
preventive and promotive services. Healthy people, having sound physique and mental
development provide a firm foundation for the national development. Whatever is spent on
the improvement for invigorating human resources for higher productivity in every sphere of
socio-economic development.
The Health and Family Welfare Department is committed to provide preventive, promotive
and curative Health Services to the people of the State through a good net-work of medical
institutions such as sub-centers, subsidiary health centers (dispensaries/Clinics etc.), primary
health centers, community health centers, Sub-Divisional and Distt. Hospitals, Government
Medical & Dental Colleges (attached hospitals).

Primary Health Care

Primary Health Care Services in the rural areas of the State are provided through a net work
of Medical Institutions comprising of Sub- Centers (2950) i.e. each for approximately 5000
population, SHCs/Rural Dispensaries/Clinics (1336) i.e. each f or approximately 10000
population, PHCs (395) i.e. each for approximately 30000 population and CHCs (129) i.e.
each for approximately 100000 population. Under Alternative Health Care Delivery System,
1187 subsidiary health centers (rural dispensaries have been transferred to department of
Rural Development and Panchayats. Where rural medical officers i.e. service providers
(doctors) have been appointed by the Zila Parishad. For the promotion of Indian Systems of
Medicine & Homoeopathy (AYUSH), 507 Ayurvedic /Unani dispensaries, 17 Ayurvedic
Swasth Kendra's, 5 Ayurvedic Hospitals, one Govt. Ayurvedic college at Patiala and 107
Homoeopathic dispensaries are functioning in the State.

The various National and State Health Programmes which have been launched to provide
Primary Health Care include a crusade against Malaria, Tuberculosis, Blindness, Leprosy and
AIDS. All the programs have been successfully implemented in the State.

Secondary Level Health Care System

While the CHCs established in rural areas serve as the first level of referral services, the
Hospitals at Sub-Divisional level and District Hospitals serve as secondary level of health
care system and give support to the services being provided in the Primary Health Care
System. Since CHCs in a way also provide specialist services, these can be considered as a
part of the secondary level health care system.
Hospital Services at the secondary level play a vital and complementary role to the Primary
Health Care System and together form a comprehensive district based health care system. A
health care system based on PHC cannot exist without a network of hospitals with
responsibilities for supporting primary care and hospital care. Both are essential part of a
well-integrated health care system.

Tertiary Level Health Care System

Tertiary level health care services are provided in the State by the specialized hospitals and
hospitals attached to State Medical Colleges. These institutions besides providing support to
the secondary level health care system, are expected to carry out research and manpower
development for the health services of the State.

Delivery of Family Planning Services

In order to provide Family Planning Services in the urban areas, 23 Urban Family Planning
Centers, 64 Urban Revamping Centers and 52 Post Partum Units are functioning in the State.
 NATIONAL POLULATION POLICY

As per the latest World Population Prospects released by United Nations (revision
2015),
the estimated population of India will be 1419 million approximately w
hereas China’s population will be approximately 1409 million, by 2022. In spite of
the perceptible decline in Total Fertility Rate (TFR) from 3.6 in 1991 to 2.3 in 2013,
India is yet to achieve replacement level of 2.1. Twenty four states/UTs have already
achieved replacement level of TFR by 2013, while states like UP and Bihar with large
population base still have TFR of 3.1 and 3.4 respectively. The other states like
Jharkhand (TFR 2.7), Rajasthan (TFR 2.8), Madhya Pradesh (TFR 2.9), and
Chhattisgarh (TFR 2.6) continue to have higher levels of fertility and contribute to the
growth of population.
The National Population Policy 2000, is uniformly applicable to the whole country. In
pursuance of this policy, Government has taken a number of measures under Family
Planning Programme and as a result, Population Growth Rate in India has reduced
substantially which is evident from the following:-
i. The percentage decadal growth rate of the country has declined
significantly from 21.5% for the period 1991-2001 to 17.7% during 2001-
2011.
ii. Total Fertility Rate (TFR) was 3.2 at the time when National Population
Policy, 2000 was adopted and the same has declined to 2.3 as per Sample
registration Survey (SRS) 2013 conducted by the Registrar General of
India.
As the existing NPP-2000 is uniformly applicable to all irrespective of religions and
communities etc., therefore no proposal is under consideration of the Government to
formulate new uniform population policy. The steps taken by the Government under
various measures/programme are given below:-
Steps/Measures to Control the Population Growth of India by
the Government of India

On-going interventions:
 More emphasis on Spacing methods like IUCD.
 Availability of Fixed Day Static Services at all facilities.
 A rational human resource development plan is in place for provision of IUCD,
minilap and NSV to empower the facilities (DH, CHC, PHC, SHC) with at least
one provider each for each of the services and Sub Centres with ANMs trained
in IUD insertion.
 Quality care in Family Planning services by establishing Quality Assurance
Committees at state and district levels.
 Improving contraceptives supply management up to peripheral facilities.
  Demand generation activities in the form of display of posters, billboards
and other audio and video materials in the various facilities.
 National Family Planning Indemnity Scheme’ (NFPIS) under which
clients are insured in the eventualities of deaths, complications and failures
following sterilization and the providers/ accredited institutions are
indemnified against litigations in those eventualities.
 Compensation scheme for sterilization acceptors - under the scheme MoHFW
provides compensation for loss of wages to the beneficiary and also to the
service provider (& team) for conducting sterilisations.

 Increasing male participation and promotion of Non Scalpel Vasectomy.

 Emphasis on Miniap Tubectomy services because of its logistical simplicity
and requirement of only MBBS doctors and not post graduate
gynecologists/surgeons.

 Accreditation of more private/NGO facilities to increase the provider base for

family planning services under PPP.
 Strong political will and advocacy at the highest level, especially, in States with
high fertility rates.
New Interventions under Family Planning Programme
1. Scheme for Home delivery of contraceptives by ASHAs at doorstep of
beneficiaries: The govt. has launched a scheme to utilize the services of
ASHA to deliver contraceptives at the doorstep of beneficiaries.
2. Scheme for ASHAs to ensure spacing in births: The scheme is operational
from 16th May, 2012, under this scheme, services of ASHAs to be utilised for
counselling newly married couples to ensure delay of 2 years in birth after
marriage and couples with 1 child to have spacing of 3 years after the birth of
1stchild. ASHAs are to be paid the following incentives under the scheme:-

a. Rs. 500/- to ASHA for ensuring spacing of 2 years after marriage.

b. Rs. 500/- to ASHA for ensuring spacing of 3 years after the birth of 1st
child.
c. Rs. 1000/- in case the couple opts for a permanent limiting method up to
2 children only. The scheme is being implemented in 18 States of the
country (8 EAG, 8 NE Gujarat and Haryana).
3. Boost to spacing methods by introduction of new method PPIUCD (Post-
Partum Intra Uterine Contraceptives Device.
4. Introduction of the new device Cu IUCD 375, which is effective for 5
years.
5. Emphasis on Postpartum Family Planning (PPFP) services with introduction
of PPIUCD and promotion of minilap as the main mode of providing
sterilisation in the form of post-partum sterilisation to capitalise on the huge
cases coming in for institutional delivery under JSY.
Assured delivery of family planning services for both IUCD and sterilisation.
6. Compensation for sterilisation acceptors has been enhanced for 11 High Focus
States with high TFR.
7. Compensation scheme for PPIUCD under which the service provider as well
as the ASHAs who escorts the clients to the health facility for facilitating the
IUCD insertion are compensated.
8. Scheme for provision of pregnancy testing kits at the sub-centres as well as in
the drug kit of the ASHAs for use in the communities to facilitate the early
detection and decision making for the outcome of pregnancy.
9. RMNCH Counselors (Reproductive Maternal New Born and Child Health)
availability at the high case facilities to ensure counseling of the clients
visiting the facilities.

10. Celebration of World Population Day 11th July & Fortnight: The event is
observed over a month long period, split into fortnight of
mobilization/sensitization followed by a fortnight of assured family planning
service delivery and has been made a mandatory activity from 2012-13 and
starts from 27th June each year.

11. FP 2020- Family Planning Division is working on the national and state
wise action plans so as to achieve FP 2020 goals. The key commitments of
FP 2020 are as under :
 Increasing financial commitment on Family Planning whereby India
commits an allocation of 2 billion USD from 2012 to 2020.
 Ensuring access to family planning services to 48 million (4.8 crore)
additional women by 2020 (40% of the total FP 2020 goal).
 Sustaining the coverage of 100 million (10 crore) women currently
using contraceptives.
Reducing the unmet need by an improved access to voluntary family planning
services, supplies and information.In addition to above, Jansankhya Sthirata
Kosh/National Population Stabilization Fund has adopted the following strategies as a
population control measure:-

Prerna Strategy:- JSK has launched this strategy for helping to push up the
age of marriage of girls and delay in first child and spacing in second child the
birth of children in the interest of health of young mothers and infants. The
couple who adopt this strategy awarded suitably. This helps to change the
mindsets of the community.
Santushti Strategy:- Under this strategy, Jansankhya Sthirata Kosh, invites
private sector gynaecologists and vasectomy surgeons to conduct sterilization
operations in Public Private Partnership mode. The private hospitals/nursing
home who achieved target to 10 or more are suitably awarded as per strategy.
National Helpline: - JSK also running a call centers for providing free advice
on reproductive health, family planning, maternal health and child health etc.
Toll free no. is 1800116555.
 Advocacy & IEC activities:- JSK as a part of its awareness and advocacy
efforts on population stabilization, has established networks and partnerships
with other ministries, development partners, private sectors, corporate and
professional bodies for spreading its activities through electronic media, print
media, workshop, walkathon, and other multi-level activities etc. at the
national, state, district and block level.

REFERENCES:

(1) k. Park, Text book of preventive and social medicine, Bhanot publication,18thedition,
Page no.674-699.

(2) B.T. Basvanthappa, Community health nursing, Jaypee Publication, 6th edition, Page
no.584-605.

(3) K.K. Gulani, Community health nursing, Kumar Publication, 3rd edition, Page no.591-
593.

(4) Dr. Sr. Mary Lucita, Public health and Community Health Nursing, B.I. publication,

(5) John M. Cookfair, Nursing care in the community, Mosby Publication, 2nd edition,
Page no. 65-81.

(6) Trained nurses association of India, Text book of nursing administration and
Management, First edition, Page no. 253-260

(7) www.google. Com

(8) https://www.mapsofindia.com/my-india/.../what-is-the-national-policy-for-ayush

(9) https://brainly.in/question/2883499