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Why Alma Ata declaration?

Alma Ata & Primary Health Care in IndiaIndia30yrs Celebration

1960,Health agencies finding Unequal distribution of Health Services between Developed &Developing countries Between rich & poor within the same country Avenues of Health did not change the Health status of people

World Health Assembly 1997

In the World Health assembly, in 1977, 1977, an answer was defined. They said, The defined. main social goal of Governments and the WHO in the coming decades should be the attainment, by all the citizens of the world (by the year 2000) of a level of 2000) health that will permit them to lead a socially and economically productive life (or) Health for All by 2000A.D 2000A (HFA 2000).This was a revolutionary 2000) statement, because it stated the desired outcome. outcome.

Alma Ata conference 1978

In September, 1978, a joint WHO-UNICEF 1978, WHOInternational conference was held at Alma Ata , in the then USSR. The Alma Ata USSR. declaration reaffirmed that the goal was HEALTH FOR ALL and the way to get there was through PRIMARY HEALTH CARE. CARE. PHC was not just a package of services, or a level of care or an 8 point programme. programme. It was a philosophy that placed peoples Health in Peoples Hand. Hand.

So, Primary Health Care .

So primary Health care was a revolutionary, bottom-up, people bottomcentered approach for achieving Health for all. It was focused on the all. community and not on the Health Professionals; Professionals; using a consumer perspective rather than a provider perspective. perspective. (example(example-Evaluating a teacher)

PRIMARY HEALTH CARE AS PER ALMA ATA DECLARATION

Essential Health care, based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self determination. determination.

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Principles
1. 2. 3. 4. Community participation Equitable distribution Appropriate technology InterInter-sectoral cordination.

Minimum Elements
1. Health education 2. Food supply and nutrition 3. Safe water and basic sanitation 4. Maternal & child care including Family planning 5. Immunisation 6. Prevention and control of locally endemic diseases. 7. Appropriate treatment of common illnesses and injuries. 8. Provision of Essential drugs.

History of Primary Health care in India

Evolution of Health systems in India 19461946-Sir Joseph Bhore Committee or Health Survey and Development Committee was constituted. It was guided by the lofty principle that nobody should be denied access to health services for his inability to pay' and that the focus should be on rural areas.

19521952-A move to set up primary Health centres

19521952A start was made to setup primary health centres to provide integrated promotive, preventive, curative and rehabilitative services to entire rural population, as an integral component of wider Community Development Programme. Programme. In 1952, India was the first country to 1952, launch a national programme emphasizing family planning to stabilize the population at a level consistent with the requirement of national economy. economy.

During 1970s
1970s1970sThe political changes that took place in the 1970s impelled the Central Government to implement the vision of Sokhey Committee of having one Community Health Worker for every 1000 people to entrust peoples health on people's hand'. India has come quite close to Alma Ata Declaration on Primary Health Care made by all countries of the world in 1978. 1978.

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19751975-ICDS
1975 The ICDS(Integrated child Development Services) scheme was began in selected Community Development blocks in 1975.Two major evaluation of the scheme were conducted in 1978&1982.The positive results of these evaluation led the government to accelerate the expansion of ICDSs through out the country in 1982.

19821982-National Health policy

In 1982, Government made a major move in health politics by coming up very sharply against the health work done in the country during the last 35 years. National Health Policy was thus formed in 1982 to make architectural corrections in health care system. National Health Policy gave a general exposition of the policies which require recommendation in the circumstances then prevailing in health sector.

19851985-UIP
19851985The Universal Immunization Programme (UIP) was launched to provide universal coverage of infants and pregnant women with immunization against identified vaccine preventable diseases.

19921992-93 CSSM
From the year 1992-93, the UIP has 1992been strengthened and expanded into the Child Survival and Safe Motherhood (CSSM) Project. It involved sustaining the high immunization coverage level under UIP, and augmenting activities under Oral Rehydration Therapy, prophylaxis for control of blindness in children and control of acute respiratory infections.

Safe Motherhood
Under the Safe Motherhood component, training of traditional birth attendants, provision of aseptic delivery kits and strengthening of first referral units to deal with high risk and obstetric emergencies were being taken up.

1997-RCH1997-RCH-Phase 1
In 1997, Reproductive and Child Health (RCH- Phase1) programme (RCHwas launched which incorporated child health, maternal health, family planning, treatment and control of reproductive tract infections and adolescent health

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20052005-2010 RCH Phase 2

RCH Phase-2 (2005-2010) aims at Phase- (2005sector wide, outcome oriented, program based approach with emphasis on decentralization, monitoring and supervision which brings about a comprehensive integration of family planning into safe motherhood and child health.

National Rural Health Mission (2005(2005-2012)

The National Rural Health Mission (2005-2012) is (2005a major undertaking by the present United Progressive Alliance Government to honor its commitments under common minimal programme. It is also strategic framework to implement the National Health Policy 2002. It has adopted key guidelines given in National Health Policy 2002, e.g. equity, decentralization, involving Panchayat Raj Institutions (PRIs) and local bodies in owning primary health care management, strengthening primary health care institutions and suggestions for generating alternate source of financing.

Goals of NRHM
The NRHM subsumes key national programmes, namely, Reproductive and Child Health-2 (RCH-2), National Health- (RCHDisease Control Programmes and Integrated Disease Surveillance Project. The mission covers the entire country, with special focus on 18 states, which have relatively poor infrastructure Reduction in IMR and MMR; Universal access of public health services such as womens health, child health, Provision of drinking water, sanitation and hygiene, immunization and nutrition; prevention and control of communicable and non communicable diseases;

Goals continued
access to integrated comprehensive primary health care; population stabilization; revitalization of local health tradition and mainstreaming AYUSH; and promotion of healthy lifestyles.

Core strategies of NRHM

Train and enhance capacity of Panchayat Raj Institutions to own, control and manage public health services. Promote access to improved health care at household level through female health activist (ASHA) Setting up Village Health Committee to develop health plan for each village Strengthening sub-centers through untied fund suband provision of 30-50 bedded CHC per lakh 30population for improved curative care to Indian Public Health Standards (IPHS)

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Core strategies continued..

Integrating vertical health programmes at all levels Technical support to National, State and District Health Mission in preparation of District Health Plan. Strengthening capacities for data collection, assessment and review for evidence based planning and empowering health care institutions for preventive health care. Promoting non-profit sector particularly in nonunderserved areas.

Present Rural Health System

STAFFING PATTERN

Village Level

Village Level Health worker Local Dai Anganwadi worker

A. STAFF FOR SUB - CENTRE

Number of Posts

B. Staff for Primary Health Centre

1. Medical Officer 2. Pharmacist

Number of Posts
1 1 1 1 1 1 1 1 1 1 1 4

1. Health Worker (Female)/ANM 2. Health Worker (Male) 3. Voluntary Worker (Paid @ Rs.100/- p.m. as honorarium) Rs.100/Total:

1 1 1

3. Nurse Mid-wife (Staff Nurse) Mid4. Health Worker (Female)/ANM 5. Health educator 6. Health Assistant(Male) 7. Health Assistant (Female)/LHV 8. Upper Division Clerk

9. Lower Division Clerk 10 Laboratory Technician 11. Driver (Subject to availability of Vehicle) 12. Class IV

Total:

15

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C. Staff For Community Health Centre

Number of Posts

1. Medical Officer ..4 2. Nurse Mid Wife(staff Nurse) ...7 Mid 3. Dresser ..1 4. Pharmacist/Compounder .................................................................1 5. Laboratory Technician ......................................................................1 6. Radiographer ....................................................................................1 7. Ward Boys.2 8. Dhobi................................................................................................1 9. Sweepers..........................................................................................3 10. Mali ................................................................................................1 11. Chow idar ..1 12. Aya...................1 13. Peon....................1

Total: .....................................................................................................25

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Current Health Scenario

20052005-06 National Family Health Survey (NFHS(NFHS-3) Key Findings

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Overview
NFHSNFHS-3 is the third in the NFHS series of surveys, preceded by NFHSNFHS1 in 1992-93 and NFHS-2 in 1998-99 1992NFHS1998NFHS surveys are conducted under the stewardship of MOHFW IIPS is the nodal agency for the National Family Health Surveys

Scope of NFHS-3 NFHSAll 29 states are covered Slum and non-slum areas of noneight cities, i.e. Chennai, Delhi, Hyderabad, Indore, Kolkata, Meerut, Mumbai, Nagpur Interviews were conducted with Women age 15-49 15Men age 15-54 15-

NFHSNFHS-3 Sample
for 29 states
Number Response Interviewe Rate d Households Women (age 15-49) 15Men (age 151554) 109,041 124,385 74,369 97.7 94.5

Selected Household Characteristics

Percent of households

93
Electricity

56 68 51

Piped water

12 25 83

Any toilet facility

26 45

87.1
Urban

Rural

Total

Education status
Universal primary school attendance is attainable in the short run, but only in urban areas In rural areas, one in five children age 6-10 is not 6attending school with a persistent gender gap Drop-out rates between primary and secondary school Dropare very high for both girls and boys, though the gender gap also widens considerably With no more than one in five adults with 10+ years of education, education will be a major bottleneck for sustained economic growth in India There is widespread support among both women and men for teaching most family life education topics in school
NFHS- 3, India, 2005-06

FAMILY PLANNING

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Total Fertility Rate

4.0 3.5 3.0 2.5 2.0 1.5 1.0
NFHS-1 NFHS-2 NFHS-3

Knowledge of Modern Methods

Percent of women and men 15-49 aware of family planning methods
Women Men
95 97 79 74 51 69 83 85 11 20 87 93

3.5 3.4 2.9 2.7 2.5 2.1 2.0 1.5 1.0 NFHS-3
Urban Rural Total

3.0 3.0 2.7

Female sterilization Male sterilization Condom/Nirodh IUD Pill Emergency contraception

Female condom Injectables

17 45 49

Current Contraceptive Use by Method

Percent of currently married women age 15-49

Trends in Contraceptive Use by Age

Percentage of married women using any method

NFHS-1

NFHS-2
70

NFHS-3
73 67 61 56 69 65

56

49 37 5
n Co m do
8 13 7 33 26 21 56 49 42

63 56

63 57

Family planning use among younger Women is increasing.

Family Planning use shows increase in every age over the three NFHS period.

46

1
d od ion io n t ho zat zat eth me rili ri li ym rn st e ste An de le le o ma Ma ym Fe An IUD

2
P il

3
l

15-19

20-24

25-29

30-34

35-39

40-44

45-49

Age

Unmet Need
Unmet need for Spacing 6% Limiting 7% Total 13%

Key Findings
A sizeable proportion of younger women are not aware of spacing methods. Female sterilization continues to be the dominant family planning method. Despite efforts to promote NSV, prevalence and even knowledge of male sterilization is decreasing Users are not fully informed before they start using method Discontinuation of methods very high

Unmet need in NFHS-2 for + Spacing 8% +Limiting 8% Total 16%

Total demand for family Planning

81% is met 19% is not met

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Trends in Antenatal Care

Percent of women who had any ANC* 84 86 NFHS-1 91 59 NFHS-2 72 60 NFHS-3 77 65 66

ANTENATAL CARE

Urban
* For last births in the past 3 years

Rural

Total

Maternity Care
(for most recent birth in the last 5 years)

Trends in Delivery CareOnly about 1 in 7 home deliveries

Percent

are assisted by a skilled provider

Institutional Delivery
41 34 42 35

75

Urban
52 44 35

Rural

Total
61

Delivery assisted by health personnel

49

29 19 23

37

26

3+ ANC

IFA for 90+ days

Postnatal care within 2 days

NFHS-1

NFHS-2

NFHS-3

NFHS-1

NFHS-2

NFHS-3

*For live births in the past 5 years

Are women* using the public sector for their deliveries?

Percent

Summary
Any ANC increased by 11 percentage points and 3+ ANC visits by 7 percentage points between NFHS-2 NFHSand NFHS-3 NFHSStill, half or less than half of women get ANC in the first trimester and get 3+ ANC visits

68

84

39 20 13
14
Urban Rural

33 18

Institutional deliveries increased by 7 percentage points between NFHS-2 and NFHS-3 NFHSNFHSNonetheless, more than half the deliveries still take place at home; half are not assisted by health personnel The majority of mothers with a recent delivery did not receive any postnatal care

29 18
Total

24 8
Lowest Highest

19
SC

12
ST

Residence *For live births in the past 5 years

Wealth index

Caste/tribe

10

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Infant Mortality Rate

NFHS-1 NFHS-2 NFHS-3

85 73 79 68 62 47 42 57

CHILD HEALTH

56

Urban

Rural

Total

Infant Mortality Rates

90 80 70 60 50 40 30 20 10 0
20 80

Infant Mortality Rates by State

73 70 60 50 71 70 69 66 65 65 62 61 57 54 52 50 48 45 45 43 42 42 42 40 38 38

79 65 57 57 64

27
40

36

34 34 30 30

11

30

M D C B an gl ad es h

P ak is ta n

Sr iL an ka

LD C

C hi na

In di a

15 15

N ep al

10 0 AS AR AP KA NA WB MZ GJ RJ PJ DL HP UP MP BH OR CH HR MH MN MG GO KE JH JK SK IN UT TR TN

Steady Decline in Infant Mortality Rates

80 70 60 50 40 30 20 10 0 NFHS-1 NFHS-2 NFHS-3 79 68 57

IMMUNISATION

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Child Immunization Trends

Percent of children age 12-23 months vaccinated

DropDrop-outs Are a Problem for Polio and DPT Vaccine

100
Percentage of children age 12-23 months 93 76 67 89 78

BCG Polio3 DPT3 Measles All Vaccines NFHS-1 35 NFHS-2 42 54 52 55 55 51

62

72

78
80

63

78

60 40 20

55

59

0 DPT 1st dose 2nd dose 3rd dose Polio

42 44 NFHS-3

Full Vaccination
Only 44% of children age 12-23 12months are fully vaccinated (only a slight increase in coverage from 42% in NFHS-2) NFHSBetween NFHS-2 and NFHS-3, full NFHSNFHSvaccination coverage for children increased in 19 of the 29 states and dropped in the remaining 10 states

TREATMENT OF CHILDHOOD DIARROHEA

Trends in Treatment of Childhood Diarrhoea with ORS

Percent of children under age 3 with diarrhoea in the past 2 weeks NFHS-2 NFHS-3

Percentage Received Any ORT or Increased Fluids by State

85 75 69 67 68 72

63 59 55 53 53 54 43 43 43 48 48 49 46 47 47 47 47

65

33

33

39 40

25

24

27

26

33 25 26 26

H AP A R M N M P K A N G U T M H O R TN W B SK

JH PJ G In J di a D L C H JK

TR G O M Z M G H P KE

Urban

Rural

Total

12

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Trends in Child Nutritional Status

Percent of children age under 3 years

NFHS-3

NFHS-2

51

CHILDHOOD NUTRITIONAL STATUS

45

43

40

20

23

Stunted
(Low-height-for-age)

Wasted
(Low-weight-for-height)

Underweight
(Low-weight-for- age)

Anaemia among Children

Percent of children 6-35 months with anaemia

79 72

81

74

Total

Urban

Rural

NFHS-2

Nutritional Status of Adults

Percent of women and men age 15-49
60

Malnutrition of Women by Residence and Education

Percent of women age 15-49

Women

Men

55

50 40
13 24 7 7 13 14 21 11

36

30

34 24

20 10 0

36 25

41

42

35

35 25

36

13

R ur al ed uc at io n

U rb an

ye ar s

ye ar s

ye ar s

To ta l

N o

BMI below normal

Overweight/Obese

Anaemic

Underweight

Overweight

N FH S2

10 +

89

<8

to ta l

13

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TUBERCULOSIS

NFHS-3, 2005-06

Conclusions: Tuberculosis
NFHSNFHS-3 demonstrates that use of solid fuels increases the TB level; the lowest prevalence is in households using clean fuels such as gas/electricity Misconceptions about TB transmission are still high, suggesting the need for awareness campaigns Programmes need to address higher prevalence groups such as older persons, persons in rural areas, and persons in the east and northeastern parts of India

NFHS-3, 2005-06

Life styles: Tobacco and alcohol use Tobacco and alcohol are important risk factors for morbidity and mortality among adults Studies associate alcohol use with accidents/injuries and violence against women Tobacco and alcohol use by women, especially during pregnancy, is a matter of concern since it entails serious reproductive risks

HIV/AIDS

NFHS-3, 2005-06

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AIDS Awareness
Percent of women and men age 15-49 who have heard of AIDS
Urban Rural Total

HIV Prevalence by Residence and Sex, India

Sex Urban Wome n (%) 0.29 0.18 0.22 Men (%) 0.41 0.32 0.36 Total (%) 0.35 0.25 0.28

Women
46 57

81

Men
73 80

94

Rural India

NGOS
HIV prevalence rate is 60% higher among males than females and 40% higher in urban areas than rural areas

4 success stories

1. Comprehensive Rural Health Project, Jamkhed

Crucial features Integration of Health and Development initiative A base hospital and a peripheral health programme. Active Mahila Mandals (womens groups) and Farmers groups Empowered Village Health Workers

The Proof
Between 1971 and 1993, the IMR dropped from 176 to19 per 1000 live births, The birth rate from 40 to 20 live births per 1000 population and underunder-5 immunisation cover from 0.55% to 92%

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2. The CHAD model

Key features are A 4-tier service structure with 4villagevillage-level part time community Health worker (PTCHW),middle-level (PTCHW),middlehealth aides, doctor/Nurse run mobile clinics in each village every month, and the CHAD Hospital with facilities for caesarian sections. A well planned focus on maternal and child health services. A computerised Health Management Information System that is dynamic and functional. Strong curative Health services back up to the primitive and preventive health work.

The result
IMR fell from 84 in1979 to 30 in 1998. The birth rate from 26.7 to 16.1. 97%of antenatal mothers get ANC and 95% of children are completely immunized.

3. KCPPHC model
The Palani Hills Development Trust (PHHDT) is made of health professionals and grass roots community members interested in the provision of sustainable and modern primary health care to a population of 17,000 people living in a remote part of the Eastern Palani Hills.

In 1988 the health parameters in the area were appalling with an infant mortality rate (IMR) of around 200. The IMR is now (excluding the current year when 6 extreme low birth weight babies died) around 252535 (Tamil Nadu average 30) despite it being in one of the economically poorest and under-serviced areas in underTamil Nadu.

The resources available were limited to around Rs. 200 (US$4) per person per year, with the community itself meeting 75% of the health care program costs. Low costs are possible because of rational evidence based health care. A landless agricultural worker earns Rs 70 (men) and 40 (US$1 women) per day for work available 240 days/year.

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The health care program now involves

A base primary health centre supporting 2 subsub-centres where patients with acute medical emergencies are stabilised and then referred safely giving a much better chance of good outcome, uncomplicated acute medical problems and mothers in labour are managed as both in and out patients, and preventive health care integrated through a modern health screening system. The health centre can perform basic radiology and ultrasonography.

A comprehensive community based primary health care work in peripheral villages targeting 7000 of the poorest members of the 17000 total population in the target area. This program includes antenatal care, child health, chronic disease screening and recall systems as well as home visits and health education in schools and villages. These activities ensure that the weakest members of the community are given a priority.

25 Village level health workers from the poorest sections of the target community work voluntarily and help form a health committee that has the scope to change and monitor the program according to community needs.

Regular staffs are 8 full time health workers from the target community, 2 primary health care nurses, a full time specialist family physician and a trainee family physician as well as visiting obstetrician and gynaecologist. We rely on using locally developed clinical guidelines adapted from modern evidence based guidelines in a way that is sustainable by a poor rural community.

The goal
The goal of the program is to show Gods love through the nature of the health care we provide, even in seemingly hopeless situations and especially to people for whom others do not provide health care.

Summary of vital statistics compared to previous years

Data refers to the 7000 population covered by full primary health care activities only. Only some of the previous years data are given to compare current year data for lack of space

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YEAR

1990

1996

1998-9

STATISTICS
YEAR 1990 1996 1998-9 2001-2002 20032004 2005-6 20067 Tamil Nadu * All India IMR >200 80 40

20012002

20032004

2005-6

20067

Tamil Nadu *

All India

19= 3/ 159

27 = 3/112

3/130= 23

6/100= 60

30

57

Total population with primary health care

1800

3000

4000

6928

7000

7000 (6846 +/200)

7000

Complete immunization-n rates 12% 95% 95% 95% >95% 95% @ 95% ?80% ?70%

Perinatal mortality

60

20= 2/112

3/130=23

6/100=60

Birth Weight Average

?<2kg

2.7

2.61

2.7kg

2.5kg

YEAR

1990

1996

1998-9

20012002

20032004

2005-6

20067

Tamil Nadu * Target 35% hosp 45% HW

All India

YEAR

1990

1996

1998-9

20012002

20032004

2005-6

20067

No of mothers delivered in a. hospital-by b. HW/VLHW c. by unskilled person

<20%

a.79b.50c.30

492736 Total 112

552253

452525

Tamil N ad u *

All India

New adult TB patients

18/ 1800

19/ 3000

21/4000

34/ 6928

36/ 7000

37/ 7000

16/ 7000

% of mothers ? receiving at least 3 antenatal visits to Health care worker

40%

85%

98%

?90%

95%

95%

72

% TB patients completing treatment

80%

80%

80%

95% or 43 0f 45

91%

97%

11/12

?80%

Crude birth rate Maternal mortality % Eligible mothers having sterilization or other birth control 3/28 ?15% 0/35 ?40% 0/42 70% 0 26 of 89= 29% 0 26 of 40 = 65% 0 46/69 0 23/60 Crude death rate 2/ 1000 4/ 1000

Inaccur Ate data? 26

23

17

19

14

22

25

5.49

10**

10

11

Explanatory points *In comparing our data with that for India and the Tamil Nadu state average it is important to realise that 1. The project area is one of the most underdeveloped areas in Tamil Nadu and 2. 2. The data further refers to the poorest 40% of that areas population.

Summary of important developments and difficulties/ failures

Our vital statistics continues to show that we can achieve significant results in health standard improvements in rural and poor communities through modern primary health care. Our data on most health parameters over the last few years is better than the Tamil Nadu state average despite our target area being a backward area and the statistics reflecting the poorest 40% of that population.

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10/30/2008

We have continued to improve on standards of health care, especially in the stabilisation of critically ill patients before referral and in the management of chronic diseases, yet keep the costs manageable by adapting modern clinical guidelines.

We continue to work closely with the Goodwill childrens society in providing health care to children sponsored by them. Their activities continue to considerably enhance the educational standards of school children. Another joint eye camp organised by them and Arvind eye hospital in KCPPHC resulted in several elderly patients accessing free cataract surgeries

The program provided training in primary care to family medicine registrars and to other health workers seconded from other projects

Health promotion in schools as a part of the school curriculum continues but village based health education has sometimes been difficult in large villages, finding the places for people to gather. We have increased health promotion activities to targeted smaller groups (such as youth, mothers with children etc.) while reducing our traditional methods of gathering a whole population in a village in evening programs each week in different places. Poster campaigns on smoking and domestic violence were attempted this year

Our Failures and Disappointments

There has been a continued welcome improvement in time available to see patients despite increasing patient numbers because of programs that allow a team approach to holistic health care where responsibilities in health care are increasingly shared by health workers as well as doctors
We lost 6 very low birth weight babies this year, which have reflected on our IMR being much higher this year. We have protocols to admit low birth weight infants for 1-3 days to establish breast-feeding 1breastand improve care but not many mothers access these services often because of taboos about leaving home after delivery. Our % delivery to be done in health centers is also below target levels despite steps such as contracts between mothers and health center to fix delivery charge for each mother at a affordable level

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Environmental sanitation remains a difficult problem but 24 model toilets in remote villages were constructed with the help of NGOs. These model toilets have already generated interest in other people wanting toilets. The government scheme for sponsoring individual toilets in homes is very difficult for poor people to access.

The work schedule for all staff is heavy and demanding and sometimes leads to differences between staff members. We need to find a better way of working where we also support each other more through a stronger fellowship and accept limitations in a kinder way to each other.

OUR TEAM

4. The Mitra model

3-tier health care delivery structure. Village based prioritisation based on community diagnosis that is revised annually. Integration of health work with education programmes, backed by self-help groups selfand a community based health insurance programme. A focus on community based control of Malaria which is the main cause of morbidity and mortality.

Result
Fall of IMR from 203 in 1995 to 102 in 2001.

Conclusions

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10/30/2008

There has been an improvement in the Health parameters over the years but it has been very slow and there are varied discrepancies between the rural and urban, and between various states. With its knowledge base, its administrative and institutional strengths and its growth potential India is capable of much higher levels of achievements in health.

The political will for Primary health care is low and needs much more advocacy. There has not been much training of the medical and paramedical personnel with regard to primary health care. The training of doctors nurses and paramedical is more in terms of secondary and tertiary level of care and hence a sense of inadequacy and dissatisfaction is felt when placed in primary heath care centre. There needs to be a compulsory training and hands on experience of the doctors, nurses and paramedics during the training period which needs to be implemented by the respective governing bodies.

Ongoing medical education and skill training of the Health personnel at the primary health care so that they are updated with the latest guidelines and provide quality care to patients.

THANK YOU

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