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PSM 2 - Complete Exam Revision Notes

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🔴 RED TOPIC 1: Primary Health Care (PHC) / Health Education

Primary Health Care

"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."

• Social equity
• Equity / Self-reliance
• Nationwide coverage
• Intersectoral coordination
• People's involvement

1. Education about prevailing health problems and methods of prevention
2. Promotion of food supply and proper nutrition
3. Adequate supply of safe water and basic sanitation
4. Maternal and child health care, including family planning
5. Immunization against infectious diseases
6. Prevention and control of endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs

• Growth monitoring
• Oral rehydration therapy
• Breast feeding
• Immunization
• Food supplementation
• Female education
• Family spacing

• Sub-centre: 1 per 5,000 (plains) / 3,000 (hilly/tribal) - staffed by 1 ANM + 1 MPW (M)
• PHC: 1 per 30,000 (plains) / 20,000 (hilly/tribal) - staffed by 1 Medical Officer + 14 parastaff; 4-6 beds
• CHC: 1 per 1,20,000 (plains) / 80,000 (hilly/tribal) - 30 beds; 4 specialists (physician, surgeon, OBG, pediatrician)

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Health Education

"A process aimed at encouraging people to want to be healthy, to know how to stay healthy, to do what they can individually and collectively to maintain health, and to seek help when needed."

"The process by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance or restoration of health."

• Knowledge - increase health knowledge
• Attitude - change attitude
• Practice - modify health behaviour

• Credibility, Relevance, Accessibility, Variety, Education, Needs, Knowledge, Involve, Simple, Self-reliance

• Source → Message → Channel → Receiver → Effect (feedback)

1. Build healthy public policy
2. Create supportive environments
3. Strengthen community action
4. Develop personal skills
5. Reorient health services

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🔴 RED TOPIC 2: PMR / MMR

Perinatal Mortality Rate (PMR)

PMR = (Stillbirths + Early Neonatal Deaths in <7 days) / Total Births × 1000

• Stillbirth rate = Stillbirths / Total births × 1000
• Early neonatal mortality rate = Deaths in 0-6 days / Live births × 1000

• Birth asphyxia (most common)
• Birth injuries
• Prematurity / low birth weight
• Infections (sepsis, pneumonia)
• Congenital malformations
• Placental/umbilical cord complications

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Maternal Mortality Ratio (MMR)

"The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from unintentional or incidental causes."

MMR = (Maternal deaths / Live births) × 1,00,000

1. Direct obstetric deaths - from obstetric complications (haemorrhage, pre-eclampsia, sepsis, obstructed labour, unsafe abortion). Most common cause: Haemorrhage (25-30%)
2. Indirect obstetric deaths - from pre-existing disease aggravated by pregnancy (e.g., cardiac disease, anaemia, malaria)
3. Late maternal death - from direct/indirect obstetric causes, >42 days but <1 year after termination

• Delay 1: Decision to seek care
• Delay 2: Reaching health facility
• Delay 3: Receiving adequate care

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🔵 BLUE TOPIC 1: UNICEF / WHO - Structure, Functions, Work in India

WHO (World Health Organization)

• World Health Assembly (WHA) - Supreme governing body; meets annually in May; all member states represented
• Executive Board - 34 members (technically qualified); meets twice/year; implements WHA decisions
• Secretariat - Director General + technical/admin staff; headed by DG (currently Dr. Tedros Adhanom Ghebreyesus)

1. Directs and coordinates authority on international health work
2. Assists governments in strengthening health services
3. Furnishes technical assistance and emergency aid
4. Promotes cooperation among scientific groups
5. Develops international standards for food, drugs, biological products
6. Promotes maternal and child health and welfare
7. Promotes mental health
8. Fosters activities in nutrition, housing, sanitation, recreation, and other aspects
9. Promotes and conducts research in health
10. Develops/establishes norms and standards, promotes and transfer of knowledge

• Technical assistance to National Health Programmes (polio, TB, malaria, HIV)
• Pulse Polio Programme support
• Expanded Programme on Immunization (EPI)
• Disease surveillance and reporting (IHR - International Health Regulations)
• Strengthening health workforce and disease control

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UNICEF (United Nations Children's Fund)

• Governed by a 36-member Executive Board
• Programme countries headed by country representatives
• India office: New Delhi

1. Provides long-term humanitarian and developmental assistance to children and mothers
2. Works in areas of child health, nutrition, safe water, sanitation, education
3. Immunization - supplies vaccines, cold chain equipment
4. GOBI-FFF programme
5. Baby Friendly Hospital Initiative (BFHI)
6. Child Rights advocacy (UNCRC - UN Convention on the Rights of the Child, 1989)
7. Water, sanitation and hygiene (WASH)
8. Nutrition: management of SAM (Severe Acute Malnutrition)

• Immunization support (cold chain, vaccines)
• ICDS (Integrated Child Development Scheme) support
• ORS (Oral Rehydration Salts) promotion
• BFHI
• Adolescent health (RKSK - Rashtriya Kishor Swasthya Karyakram)
• Child nutrition, POSHAN Abhiyan support

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🔵 BLUE TOPIC 2: Disaster Management / Planning Cycle

Disaster Management

Any occurrence that causes damage, ecological disruption, loss of human life, deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area.

• 4 priorities: (1) Understand disaster risk; (2) Strengthen governance; (3) Invest in DRR; (4) Enhance disaster preparedness for response

PREVENTION → MITIGATION → PREPAREDNESS → RESPONSE → RECOVERY → RECONSTRUCTION

1. Prevention - Measures to avoid disasters (e.g., earthquake-proof buildings, flood barriers)
2. Mitigation - Reduce impact/damage if disaster occurs (e.g., land-use planning, building codes)
3. Preparedness - Plans and readiness before disaster (drills, early warning systems, stockpiling)
4. Response - Immediate actions during/after disaster (rescue, evacuation, first aid, SAR teams)
5. Recovery - Restoring services post-disaster (rehabilitation, reconstruction)
6. Reconstruction - Long-term rebuilding (back to normal or better)

• Disaster Management Act, 2005
• NDMA - National Disaster Management Authority (headed by PM)
• SDMA - State Disaster Management Authority (headed by CM)
• DDMA - District DMA (headed by Collector/DC)
• NDRF - National Disaster Response Force (12 battalions)
• NIDM - National Institute of Disaster Management

• Rapid Health Assessment
• Medical First Response (MFR)
• Emergency Medical Services
• Disease surveillance post-disaster
• Mental health support (PTSD, grief)

• Black - Expectant/Dead
• Red - Immediate (life-threatening, can survive with treatment)
• Yellow - Delayed (serious but stable)
• Green - Minor (walking wounded)

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🔴 RED TOPIC 3: Demographic Cycle / Population Pyramid

Demographic Transition Theory (Notestein & Thompson)

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Population Pyramid

• Broad base → high proportion of children → young population → high fertility
• Narrow apex → high mortality in elderly
• Bulge in middle → "baby boom" generation
• Female excess at top → women live longer (longevity)

1. Shows age-sex composition
2. Indicates stage of demographic transition
3. Helps in planning health services (pediatric vs. geriatric needs)
4. Predicts future population trends
5. Shows dependency ratio

(Population <15 + Population >65) / Population 15-64 × 100

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🔵 BLUE TOPIC 3: Kangaroo Mother Care (KMC) / Baby Friendly Hospital Initiative (BFHI) / ICDS

Kangaroo Mother Care (KMC)

1. Kangaroo position - Skin-to-skin contact (baby placed on mother's chest, between breasts, prone position)
2. Kangaroo nutrition - Exclusive breastfeeding
3. Kangaroo discharge - Early discharge with adequate support

• Maintains thermal regulation (prevents hypothermia)
• Promotes breastfeeding
• Reduces morbidity and mortality in preterm/LBW babies
• Promotes mother-infant bonding
• Reduces hospital stay
• Reduces risk of nosocomial infections

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Baby Friendly Hospital Initiative (BFHI)

1. Have a written breastfeeding policy routinely communicated to all staff
2. Train all healthcare staff in skills to implement this policy
3. Inform all pregnant women about the benefits of breastfeeding
4. Help mothers initiate breastfeeding within one hour of birth
5. Show mothers how to breastfeed and maintain lactation
6. Give newborns no food or drink other than breast milk (unless medically indicated)
7. Practice rooming-in (mother and baby together 24 hours/day)
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers to breastfeeding infants
10. Foster establishment of breastfeeding support groups

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ICDS (Integrated Child Development Scheme)

• Children 0-6 years
• Pregnant and lactating mothers
• Adolescent girls (SABLA scheme)

1. Supplementary nutrition (hot cooked meals at Anganwadi)
2. Immunization (coordinated with health dept)
3. Health check-up (growth monitoring, minor illnesses)
4. Referral services
5. Pre-school non-formal education (3-6 years)
6. Nutrition and health education (for mothers)

• 1 AWC per 1000 population (400-800 in tribal/hilly areas)
• Run by Anganwadi Worker (AWW) + Anganwadi Helper
• AWW is a village-level frontline worker

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🔴 RED TOPIC 4: Contraceptive Methods / Adolescent Friendly Health Services

Contraceptive Methods

• Female: Tubectomy (laparoscopic / minilaparotomy / Pomeroy's technique)
• Male: Vasectomy (non-scalpel vasectomy - NSV preferred; simpler, fewer complications)

• Failure rate: <0.1%
• Takes 10-15 minutes under local anaesthesia
• Preferred over conventional vasectomy

• Inhibit ovulation (main mechanism)
• Thicken cervical mucus
• Alter endometrium
• Reduce tubal motility

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Adolescent Friendly Health Services (AFHS) / RKSK

• Early adolescence: 10-14 years
• Late adolescence: 15-19 years

1. Nutrition
2. Sexual and reproductive health (SRH)
3. Substance misuse
4. Non-communicable diseases (NCDs)
5. Mental health
6. Injuries and violence

• AFHC (Adolescent Friendly Health Clinics): At CHC/PHC level; weekly clinic days
• Peer Educators (PE): Trained adolescent volunteers who spread health messages
• Link workers (MLW/FLW): Facilitate adolescent access to services

• Girls 10-19 years: Weekly IFA (100 mg elemental iron + 500 mcg folic acid)
• Boys 10-19 years (where anaemia prevalence >20%)
• Day: Monday for school-going; Wednesday for out-of-school adolescents

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🔵 BLUE TOPIC 4: Panchayati Raj / Bhore Committee / Shrivastava Committee

Panchayati Raj System

• Gram Sabha: All voters in a village; meets 2-4 times/year; basic unit of democracy
• Reservation: Minimum 1/3 seats for women (many states now 50%)
• PESA Act 1996: Extension to tribal areas (5th Schedule)

• Gram Panchayat responsible for: sanitation, water supply, health centres, primary education
• Village Health Sanitation and Nutrition Committees (VHSNC) function under GP
• VHSNC has ~15 members, includes ANM, AWW, ASHA, Panchayat members

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Bhore Committee (1946) - Health Survey and Development Committee

1. Short-term plan: 75-bed hospital per 40,000 population; PHC for 40,000 with 2 doctors
2. Long-term plan: 75-bed hospital per 10,000-20,000 population; comprehensive health services
3. Barefoot doctors concept (village level health workers)
4. Integration of preventive and curative services
5. Social orientation of doctors - 3 months rural training
6. Development of health infrastructure at all levels
7. Free preventive and curative services to all
8. Establishment of National Health Service (similar to UK NHS)

• Bhore Committee report became blueprint for independent India's health system
• Led to establishment of PHCs
• "Social physician" concept introduced

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Shrivastava Committee (1975) - Group on Medical Education and Support Manpower

1. Community Health Volunteer (CHV): One CHV per 1000 population; local village person; 3-month training; responsible for first contact care
2. Community Health Worker (CHW): As an intermediary worker
3. Multipurpose workers (MPW) concept - replace single-purpose workers with MPW
4. Integration of medical education with social needs
5. MBBS curriculum should include community orientation
6. Led to formation of MPW scheme (1974-75) - ANM (F) and MPW (M) at sub-centre

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🔴 RED TOPIC 5: Mental Health

Mental Health

"A state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community."

• Launched: 1982
• Objective: Ensure availability of minimum mental health care for all; encourage community participation; integrate mental health with general health services

• Component of NMHP
• Pilot launched: 1996 in Bellary, Karnataka
• Services at district level: outpatient, inpatient, emergency services, community outreach

• Replaced Mental Health Act 1987
• Right to mental healthcare - every person has right to access quality mental healthcare
• Decriminalization: Attempted suicide no longer punishable (Section 309 IPC reformed)
• Advance directives allowed
• Prohibits electroconvulsive therapy (ECT) without consent
• Mandatory insurance for mental illness (as for physical illness)
• Central Mental Health Authority (CMHA) and State Mental Health Authorities (SMHA) to be established

• Among top 10 causes of death worldwide
• Most common method: hanging (India), firearms (USA)
• Risk factors: depression, substance abuse, previous attempt, family history
• Zero means: Remove access to lethal means (means restriction)

• ICD-11 (WHO, 2022) - International Classification of Diseases
• DSM-5-TR (APA, 2022) - Diagnostic and Statistical Manual

• Prevalence of mental disorders in India: ~14% (NMHS 2015-16)
• Most common: Common Mental Disorders (depression, anxiety) - 10%; Severe Mental Disorders (schizophrenia, bipolar) - 1-2%

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🔵 BLUE TOPIC 5: Juvenile Delinquency

Juvenile Delinquency

• Replaced JJ Act 2000
• Children in conflict with law (CCL) - those who commit offenses
• Children in need of care and protection (CNCP)
• Juvenile Justice Board (JJB): For CCL; consists of Judicial Magistrate + 2 social workers
• Child Welfare Committee (CWC): For CNCP
• Children 16-18 years committing heinous offenses can be tried as adults (after assessment by JJB)

• Primary: Parenting education, school-based programmes, poverty alleviation
• Secondary: Early identification, counselling, diversion programmes
• Tertiary: Rehabilitation, Observation homes, Special homes, After-care homes

• Observation Home - temporary stay for CCL
• Special Home - for CCL after order of court
• Place of Safety - for CCL aged 18+ during trial
• Shelter Home - for CNCP
• After-care organization - post-release support

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🔵 BLUE TOPIC 6: Health Care Delivery System in India

Health Care Delivery System in India

1. Primary level - Sub-centre, PHC, CHC
2. Secondary level - District hospitals, Sub-divisional hospitals, Taluk hospitals
3. Tertiary level - Medical college hospitals, AIIMS, PGI

• Urban Health Centre (UHC): For 50,000 population
• Urban Community Health Centre (UCHC): For 2.5 lakh
• ESIS (Employees' State Insurance Scheme) - for organized sector workers
• CGHS (Central Government Health Scheme) - for Central Govt employees

• Major providers in rural areas
• e.g., Christian Medical Association, Aga Khan Foundation

• ~70% of all health care in India
• Mostly curative; urban-based
• Largely unregulated

• Ayurveda, Yoga, Unani, Siddha, Homeopathy
• Integrated into health system; AYUSH centres at PHC/CHC levels

• Launched: 2005 (NRHM) merged with NUHM (2013) to form NHM
• Sub-missions: NRHM (rural) + NUHM (urban)
• Key components: ASHA, Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), RKS (Rogi Kalyan Samiti), Village Health Sanitation and Nutrition Committees (VHSNC)

• 1 per 1000 population (1 per habitation in tribal/hilly)
• Village-level frontline worker; NOT a government employee (incentive-based)
• Link between community and health system
• Minimum qualification: 8th standard (10th in some states)

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🔵 BLUE TOPIC 7: National Health Policy 2017 - Key Objectives

National Health Policy 2017 (NHP 2017)

1. Universal Health Coverage (UHC) as an overarching goal
2. Increase public health expenditure to 2.5% of GDP
3. Health and Wellness Centres (HWC) - transform 1.5 lakh sub-centres and PHCs into HWCs for comprehensive primary care
4. Disease control: eliminate malaria by 2027, kala-azar by 2017, lymphatic filariasis by 2017, leprosy by 2018
5. Reduce tobacco use by 15% by 2020
6. Achieve 90% immunization coverage by 2025
7. Establish National Formulary of India
8. AYUSH integration
9. Strengthening regulatory framework (clinical establishments act)
10. Digital health - e-health records, telemedicine

• Communicable: malaria, dengue, TB, HIV, leprosy, NTDs
• Non-communicable: cardiovascular disease, cancer, diabetes, mental health, injuries

• NHP 2002 focused on infectious diseases; NHP 2017 addresses NCD burden too
• NHP 2017 explicitly promotes AYUSH
• NHP 2017 emphasizes HWC and primary care strengthening
• NHP 2017 proposes "Standard Treatment Workflows"

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Quick MCQ High-Yield Recall Table

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