Sub-Centre

Definition and Position

Establishment Norms

Indian Public Health Standards (IPHS) for Sub-Centres

• Essential - minimum assured services
• Desirable - services all states/UTs should aspire to achieve

Categorization of Sub-Centres

Type A Sub-Centre

• Provides all recommended services except conducting deliveries as a facility.
• ANMs trained in midwifery may conduct normal deliveries at home if needed.
• Applicable to sub-centres in remote, hilly, desert, or tribal areas with poor transport; or those without adequate physical infrastructure for a labour room.
• If demand for deliveries rises, the sub-centre may be upgraded to Type B.

Type B Sub-Centre (MCH Sub-Centre)

• Developed as a delivery facility.
• Also caters to adjacent Type A sub-centre areas for delivery.
• Provides full intra-natal services including: managing labour using Partograph, identification and management of danger signs during labour, and basic emergency obstetric care.

Staff / Manpower

Site of Service Delivery

• Villages - during Village Health and Nutrition Day (VHND) / Immunization sessions
• During house visits
• During house-to-house surveys
• During community meetings and events
• At the facility premises - minimum 6 hours of routine OPD per day, 6 days a week (where 2 ANMs are provided, one must remain at the centre at all times)

Functions / Services Provided at Sub-Centres

1. Maternal and Child Health (MCH)

• Early registration of all pregnancies (within first trimester)
• Minimum 4 ANCs; scheduled at 12 weeks, 14-26 weeks, 28-34 weeks, and 36 weeks to term
• General examination: weight, BP, anaemia, abdominal and breast examination
• IFA supplementation, Tetanus Toxoid injection
• Minimum lab investigations: urine test for pregnancy confirmation, Hb estimation, urine for albumin and sugar
• Name-based tracking of all pregnant women
• Identification of high-risk pregnancies and danger signs
• Malaria prophylaxis in endemic zones
• Counselling on diet, rest, institutional delivery, and birth preparedness
• Tobacco cessation counselling for pregnant mothers

• Management of labour using Partograph
• Identification and management of danger signs during labour
• Basic first aid for obstetric emergencies before referral

• Three home visits (within 24 hours, 3rd day, and 7th day) and visit on 42nd day
• Breastfeeding promotion; essential newborn care
• Identification of sick newborns and referral

2. Family Planning Services

• Counselling on family planning methods
• Distribution of contraceptives (condoms, oral pills)
• Interval IUCD insertion (Essential)
• Referral for sterilization services

3. Immunization

• Immunization of infants, children, and pregnant women as per National Schedule
• Cold chain maintenance (vaccines are supplied from PHC level; not stored at sub-centre)

4. Nutritional Services

• Management of malnutrition - identification and referral
• Distribution of Iron-Folic Acid (IFA) tablets, Vitamin A solution
• Promotion of iodized salt; testing for iodine using salt testing kits (via ASHAs)

5. Diarrhoeal Disease Control

• Promotion of ORS
• Referral of severe cases

6. Disease Surveillance and Control

• Prevention and control of locally endemic diseases (malaria, kala-azar, Japanese encephalitis)
• Identification of TB suspects and referral for DOTS
• Vector control activities

7. School Health Services

• Periodic health check-ups of school children
• Screening for anaemia, nutritional status, visual acuity, hearing problems, dental problems, physical disabilities, learning disorders
• Immunization and micronutrient supplementation
• Deworming

8. Adolescent Health Care

• Adolescent and reproductive health counselling
• Nutritional counselling and management of nutritional anaemia
• STI/HIV/RTI management and referral
• Services preferably through adolescent-friendly clinic for 2 hours, once a week on a fixed day

9. National Health Programmes

• RNTCP (Tuberculosis control)
• National Vector-Borne Disease Control Programme
• National AIDS Control Programme - IEC activities, HIV risk screening
• National Tobacco Control Programme - awareness on ill effects of tobacco
• Fluorosis-endemic area services - identification and referral
• Oral health education

10. Environment and Sanitation

• Promotion of sanitation including use of toilets and garbage disposal
• Testing of water quality and disinfection of water sources

11. Vital Events and Records

• Recording and reporting of births, deaths, maternal deaths, infant deaths to health authorities

12. Coordination and Monitoring

• Coordinated services with AWWs (Anganwadi Workers), ASHAs, Village Health Sanitation and Nutrition Committee (VHSNC), and Panchayati Raj Institutions (PRIs)
• Monthly review meetings at PHC level attended by all health workers
• Supervisory visits by LHV, Health Assistant (Male), and Medical Officer

13. Outreach / Field Services

• Village Health and Nutrition Day (VHND) at Anganwadi centres
• House-to-house surveys for annual enumeration of population, births, deaths, and disease detection

14. Promotion of AYUSH

• Locally available medicinal herbs/plants grown around the sub-centre as per AYUSH department guidelines (Desirable)

Key Points for Exams

• Sub-centre = first contact point between community and health system
• Population norms: 5,000 (plain) / 3,000 (tribal/hilly)
• ANM (Auxiliary Nurse Midwife) is the key worker at the sub-centre
• Supervised by LHV and Health Assistant (Male) from PHC (1 LHV/HA per 6 sub-centres)
• Type A = no delivery facility; Type B = MCH sub-centre with delivery facility
• IPHS for sub-centres revised in 2012
• Park's Textbook of Preventive and Social Medicine, pp. 1000-1005 (IPHS Sub-centre section)

Public-Private Partnership (PPP) in Health Care

Definition

Why PPP in Health? - Rationale

• In India, almost 75% of health services are provided by the private sector (82% of outpatient visits, 52% of inpatient expenditure, 40% of institutional births).
• The private sector holds 58% of hospital buildings, 29% of hospital beds, and 81% of doctors in India.
• Government resources alone are insufficient to meet the health needs of the growing population.
• PPP is especially important for Reproductive and Child Health (RCH II) to ensure preventive and curative services reach the community.

Objectives of PPP in Health

1. Improve availability and access to health services, especially in underserved areas.
2. Supplement government health services without replacing them.
3. Use private sector efficiency to improve quality of care.
4. Ensure sustainability of services through shared investment and risk.
5. Reduce the financial burden on the government for capital-intensive services.
6. Extend coverage of national health programmes (TB, HIV, MCH, etc.).

Types / Models of PPP

1. Contracting Out (Service Contracts)

• Government contracts private agencies to deliver specific health services.
• Government retains responsibility; private sector provides the service.
• Examples: Contracting private labs for diagnostic services, outsourcing cleaning/laundry/dietary services in government hospitals, private ambulance services.

2. Contracting In

• A private provider is brought into a government facility to manage and deliver services within that facility.
• Example: Specialist doctors contracted into PHC/CHC.

3. Social Franchising

• The government licenses private providers to deliver standardized, quality-assured services under a common brand.
• Example: Netrhyog (family planning), SurakshaClinic network.

4. Voucher Schemes

• Government issues vouchers to beneficiaries (usually poor/marginalized), which they can use at empanelled private providers.
• Example: Janani Suraksha Yojana (JSY) - conditional cash transfer encouraging institutional delivery in both public and private empanelled hospitals.

5. Management Contracts

• Government retains ownership of facility but contracts a private body to manage operations.
• Example: Private management of district hospitals in some states.

6. Build-Operate-Transfer (BOT) / Build-Own-Operate-Transfer (BOOT)

• Private sector builds and operates a facility for a fixed period, then transfers it to the government.
• Common in hospital construction in urban areas.

7. Public Financing of Private Not-for-Profit Providers (NGOs)

• Government funds NGOs and voluntary organizations to deliver specific services in remote/tribal areas.
• Example: Mission hospitals, Christian Medical Association hospitals receiving government grants for TB and leprosy services.

8. Lease Contracts

• Government leases facilities/equipment to private parties for operation while retaining ownership.

Key Examples of PPP in India

PPP in Specific National Programmes

TB / RNTCP

• Private sector manages a major proportion of TB patients.
• PPP facilitates DOTS delivery, case notification, and drug supply through private practitioners and NGOs.

HIV / AIDS (NACP)

• PPP-ICTCs (Integrated Counselling and Testing Centres) established in private facilities (for-profit/not-for-profit hospitals, labs, NGOs) supported by the National AIDS Control Programme.
• Provide free HIV counselling and testing services.

Maternal Health (RCH II / NHM)

• PPP is a major strategy under RCH II to ensure preventive and curative reproductive and child health services.
• Private obstetricians empanelled for emergency obstetric care (e.g., Chiranjeevi Scheme).
• JSY includes empanelled private facilities for institutional deliveries.

Eye Care (NPCB)

• Coverage of underserved areas through public-private partnerships with voluntary organizations and private eye hospitals.

Role of Voluntary Health Agencies (as PPP partners)

• (a) Supplementing government work - lending personnel, funds, equipment, and supplies where government resources fall short.
• (b) Pioneering - exploring new approaches and demonstrating feasibility before government adoption (e.g., family planning was pioneered by voluntary agencies).
• (c) Education - health education in areas where the government cannot cope alone.
• (d) Demonstration - experimental projects (e.g., Rockefeller Foundation's bore-hole latrine demonstration for hookworm control).
• (e) Guarding government work - setting examples and providing constructive criticism.
• (f) Advancing health legislation - mobilizing public opinion for health law reforms.

• Indian Red Cross Society (since 1920) - disaster relief, MCH, family planning, blood banks
• Hind Kusht Nivaran Sangh - leprosy control
• Tuberculosis Association of India
• Family Planning Association of India
• Central Social Welfare Board
• Voluntary Health Association of India (VHAI)

Advantages of PPP

1. Expands coverage and reaches underserved and remote populations.
2. Improves quality through competition and performance-based contracts.
3. Reduces government capital investment through private financing.
4. Brings in private sector managerial efficiency and innovation.
5. Allows government to focus regulatory role while private sector delivers services.
6. Bridges gaps in specialist services (e.g., obstetrics, oncology) at peripheral levels.
7. Faster delivery of new infrastructure (BOT model).

Disadvantages / Challenges of PPP

1. Risk of cream-skimming - private providers may cherry-pick profitable cases, avoiding complex or poor patients.
2. Weak regulatory framework leads to variable quality and accountability.
3. Private providers concentrated in urban areas; PPP may not reach rural/tribal populations.
4. Lack of clear roles and responsibilities in contracts.
5. Inadequate monitoring and supervision mechanisms.
6. Equity concerns - poorer communities may be left out if PPP prioritizes profitability.
7. Risk of commodification of health care.
8. Lack of ownership and commitment from stakeholders in many schemes.
9. Information asymmetry - patients cannot judge quality of care.

Prerequisites for Successful PPP

1. Clear legal and policy framework governing partnerships.
2. Well-designed contracts with explicit roles, responsibilities, and performance indicators.
3. Strong government stewardship and regulatory capacity.
4. Transparency and accountability mechanisms.
5. Genuine commitment from both public and private sectors.
6. Equity safeguards to protect the poor and marginalized.
7. Regular monitoring, evaluation, and feedback loops.

Key Points for Exams

• In India, ~75% of health services are delivered by the private sector - the primary reason PPP is important.
• PPP was formally advocated under RCH II and NRHM/NHM.
• Chiranjeevi Scheme (Gujarat) is the classic example of PPP for emergency obstetric care.
• Ayushman Bharat-PMJAY is the largest health insurance-based PPP globally.
• PPP-ICTCs are established under NACP for HIV testing.
• Voluntary health agencies are considered non-governmental PPP partners with functions: supplementing, pioneering, education, demonstration, guarding, legislation.
• Park's Textbook of Preventive and Social Medicine (Health Care Delivery Systems, Private Agencies, NRHM, RCH II sections)