Part A1 – Guidelines for Sub Centres Indian Public Health Standards (IPHS) Revised 2012 Table of Contents MESSAGE ............................................................................................................................................... 3  FOREWORD ............................................................................................................................................ 4  PREFACE ................................................................................................................................................ 5  ACKNOWLEDGEMENTS ........................................................................................................................ 6  EXECUTIVE SUMMARY ......................................................................................................................... 8  INDIAN PUBLIC HEALTH STANDARDS FOR SUB-CENTRES .......................................................... 10  Introduction ............................................................................................................................................................. 10  Objectives of the Indian Public Health Standards for Sub-Centre..................................................................... 10  Categorization of Sub-Centres .............................................................................................................................. 10  Services to be provided in a Sub-Centre ............................................................................................................. 13  Manpower ................................................................................................................................................................ 23  Physical Infrastructure ........................................................................................................................................... 23  Furniture .................................................................................................................................................................. 24  Equipment ............................................................................................................................................................... 25  Drugs .................................................................................................................................................................. 25  Support Services .................................................................................................................................................... 25  Waste Disposal ....................................................................................................................................................... 25  Record Maintenance and Reporting ..................................................................................................................... 25  Monitoring Mechanism .......................................................................................................................................... 26  Quality Assurance and Accountability ................................................................................................................. 26  ANNEXURES ........................................................................................................................................ 27  Annexure 1 NATIONAL IMMUNIZATION SCHEDULE FOR INFANTS, CHILDREN AND PREGNANT WOMEN 27  Annexure 2 JOB FUNCTIONS OF HEALTH WORKER FEMALE/ANM, STAFF NURSE, HEALTH WORKER MALE ........................................................................................................................................................ 29  Annexure 3 LAYOUT OF Sub-CENTRE ................................................................................................................ 41  Annexure 4 LIST OF FURNITURE, OTHER FITTINGS AND SUNDRY ARTICLES .............................................. 44  Annexure 5 EQUIPMENT AND CONSUMABLES .................................................................................................. 45  Annexure 5A: NEWBORN CORNER IN LABOUR ROOM ..................................................................................... 49  Annexure 6 SUGGESTED LIST OF DRUGS .......................................................................................................... 51  Annexure 7 STANDARDS FOR DEEP BURIAL PIT; BIO-MEDICAL WASTE (MANAGEMENT AND HANDLING) RULES, 1998 ............................................................................................................................................ 54  Annexure 8 RECORDS AND REPORTS ................................................................................................................ 55  Annexure 8b: IDSP FORMAT ................................................................................................................................. 56  Annexure 9 CHECKLIST ........................................................................................................................................ 58  Annexure 9A: A SIMPLER CHECKLIST THAT CAN BE USED BY NON- GOVERNMENTAL ORGANIZATION/PANCHAYATI RAJ INSTITUIONS/ SELF HELP GROUPS ....................................... 60  Annexure 10 PROFORMA FOR FACILITY SURVEY OF Sub-CENTRES ON IPHS ............................................. 62  Annexure 11 MODEL CITIZEN’S CHARTER FOR Sub-CENTRES ...................................................................... 68  Annexure 12LISt OF ABBREVIATIONS ................................................................................................................ 69  REFERENCES ...................................................................................................................................... 71  LIST OF MEMBERS OF THE TASK FORCE CONSTITUTED FOR REVISION OF IPHS DOCUMENTS .................................................................................................................................................. 72  Indian Public Health Standards Revised 2012 Page 2 MESSAGE     National Rural Health Mission (NRHM) was launched to strengthen the Rural  Public  Health System  and  has  since  met  many  hopes  and  expectations. the  Mission seeks to provide effective health care to the rural populace throughout  the country with special focus on the States and union territories (uts), which  have weak public health indicators and/or weak infrastructure.    towards this end, the Indian Public Health Standards (IPHS) for Sub‐centres,  Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub‐District  and District Hospitals were published in January/February, 2007 and have been  used as the reference point for public health care infrastructure planning and up‐ gradation in the States and uts. IPHS are a set of uniform standards envisaged to  improve the quality of health care delivery in the country.    The IPHS documents have been revised keeping in view the changing protocols of the existing  programmes and introduction of new programmes especially for Non‐Communicable Diseases.  Flexibility is allowed to suit the diverse needs of the states and regions.    Our country has a large number of public health institutions in rural areas from Sub‐centres at the  most peripheral level to the district hospitals at the district level. It is highly desirable that they  should be fully functional and deliver quality care. I strongly believe that these IPHS guidelines will  act as the main driver for continuous improvement in quality and serve as the bench mark for  assessing the functional status of health facilities.    I call upon all States and uts to adopt these IPHS guidelines for strengthening the Public Health  Care Institutions and put in their best efforts to achieve high quality of health care for our people  across the country.    Indian Public Health Standards Revised 2012 Page 3 FOREWORD     the  National  Rural  Health  Mission  (NRHM)  launched  by  the  Hon’ble  Prime  Minister of India on 12 April 2005, aims to restructure the delivery mechanism  for  health  to  providing  universal  access  to  equitable,  affordable  and  quality  health care responsive to the people’s needs. the implementation framework of  NRHM,  envisaged  that  the  public  health  institutions  including  Sub‐centres  would be upgraded from its present level to a level of a set of standards called  “Indian  Public  Health  Standards  (IPHS)”.  IPHS  for  Sub‐Centers  (SCs),  Primary  Health Centers (PHCs),  Community  Health  Centers  (CHCs)  and  hospitals  were  developed  and  last  released in January/February, 2007 and have since been  used as the reference point for public health care infrastructure planning and  up gradation in the States and union  territories (uts). Sub‐Centre is the most  peripheral and first contact point between the primary health care system and  the  community.  therefore the success  of  any  nationwide  program  depends  largely  on  the  well  functioning  Sub‐centres  providing  services  of acceptable  standards to the people.  As setting standards is a dynamic process, need was felt to update the IPHS keeping in view the  changing protocols of existing National Health Programmes, introduction of new programmes  especially  for  Non‐Communicable  Diseases  and  prevailing  epidemiological  situation  in  the  country.  The  IPHS  for  Sub‐centres  has  been  revised  by a task force comprising of various  stakeholders under the Chairmanship of Director General of Health Services. Subject  experts,  NGOs, State representatives and health workers working in the health facilities have also been  consulted at different stages of revision.  The newly revised IPHS for SC has considered the services, infrastructure, manpower, equipment  and drugs in two categories of Essential (minimum assured services) and Desirable (the ideal level  services which the states and uts shall try to achieve). Sub‐centres have been categorized into two  categories depending upon the prevailing epidemiological situation and resources available in  different parts of the country. this has been done to ensure optimal utilization of resources. States  and uts are expected to categorize the Sub‐centres and provide infrastructure according to the laid  down guidelines in this document.  I would like to acknowledge the efforts put by the Directorate General of Health Services in  preparing the guidelines. It is hoped that this document will be useful to all the stakeholders.  Comments and suggestions for further improvements are most welcome.  (P.K.Pradhan)  Indian Public Health Standards Revised 2012 Page 4 PREFACE     the Sub‐centres are vital peripheral institutions for providing primary health care  to the people and play an important role in the implementation of various Health &  Family  Welfare  programmes  at  the  grass‐root  level.  One  of  the  important  components of National Rural Health Mission (NRHM) is to strengthen the Sub‐ centres to the level of Indian Public Health Standards (IPHS), which were first  prescribed in early 2007. The aim of the IPHS is to provide quality services  which are of optimum level, fair and responsive to the client’s needs, provided  equitably and which deliver improvement in the health and wellbeing of the  population (Effective). In addition, services should be affordable (Economical) and  have inherent element of accountability.    A task force was constituted in early 2010 to review the existing IPHS, remove mismatch if any,  between services and infrastructure provided, incorporate new programmes and protocols in line  with the changing requirements of the country taking into consideration the minimum functional  level needed for providing a set of assured services. The task of revision was completed as a result  of consultations held over many months with task force members, programme officers, Regional  Directors of Health and Family Welfare, experts, health functionaries, representatives  of  Non‐  Government  organizations,  development  partners  and  State/union  territory  Government  representatives after reaching a consensus. the contribution of all of them is well appreciated.    The primary focus of Sub‐centre remains the Reproductive and Child Health (RCH) services.  However, services in respect of important Non‐Communicable Diseases have also been included. It  has been envisaged not to promote all Sub‐centres for intranatal facilities. the Sub‐centres which  are well located with good infrastructure, adequate catchment area and good caseload will be  promoted for providing intranatal services at the Sub‐centre in addition to all other recommended  services. Such Sub ‐Centres will be categorized as type b. the other type of Sub‐centres (type A) will  provide all recommended services except the facilities for conducting delivery will not be available  here. This type of categorization is expected to result in service provision as per the need of  population.    Setting standards is a dynamic process and this document is not an end in itself. Further revision of  the standards shall be undertaken as and when the Sub‐centres will achieve a minimum functional  grade. It is hoped that this document will be of immense help to the States/union  territories  and other stakeholders in bringing up Sub‐ centres to the level of Indian Public Health Standards,  which will also help the country in achieving the National and Millennium Development Goals.  Indian Public Health Standards Revised 2012 Page 5 ACKNOWLEDGEMENTS The revision of the existing guidelines for Indian Public Health Standards (IPHS) for different levels of Health Facilities from Sub-Centre to District Hospitals was started with the formation of a task Force under the Chairmanship of Director General of Health Services (DGHS). This revised document is a concerted effort made possible by the advice, assistance and cooperation of many individuals, Institutions, government and non-government organizations. I gratefully acknowledge the valuable contribution of all the members of the task Force constituted to revise Indian Public Health Standards (IPHS). the list of task Force Members is given at the end of this document. I am thankful to them individually and collectively. I am truly grateful to Mr. P.k. Pradhan, Secretary (H & FW) for the active encouragement received from him. I also gratefully acknowledge the initiative, inspiration and valuable guidance provided by Dr. Jagdish Prasad, Director General of Health Services, Ministry of Health and Family Welfare, Government of India. He has also extensively reviewed the document while it was being developed. I sincerely acknowledge the contribution of Dr. R.k Srivastava, Ex- DGHS and Chairman of task Force constituted for revision of IPHS who has extensively reviewed the document at every step, while it was being developed. I sincerely thank Miss k. Sujatha Rao, Ex-Secretary (H&FW) for her valuable contribution and guidance in rationalizing the manpower requirements for Health Facilities. I would specially like to thank Ms. Anuradha Gupta, Additional Secretary and Mission Director NRHM, Mr. Manoj Jhalani Joint Secretary (RCH), Mr. Amit Mohan Prasad, Joint Secretary (NRHM), Dr. R.S. Shukla Joint Secratary (PH), Dr. Shiv Lal, former Special DG and Advisor (Public Health), Dr. Ashok kumar, DDG Dr. N.S. Dharm Shaktu, DDG, Dr. C.M. Agrawal DDG, Dr. P.L. Joshi former DDG, experts from NHSRC namely Dr. t. Sunderraman, Dr. J.N. Sahai, Dr. P. Padmanabhan, Dr. J.N. Srivastava, experts from NCDC Dr. R.L. Ichhpujani, Dr. A.C. Dhariwal, Dr. Shashi khare, Dr. S.D. khaparde, Dr. Sunil Gupta, Dr. R.S. Gupta, experts from NIHFW Prof. b. Deoki Nandan, Prof. k. kalaivani, Prof. M. bhattacharya, Prof. J.k. Dass, Dr. Vivekadish, programme officers from Ministry of Health Family welfare and Directorate General of Health Services especially Dr. Himanshu bhushan, Dr. Manisha Malhotra, Dr. b. kishore, Dr. Jagdish kaur, Dr. D.M. thorat and Dr. Sajjan Singh Yadav for their valuable contribution and guidance in formulating the IPHS documents. I am grateful to the following State level administrators, health functionaries working in the health facilities and NGO representatives who shared their field experience and greatly contributed in the revision work; namely: Dr. Manohar Agnani, MD NRHM from Government of MP Dr. Junaid Rehman from Government of kerala. Dr. kamlesh kumar Jain from Government of Chhattisgarh. Dr. Y.k. Gupta, Dr. kiran Malik, Dr. Avdesh kumar, Dr. Naresh kumar, Smt. Prabha Devi Panwar, ANM and Ms. Pushpa Devi, ANM from Government of uttar Pradesh. Dr. P.N.S. Chauhan, Dr. Jayashree Chandra, Dr. S.A.S. kazmi, Dr. L.b. Asthana, Dr. R.P. Maheshwari, Dr. (Mrs.) Pushpa Gupta, Dr. Ramesh Makwana and Dr. (Mrs.) bhusan Shrivastava from Government of Madhya Pradesh. Dr. R.S. Gupta, Dr. S.k. Gupta, Ms. Mamta Devi, ANM and Ms. Sangeeta Sharma, ANM from Government of Rajasthan. Dr. Rajesh bali from Government of Haryana. NGO representatives: Dr. P.k. Jain from Rk Mission and Dr. Sunita Abraham from Christian Medical Association of India. tmt. C. Chandra, Village Health Nurse, and tmt. k. Geetha, Village Health Nurse from Government of tamil Nadu. I express my sincere thanks to Architects of Central Design bureau namely Sh. S. Majumdar, Dr. Indian Public Health Standards Revised 2012 Page 6 Chandrashekhar, Sh. Sridhar and Sh. M. bajpai for providing inputs in respect of physical infrastructure and building norms. I am also extremely grateful to Regional Directors of Health and Family Welfare, State Health Secretaries, State Mission directors and State Directors of Health Services for their feedback. I shall be failing in my duty if I do not thank Dr. P.k. Prabhakar, Deputy Commissioner, Ministry of Health and Family Welfare for providing suggestions and support at every stage of revision of this document. Last but not the least the assistance provided by my secretarial staff and the team at Macro Graphics Pvt. Ltd. is duly acknowledged. (Dr. Anil Kumar) Member Secretary-task force CMO (NFSG) Directorate General of Health Services June 2012 Ministry of Health & Family Welfare New Delhi Government of India Indian Public Health Standards Revised 2012 Page 7 EXECUTIVE SUMMARY In the public sector, a Sub-Health Centre (Sub-centre) is the most peripheral and first point of contact between the primary health care system and the community. The Minimum Needs Program (MNP) was introduced in the country in the first year of the Fifth Five Year Plan (1974–78) with the objective to provide certain basic minimum needs and thereby improve the living standards of the people. In the field of rural health, the objective was to establish: one Sub-centre for a population 5000 people in the plains and for 3000 in tribal and hilly areas, one Primary Health Centre (PHC) for 30000 population in plains and 20000 population in tribal and hilly area, and one Community Health Centre (CHC/Rural Hospital) for a population of one lakh. However, as the population density in the country is not uniform, it shall also depend upon the case load of the facility and distance of the village/habitations which comprise the Sub-centre. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. As Sub-centres are the first contact point with the community, the success of any nation wide programme would depend largely on the well functioning Sub-centres providing services of acceptable standard to the people. the current level of functioning of the Sub-centres is much below the expectations. In order to provide quality care in these Sub-centres, Indian Public Health Standards (IPHS) are being prescribed to provide basic primary health care services to the community and achieve and maintain an acceptable standard of quality of care. These standards would help monitor and improve functioning of the Sub- centre. Setting standards is a dynamic process. Currently the IPHS for Sub centres has been prepared keeping in view the resources available with respect to functional requirement for Sub-centres with minimum standards, such as building, manpower, instruments and equipment, drugs and other facilities and desirable standards which represent the ideal situation. The overall objective of IPHS is to provide health care that is quality oriented and sensitive to the needs of the community. Service Delivery • All “Minimum Assured Services” or Essential Services as envisaged in the Sub-centre should be available, which include preventive, promotive, few curative and referral services and all the national health programmes. The services which are indicated as Desirable are for the purpose that we should aspire to achieve for this level of facility. • keeping in view the current varied situation of Sub-centres in different parts of the country, Sub-centres have been categorized into 2 types (types A and b) taking into consideration various factors namely catchment area, health seeking behavior, case load, location of other facilities like PHC/CHC/FRu/Hospitals in the vicinity of the Sub-centre. Type A Sub Centre will provide all recommended services except that the facilities for conducting delivery will not be available here. If the requirement for delivery services goes up the sub centre may be considered for upgradation to type b. type b Sub-centre, will provide all recommended services including facilities for conducting deliveries at the Sub-centre itself. Although the main focus shall be to promote institutional deliveries, however, the facilities for attending to home deliveries shall remain available at both types of Sub-centres. Minimum Requirement for Delivery of the Services The following requirements are being projected based upon the expected number of beneficiaries for maternal and child health care, immunization, family planning and other services. This IPHS recommends two ANM (one essential & one desirable) and one Health Worker Male (essential) for type A Sub-centre. For type b Sub-centres, it is recommended to provide two ANMs (essential) and one Health Worker Male (essential). One Staff Nurse or ANM (if Staff Nurse not available) is to be provided for type b Sub-centres (desirable), if number of deliveries at the Sub-centre is 20 or more in a month. Sanitation services should be provided through outsourcing on part time basis at type A and full time basis at type b. Wherever two ANMs are provided, it shall be ensured that one of the ANMs is available at the Sub- centre and the Sub-centre remains open for providing OPD services on all working days. Only one of them may provide outreach services at a time. Indian Public Health Standards Revised 2012 Page 8 The ANM posted at type b Sub-centres should mandatorily be Skilled birth Attendance (SbA) trained. Facilities The document includes a suggested layout indicating the space for the building and other infrastructure facilities for both type A and type b Sub-centres. A list of equipment, furniture and drugs needed for providing the assured services at the Sub-centres has been incorporated in the document. A Model Citizen’s Charter for appropriate information to the beneficiaries, grievance redressal and constitution of Village Health Sanitation and Nutrition Committee for better management and improvement of Sub- centre services with involvement of Panchayati Raj Institutions (PRI) have also been made as a part of the Indian Public Health Standard. The monitoring process and quality assurance mechanism is also included. Indian Public Health Standards Revised 2012 Page 9 INDIAN PUBLIC HEALTH STANDARDS FOR SUB-CENTRES Introduction In the public sector, a Health Sub-centre is the most peripheral and first point of contact between the primary health care system and the community. A Sub-centre provides interface with the community at the grass-root level, providing all the primary health care services. It is the lowest rung of a referral pyramid of health facilities consisting of the Sub-centres, Primary Health Centers, Community Health Centres, Sub-Divisional/Sub-District Hospitals and District Hospitals. The purpose of the Health Sub- centre is largely preventive and promotive, but it also provides a basic level of curative care. As per population norms, there shall be one Sub-centre established for every 5000 population in plain areas and for every 3000 population in hilly/tribal/desert areas. As the population density in the country is not uniform, application of same norm all over the country is not advisable. The number of Sub-centres and number of ANMs shall also depend upon the case load of the facility and distance of the village/habitations which comprise the Sub-centres. There are 147069 Sub-centers functioning in the country as on March 2010 as per Rural Health Statistics bulletin, 2010. The Indian Public Health Standards (IPHS) for health Sub-centre lays down the package of services that the Sub-centre shall provide the population norms for which it would be established, the human resource, infrastructure, equipment and supplies that would be needed to deliver these services with quality. Setting standards is a dynamic process. These standards are being prescribed in the context of current health priorities and available resources. The Indian Public Health Standards (IPHS) are being prescribed to provide basic primary health care services to the community and achieve and maintain an acceptable standard of quality of care. During the course of revision of current IPHS for Sub- centre, feedback through interactions with Health Worker Females/Auxillary Nurse and Mid-wife (ANMs) was taken regarding the wide spectrum of services that they are expected to provide, which revealed that most of the essential services enumerated are already being delivered by the Sub-centres staff. However, the outcomes of health indicators do not match with services that are said to be provided. Therefore it is desirable that manpower as envisaged under IPHS should be provided to ensure delivery of full range of services. Monitoring of services may be strengthened for better outcomes. Objectives of the Indian Public Health Standards for Sub-Centre a. to specify the minimum assured (essential) services that Sub-centre is expected to provide and the desirable services which the states/uts should aspire to provide through this facility. b. to maintain an acceptable quality of care for these services. c. to facilitate monitoring and supervision of these facilities. d. to make the services provided more accountable and responsive to people’s needs. Categorization of Sub-Centres In view of the current highly variable situation of Sub- centres in different parts of the country and even with in the same State, they have been categorized into two types type A and type b. Categorization has taken into consideration various factors namely catchment area, health seeking behavior, case load, location of other facilities like PHC/CHC/FRu/Hospitals in the vicinity of the Sub-centre. States shall be required to categorize their Sub-centres into two types as per the guidelines given below and provide services and infrastructure accordingly. this shall result in optimum use of available resources. Type A type A Sub Centre will provide all recommended services except that the facilities for conducting delivery will Indian Public Health Standards Revised 2012 Page 10