health planning process

SEMINAR ON

PLANNING PROCESS

PRESENTED BYRUSHIKESH .B PAWARCON PIMS (DU) LONI

PLANNINGPlanning is a process of determining the objectives of administrative effort and devising the means calculated to achieve them.

- Millet

PLANNINGPlanning is a process of setting formal guidelines and constraints for the behavior of the firm.

-Assoff and Brundinhargh

NATIONAL HEALTH PLANNING

National Health Planning has been defined as the orderly process of defining national health problems, identifying unmet needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible and projecting administrative action to accomplish the purpose of the proposed Program.

NATIONAL DEVELOPMENT PLANNING

Definition National development

planning has been defined as “continuous, systematic, coordinated planning for the investment of the resources of a country in programmes.”

POLICY Policy is a system, which

provides the logical framework and rationality of decision making for the achievement of intended objectives.

Purposes of Planning To match the limited resources with

many problems. To eliminate wasteful expenditure

of duplication of expenditure, To develop the best course of

action to accomplish a defined objectives.

To improve the health services; and To meet the health needs and

demands of people.

GOAL OF PLANNING PROCESS

A goal is usually described in terms of What is to be attained? The extent to which it is to be attained The population or section of the

environment involved. The geographic area in which the

proposed programme will operate and The length of time required for attaining

the goal.

Elements of goal in planning process

Action Limit Population Environment Geographic area

Planning element Objectives

Policies Programmes

Schedules Budget

Planning commissionThe Planning commission consists of 7 members.

Chairman - 1 Deputy Chairman – 1 Members – 5

Planning Division Programme advisory General Secretariat Technical division

Planning Process

1. Analysis of the health situation

The population its age and sex structure Statistic of morbidity and mortality The epidemiology and Geographical

distribution of different diseases Medical care facilities The technical manpower Training facilities available Attitudes and beliefs of the population

toward diseases, its cure and prevention.

Establishment of objectives and goals

3. Assessment of Resources

4. Fixing priorities

5. Write-up of formulated plan

6. Programming and implementation

Definitions of Roles and Task. The selection, training, motivation,

supervision of the manpower. Organization and communication. Efficiency of individual institution Ex.

Hospital or Health Centers.

7. Monitoring

8. Evaluation

HEALTH PLANNING IN INDIA

BHORE COMMITTEE Chairman - Sir Joseph Bhore, Appointment - 1946 Recommendations –

Integration of preventive and curative services at all administrative level.

Development of primary health centre in two stages.

a) Short term measure ex. PHC should cater to a population of 40,000 with a secondary health centre to serve as a supervisory, coordinating and referral institutions. For each PHC 2 MO, 4 PHN, 1 Staff Nurse (ANM) & 4 Trained Dais, 2 Sanitary Inspectors, 2 HA, 1 Pharmacist, 15 other four class employees were recommended.

BHORE COMMITTEEb) Long term programme – 75 bedded

hospital for each 10 to 20 thousand population and 650 bedded hospitals at regional level, district hospitals with 2500 beds recommended.

c) To prepare “social physician”, 3 months training in preventive and social medicine.

MUDALIAR COMMITTEEChairman - Sir Mudaliar, Appointment – 1956 to 1961Recommendations –

Consolidation of first two Five Year Plans. Strengthening of the district hospital with

specialist services to serve as central base of regional services.

Regional organization in each state between the head quarters organization and the district in change of a Regional Deputy or Assistant Directors – each to supervise 2 to 3 medical, district medical and health officers.

MUDALIAR COMMITTEE

Each primary health center not to serve more than 40,000 population.

To improve the quality of health care provided by the PHC.

Integration of medical and health services

Constitution of an all India Health Service on the pattern of Indian Administrative Service.

CHADAH COMMITTEE Chairman – Dr. M. S. Chadah, Appointment –

1963 Recommendations –

In “Vigilance” operations through PHC at the block level Ex. National Malaria Eradication Programme. Monthly home visit, 10,000 populations to each one basic health worker allocated (MPHW) and to look after additional duties of collection of vital statistics, Family planning given. The family planning health assistance was to supervise 3 to 4 MPHW’s at district level.

MUKERJI COMMITTEE

Chairman – Shri. Mukerji, Appointment – 1965

Recommendations - Separate staff for the family

planning programme recommended. The family planning assistance were specified their duties only in family planning. Also recommended de link the malaria activities and other activities from family planning.

JUNGALWALA COMMITTEE

Chairman – Dr. N. Jungalwal, Appointment – 1967

Recommendations Integration and organization of personnel - a) unified cadre - b) Common seniority kept - c) recognition of extra qualification, - d) equal pay for equal work - e) special pay for specialized work- f) no private practice and - g) good service conditions should be

given

KARTAR SINGH COMMITTEE

Chairman – Kartar Singh, Appointment – 1973 Recommendations – - ANM designated as “female health worker”

All basic health workers and surveillance workers, vaccinators, health education assistant, &

- Family planning Health assistant replaced by “Male health worker”.

- MPHW introduced in malaria maintenance phase areas and smallpox controlled area.

- PHC population coverage increase up to 50,000 Population.

KARTAR SINGH COMMITTEE

PHC divided in 16 sub centers. Sub centers have given 3000 to 3500 populations. Each sub centre has provided 1 male and 1 female health worker. Then there should be a each male health and female health supervisor to supervise the work of 3 to 4 male/ female health worker.

Lady health visitor designated as female health supervisor.

MO-PHC has overall charge of all supervisors and all health workers.

Accepted Kartar Singh Committees recommendations by Govt. of India

RECOMMENDATIONS

SHRIVASTAV COMMITTEE

Chairman – Shrivastav, Appointment – 1975 Recommendations - To devise a suitable curriculum for training

a cadre of health assistants, So that they can serve as a link between qualified MO & MPHW.

- Suggested steps to improve medical educational process emphasis given on problems relevant to national requirements.

- Suggested to realize the above objectives and matters.


Creation of Banks of paraprofessional and semi professional health workers formed within the community itself. Ex. School Teacher, Post Master, Gram-sevak to provide simple promotive, preventive and curative health services needed by the community.

Establishment of two cadres of health workers namely MPHW and Health Assistant between the community level workers and Doctors at the PHC.

RECOMMENDATIONS


Development of referral services complex by establishing from proper linkage between the PHC and higher level referral and service centre.

Establish Medical and Health Education Commission for planning and implementing the reforms needed in health and medical education.

Establishment of on the lines of university grand commission.

Work load of MPHW increase and area of population increased by 5,000 population. Work load of male and female health assistant’s decrease.

Health assistant located at the sub centre.

RECOMMENDATIONS

Rural health scheme 1997

Under this scheme Shrivastav Committee provided health care through trained workers in the community health centre was initiated during 1977 to 1978. Steps were also initiated For involvement of medical colleges

in the total health care of selected PHC’s which the objectives of reorienting medical education to the needs of rural people.

Rural health scheme 1997

Reorientation training of MPW in the control of various communicable disease programme into unipurpose workers accepted by the central council of health and central family planning council in 1976.

Health for all by 2000AD- Report of working group, 1981

A working group on health was constituted by the planning Commission in 1980 with the secretary, Ministry of health and Family Welfare, as its chairman, to identify in programme terms, the goal for Health for All by 2000 AD and to outline specific programmes for the sixth Five Year plan.

Health for all by 2000AD- Report of working group, 1981

Setting out the broad approach to health planning during the Sixth Five year plan, had also evolved specific indices and targets to be achieved by the country by 2000 AD.

HEALTH SECTOR PLANNING

Water supply and sanitation Control of communicable diseases Medical education, training and

research Medical care including hospitals,

dispensaries and primary health centers Public health services Family planning; and Indigenous systems of medicine

Constraints in Health Planning process

1 Low priority to health given by political leaders and decision makers;

2 Low budget allocation to health; 3 Lack of adequate health information

system for planning, monitoring and evaluation

4 Natural resistance to change;5 Frequent change of government,

political and administrative staff and planners

Constraints in Health Planning process

6. Untrained personnel in Planning;7. Traditional planning methods and not

need-based, cost-effective, team -based and rational planning;

8. "Long Time" lag between planning and implementation

9. Rigidity of budgeting, strategy, and administrative procedures; and

10. Inadequate coordination of planning.

FIVE Year plansOBJECTIVES Control or eradication of major

communicable diseases; Strengthening of the basic health

services through the establishment of primary health centers and sub-centre;

Population control; and Development of manpower

resources.

10TH FIVE YEAR PLAN(2002-2007)

Approach To improve and enhance the

quality of primary health care in urban and rural areas.

To improve efficiency of existing health care infrastructure by strengthening and improving referral linkage.


Targets Reduction of poverty ratio by 5% points by

2007, and by 50% point by 2012. All children in school by 2003; all children

should complete 5 years of schooling by 2007.

Reduction in gender gap in literacy and wage rate by at least 50% by 2007.

Reduction in decadal rate of population growth between 2001 to 2011 to 16.2%.


Targets Increased in literacy rate to 75% within the

plan period. Reduction in infant mortality rate to 45 per

1000 live births by 2007 and 28 by 2012. Reduction of maternal mortality ratio to 2

per 1000 live births by 2007 and 1 by 2012. All villages to have sustained assess to

potable drinking water within the plan period.

Achievements during the past 55 years of plan

1st Plan1951-56

10th Plan2002-2007

1 Primary Health Centres 725 23,236 (Sep. 2005)

2 Subcentres NA 146,026

3 Community health centres - 3,346

4 Total beds (2002) 125,000 914,543

5 Medical Colleges 42 242

6 Annual admissions in medical colleges

3,500 26,449

7 Dental colleges 7 205

8 Allopathic doctors 65,000 267,500

9 Nurses 18,500 865,135

10 ANMs 12,780 506,925

Achievements during the past 55 years of plan

1st Plan1951-56

10th Plan2002-2007

11 Health visitors 578 50,393

12 Health Workers (F) (in position) - 133,194

13 Health Workers (M) (in position) - 61,907

14 Block Extension Educator - 2,645

15 Health Assistant (M) (in position)

- 20,181

16 Health Assistant (F)/LHV (in position)

- 17,371

17 Village Health Guides (2002) - 3.23.lakh

NATIONAL HEALTH POLICY 2002

The Ministry of Health and Family Welfare, Govt. of India, evolved a National Health Policy in 1983 keeping in view the national commitment to attain the goal of Health for All by the year 2000.

NATIONAL HEALTH POLICY- 2002

OBJECTIVE To achieve an acceptable standard of good health amongst the general population of the country.


Approach - To increase access to decentralized public

health system by establishing new infrastructure in the existing institutions.

- Equitable access to health services across the social and geographical expanse of the country and

- Primacy will be given to preventive and first line curative initiatives at the primary health level


OBJECTIVES To achieve an acceptable standard

of good health amongst the general population of the country;

To increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions;


Objectives To increase the aggregate public health

investment through a substantially increased contribution by the Central Government;

To strengthen the capacity of the public health administration at the State level to render effective service delivery;

To ensuring a more equitable access to health services across the social and geographical expanse of the country


Objectives To enhance the contribution of the

private sector in providing health services for the population group which can afford to pay for services;

To rationalize use of drugs within the allopathic system; and

To increase access to tried and tested systems of traditional medicine.

INDICATOR 1951 1981 2004

Demographic Changes

Life Expectancy 36.7 54 66.90 (2001)

Crude Birth Rate (per 1000 population) 40.8 33.9 (SRS) 24.1

Crude Death Rate (per 1000 population) 25 12.5 (SRS) 7.5

IMR (per 1000 live births) 146 1I0 58

Couple Protection Rate (%) - 10.4 29 (2000)

Total Fertility Rate 6.0 - 3 (2003)

Achievements of India from the Years -1951-2000

Indicator 1951 1981 2001

Epidemiological Shifts

Malaria (cases in Million) 75 2.7 2.0 (2001)

Leprosy (per 10,000) 38.1 57.3 3.7 (2001)

Small Pox (No. of Cases) >44887 Eradicated -

Guinea Worm NA >39792 Eradicated

Polio - 29709 265

Infrastructure

Sub-Centers 725 57363 137311 (2001)

Dispensaries & Hospitals 9209 23555 43322 (CBHI-96)

Beds (Private & Public) 117198 569495 870161 (CBHI-96)

Achievements of India from the Years -1951-2000

Differences in Health Status in India

Sector BPL(%) IMR1999(SRS)

<5MR(NFHS-

II)

% of Children

underweight

MMR (per lack)

India 26.1 70 94.9 47 408

Rural 27.09 75 103.7 49.6 -

Urban 23.62 44 s63.1 38.4 -

Differences in Health Status among States

Sector BPL(%)

IMR1999(SR

S)

<5MR(NFHS-

II)

% of Children

underweightMMR per lack

Better Performing States

Kerala 12.72 14 18.8 27 87

Maharashtra 25.02 48 58.1 50 135

Tamil Nadu 21.12 52 633 37 79

Low Performing State

Orrissa 47.15 97 104.4 54 498

Bihar 42.6 63 105.1 54 707

Rajasthan 15.28 81 114.9 51 607

UP 31.15 84 122.5 52 707

MP 37.43 90 137.6 55 498

Goals to be achieved by 2000-2015

Year 2003 Enhancement of legislation for regulating minimum

standard in Clinical Establishment Medical Institutions Year 2005 Eradicate Poliomyelitis and Yaws Eliminate Leprosy Establish an integrated system of surveillance, National

Health Accounts and Health Statistics Increase State Sector Health spending from 5.5% to 7%

of the budget. 1% of the total health budget for Medical Research Decentralization of implementation of public health

Programs


Year 2007 Achieve Zero level growth of HIV / AIDS.Year 2010• Eliminate Kala Azar . Reduce Mortality by 50% on account of TB,

Malaria and Other Vector & Water Borne diseases

Reduce Prevalence of Blindness to 0.5%. Reduce IMR to 30/1000 And MMR to

100/Lakh Increase utilization of public health

facilities from current level of <20 to >75%


Year 2010 Increase health expenditure by

Government from the existing 0.9 % to 2.0% of GDP

2% of the total health budget for Medical Research

Increase share of Central grants to constitute at least 25% of total health spending

Further increase of State Sector health spending to 8%

Year 2015 Eliminate Lymphatic Filariasis

National Health Policy Prescriptions

Financial Resources Equity Delivery of National Public Health

Programs The State of Public health Infrastructure Extending Public Health Services Role of Local Self-Government

Institutions Norms for Health Care Professional


Health Research Education of Health Care

Professionals Need for Specialists in "Public

Health" & "Family Medicine” Nursing Personnel Urban Health Information, Education and

Communication Role of the Private Sector


National Disease Surveillance Network Health Statistics Women's Health Medical Ethics Enforcement of Quality Standards for

Food and Drugs Regulation of Standards in Paramedical

Disciplines Providing Medical Facilities to Users from

Overseas (Health Tourism) Impact of Globalization on the Health

Sector

Recent Development The Prime Minister has launched the

Public Health Foundation of India (PHFI), to establish world-class public health institutes to train professionals in the field.

NATIONAL POPULATION POLICY

In April 1976 India formed its first- “National Population Policy. It called for an increase in the legal minimum age of marriage from 15 to 18 for females, and from 18 to 21 for males.

Policy was modified in 1977. New policy statement reiterated the importance of the small family norm without compulsion and changed the programme title to “Family Welfare Programme”

National Health Policy 2000” is the latest in this series

NATIONAL POPULATION POLICY 2000

OBJECTIVES To bring the TFR to replacement

levels by 2010. Long term objective To achieve requirements of

suitable economic growth, social development and environment protection.


1, Address the unmet needs for basic reproductive and child health services, supplies and infrastructure.

2. Make school education up to age 14 free and compulsory, and reduce drop-outs at primary and secondary school levels to below 20 percent for both boys and girls.

3. Reduce infant mortality rate below 30 per 1000 live births

Socio-demographic Goals for 2010 are as follows


4. Reduce maternal mortality rate below 100 per lack live births

5. Achieve universal immunization of children against all vaccine preventable diseases

6.Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of age.

7. Achieve 80% institutional deliveries and 100% deliveries by trained persons.



8. Achieve universal access to information / counseling, and services for fertility regulation and contraception with a wide basket of choices.

9. Achieve 100 percent registration of births, deaths, marriage and pregnancy.

10. Contain the spread of AIDS, and promote greater integration between the management of reproductive tract infections (RTI) and sexually transmitted infections (STI) and the National AIDS Control Organization



11. Prevent and control communicable diseases.

12. Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and child health services, and in reaching out to households.

13. Promote vigorously the small family norm to achieve replacement levels of TFR.

14. Bring about convergence in implementation of related social sector programmes so that family welfare becomes a people centered programme.



It deals with- women education; empowering women for improved

health and nutrition; child survival and health; the unmet needs for family

welfare services;

Women education

Women empowerment

Small family norm

Child survival and health

Child Survival and Health


It deals with- health care for the under-served

population groups like slums, tribal community, hill area population

and displaces and migrant population; adolescent’s health and education; increased participation of men in

planned parenthood; and collaboration with NGOs.

Adolescent Health and Education

Adolescent health

Increased participation of men in planned parenthood

Family welfare services

State health policy

Maharashtra state

Maharashtra State Health System

35 Districts 350 Talukas - approx. 60,000 Multi Purpose Worker [MPW] -

FemaleAuxiliary Nurse Midwife [ANM]

60,000 Multi Purpose Worker [MPW] - Male 60,000 Health Assistant [HA] – Male Nurse

Midwife / Lady Health Visitor 5,000 Doctors 55,000 Anganwadi Worker [AWW] 1

Anganwadi worker serves about 250 families or 1,000 people

STATE POPULATION POLICY

(Maharashtra)Declared on 8th March 2000 on the day of the

International women Day. The policy has following features -

Two child family norm Prevention of child marriage. Prevention of misuse of Pre-natal Sex

Determination Act Implementation of Births, Deaths and

Marriages registration act Empowerment of Gram Panchayats Recognition to Health Institutions doing quality

work Steering Committee under Chairmanship of

Hon'ble Chief Minister to monitor the Population Policy.

AIDS Awareness Rallies and Public gatherings were

organized involving the Miss World /Miss Universe for addressing the Youth about "knowing AIDS and Prevention"

Skating from Mumbai - Kolhapur, Pune - Kolhapur were organized to draw attention of people for AIDS control measures

Health Programmes in Maharashtra state

Malaria case incidence has come down from 1,58,239 cases to 76,234 cases in 2001 compared to the previous year. Similarly, Filaria cases have come down from 42,748 cases to 24,947 cases

Record Cataract operations of 3,81,929 in1999-2000 and 4,59,721 in 2000-2001 were performed.

The prevalence of 14.7/10,000 of Leprosy cases in 1991-92 has come down to 3.1 / 10,000.81

Health Programmes in Maharashtra state

The Mental Health Problems are being given priority and 10 bedded wards are being opened at every District Hospital

Heart Surgeries had been the domain of only urban areas and being costly were beyond the reach of the poor. The issue has been seriously taken up and facilities are being extended to the District Hospitals through "Jeevandai Yogana".

Integrated Population & Development Project (I.P.D)

Goals To enable individuals and couples to

achieve their personal reproductive intentions and to ensure survival and development of their children through delivery of quality reproductive and child health services including family planning.

To improve the educational and social status of women in project areas.

Project period- 1998-2002


Objectives: To improve access to essential package of quality

reproductive health services in project areas in identified groups.

To contribute to creating an enabling environment for gender equity and equality, women's empowerment and realisation of reproductive rights.

To strengthen the capacities related to reproductive and child health including family planning program, project management in project areas.


Activities Training and infrastructure

improvements Equipment supply Mobility support Group and Communication activities Panchayat and NGO activities Service Support Project Management

HEALTH PLAN OF MAHARASHTRA

An integrated approach to reduce

childhood mortality and morbidity due to diarrhoea and dehydration; Maharashtra, India 2005 – 2010

AYUSH The

Indian Systems of Medicine and Homoeopathy (ISM&H) were given an independent identity in the Ministry of Health and Family Welfare in 1995 by creating a separate Department, which was renamed as Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November 2003

http://india.gov.in/outerwin.htm?id=http://indianmedicine.nic.in/

http://india.gov.in/outerwin.htm?id=http://indianmedicine.nic.in/

http://india.gov.in/outerwin.htm?id=http://indianmedicine.nic.in/html/homoeopathy/homoe.htm



AYUSH Ayurveda, Siddha Unani and

Homoeopathy drugs are covered under the purview of Drugs and Cosmetics Act, 1940

A separate National Policy on Indian Systems of Medicine and Homoeopathy is in place since 2002.

http://india.gov.in/outerwin.htm?id=http://cdsco.nic.in/html/Copy%20of%201.%20D&CAct121.pdf

National Health Policy on AYUSH

1. To promote good health and expand the outreach of health care to our people, particularly those not provided with health cover, through preventive, promotive and curative interventions.

2. To improve the quality of teachers and clinicians by revising curricula to contemporary relevance by creating model institutions and Centres of Excellence and extending assistance for creating infrastructural facilities.

3. To ensure affordable ISM&H services and drugs which are safe and efficacious.

4. To facilitate availability of raw drugs which are authentic and contain essential components as required under pharmacopoeial standards to help improve quality of drugs, for domestic consumption and export.

OBJECTIVES


5. To integrate ISM&H in the health care delivery system and National Programmes and ensure optimal use of the infrastructure of hospitals, dispensaries and physicians.

6. To re-orient and prioritize research in ISM&H to gradually validate therapy and drugs to address in particular the chronic and new life style related emerging diseases.

7.To create awareness about the strengths of these systems in India and abroad and sensitize other stakeholders and providers of health.

8.To provide full opportunity for the growth and development of these systems and utilization of their potential, strength and revival of their glory.

OBJECTIVES


1. Legislative measures would be taken to check mushroom growth of substandard colleges.

2. Course curricula would be reinforced to raise the standards of medical training and to equip trainees for utilization in national health programs.

3.Priority would be accorded to research covering clinical trials, pharmacology, toxicology, standardization and study of pharmaco-kinetics in respect of already identified areas of strength.

STRATEGIES


4. The Medicinal Plants Board would address all issues connected with conservation and sustainable use of medicinal plants leading to remunerative farming, regulation of medicinal farms and conservation of biodiversity.

5. Medicinal Plants Board would acquire statutory status to be able to regulate registration of farmers and cooperative societies, transportation, marketing of medicinal plants and proper procurement and supply of pharmaceutical industry.

STRATEGIES


6. Protection of India’s traditional medicinal knowledge would be undertaken through a progressive creation of a Digital Library for each system and eventually for codified knowledge leading to innovation and good health outcomes.

7. Efforts would be made to integrate and mainstream ISM&H in health care delivery system and in National Programmes.

8. A range of options for utilization of ISM&H manpower in the healthcare delivery system would be developed by assigning specific goal oriented role and responsibility to the ISM&H work force.

STRATEGIES


9. up AYUSH health facilities.10. Central Government would assist

allopathic hospitals to establish Panchkarma and Ksharshutra facilities for the treatment of neurological disorders, musculo-skeletal problems as well as ambulatory treatment of bronchial asthma and dermatological problems.

11. States would be encouraged to consolidate the ISM&H infrastructure and health services

STRATEGIES


12. Pharmacopoeial work related to Ayurveda, Unani, Siddha and Homoeopathy Drugs would be expedited

13. Industry would be encouraged to make use of quality certification

14. Quality Control Centers would be set up on regional basis to standardize the in-process quality control of ISM products and to modernize traditional processes without changing the concepts of ISM.

STRATEGIES


15. States would be advised and supported to augment facilities for drug manufacture and testing.

16. Operational use of ISM in Reproductive & Child Health (RCH) would be encouraged in eleven identified areas, where the Indian systems of medicine would be useful for antenatal, intra-natal, post-natal and neonatal care.

17. North Eastern States, rich in flora and fauna, would be supported to develop infrastructure and awareness

STRATEGIES


18. Keeping in view the global interest in understanding ISM concepts and practices, modules will be formulated for introducing Ayurveda and Yoga to medical schools and institutions abroad and to expose medical graduates.

19. Awareness programmes on the utility and effectiveness of ISM&H would be launched through the electronic and print media.

STRATEGIES

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Park K. Essential of Community Health Nursing, 4th Edition, Bhanot Publication, Pp -311 – 340

Park K. Text Book of Preventive and Social Medicine 19th Edition, Bhanot Publication Pp -346 – 378, 721 – 740 – 760

Mary Lucita, “Nursing Practice and Public Health Administration” published by ELSEVIER units 3 to 13.

Basawanthappa BT, Nursing administration, Jaypee brothers medical publishers (p) ltd 2004, edition 1st , Pp:43- 49, 258-259

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professionalization of nursing. 3rd edition. Missouri: Mosby publishers 1995, Pp:36- 47

Marquis L.Bessiel, Leadership roles and management functions in Nursing theory and application, Lippincott Williams and Wilkins publications 2000 , edition 3rd , Pp:67-73

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Swansburg. C. Russell, Swansburg J. Richard, Introduction to management and leadership for nurse managers, Jones and Barlett publishers 2002, edition 3rd , Pp:68- 70

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