Transcript organization of the primary health care

THE ORGANIZATION OF THE
PRIMARY HEALTH CARE
FOR THE URBAN POPULATION
Elena A. Abumuslimova
Ph.D., Assistant Professor
Department of Public Health and Health Care,
Northern-West State Medical University named after I.I. Mechnikov,
Saint-Petersburg
DECLARATION OF ALMA-ATA
In 1978 the WHO Declaration of Alma-Ata
launched primary health care as the route
to health for all. This was a deliberate
effort to tackle huge, and largely avoidable,
differences in the health status of
populations.
 It means that people should not be denied
access to life-saving and health-promoting
interventions for unfair reasons, including
those with economic or social causes.
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WHO: THE WORLD HEALTH REPORT, 2008
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Primary health care is a people-centered
approach to health that makes prevention as
important as cure. As part of this preventive
approach, it tackles the root causes of ill health,
also in non-health sectors, thus offering an
upstream attack on threats to health.
A primary health care approach is the most
efficient, fair, and cost-effective way to organize
a health system. It can prevent much of the
disease burden, and it can also prevent people
with minor complaints from flooding the
emergency wards of hospitals. …primary health
care produces better outcomes, at lower costs,
and with higher user satisfaction.
WHO: THE ULTIMATE GOAL OF
PRIMARY HEALTH CARE IS
BETTER HEALTH FOR ALL.
FIVE KEY ELEMENTS TO ACHIEVING
THAT GOAL:
reducing exclusion and social disparities in
health (universal coverage reforms);
 organizing health services around people's
needs and expectations (service delivery
reforms);
 integrating health into all sectors (public
policy reforms);
 pursuing collaborative models of policy
dialogue (leadership reforms);
 increasing stakeholder participation.
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GLOBAL TARGETS OF PHC BY WHO(1)
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All people in every country will have ready
access at least to essential health care & to firstlevel referral facilities
All people will be actively involved in carring
for themselves & their families, as far as they
can, in community action for health
Communities throughout the world will share
government’s responsibility for the health care
of their members
All governments will assume the overall
responsibility for the health of their people
Safe drinking water & sanitation will be
available to all people
GLOBAL TARGETS OF PHC BY WHO (2)
All people will be adequately nourished
 All children will be immunizes against the
major diseases of childhood
 Communicable diseases in the developing
countries will be of no greater public health
significance than they were in the
developed countries
 All possible ways will be applied to prevent
& control non-communicable diseases&
promote mental health through influencing
the life styles & controlling the physical &
psychological environment
 Essential drugs will be available to all
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OBSTACLES TO THE IMPLEMENTATION
OF PHC STRATEGY
Misinterpretation of the PHC Concept
 Misconception that PHC is a second rate
health care for poor
 Selective PHC Strategies
 Resistance to Change
 Lack of political will
 Centralized Planning & Management
Infrastructure
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REASONS FOR SLOW PROGRESS
TOWARDS HEALTH FOR ALL (1)
Insufficient Political commitment to
implementation of HFA
 Failure to achieve equity in access to all
PHC elements
 The continuing low status of women
 Slow socioeconomic development
 Difficulty in achieving intersectoral action
for health
 Unbalanced distribution of, and week
support for, human resources
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REASONS FOR SLOW PROGRESS
TOWARDS HEALTH FOR ALL (2)
Widespread inadequacy of health
promotion activities
 Weak health information systems and no
baseline data
 Pollution, poor food safety, and lack of safe
water supply and sanitation
 Rapid demographic and epidemiological
changes
 Inappropriate use of, and allocation of
resources for, high cost technology
 Natural and man-made disasters
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NEW TRENDS THAT WILL INFLUENCE
HEALTH IN THE 21ST CENTURY
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Widespread absolute and relative poverty
Demographic changes: aging and growth of
cities
Epidemiological changes: continuing high
incidence of infections diseases; increasing
incidence of non-communicable diseases,
injuries and violence
Global environmental threats to human
survival
New technologies: information and
telemedicine services
Advances in biotechnology
Globalization of trade, travel and spread of
values and ideas
PRIMARY HEALTH CARE IN THE 21TH CENTURY
Policy Objectives to Reinforce the PHC
approach by WHO:
 Make health central to development and
enhance prospects for intersectoral action
 Combat poverty as a reflection of PHCs
concern for social justice
 Promote equity in access to health care
 Build partnerships to include families,
communities and their organizations
 Reorient health systems towards promotion
of health and prevention of disease
PRINCIPLES OF PHC
Health Prevention & Promotion
 Equity
 Appropriate Technology
 Community Participation
 Intersectoral Coordination
 Decentralization
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COMPONENTS OF PHC
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Education concerning prevailing health
problems & the methods of preventing &
controlling them
Promotion of food supply and proper nutrition
An adequate supply of safe water and basic
sanitation
Maternal and Child Health (MCH) including
Family Planning (FP)
Immunization against major infectious diseases
Prevention and control of locally endemic
diseases
Appropriate treatment of common diseases and
injuries
Provision of essential drugs
THE ORGANIZATION OF PRIMARY
PUBLIC HEALTH SERVICES
IN RUSSIAN FEDERATION
ESTABLISHMENTS IN PHC IN RUSSIA
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Polyclinic (render the territorial polyclinics
serving adult population)
Children's polyclinics
 Female consultations
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protect the motherhood
and the childhood
A MODERN POLYCLINIC IS A LARGE
MULTYFIELD TREATMENT-&-PROPHYLACTIC
ESTABLISHMENT, INTENDED TO RENDER
MEDICAL AID AT OUTPATIENT RECEPTION
HOURS & AT HOME,
& ALSO TO REALIZE A COMPLEX OF
PREVENTIVE ACTIONS ON IMPROVEMENT OF
THE POPULATION HEALTH AND PREVENTION
OF DISEASES.
THE MAIN ASPECTS OF WORK OF A
MUNICIPAL POLICLINIC
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medical – diagnostic work, including selection
for sanatorium-and-spa treatment, examination of
temporary disability, reference to medicalsocial examination;
 preventive work, sanitary – antiepidemic work;
 organizational – methodical work (management,
planning, statistical account and reporting, analysis
of activity, improvement of professional skills, etc);
 organizational – mass work (sanitary – hygienic
education of the population, popularization of a
healthy way of life). Medical workers of a polyclinic
should know main risk factors of the major diseases
and for popularization of medical knowledge use
correctly main forms and methods of educational
work.
THE BASIC ORGANIZATIONAL METHODICAL PRINCIPLES OF WORK
District principle - attaching to a medical
post of normative number of inhabitants
 Dispanserisation method - regular active
supervision over a state of health of the
certain contingents
 Accessibility of PHC
 Preventive orientation of PHC
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THE BASIC SCHEDULED - NORMATIVE
PARAMETERS
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The district specification (1700 patients on one
post of the local therapist);
Norm of local therapist loading (5 visits at one
hour on reception in a polyclinic and 2 visits at patient service at home)
The function of physician position (number of
visits per year for one post of doctor)
The regular specification of local therapists (5,9
on 10 000 inhabitance more senior than 18 years
old).
The head physician of a polyclinic has the right
to change these parameters depending on local
conditions. For example, he can increase or
reduce number of a site and loading of doctors.
FUNCTION OF THE DISTRICT PHYSICIANTHERAPIST
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Rendering of the qualified medical aid in
speciality “internal diseases” during outpatient
reception hours and at home.
Provide preventive and sanitary –
antiepidemic work, dispensarisation & hygienic
popularization.
Timely hospitalization of patients in
accordance with established order.
Organization of consultations of patients with
doctors of other specialties.
Realization of medical and rehabilitation
activities in out-patient establishment.
Realization of examination of temporary
disability and reference to medical-social
examination.
Analysis health status of the served population.
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Reorganization of out-patient - polyclinic service in
Russia will pass in a direction of creation of
institute of family doctors/ general practitioner
(GP).
GP is the expert widely focused in the basic medical
specialities, and capable to render the multyfield
out-patient medical aid for the most widespread
diseases and urgent conditions (GP is the highly
skilled expert of a primary link at a pre-hospital
stage).
Number of a served contingent at the doctor of the
general/common/ practice - 1500 adult person, at the
family doctor (in view of the children's population) no more than 1200 person in all age.
DUTIES OF THE GP (1)
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GP should know the demographic and medico-social
characteristic of the attached contingent.
Promote healthy way of life;
Give recommendations for questions of feeding,
preparations of children for preschool establishments;
Advice about family planning;
Carrying out antiepidemic actions;
Revealing the primary and latent forms of diseases and
risk factors;
DUTIES OF THE GP (2)
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Organization of all complex of diagnostic, medical improving and rehabilitation actions;
Diagnostics of pregnancy and supervision over current of
pregnancy, treatment extragenital diseases, revealing of
contra-indications to pregnancy, a direction on
interruption, conducting the postnatal period;
Organization help, together with establishments of social
security and services of mercy for lonely, aged and
disable people and chronic ill patients, including
placement of patient in houses-boarding schools and so
forth;
Carrying out of medical-social examination;
The analysis of a state of health of the attached
contingent, conducting the registration - accounting
documentation.
PREVENTIVE PROPHYLAXIS CONCEPT
Preventive prophylaxis (preventive measures) is
a main component of medicine.
Creation of system of the prevention of diseases
and elimination of risk factors is the major
social, economic and medical tasks of the state.
There are individual and public forms of
preventive prophylaxis.
THREE KINDS
OF PREVENTIVE
MAINTENANCE
(1):
Primary preventive maintenance
 Secondary preventive maintenance
 Tertiary preventive maintenance
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THREE KINDS
OF PREVENTIVE
MAINTENANCE
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(2):
Primary preventive maintenance is a system of
measures of the prevention of illness occurrence
and influence of risk factors in diseases
development (vaccination, a rational way of work
and rest, a rational qualitative food, physical
activity, improvement of an environment, etc.)
THREE KINDS
OF PREVENTIVE
MAINTENANCE
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(3):
Secondary preventive maintenance is a complex of
actions eliminat the expressed risk factors, which
under certain conditions (immune status decrease,
the overstrain, adaptability failure) can lead to
occurrence, aggravation or relapse of disease.
THREE KINDS
OF PREVENTIVE
MAINTENANCE
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(4):
Tertiary preventive maintenance is a complex of
rehabilitation actions of the patients who have lost an
opportunity of high-grade ability to live. Tertiary
preventive maintenance has four directions of
rehabilitations:
- social (formation of confidence of own social
suitability),
- labour (an opportunity of restoration of labor skills),
- psychological (restoration of behavioral activity of the
person),
- medical (restoration of functions of bodies and
systems).
THE MAJOR COMPONENT OF ALL
PREVENTIVE ACTIONS IS FORMATION AT
THE POPULATION MEDICAL -SOCIAL
ACTIVITY AND INSTALLATIONS ON
A HEALTHY WAY OF LIFE.
DISPENSARISATION
(PROFILACTIC MEDICAL EXAMINATION)
Dispensarisation is a main method of
secondary prophylactic using in PHC.
Dispensary method is regular active
supervision over a state of health of the
certain groups of patients which include:
 active early revelation;
 dynamic follow up;
 complex sanitation.
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THE EVALUATION OF THE ORGANIZATION OF
THE DISPENSERISATION
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Quality of dispenserisation:
coverage by dispensary supervision of those who were not
observed within one year period,
coverage by various social–prophylactic and medical–
preventive measures (sanatorium-and-spa treatment, invalid
food, rational employment, etc.);
Efficiency of dispensarization:
dynamics of morbidity rate and disease rate according
to MRTD (morbidity rate with temporary disability) –
for working persons;
general disease rate – due to the main and
accompanying pathology;
hospitalized morbidity;
incapacity, including primary one;
lethality;
outcomes of dispensarisation according to annual
account – recovery, improvement, without changes,
deterioration.
ESTIMATION OF ACTIVITY
OF MUNICIPAL POLYCLINIC
The analysis of activity of out-patient –
polyclinic establishments is carried out for:
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the improvement of organization of work of
municipal polyclinics,
current and forward planning of their activity;
evaluation of efficiency of various methods of
treatment
evaluation of efficiency of diagnostic, new
medical technologies and new forms of the
organization of work;
evaluation of quality of rendering of the
primary medical-aid to urban population.
QUANTITATIVE COEFFICIENTS OF ACTIVITY
OF MUNICIPAL POLYCLINIC
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Occupation of posts of doctors
Ratio number of physician posts to number of
posts of the middle medical personnel
Dynamics of patient visits to the polyclinic
Distribution of visits of a polyclinic by the
form of application (for treatment or for
preventive medical check up)
Loading for a medical post (for a year, month,
reception hours)
Completeness of coverage of the population
served by a polyclinic by preventive medical
check ups
QUALITATIVE COEFFICIENTS OF
ACTIVITY OF MUNICIPAL POLYCLINIC
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A level of the general disease rate (due to visits)
A level of disease rate with certain diseases
Structure of the general disease rate
Primary disablement
Structure of primary disablement
Structure of contingents of the disabled persons
Death rate at home
Relative number of incorrect diagnoses
Number of the advanced cases of oncologic
diseases
Frequency of cases (days) of temporary
disablement.
Structure of disease rate with temporary
disablement etc.
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