Transcript Organization of treatment-prophylactic assistance for the

Public health and public health system
– the science studying public health, its forming factors and conditions,
and creating the treatment-prophylactic methods aimed at public
health improvement. In contrast to clinical disciplines, public health
studies the health of collectives, social groups and the entire society
but not the health of separate individuals.
Population’s health (Public health)
– is the state of the population’s health, depending on complex social,
economical, medical, cultural and environmental factors, which is
measured by demographic indices, physical development, morbidity
and disability characteristics.
Human health
– is the state of complete social, biological and mental prosperity, when
the functions of all human organs and systems are equalised with
nature and social environment, at the absence of any illnesses,
pathological states or physical defects.
Theme 1
Organization of the health care for the urban
population
The basic parameters of public health are:
1. Physical development (status)
2. Demographic parameters (mortality and birth rate)
3. Morbidity
4. Physical disability (handicap)
Social and economic conditions
(Economy, climate, geographical position, industry,
agriculture)
Natural factors
(meteorological, hydrological,
geological)
Working
condition
Biological factors
(heredity,physical constitution)
Demographical
Indicators indices,
of
PhysicalPublic
development
health indices,
Morbidity and handicap indices
Level of development of
public health care
Living
conditions
Methods of study of public health and public
health system as a science:
1. Statistical
2. Experimental
3. Economical
4. Historical
5. Mathematical
6.Sociological
Special sociological methods of the research:
1. Medical surveys
2. Supervision
3. Interrogation, interview, questionnaire
Main principles of organization of national public
health services
accepted on 23 sessions of the World Health Organization
Assembly May, 22, 1970
 1. Maintenance of the population with qualified, accessible
and free-of-charge medical care.
 2. The state character of national public health services.
 3. Rational preparation of the national medical staff.
 4. Preventive supervision in all parts of medical service.
 5. Health education of the population.
 6. Use of achievements of a world medical science in medical
practice.
Public health is a system of treatment-preventive, antiepidemic, rehabilitation measures, which includes the following
directions:
 1. treatment-preventive activity (ambulatory, polyclinic,
hospital, dispensary etc.);
 2. system of the maternal and child health protection;
 3. sanitary – anti-epidemic service;
 4. pharmaceutical industry;
 5. Medical education and medical science;
 6. Sanatorium activities;
 7. Medical insurance.
The main problems in the development of primary
health care are:
 the material maintenance (resource provision) of establishments,
 levels of preparation of the medical personnel,
 quality of medical care.
The primary stage of rendering medical care to the urban
population are (PHC):
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medical (auxillary) ambulatory,
polyclinics (out-patient establishments),
female medical centre (consultation) and maternity homes,
establishments of urgent assistance (ambulance).
Reforms in the public health services of RF have lead to new
technological services :
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day-time hospitals,
hospital at homes,
surgical ambulatory services,
family doctor (GP) etc.
The polyclinic is
 a highly developed specialized health care establishment, in
which medical assistance is offered on the site and at patient’s
home; it carries out complex measures on treatment and
prevention of diseases and their complications.
The polyclinics are divided:
 by the organization of work on incorporation with stationers
and independent (not incorporated);
 by territorial principle;
 by the profile of their services: children's, adult, dental,
physiotherapy etc.
The basic structural divisions of the polyclinic are:
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Management of the polyclinic;
Registery service;
Treatment-preventive sections;
Diagnosis assisting divisions (for example, laboratory,
endoscopy, etc.);
Statistic and methodical section.
Principles of rendering of ambulatory – policlinic
care:
sector principle;
general availability;
accessibility;
preventive orientation;
dispensary method.
The main directions of activity of the sector therapist are:
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treatment,
preventive measures,
diagnostic,
anti-epidemic,
sanitary – educational,
statistical (filling the registration documentation),
medical-social expertise.
Principles of dispensarisation include three obligatory
elements:
 1. Active revealing of diseases at the early stages.
 2. Regular supervision over the revealed patients and
maintenance of them with qualified medical care.
 3. Public preventive maintenance, sanitary education.
The basic forms of medical and statistical documents of
a polyclinic:
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1. Statistical coupon for registration of final diagnoses.
2. Medical card of the outpatient.
3. Control card of dispensary supervision.
4. The book of record of calls of the doctor on the house
5. The summary sheet of the diseases which are subject to
dispensary supervision (control).
 6. Annual report of the polyclinic.
Activity of a polyclinic
1. Maintenance of the population is defined by the polyclinic help
is defined as the relation:
Number of visits to a polyclinic for the estimated period
Number of the inhabitants served by the given polyclinic
 (average 8-10 visits per one year for 1 person )
2.
Average of visits for one doctor per one year (actual loading
on the doctor):
Number of visits of a polyclinic + number of visits in-home
Number of occupied medical posts
3. Planning annual normative loading on the doctor:
F = B*C*Y, where
F - function of a medical post (annual loading on the doctor);
В - loading of the doctor of the given speciality on 1 hour work in
a polyclinic (5 persons - for the therapist) and in-home (2
persons);
С - number of work hours in a polyclinic (4 hours) and in-home
(2 hours) per 1 day;
Y - number of working days in one year (280-283 days).
4. The parameter of scope by medical examination is
calculated as the relation of (%):
Number of persons, past medical examination* 100
Number of the persons suspect to pass medical examination
( the scheduled specification - 100 %)
Theme 2
Organization of hospital care for the urban population
 Nowadays there are about 12 thousands of hospital establishments
in the Russian Federation’s public health system.
 The average duration of stay for patients in the hospitals is about
16 days, while the average number of days for beds usage is about
300 days.
 These parameters are higher in oncological clinics.
 The parameter of hospitalization shows how many people from
100 are hospitalized in the given year, and the average is 20.
 Nowadays international standards define the optimum size of
general type hospital - to have between 600 and 800 beds, and a
minimal size of 300 beds, it gives the possibilities to develop or
create hospitals for 5-7 basic specialities.
The reforming of public health services is directed to the:
 intensification of stationary medical care,
 reduction (about 20 % and more) of the number of unused beds,
 reduction of the periods of hospitalization,
Municipal (urban) hospital
 – is a treatment-prophylactic establishment ensuring the
qualified service for the population on the basis of achieved
modern medical science and technology.
From the type, volume and character of rendered medical care
and the system of work organization, the urban hospital can be:
 By profile – multi-profile or specialized;
 By the system of organization - incorporated or not incorporated with a
polyclinic;
 By volume of activities – of various categories ( capacity of beds).
The basic tasks for the urban hospital are:
 - rendering of highly skilled treatment-preventive care to the
population;
 - supply of high medical services to the workers of industrial
enterprises and to teenagers engaged in industries and vocational
training;
 - rendering of modern methods of prevention, diagnosis and
treatment to the population on the basis of achieved science and
technology, and also extending their work experiences to treatmentpreventive establishments;
 - developing and perfecting of the organizational forms and methods
of medical services to the population, caring for the patients and
increasing the quality and culture of work;
 - studying the causes of general diseases inside the population,
sickness with temporary loss of work capacity in the sphere of
workers and employees, developing and realizing of improvement
measures directed to the decreasing and liquidating the most
widespread diseases;
The important section of activity – mutual continuity of the inspection
and treatment of patients between the polyclinics and hospitals, which
is achieved by the ways of:
 - mutual exchange of information between the doctors of the
polyclinic and hospitals about the condition of patients, directed
to the hospitalization and discharge of patients from the
hospitals;
 - invitation of stationary doctors to participate in dispensary
activities (medical check ups) and in the analysis of its efficiency;
 - hospital’s experts should carry out activities aimed at the
improving of the professional skills of polyclinic doctors (joint
clinical conferences, analysis of mistakes, carrying out
consultation etc.).
The hospital establishments by profile are:
 multi-profile or general;
 specialized (cardiological, infectious, gastro-enterological,
dermatological, maternity homes) are usually located in big
cities.
 Both general and specialized hospitals can be clinical bases
of medical institutions.
At the head of the hospital there is the main doctor.
He is answerable for all the treatment-preventive, administrative
and financial activities of the establishment.
Functions of the main doctor:
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to organize and supervise the regulations and timely
inspection and treatment of patients, dispensary services,
to carry out preventive and anti-epidemic activities,
to improve the professional skills of medical personnel,
to supervise the correctness in conducting the histories of
diseases,
to secure the hospital with medical and economic
equipment,
to analyze the parameters of the hospital’s activity,
to approve the plans of work and the hospital’s forecasts,
to supervise the usage of materials and medicines,
to answer for the sanitary conditions of the hospital,
to answer for the selection of personnel.
The main doctor has assistants for the medical, economic
and administrative work.
The functions of the main doctor`s assistant for medical
work are:
 to answer for the organization and quality of all medical
activities in the hospital;
 to supervise directly for the treatment-preventive and sanitary –
anti-epidemic work of the hospital;
 to check the efficiency of treatment-preventive activities;
 to analyze every case of death in the hospital;
 to provide the organization of medical feeding (nutrition) and
medical physical activities;
 to organize the consultative assistance to a patient.
The factors influencing the parameters of the
hospital’s activities:
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type and profile of the hospital;
structure of the patients;
timeliness of observation;
quality of treatment;
qualification of medical personnel;
organisation of the hospital’s work;
quality of polyclinical care.
 The analysis of parameters is made by comparing with the
similar data of the given hospital for the last year; with the
data from other hospitals; with the data from the republican
hospital.
The basic forms and kinds of medical and statistical
documents of a hospital:
 1. The log book of reception of patients and refusals from
hospitalization.
 2. A history of disease (case history).
 3. A hospital discharge card.
 4. The sheet of the account of movement of patients and fund
of beds.
 5. The magazine of registration of operative interventions.
 6. The book of pathoanatomical openings.
 On the basis of the data registered in the documents, the annual
report of the hospital is made.
Activity of a hospital
1.The parameter of presence of doctors in a hospital is defined
as the relation of %:
Number of occupied medical posts100
Number of regular medical posts
2. The parameter of presence of auxillary medical personnel
in a hospital is
defined as the relation of %:
Number of the occupied posts of auxillary
medical personnel____________________ 100
Number of the regular posts of auxillary
medical personnel
 3. Mid-annual employment of bed (actual number of days
of work of bed during one year):
Number of bed-days carried out by the patients
Number of mid-annual beds
 (the settlement specifications - 330-340 days for hospitals of a
city, 310 days for hospitals of a village)
 4. Circulation of bed:
Number of patients having left(discharged + died)
Number of mid-annual beds
(the scheduled specification - 17-20)
 5. Average duration of stay of the patient in the bed:
Number of bed-days carried out by the patients
Number of patients having left (discharged + died)
the average index in city hospitals - 15 days, 13 days - for
hospitals of a village)
 6. Hospital Death rate (as a whole for a hospital and its
branches), in %:
Number of dead
100
Number of patients having left (written out + died)
 7. Parameter of the divergence between the clinical and
pathoanatomical diagnoses, in %:
Number of the divergences between the clinical and
pathoanatomic diagnoses
_____________________________ 100
The general number of cases of postmortem
 (the parameter should not exceed 10 %)
Theme 3
Maternity and Childhood Health Care
The typical establishments rendering the treatmentand-prophylactic care to women and children:
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1. Maternity (labor) home.
2. Female consultation.
3. Houses of rest and sanatoria for the pregnant women.
4. Houses of rest and sanatoria for scold also with a child.
5. Children's polyclinic.
6. Children's hospital.
7. Day nursery, a day nursery - garden, specialized day nursery
- gardens (logopaedic, ophthalmologic and others).
8. Schools.
9. Children's homes.
10. Children's sanatoria, children's summer improving
establishments.
Main principles of the organization of women and
children treatment-and-prophylactic assistance :
 1. Treatment-and-prophylactic service according to the age and
physiological features of women and children.
 2. Mutual continuity between all establishments and systems of
the maternity and childhood health care: a precise system of
supervision over motherhood and childhood.
 3. Preventive orientation, unity of preventive and medical
activities.
The system of maternal and child health care includes 2 basic
units:
 1. The gynaecological help unit;
 2. The treatment-and-prophylactic assistance to children.
 Maternity and childhood health care – is a system of the state
and public actions directed to the strengthening of the health of
mothers (women in general) and children.
The social - hygienic value of maternal and child health care :
 1. reduction of death rate among women and children;
 2. prevention, control and reduction of diseases among
women and children;
 3. maintenance and improvement of education among the
younger generation, beginning with the early childhood.
Female consultation unit
 is the treatment-and-prophylactic establishment providing
assistance to pregnant women and gynaecological patients and
also conducting actions for the improvement of living and
working conditions for women, as well as the increasing of
their sanitary-and-hygienic culture (conditions).
Exchange card
 is a document providing mutual continuity in the work of the
female consultation unit, the maternity hospital and the
children's polyclinic.
 It is given out to the woman at the female consultation from the
30th week of her pregnancy.
The Exchange card consists of 3 parts.
 The 1st part - is filled in the female consultation unit, it contains
data which were received during history taking, examination and
investigation of the pregnant woman. This part remains at the
maternity home.
 The 2nd part - is filled at the maternity home, it contains the
information about the delivery process and the newborn. It is
handed out to the woman for transfer to the female consultation.
 The 3rd part - is filled at the maternity home, it contains the
information about the delivery process and newborn. It is handed
out to the woman for transfer to the children's polyclinic.
Primary goals of female consultation unit:
 1. treatment-and-prophylactic assistance to the women during
the pregnancy and after delivery;
 2. reduction of parents’ death rate, early childhood death rate
(infant mortality), gynaecological diseases;
 3. realization of psychological preparations of pregnant women
before delivery;
 4. rendering of general and specialized assistance to women
with gynaecological diseases and pathologies;
 5. studying and improving the living and working conditions of
working women;
 6. increasing of the sanitary-and-hygienic culture of women;
 7. organization of actions against abortions through the use of
contraceptive means;
 8. rendering of social - legal assistance to women;
 9. organization and realization of statistical work.
Principles of female consultation unit work
organisation :
 Female consultation units work according to sector principle.
 There are a gynaecological unit and 2 therapeutic units included
in the site which are able to control about 2000-2500 women of
all ages.
 A gynaecologist and a midwife receives about 7000-8000 visits
per year.
Active supervising care
 is the visiting of the child at home with the purpose of
supervising over the conditions of its health and development.
 During the first month the doctor visits a healthy child 3 times,
and the nurs medical visits 4 times
The basic parameters of activity of female
consultation:
A. Quantity indicators:
1. The average number of visits to the gynaecologist for one
year (actual loading of the gynaecologist):
Number of visits to the female consultation unit to gynaecologists
for one year___________________________________________
Number of gynaecologists at the unit
2. The parameter of the average quantity of women in
reproductive age in the locality of a gynaecologist:
Number of women in reproductive age, being observed in the
female consultation unit________________________________
Number of gynaecologic localities
B. Parameters of medical and diagnostic work:
1. Timeliness of receipt of the pregnant women under
supervision of the consultation (%):
Number of pregnant women, arrived under the supervision of
female consultation units with the term of pregnancy less then
12 weeks (the early receipt pregnant on the account) 100
The general number of pregnant women, who stayed under the
supervision of female consultation units in estimated terms (one
year)
2. The average quantity of visits of pregnant women to the
female consultative unit:
Number of visits by pregnant women to the female consultative
unit________________________________________________
The general number of the women who are observed in the
consultation and have given birth in estimated terms (one year)
3. Also can be estimated parameters of : frequency of mistakes
of gynaecologists in defining of the time of delivery (delivery
dates), character of outcomes of pregnancy (urgent, premature
birth, abortions), the level and structure of diseases of pregnant
women, densities and frequency of separate gynaecological
diseases and others.
The basic parameters of activities of a maternity home:
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Parameters of usage of beds are calculating as in hospital.
Parameters for medical and diagnostic work:
1. Frequency of complications at delivery (on 1000 births):
Number of complicated deliveries within the estimated period
(1year)
*1000_
Number of deliveries in this maternity home for this period
2. Frequency of the complicated deliveries with diseases (on
1000 deliveries):
Frequency of complicated deliveries with diseases within the
estimated period (1year)
*1000
Number of deliveries in this maternity home for this period
B. Parameters for medical and diagnostic work:
 1. Frequency of complications at delivery:
Number of complicated deliveries within the estimated period
(1year)
*1000_
Number of deliveries in this maternity home for this period
 2. Frequency of the complicated deliveries with diseases:
Frequency of complicated deliveries with diseases within the
estimated period (1year)
*1000
Number of deliveries in this maternity home for this period
 3. Frequency of operations during deliveries:
 Number of deliveries through operations
*1000
Number of the carried out deliveries in a maternity home for
this period
 4. Frequency of mother’s death rate:
 Number of deaths(for lying-in women) within an estimated
period
*1000
Number of deliveries in this maternity home for this period
 5. Parameters of the state of health for the newborn,
including the parameter for children born dead:
Number of children, born dead for the estimated period*1000
Number of children, born alive and dead for this period
 6. Also can be estimated the parameters of the: level and
structure of diseases for women lying in a maternity hospital,
the reasons of the parent death, parameters of the activity of
the gynaecological branch is also estimated.
The basic parameters of activity of a children's polyclinic
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Number of visits per year to one pediatrician
а) In a polyclinic:
The general number of visits to a polyclinic
Number of sektor pediatrician
b) At-home:
The general number of home visits
Number of sektor pediatricians
2. Early scope of newborn children by supervision of %:
Number of newborns that were visited at home within the first 3
days after discharge from maternity hospitals
*100
Number of newborns, staying under supervision
 4. Frequency of breast feeding (%):
Number of children about 4 months old who are on breast
feeding_________________________________________
Number of children who have reached 1 year of life
 5. The Index of health for children of about one year (%):
Number of children about one year old who have never been
sick
*100
Number of children who have reached 1 year of life
 6. Also can be calculated the parameters of: diseases of
children from different age groups, the structure of the diseases,
the conditions of realization of inoculations among children.
THEME 4
Economy and planning of the public health
services
The economy of public health studies :
 the action of economic laws in public health services, gives a
concrete economic substantiation (explanation) to medicalsocial measures and activity of public health establishments .
 The economy of public health develops and explains the
rational tendencies in the effective utilization of material,
financial and menpower resources of the public health
system.
The economy of public health has the tasks:
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to increase the efficiency of public health;
to search and use the internal resources to improve public
health;
the rational use of material and menpower resources;
to prove economically plans of public health development.
The basic questions in which the economy of public
health services is engaged are:
 questions of financing public health services;
 development of approaches and methods of pricing for various
kinds of medical services;
 research in the role of public health services in the general
economy (proves social, medical and economic efficiency of
public health services);
 development of rational methods and an effective uzation of
material, financial and manpower resources for public health
services.
The main methods resurch of public health
economy:
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economic analysis;
financial analysis;
study specifications;
economic-mathematical methods;
economic experiment.
There are 2 parts of economy: macroeconomy and
microeconomy.
 Macroeconomy is the efficiency in the activities of all
branches as a whole.
 Microeconomy is the efficiency in the activities of one doctor
or one treatment-preventive establishment.
Kinds of economic benefits:
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the reduction of temporary disability;
the reduction of disability;
the reduction of premature (untimely) deaths.
life expectancy increase
morbidity decrease
Kinds of efficiency in public health services:
 Medical efficiency - consists of the changes of a level and
character of the disease and its tendencies.
 Social efficiency - consists of optimisation in the levels of
birth rate, reduction of the death rate and the increase in life
expectancy.
 Economic efficiency - the positive contribution which brings
the public health services by improvement of health of the
population in the growth of the national income of the state.
The factors that make up the needs of the population
in the treatment-and-prophylactic help:
 social and economic (working conditions, life, rest, food);
 morbidity of the population;
 organizational - medical (system of the organization of
medical aid, the level of development of public health services,
the level of development of medical science);
 social-economical welfare;
 climatic and geographical;
 level of the health education;
 development of the internal infrastructure of the country;
 development of national medicine (medical network).
Planning
 is one of the major functions of management and it represents
the process of program formation for the development and
ways of achieving set purposes and projects.
Principles of planning:
 1. Planning on regions (realization of planning at regional
levels).
 2. Scientific character (validity of parameters of the plan
which should be the base for the parameters of the disease and
the needs of the population for medical aid).
 3. Reality of plans, their feasibility as well as its realization.
 4. Communication; current and forward planning.
 5. Optimum combination of the territorial and sectoral
planning.
Methods of the public health planning :
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Analytical
Comparative
Balance
Normative
Economic-mathematical and others.
There are various kinds of planning by time:
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current planning;
short-term planning;
strategic planning.
The plan of the public health services includes the
following sections:
 development of a network of establishments of the public
health services;
 medical staff;
 capital investments (construction and the equipment of the
establishments);
 logistic plans;
 financial plan.
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At the formation of programs for the development of
the public health services, it is necessary to take into
account the needs of the population in treatment-andprophylactic care. In practice, these needs act as
references of the population in medical institutions
behind the treatment-and-prophylactic help, and it is
expressed by the number of visits by 1 inhabitant within
one year both to separate experts, and to all specialists
put together.
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Any planning takes into account 3 major factors – 3 М
(money, material and manpower).
Planning of the outpatient - polyclinic help
 The outpatient - polyclinic help is planned by measuring of the
number of visits to the outpatient - polyclinic establishments
by 1 inhabitant per year (within a year).
 The absolute need for a medical post for the outpatient polyclinic network is calculated with the help of the following
formula:
 M = (V  P) : F , where
 M - Need for a medical post;
 V – the norm of the outpatient - polyclinic visits by one
inhabitant per year;
 P - Population;
 F - Scheduled function of a medical staff post.
Planning of the hospital care
 The instrument for the planning of the stationary help is the
measuring (the number) of medical beds.
 The needs of the population for medical beds can be calculated
under the formula:
 B = (A IR) : D100, where
 B - Need in beds on 1000 population;
 А – the level of morbidity on 1000 population;
 I – index of hospitalization (20-25 %);
 R - Average duration of stay of the patient in bed (in days);
 D- Mid-annual usage of a bed (in days).
Settlement norms of doctors’ loading of the outpatient
- polyclinic establishments, on 1 business hour
Speciality of the
doctor
Number of visits during 1 hour of work
In a polyclinic
In-home
Therapist
Surgeon
5,0
9,0
2,0
1,25
Gynaecologist
Neuropathologis
Phthisiatrician
5,0
5,0
5,0
1,25
1,25
1,25
Ophthalmologist
Otolaryngologist
8,0
8,0
1,25
1,25
Norms of needs of the population in the outpatient polyclinic care for various specialities
Speciality
Therapy
Surgery
Gynaecology
Neurology
Phthisiology
Ophthalmology
Otolaryngology
Number of visits for 1
inhabitant per one year
2,0
1,5
0,9
0,4
0,7
0,5
0,4
Examples of calculation.
 Calculate the need for medical posts of therapists for the outpatient polyclinic establishments of the area with the population of 45 000
persons.
 Function of a medical post of the therapist - 6720, norm of visits for
1 inhabitant per one year on therapy - 2 (table 2)
 M = (V  P) : F = 2  45000 :6720= 13 posts
Example of calculation of need in beds for the maternity house.
 It is supposed, that the level of birth rate in the planned period will
make 12 on 1000 population. Scope by stationary obstetric 4 should
be 100 %. Average duration of stay in a maternity home is equal to
5 days, mid-annual employment of bed - 300 days.
 B = (A IR) : D100 = (121005) : 300100 =0,2 (on 1000
population)
Theme 5
Financing of the public health services
The system of public health is determined by the form
of financing.
There are 4 types of public health in the countries of
the world:




State system (the basic source of financing is the state budget)
Private (individual) system (all medical services are paid by the
patients)
Insurance system ( an insurance payment by state enterprises,
organizations and citizens)
Mixed
 Many states today carry out the mixed systems of public health
which runs together with various organizational forms and,
except for the named developed countries above.
 The mixed system entitles a combination of two or more of the
above systems.
 ‘Public health services in Italy, Norway, Belgium, and Canada
can also be possible attributed to the mainly state system.
 In these countries the most part of funds for public health
services comes from the state budget formed mainly from
obligatory taxes of the population and businessmen.
 The Russian Federation also belongs to these groups of the
countries as, despite the reform of public health services with
the introduction of obligatory medical insurance; the most part
of public health services comes from the state budget and
resources of Subjects of the Federation.
 The mainly insurance system is observed in the majority of
European countries, some states of Latin America, Japan and
others.’
Bases of insurance medicine





Medical insurance is carried out in two kinds:
Obligatory;
Voluntary.
Voluntary medical insurance may be collective or individual.
For the realization of the state policy in the field of obligatory
medical insurance federal and territorial funds are created.
Advantages of the insurance medicine:
Occurrence of additional sources of financing for the
public health services;
Improvement of quality for rendered medical services;
Minimum social (financial) maintenance is guaranteed
for all groups of the population;
Rational use of resources;
Expansion of economic independence for treatment-andprophylactic establishments.
Any type of medical insurance has its basic
program:
 1. The rendering of outpatient and polyclinical care;
 2. Rendering the stationary care;
 3. Rendering the speedy and urgent help, including
traumatological care;
 4. Medicinal supply.
 Financing of the treatment-and-prophylactic establishments is
carried out on the basis of the budgeting.
 The treatment-prophylactic budget (T.P.E budget) is a financial
plan for the forthcoming expected charges for the maintenance of
the establishment.
Basic articles of the T.P.E budget are:
 ARTICLE 1. Wages. The basic place in the budget of medical
institutions – takes up to 50-60 %.
 ARTICLE 3. Economic charges. Densities of charges under the
given article are up to 10 %,
 ARTICLE 8. Research work and purchase of books for a library.
 ARTICLE 9. Charges on feeding. The total sum from the budget for
this given article is up to 15-20 % of the hospital’s budget.
 ARTICLE 10. Purchase of the medicines.
 ARTICLE 12. Purchase of the equipment and stock.
 ARTICLE 16. Major overhaul of some buildings.
Reserves for the decreasing expenses in treatmentpreventive establishments:








Increase of professionalism of doctors and medical sisters;
Reduction of the number of duplicated inspections;
Expansion in the volume of services should be carried out on
the polyclinic and outpatient level, including surgical
interventions;
Expanding the network of social stations (hospices, nursing
homes);
Increasing of the number of home stations;
Introducing of the advanced medical achievements into
practice;
Reducing of the periods of hospitalization together with the
improvement of the continuity in the work of polyclinics and
hospitals;
Rational organization of the reception and discharge of patients.
Specificities in public health:
 1. Specificity in the organization of medical territorial and
industrial sites;
 2. Specificity in the requirement of beds, both generally and in
specialized hospitals.
 3. Personnel specificity in the medical and other attending
staffs of the treatment-preventive and sanitary – epidermal
establishments.
 4. Specificity of medical and special equipment (instruments,
tools, devices).
 5. Specificity of soft stocks, furniture, economic equipment,
transport.
 6. Building specifications, specificity in the rooms’ areas in
hospital establishments.
 7. Financial specifications in the content of public health
establishments by estimated clauses.
Requirement norms in public health:
 1. Number of the ambulatory – polyclinic visits for 1
inhabitant per one year.
 2. Percentage of patients needing hospitalization.
 3. Number of laboratory analyses for 1 patient
 4. Number of X-ray analysis for 1000 inhabitants.
 5. Number of necessary preventive inoculations
 6. Coefficient of repeated visits
 7. Norm for the average stay of a patient in bed for the
normal and special forms.
Theme 6
Organization of Rural Health Care
Medical care for the rural population is organized on the same bases
and principles as that of the towns and cities, however there are still
some differences which are related to the following facts and factors:







1. In the villages unlike in the cities the population density is
smaller.
2. The character of movement for the village inhabitants is
different from that in the cities;
3. The radius of services and the distances in the
countryside are more than in the cities;
4. The roads in the countryside are worse than in the cities.
5. Specificity of work and life.
6. There is the seasonal character of work.
The basic feature in the organization of medical care for the
village population is the “stages” and the presence of special
medical establishments in the villages.
Stages of rendering medical assistance:
 1 stage = Rural local hospital (RLH) and Medical Assistant
and Obstetrician Posts (MAOP)
 2 stage = District hospital (DH)
 3 stage = Central regional hospital (CRH)
 Besides the above, in case of the necessity the village
inhabitants can receive medical care at the urban
establishments of public health and clinics of medical
institutes.
Functions of Medical Assistant and Obstetrician
Posts (MAOP)


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



Provision of first aid assistance
Provision of epidemiological-preventive measures
Provision of obstetric assistance on physiological delivery
Provides dispensary care
Undertaking of current sanitary supervision
Provision of the emergency assistance (ER)
Observation of pregnancy
Provision of medical and prophylactic care to the children
Direction and in case of emergency or seriousness
accompanying patients to the RLH
Radius of population’s service for the MAOP = 4-5 km.,
Quantity of population served by the MAOP = from 1000 to
3000 people.
Functions of a rural hospital:
 1. Rendering of the outpatient help in a polyclinic branch
 2. Organization of treatment-and-prophylactic activity in the
area.
 3. Organization of sanitary – anti-epidemiological work in
the area.
 4. Treatment-and-prophylactic care to women, children
 5. Rendering of fast and urgent help.
 6. Analysis of the disease and drawing up of the report
about the results of work.
 7. Organizational and methodical work on a site.
 8. Preparation of patients for the consultations of regional
experts on a place.
 All medical establishments which are included in the structure
of the medical site, are incorporated and work within one plan
under the direction of the chief medical officer of the rural
hospital.
 The character and volume of medical aid in the rural hospital
is basically determined by its capacity, equipment and the
presence of medical specialists.
 The capacity of the rural hospital depends on the radius of
service, number and density of the population, the distance to
the regional hospital, the presence of industrial enterprises, and
also the features or peculiarity of local conditions.
Four categories of the village local hospitals are
distinguished:





I – 100-200 beds
II – 50-75 beds
III – 35-50 beds
IV – 25-35 beds
There are often hospitals with 35 beds.
Features in the organization of the outpatient and stationary
services in a rural hospital are:
 - There is no precise restriction of time for the outpatient
reception;
 - The hours for receiving patients should be assigned at the
time, that is the most convenient for the population, in view of
seasonal prevalence of agricultural works;
 - The possibilities for a medical assistant to receive a patient in
the absence of doctors for various reasons;
 - The calls for doctors at homes is only possible in the village,
where the village local hospital is located, the calls from
homes in the other villages are carried out by the medical
assistant;
 - Allocation of one preventive day per one week by the doctor
for a tour along the site and performing of functions assigned
to him;
 - Watching in at the station, with the right to go home and
obligatory informing other personnel about his location, in
case of the necessity to render urgent help.
Functions of a district hospital are:




Provision of the qualified medical care at the district
level.
Provision of the Emergency Service (ER)
Consultative and practical assistance to the rural staff
Administrative control of the rural hospitals work
Functions of a regional hospital:


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
1. Highly qualified medical care is provided.
2. Coordination of medical care in the Medical and Prophylactic
Establishment (MPE)
3. Provision of the Emergency Service (ER)
4. Statistical control
5. Consultative and diagnostic assistance
6. Provision of both the polyclinical and hospital care
7. Provision of sanitary and anti-epidemiological assistance
8. Scheduled departures of experts of an area
9. Organization of the clinical-diagnostic conferences for
doctors of an area
10. The analysis of contingents of patients and volume of the
help, defects of the help of doctors, diagnostic and clinical
mistakes/
The functions of the main doctor
 - Directly carries out the management of activities of the CRH,
answers for all preventive, medical (treatment), diagnostic,
administrative and financial activities of the hospital;
 - Supervises the work of all public health establishments of the
area;
 - Is responsible for the organization and the level of public health
services in the area.



The main doctor has the following assistants:
For organizational-methodical work;
For childhood and delivery assisting;
For the medical part.
 For the purpose of improvement of the doctors’ professional
skills, clinical-anatomic conferences, seminars, meetings,
lectures and reports where the doctors are acquainted with new
methods of work are organized at the base of the central
regional hospital.
 The specialization and improvement of professional skill for
the average medical workers, medical assistance-obstetrician
as a rule, are also carried out on the base of the CRH.
 The regional hospital is the medical, methodical and
educational public health centre.
There are 5 categories of regional hospitals.
 The number of beds or the capacity of the regional hospital
depends on the population of the area.
 The most expedient regional hospitals have 1000 beds with all
specialized branches.
 In a regional hospital irrespective of its capacity there should
be the following structural divisions: a hospital; the advisory
(consultative) polyclinic; treatment-diagnostic branches;
laboratories; a room for medical statistics; a branch for
emergency and consultative services.
The consultative polyclinic
 together with the branch for emergency consultative service
organizes and carries out the sending out of the consultants
(experts).
 In case of the necessity the patient through the reception is
directed to the hospitalization to the appropriate branch of the
regional hospital.
 The consultative polyclinic regularly analyzes cases of
divergence from the diagnoses, mistakes made by the doctors of
the treatment-preventive establishments of the areas during their
inspection and treatment of patients.
Regional dispensary
The
third
step
Regional Hospital
Regional Centre of Sanitary and Epidemiological Observation
City centres of specialized medical care
Regional dispensary
and other MPE
Th
e
sec
on
d
ste
p
Th
e
fir
st
ste
p
Outpatients
(Polyclinic)
Allergologist
Oncologist
Pulmonologist
District Hospital
District CSEO
In-patients
Cardiologist
Hematologist
Neurologist
Rural Hospital
Outpatients
(ambulatory)
Endocrinologist
Maternity house
Kindergarten
In-patients
(hospital)
MAOS
Theme7
Disability and Medical Sanitary Establishments
Disability
 The state of an individual when he/she is not able to work due to
medical reasons.
Types of Disability:




Temporary.
Permanent.
If a patient is sick continuously during 4 months with the
same disease or within 1 year with breaks during 5 months,
he is direct to the social-medical examination.
The purpose of this examination is to determine the working
capacity of the man.
Disablity can be divided into 3 groups:
 I group
 II group>> II-a group II-b group
 III group
Hospital’s certificates of disability can be
issued/obtain:








1.
2.
3.
4.
5.
6.
7.
8.
Through illness.
On pregnancy and births.
On a short leave to care for a sick child.
On a short leave to take care for aged parents.
During quarantine.
During traumas
In case of an accidents.
After a medical abortions





The commission of medical-social-experts is made
up of:
1. The head of the department,
2. The deputy main doctor for treatment,
3. The deputy main doctor for the medical-social examination
4. The main doctor.
Some independent experts - advisers from other treatmentpreventive establishments, representatives of trade-union
organizations and social workers are also invited.
Functions of the Commission of clinical experts:
 1) Prolongation of a hospital sheet (certificate of disabililty) till recovery.
 2) The resolution of complex (difficult) and disputed questions of
examination
 3) Issueing of a hospital sheet(certificate) for sanatorium treatment
 4) Employment of patients without attributes of physical disabiility
 5) The Direction to the Socio-medical expert Commission “SMEC”.
Composition of the Socio-medical expert Commission “SMEC”.
 _ The Assistant head physician for disability
examination(determination).
_
The Assistant head physician for medical work.
_
The head Physician (General)
_
Doctors
– specialists.
Functions
of the Socio-medical expert Commission
“SMEC”




_
Prolongation of temporal disabilidity period for over 4 months
_
The determination of physical disability groups and re-examination.
_
Defining the reasons for physical disability
_
Labor recommendations to the disable, employment and conversion
training.
Functions of a disability certificate:
_
Medical
_
Statistical
_
Legal
_
Economic
The schem(extend) for issueing a medical certificate of
disability:
 The attending physician can offer a certificate for 5 days + 5 days
extension.
 Head of department.
}
 The attending physician from 10 days} up to 1 month
 CEC from 1month up to 4 months.
 SMEC from 4 months and above.
Morbidity with temporary disability is calculated for the
working population. It is calculated on 100 workers and is
characterized by 3 parameters:
Number of cases of disability.
Number of days of temporary disability.
Duration of one case of disability.
Number of cases of disability.
This parameter is calculated in the following way.
Number of cases of disability within a year divided by the
number of workers and multiplied by 100
Number of days of temporary disability.
This parameter is calculated by:
The number of missed working days divided by the number
of workers and multiplied by 100.
Duration of one case of disability.
This parameter is calculated in the following way:
Number of cases on 100 workers divided by the number of days
of invalidity multiplied by 100.
Parameters of morbidity with temporary
disability in norm:
number of cases of diseases with temporary disability on 100
working (from 60 up to 120 cases);
number of days of temporary disability on 100 working (from 600
up to 1200 days);
average duration (in days) one case of temporary disability (from 8
about 10 days).
Health certificate
The basic medical document, given to workers in cases of
disease, is the sick-list (health certificate).
The health certificate has 4 functions:
1. Medical;
2. Legal;
3. Financial or economic
4. Statistical.
Situations when a health certificate can be given:
1.
2.
3.
4.
5.
In case of any disease;
In case of a trauma;
In case of contact with infectious patient;
On a leave to take care of a sick child;
On a leave to take care for elderly parents or other lonely
relatives;
6. During pregnancy or delivery (after birth);
7. In case of an abortion.
The kinds of rehabilitation are:
 Medical rehabilitation. The prescription of medicines, medical
physical activities, physiotherapy procedures are directed to the
improvement of the conditions of health.
 Social rehabilitation. The whole complex of measures is directed
to the giving a person the understanding, that he is necessary to
other people, the state, friends, relatives. Societal organizations
for the disable are formed, for example, an organization for the
blinds.
 Labour rehabilitation. An opportunity to work among the healthy
people and to feel like a member of the large society, carrying
out industrial norms or special tasks is reflected very well in the
emotional conditions of the invalids.
Medical Sanitary Establishment (MSE)
 – is a hospital-polyclinical complex in which a polyclinic, a
hospital, a health centers and shops are located and function
directly within the enterprise, as well as other healthimproving establishments (curative-diagnostic branches,
studies), preventive branches (studies), night and day time
dispensaries - sanatoria, dietary dining rooms etc.
Types of Medical Sanitary Establishments:
 1.
Closed (when it’s used by members of the establishment only)
 2.
Open (when other members of the public can use it’s facilities)
 MSE are created by large enterprises or group of enterprises with a work force of
4000 or more workers, and at the chemical, coal, mining and petroleum-refining
industrial enterprises - 2000 and more.
Primary goals of the MSE:
 1. Provision of treatment-and-prophylactic assistance.
 2. Development and realization jointly with administration of the
enterprise, trade-union and the public,
CSES the preventive
actions directed at strengthening and health care of members.
 3. Decrease (reduction) of disease.
 *The locality sectional doctor in MSE - 2000 persons, and at the
chemical, coal, mining and a petroleum-refining industrial
enterprises - 1500 workers.
 *At the formation of the complex sites both the industrial
(homogeneous working conditions and the set of trades), and
territorial (affinity/closeness of the location) a principle are taken
into consideration.
The role of the medical complex’s therapist:
 1. Rendering of the therapeutic assistance.
 2. Realization of prophylactic activities (studying of working
conditions of workers, the analysis of disease, realization of
prophylactic medical examination, sanitary - improving and
anti-epidemiological activiites).
Theme 8
Organization of the Centre for Sanitary
and Epidemiological Supervision
Sanitary-and-epidemiological well-being
 is a state of health of the population, the inhabitancy of persons,
i.e, the state of their surroundings in which there are no harmful
factors affecting the lives of the persons or their surroundings
thus providing favourable living conditions.
Factors of the inhabitancy:




1.Biological (virus, bacterial, parasitic, etc)
2.Chemical
3.Physical (noise, vibration, ultrasound etc.)
4. Social (food, conditions of life, working, resting etc).

By “harmful factors affecting the lives of persons” we
mean factors of their living surroundings, that create the
treat to either the lives of the people or their future
generations.
 By “favourable living conditions”, we mean, a living
condition, in which harmful factors affecting the lives of
persons are absent (a harmless condition), these are
conditions which have thestate
ability
to restore the destroyed
Sanitary-Epidemiological
(condition)
functions in a human organism.
 is the state of health of the population and their living surroundings
within a define territory at the particularly specified time.
Social-hygienic monitoring
 – is the state system of monitoring or supervising the state of
health of the population and the living surroundings, it’s the
analysis, estimation and forecasting and also the definition of
the ‘cause-effect’ - relationship between the state of health of
the population and the influence of factors of inhabitancy.
The state sanitary-and-epidemiologic supervision
 – this is an organ which activities include the prevention (warning), detection
and the supression of infringements of the legislation in the field of
maintaining the sanitary and epidemiological well-being of the population,
with the purpose of the public’s health care and care of the living
surroundings.
The sanitary-and-epidemiologic conclusion
 is a document certifying the conformity or discrepancy of
factors of inhabitancy, various kinds of activity, production,
work and services, projects and documentation as well as the
construction projects and exploitation documents, to sanitary
rules.
 Sanitary-epidemiological actions are the organizational,
administrative, veterinary and other measures directed to the
elimination or decrease (reduction) of harmful influence.
 Among the characteristics of areas of CSES service they are
responsible for the sanitary supervision, housing of area
(locations), water supply, water drainage etc.); There is a
communication between the CSES with public organizations
The concept of « CSES » include in its components in detail:
 1. State sanitary - improving measures;
 2. Sanitary legislation;
 3. Practical activity of bodies and the establishments of
sanitary – epidemiological services;
 4. Research work in the field of hygiene, epidemiology,
microbiology and infectious pathology;
 5. State system of preparation of the sanitary staff, and
also preparation of the workers of a network of hygiene and
epidemiology.
 6. Mass improvements in the participation of the
population in the organization and realization of preventive
measures;
 7. The system of measures on the distribution of medical
and hygienic knowledge among the population.
Division of the Centre of Sanitary and
Epidemiological Observation (CSES)
Operative management

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

Department of hygienic control of the nutrition
Department of municipal hygiene
Department of hygienic control of the labour
Department of sanitary-hygienic supervision under MPE
Department of hygienic control of children and teenagers
Department of hygienic control of the environment
Department of radiological medicine
Department of supervision under sources of non-ionized
radiation
Department of disinfecting control
Department of epidemiological control
Division of the Centre of Sanitary and Epidemiological
Observation (CSES) Laboratory management





Microbiological laboratory
Sanitary-hygienic laboratory
Radiological laboratory
Acoustical laboratory
Laboratory of medical parasitology
Structure of a CSES
Chief sanitary
officer
Deputy-Chief Sanitary
officer
Deputy-Chief Sanitary officer
(organization and
methodological research)
Deputy-Chief Sanitary officer
(antiepidemiological affairs)
Administrative structure of CSES services of RF:
Chief sanitary officer
Regional CSES
City CSES
Zonal CSES
Kinds of sanitary supervision



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







1) Precautionary sanitary supervision
1. Choice of a site .
2. Sanitary - hygienic examination.
3. Sanitary - hygienic estimation and development of the
requirements to technological process
4. The control of construction
5. Reception of objects, entered into operation, of construction
6. Sanitary - hygienic examination of new kinds of production
2) Current sanitary supervision .
1. Maintenance of the sanitary - hygienic requirements for the
development of rules of the internal schedule.
2. Periodic visits of the object by sanitary doctors and their
assistants.
3. Supervision over conditions of health of the population
(organization of routine medical check-ups)
4. Realization and control of laboratory research.
5. Development of the tasks and offers on the elimination of
sanitary lacks and improvement of sanitary condition of objects.




The rights of the officials of the CSES of RF (separate
rules(situations))
To bring into bodies of the state authority and managements
the offers on performance of the sanitary legislation of
Russian Federation; i.e to inform the state authorities about
the implementation of sanitary legislation of the Russian
Federation.
To visit freely and to carry out inspections of organizations,
enterprises, housing conditions of the citizens, conditions of
work of the citizens engaged in individual labour activity,
with the purpose of checking the
performance(implementation) of the sanitary legislation of
Russian Federation, realization of hygienic and antiepidermical measures and observance of sanitary rules in
working places.
To explain to enterprises, organizations and citizens the
requirements concerning the realization of hygienic and antiepidermic measures and the elimination of sanitary offences,
and also to carry out the control on the
performance(implementation) of these requirements;
To charge for the realization of specialized expert



The rights of the officials of the CSES of RF (separate
rules(situations))
To suspend pending realization of necessary measures and
elimination of available sanitary rules, and in case of
impossibility of their observance - to stop works on designing
and construction, operation of the working enterprises,
manufacture and application of production of a national
economy, manufacture, storage, transportation both with the
realization of food, raw material and foodstuff, use of water for
the drinking, economic and cultural - improving purposes;
To examine sanitary offences by businesses, to impose
administrative penalties(fines), to transfer materials to
investigatory bodies for excitation of criminal cases, to present
to the higher officials or management bodies offers on the
application of influential disciplinary measures;
To receive without any restrictions from the enterprises,
organizations and citizens item of information and documents
necessary for the performance of assigned tasks and assigning
these items to bodies and establishment of the Russian
Federation;
The Federal Agency of supervision
in sphere of protection of the rights of consumers and wellbeing of the person is formed according to the decree of the
president of the Russian federation from March, 9th 2004.
 The part of functions of Ministry of Health of the Russian
federation, the Ministry of economic development and trade, the
ministry of an antimonopoly policy is transferred Federal
Agency.
 Federal Agency is the authorised federal enforcement authority
which is carrying out functions:
 under the control and supervision in sphere of maintenance of
sanitary-and-epidemiologic well-being of the population of the
Russian federation,
 protection of the rights of consumers in the consumer market.
 In federal Agency of supervision in sphere of protection of the
rights of consumers and well-being of the person 89 territorial
administrations and 90 centres of hygiene and epidemiology in