THE ORGANIZATION OF THE PRIMARY HEALTH CARE FOR THE URBAN POPULATION

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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

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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

• 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.

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WHO the ultimate goal of primary health care is
better health for all.
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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)

• All people in every country will have ready
  access at least to essential health care to
  first-level 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
  governments 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

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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

• 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

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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

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Primary health care by WHO

• PHC is essential health care based on practical,
  scientifically sound, and socially acceptable
  methods and technology made universally
  accessible to individuals and families in the
  community through their full participation and at
  a cost that the community and the country can
  afford It forms an integral part of the
  countrys health system, of which it is the
  central function and the main focus, and of the
  overall social and economic development of the
  community

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Principles of PHC

• Health Prevention Promotion
• Equity
• Appropriate Technology
• Community Participation
• Intersectoral Coordination
• Decentralization

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Components of PHC

• 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

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The organization of primary public health
services in Russian Federation
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Establishments in PHC in Russia

• Polyclinic (render the territorial polyclinics
  serving adult population)
• Children's polyclinics
• Female consultations

protect the motherhood and the childhood
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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.
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The main aspects of work of a municipal policlinic

• medical diagnostic work, including selection
  for sanatorium-and-spa treatment, examination of
  temporary disability, reference to medical-
• social 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.

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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

• 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.

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Function of the district physician-therapist

• 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.

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Duties of the GP (1)

• 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

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Duties of the GP (2)

• 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.

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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.

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Three kinds of preventive maintenance (1)

• Primary preventive maintenance
• Secondary preventive maintenance
• Tertiary preventive maintenance

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Three kinds of preventive maintenance (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.)

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Three kinds of preventive maintenance (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.

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Three kinds of preventive maintenance (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).

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The major component of all preventive actions is
formation at the population medical -social
activity and installations on a healthy way of
life.
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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

• Quality of dispenserisation
• coverage by dispensary supervision of those who
  were not observed within one year period,
• coverage by various socialprophylactic and
  medicalpreventive 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.

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Estimation of activity of municipal polyclinic

• The analysis of activity of out-patient
  polyclinic establishments is carried out for
• 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.

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Quantitative coefficients of activity of
municipal polyclinic

• 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

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Qualitative coefficients of activity of municipal
polyclinic

• 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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Thank you for your attention!