THE ORGANIZATION OF THE PRIMARY HEALTH CARE FOR THE URBAN POPULATION

1. 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

2. 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.

3. 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.

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

5. 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.

6. 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 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Principles of PHC • Health Prevention & Promotion • Equity • Appropriate Technology • Community Participation • Intersectoral Coordination • Decentralization

14. 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

15. The organization of primary public health services in Russian Federation

16. Establishments in PHC in Russia • Polyclinic (render the territorial polyclinics serving adult population) • Children's polyclinics • Female consultations protect the motherhood and the childhood

17. 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 populationhealth and prevention of diseases.

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. 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 antiepidemicactions; • Revealing the primary and latent forms of diseases and risk factors;

24. 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 extragenitaldiseases, 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.

25. 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.

26. Three kinds of preventive maintenance (1): • Primary preventive maintenance • Secondary preventive maintenance • Tertiary preventive maintenance

27. Three kinds of preventive maintenance (2): • Primary preventive maintenanceis 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.)

28. Three kinds of preventive maintenance (3): • Secondary preventive maintenanceis 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.

29. Three kinds of preventive maintenance (4): • Tertiary preventive maintenanceis 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).

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

31. 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.

32. 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 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.

33. 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.

34. Quantitativecoefficients 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

35. 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.

36. Thank you for your attention!