Health Care of the Community

1. Health Care of the Community

2. Contents • Health care vs medical care • Levels of health care • Changing concepts • Principles and elements of primary health care • Discussion of 2 events of Gadchiroli district, Maharashtra

3. What is health?? Observations on health care services: • Predominantly urban oriented • Mostly curative in nature • Accessible only to a part of the population Challenges: • Population coverage • Adequacy of services • Acceptable level of health

4. Concept of health care Health care implies more than medical care……Give reasons • Multitude of services provided to individuals by health system or professions for promotion, maintenance and restoration of health • Medical care is a subset of health care system • Health care is a public right, responsibility of the Government to provide this care to all people

5. Health System • Health services delivered by health system • Variation of health services throughout the country as per the socio economic variability • Health system constitutes: management sector and organisational matters

6. Themes related to delivery of health services: • Meet the needs of entire population and not selected groups • Comprehensive services • Develop effective primary health care services supported by appropriate referral system Shift from: Medical care to health care Urban population to Rural population

7. Levels of health care: Primary Secondary Tertiary

8. Primary level of health care: • First level of contact of the individuals, family and community with the national health system • Provision of primary health care • Most effective within the context of area’s needs and limitations • Provided by primary health centers and subcenters • Field workers • Bridge the cultural gap between the rural people and organised health sector

9. Secondary level of health care: • Intermediate level of health care • Deals with more complex health care problems • Provided by district hospitals and community health centres • First referral level

10. Tertiary level of health care: • More specialized level of health care services • Requires specific facilities • Availability of specialized health care professionals • Provided by regional or central level health care institutions • Medical college hospitals, Apex institutions • Second referral level

11. Fundamental function of health care system: Sound referral system • Two way exchange of information and returning patients to those who referred them: Ensures continuity of care Ex. RNTCP

12. Changing Concepts: With a commitment to improve health • Comprehensive health care • Basic health services • Primary health care

13. Comprehensive health care: Term used by Bhore committee in 1946 Comprehensive: Provision of integrated preventive, curative and promotional health services from “womb to tomb” to every individual residing in the geographical area Bhore committee defined comprehensive health care as: • Provide adequate preventive, promotive and curative healthcare services • Be close to the beneficiaries • Widest cooperation between people, service and profession • Available to all irrespective of their ability to pay • Serve the vulnerable and weaker sections of the community • Create and maintain a healthy environment in homes and working places

14. Bhore committee suggested that medical care should be replaced by comprehensive health care • This formed the basis of national health planning in India and led to formation of PHCs and SCs • However, inadequacy of logistics and limited area of service delivery led to poor performance of this system

15. Basic Health Services: • This concept was put forward by UNICEF/WHO in 1965 • Defined as network of coordinated, peripheral, intermediate health units capable of performing effectively a selected group of functions essential to the health of an area and assuring the availability of competent professional and auxiliary personnel to perform these functions. • Drawbacks: Lack of community participation, lack of intersectoral coordination and dissociation from socio economic aspects of health

16. Primary Health Care: New approach came into existence in 1978 The Alma Ata international conference defined primary health care as “essential health care made universally accessible to individuals and acceptable to them through their full participation and at a cost the community and country can afford”

17. www.thelancet.com Vol 386 December 12, 2015...... India still struggles with rural doctor shortages Two siblings aged 5 and 6 years died in a remote village in central India after they were given an injection by a quack. The village, Khodsanar in Chhattisgarh state, is accessible only by boat and is more than 40 km away from the nearest government hospital. The incident highlights the poor state of rural health care in India, a system blighted by lack of access to health-care facilities, shortages of doctors and paramedic staff , and the predominance of untrained private practitioners as the first point of care. Although the number of health facilities in rural areas of India have increased, convincing doctors to work remains a challenge.

18. Principles of Primary Health Care Equitable distribution Community participation Intersectoral coordination Appropriate technology

19. Equitable distribution Equal vs Equitable Social injustice: Worst hit are the needy and vulnerable groups, rural and tribal residents Failure is due to inaccessibility: Geographical or cultural barriers Shift the center of gravity from cities to rural and far to reach areas Irrespective of their ability to pay, health services must be shared by all Social security schemes, PDS

20. Community participation Involvement of the individuals, families and communities in promotion of their own health and welfare Planning, implementation and maintenance of health services Overcome the cultural and communication barriers Village health guides and trained dais ASHAs Influenced from the Bare foot doctors of China Ex. Community outreach camps, ANC clinic in Bengre slum, Involvement of religious institutions and leaders to deliver health services (Ex. TB, Polio)

21. Intersectoral approach Increasing realization of the fact that components of primary health care cannot be provided by the health sector alone Agriculture, animal husbandry, food, industry, education, housing, public works, communication Strong political will Planning with other sectors to avoid duplication of activities Ex. Malaria programme, Nutrition supplements to TB patients

22. Appropriate technology “Scientifically sound, adaptable to local needs, acceptable to those who apply it and those for whom it is used and that can be maintained by the people themselves, with the resources the community and country can afford” Locally adaptable and making optimum utilization of the available resources Ex. DDK, Trained Dais, ORS, LLITNs

23. Primary health care: Starts with the people Health by the people and placing the health in people’s own hands

24. Elements of primary health care: • Education concerning the prevailing health problems and methods of preventing and controlling them • Promotion of food supply and nutrition • Adequate supply of safe water and basic sanitation • Maternal and child health care including family planning • Immunization against major infectious diseases • Prevention and control of locally endemic diseases • Appropriate treatment of common diseases and injuries • Provision of essential drugs

25. Principles of primary health care • Equitable distribution • Community participation • Intersectoral coordination • Appropriate technology

26. Discussion Events: • Sickle cell anemia among the residents of Gadchiroli: Set up of tribal research center: People not having ownership: Solution • Death of a neonate: Various reasons: Malnutrition, Illiteracy, ignorance, no colostrum given, bottle feeds, poor hygienic conditions, River flooded with rain, no bridge to cross the river: Solutions

27. Health services at community level • Subcenter: Population and interface • Primary health center • Community health center Situation Analysis: • Variation in health status across the country • Case study of Gorakhpur deaths • Accreditation of health care institutes

28. Indian Public Health Standards Objective of IPHS: • To provide basic comprehensive services • To provide quality care • To maintain acceptable level of quality of care • Monitor and improve the functioning of these centers Categorization of centers:

29. Primary Health Centers (PHCs) • Concept: Bhore committee: Services at close to the people • National Health Plan (1983) • Population: 30,000 Functions: • Medical care, MCH • Water+ sanitation • Prevention and control: endemic diseases • Collect, report vital statistics • Health education • National Health Programmes • Referral, laboratory services

30. Indian public health standards for PHCs • For PHCs covering a population of 20,000-30,000 with six beds • Two types: • Type A: <20 deliveries per month • Type B: ≥20 deliveries per month

31. Standards Essential Services: • Medical care: OPD and 24 hours emergency services, Inpatient services (6 beds) • Maternal and child care • Antenatal • Intranatal • Postnatal: 0 and 3rd day at center, 7th and 42nd day at the home 3 additional visits for LBW baby: on 14th, 21st and 28th day EBF, Immunization • Newborn care: Facilities for essential newborn care, newborn care corner in labour room/OT, Kangaroo mother care • Care of child: Emergency care of sick child including IMNCI, immunization, assess growth and development

32. Continued…. • Full range of family planning • Safe abortion services: Manual vacuum aspiration • Health education: STI/RTI • Nutrition services: Diagnose anemia, vitamin A deficiency • School health services: General screening, medicines, mid day meal, deworming • Adolescent health: Adolescent friendly clinic: 2 hours: once a week Adolescent health information, TT immunization, Nutritional counselling, STI/RTI management, ICTC referral services. • Control epidemics

33. Continued…. • Collect, report vital events • Training • Basic lab services • National Health Programmes: • RNTCP • NPCB • NVBDCP: Participation in MDA • NACP: screening, referral linkages with ICTC for confirmation, Support to patients receiving ART • NMHP • NPCDCS: Warning signals assessment and referral, activities at PHC level • NPHCE: Weekly geriatric clinic

34. Continued…. • Selected surgeries • Physical Medicine and Rehabilitation (PMR) services: Screening, early identification, counselling and issue of disability certificate • Maternal death review • Functional linkages with subcenter: Monthly review meeting, VHND at AWC

35. Staffing pattern • Medical Officer: 1-1 • AYUSH: nil-1 • Account manager: nil- 1 • Pharmacist: 1 • Nurse: 3 • Health worker (F): 1 • Health assistant: 1-1 • Lab technician: 1

36. Continued…. • Clerks: 2-2 • Lab technician: 1-2 • Driver: 1- Outsource • Class IV: 4-4

37. Community Health Centres (CHCs) • Population: 80,000 to 1.2 lakh • 30 beds; specialists: surgery, medicine, OBG, paediatrics-X ray, lab facilities • New non-medical post: Community Health Officer • Refer: Nearest Medical College/State level hospital

38. IPHS standards • Routine , emergency cases: • I&D, hernia , hyrocoele, appendicitis • Intestinal obstruction, haemorrhages • Medicine cases: routine +emergencies • Maternal health • Caesarean • New born care • Family planning • Safe abortion

39. Continued…. • National Health Programmes: • RNTCP • NACP • NVBDCP • NPCDCS • NTCP: 5 A’s • IDSP • School health • Blood storage facilities

40. Broad categories of IPHS standards • Infrastructure and population • Medical, Surgical care and Lab services • MCH • FP • Adolescent • School • Nutrition • Epidemics • NHPs

41. Health promoting schools: • Yoga • HE and counselling services • Peer leaders as health educators • Adolescent health education • Linkages with out of school children • First aid corners

42. REVIEW

43. Broad categories of IPHS standards • Infrastructure and population • Medical, Surgical care and Lab services • MCH • FP • Adolescent • School • Nutrition • Epidemics • NHPs

44. Job description of Members of Health Team

45. Job description of Medical Officer • Captain: health team, morning: OPD, supervisor • Plan and implement UIP • Proper implementation: IMNCI • School visits • Training: ASHAs, AWWs, Dais • National Health Programmes: guidelines • Visit sub-centres: fixed days • Once a month: staff meeting • Team work and leadership

46. Female Health Worker • Maternal and Child Health • Family planning • MTP • Nutrition • UIP • Dai training • Communicable diseases • Vital events

47. Continued…. • Record keeping • Treat minor ailments • Team activities

48. Health worker male • Record keeping • NVBDCP: • Malaria • Kala azar: fever 15 days, suspect : PHCs • JE • Filariasis: lymphoedema • Identify skin patches • RNTCP

49. Continued… • NBCP • RCH programme • Communicable diseases • Environmental sanitation • Health education • Record maintenance

50. Health assistant (Female) • Covers: 30,000 population (20,000: hilly) • 6 subcenters • Supervision, guidance, Team work • Train ASHAs/Dais • Supplies, equipment, maintenance: sub-centres • Records, reports: scrutiny