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Community Medicine-1.ppt
1. Health Institutions:
Type of Health Facilities:
a) Primary Health Care Facilities (more detailed in attached file):
Health Unit: The Health Unit (HU) represents the first level of the health
system and it is considered the first contact level between the service
provider and the client. The HU provides mainly preventive services and
health education, but also some limited services of very basic curative care.
More complicated cases are referred to the next Health Centre or District
Hospital. The HU provides its services to a catchment area of approximately
1,000-5,000 population.
Health Center including Motherhood & Childhood center: The Health
Centre (HC) represents the second level of the health system and serves a
catchment area of 5,000-20,000 population. It provides the same PHC
services as the HU. But in addition it provides basic diagnostic (laboratory)
and a wider range of curative services, including minor operations such as
surgical incision of abscesses under local anaesthesia, dressing, etc. The HC
receives referred cases from HU and itself refers complicated cases to the
District Hospital.
2. 3. District Health Hospital:
The District Hospital (DH) represents the third level of the health system
and serves a catchment area of 60,000-150,000 population. It provides
all the services, which are delivered at the HC, but at a larger scale. In
addition, it provides life-saving emergency surgical operations, blood
transfusion services, and inpatient services. The standard district
hospital has four departments: internal medicine, pediatrics, gyn-
obstetrics and surgery. The district hospital is the referral centre for
surrounding HCs and also supervises these HCs. The DH refers cases of
complexity exceeding its capacity to the next higher level.
b)Curative Facilities:
1.General Hospital
2.Specialized Hospital
3.Motherhood & Childhood Hospital.
3. Job Description of some health staff:
1.General Medical Doctor (Physician): ► CHILD HEALTH : IMCI, ►
WOMEN’S REPRODUCTIVE HEALTH: FP, ANC, Safe Delivery, Post-
Natal Care, STDs, ► MANAGEMENT OF COMMUNICABLE
DISEASES: TB / DOTS, Leprosy, Malaria, Bilharziasis / Helminthiasis,
Hepatitis,► MANAGEMENT OF NON-COMMUNICABLE DISEASES:
Hypertension, Diabetes, ► PRIMARY EYE CARE, ► SKIN INFECTION
MANAGEMENT,► MEDICAL & SURGICAL EMERGENCIES: Injuries
(accidents, bullets), Animal bites, Shocks, Burns, Acute Abdomen,
► MINOR SURGERY: Circumcision, Abscess incision / drainage,
Health education
4. 2. Doctor Assistant: he provide the following preventive and curative services:
provide all PHC services including vaccination, ► CHILD HEALTH : IMCI,►
MANAGEMENT OF COMMUNICABLE DISEASES: TB / DOTS, Leprosy, Malaria,
Bilharziasis / Helminthiasis, Hepatitis,► If the medical doctor is unavailable he
provide MANAGEMENT(follow up) OF NON-COMMUNICABLE DISEASES:
Hypertension, Diabetes, ► PRIMARY EYE CARE, ► SKIN INFECTION
MANAGEMENT,► If the medical doctor is unavailable he provide MEDICAL &
SURGICAL EMERGENCIES (first Aids): Injuries (accidents, bullets), Animal bites,
Shocks, Burns, Acute Abdomen, ► MINOR SURGERY: Circumcision, Abscess incision
/ drainage, Health education, referring complicated cases to doctors, participate in
health campaigns, Nutrition management.
3. Nurse: the same like Doctor Assistant.
4. Midwife: ► WOMEN’S REPRODUCTIVE HEALTH: FP, ANC, Safe Delivery, Post-
Natal Care, STDs, Health education, Nutrition management for women, discovering
and referring pregnant women with danger signs, Home Based Care for mother and
child, Newborn Resuscitation, Perform basic EmOC services, Vaccination services for
Mother and Child.
5.
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What are our basic HR
objectives?
Is equitably distributed – rural vs urban
Is efficiently used – balance of MD and
paraprofessionals, PHC vs hospital
Has Appropriate skills (quality)
both clinical and administrative
Is motivated to solve problems at each level
Follows rules and standards (“good agents”)
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HR Management Systems Problems
Alignment of staff with organizational structure
Hiring, Promoting, Firing and Transfers
Migration and Premature Death
Incentives for improving performance
Training
HR Planning
Conflict Resolution Mechanisms
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Staffing Organizational Structure
Are staff with the right skills in the right
organizational units?
Is there a critical mass of skilled people in each
organizational unit?
Colombia example of “Analytical” Unit
What to do about “over staffing”?
How do you know?
Golden handshakes?
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Hiring and Recruitment
How do you avoid patronage and create merit hiring
process?
What pre service training requirements are
appropriate?
What is role of Civil Service regulations?
Permanent vs. Contract staffing?
Current skill level in national or local labor pool?
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Migration and Premature Death
Shortage of nurses in English speaking countries often
due to migration to U.S., Britain, South Africa
HIV/AIDS deaths of health workers are creating a
crisis in high incidence countries in Africa
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Promotions and Career Paths
How can you design promotion procedures that are
fair and related to performance vs. allowing unfair
favoritism or simple longevity?
Defined steps and opportunities for career
advancement?
Docs as administrators?
Hospital administrators as career?
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Disciplining and firing
Civil service rules usually restrict management options
to extreme cases
Unions usually defend workers
Accepted practice vs. enforcing regulations – case of
the absent doctors
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Transfers, maternity leave and vacations
Who controls transfers? Local or central?
Who initiates transfers? Staff or management?
How can transfers, vacations and maternity leave be
replaced?
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Incentives in large organizations
Monetary
Salary scale – tends to reward longevity more than skills and
performance
Benefits – pensions, insurance
Bonus – can be tied to performance
Performance increases for groups vs individuals
Problem of declining budgets and increasing
percentage allotted to salaries
Problem of competition with private sector for
providers and effect on salaries and hours
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Incentives in Large Organizations
Non-monetary
Housing, schooling, other benefits
Promotion opportunities
Training opportunities
Symbolic rewards
Problem of Incentives for Rural Service
Restrictions of Labor Laws and Civil Service
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Pre-service training/education
Quality of training institutions – accreditation and
explosion of private sector
Job descriptions usually define requirements for
providers but seldom for administrative positions
MOH does usually not control medical schools but
often does control nursing and non-professional staff
schools
Rural schools to “keep ‘em down on the farm”
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In-service training
Upgrade current skill levels – continuing training
“too much training” disrupts service
Local capacity to provide training
Cascade system, training of trainers
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HR Planning
PAHO/”Stalinist” Planning Models
Plan for large public sector
Model of population based “needs” dictates hiring and
training planning
i.e. # MD per population or # nurses per MD
Thomas Hall’s planning model
Software to estimate both supply and demand
Only for public sector planning
How to plan for dynamic public/private system?
US failure: planning model leads to oversupply of MD
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Conflict Resolution Mechanisms
Define clearly responsibilities and roles
Transparency of recruitment, promotion, and
disciplinary processes
Role of unions
Politicization of labor conflicts is often the downfall of
ministers
20. HEALTH Economic
• Cost Minimization Analysis (CMA): Comparison of costs of different
interventions that are assumed to provide equivalent benefits
• Cost Effectiveness Analysis (CEA): Benefits are measured in natural units (e.g.
Life years gained, heart attacks avoided)
– CEA is an expression of the desired effect of a programme, service, institution or
support activity in reducing a health problem
– CEA measures the degree of attainment of pre-determined objectives and targets
– Most comprehensive indicator of CEA: Quality adjusted life years (QALYs)
gained
• Cost Utility Analysis (CUA): Comparison of costs and benefits of health
technologies that impact both quality and quantity of life
– CUA measures health benefits as healthy years; QALYs, DALYs (Disability
adjusted life years), healthy year equivalent are used
– CUA is multi-dimensional
– Most widely used measure of benefit in CUA: Quality adjusted life years
(QALYs)
• Cost Benefit Analysis (CBA): Benefits are measured in monetary terms
– Human capital approach
– Willingness to pay approach 20
21. • Cost Accounting: A quantitative management technique which provides basic
data on cost structure of any programme
• Input-Output Analysis: An economic technique which enables calculations to be
made of the effects of changing the inputs
• Network Analysis: Is the graphic plan of all events and activities to be completed
in order to reach an end objective
– Programme Evaluation and Review Technique (PERT): An arrow diagram
representing the logical sequence in which events must take place. It aids in
planning, scheduling and monitoring the project; allows better communication
between various levels and helps furnish timely, updated progress reports
– Critical Path Method (CPM): The ‘longest path’ of the network is called as
critical path. If any activity along the critical path is delayed, entire project will be
delayed
• Systems Analysis: Is a management technique of finding out the cost-
effectiveness of the available alternatives
• Planning Programming Budgeting System (PPBS): It helps decision makers to
allocate resources so as to help achieve objectives in the most efficient way
– It allows grouping of activities related to each objective
– Zero Budget Approach: All budgets start at zero and no one gets any budget that
he cannot specifically justify on a year-to-year basis
• Work Sampling: Systematic observation and recording of activities of one or
more individuals, carried out at pre-determined or random intervals
– It provides quantitative measurement of various activities 21
22. Environmental Health
INTRODUCTION
Most diseases caused by or influenced by
environmental factors.
Estimated that 80% of all cancers are caused by
pollutants in:
Air.
Water.
Food.
Climate.
Space.
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23. INTRODUCTION
Environmental epidemiology provides scientific basis
for studying and interpreting the relations between
sanitation
hygiene
air/water/soil
food
fast foods
tobacco
alcohol
house/office
leisure
NCD
malformation
effect
behaviour
KAP
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27.
National Research Council (1991):
The study of the effect on human health of
physical, biologic, and chemical factors in the
external environment.
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28. WHO
Implement epidemiologic studies of the health
effects of chemical and physical hazards in the
environment
Asbestos.
Toxic metals and pesticides.
Air pollutants.
Solvents.
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29. WHO
Provide consultant support and assist in developing
technical information and guidance material on
environmental epidemiology.
Training activities and collaborate in transferring
information and methods.
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30. WHO
Geneva from 7 – 13 October 1975:
Produced “Guidelines on Studies in Environmental
Epidemiology”.
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33.
Smallpox (WHO 1967 – at 31 countries)
10 to 15 million new cases.
2 million death.
Methyl-mercury poisoning
Minamata Bay, Kyushu Island, Japan (1950’s)
Rheumatic fever.
Smoking / asbestos and lung cancer.
AIDS.
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34. METHOD
Appropriate methods or study design:
Case study.
Case series.
Cross sectional study.
Case-control study.
Cohort.
Randomized clinical trial.
Animal study.
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35.
Limitations:
Small number of expose people.
Agent still under research investigation.
Only small increase of risk.
Result is not inferable to other subject.
Co incidence.
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36. EXPOSURE
Complete data and information:
Exposure history (concentration, duration,
frequency).
Pre and post exposure health problems.
Route of exposure (inhalation, ingestion, skin).
Ratio of absorption (body weight).
Half life of the substance.
Measure metabolites.
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37. HEALTH IMPACT
Identify health implication due to the exposure:
Illness
Acute.
Chronic.
Biological markers
Chronic diseases.
Exposure assessment.
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38. RISK ASSESSMENT
Present of risk or not.
Decreasing of 37% mean population blood lead due to
reducing usage of leaded petrol.
An increase of 2.5 times mortality rate during fog
episode in London 1952.
Risk communication.
Hazard index:
< 1
Acceptable cancer risk: 1 : 1 000 000 population.
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