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Transcript of 1 Establishing Health Services Gilbert Burnham, MD, PhD Johns Hopkins University.
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1
Establishing Health Services
Gilbert Burnham, MD, PhD
Johns Hopkins University
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Lecture Outline
Section A: Health Needs
Section B: Disease Focus vs. Health Focus
Section C: What Should a Health System Be
Able to Do in Emergencies?
Section D: Manner of Providing Health
Services
Section E: Making Specific Decisions
Section F: How Much of What Is Needed?
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Section A
Health Needs
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What are the Health-RelatedNeeds of the Displaced?
When people are displaced to an area, what
would cause them to become ill?
– Diseases they brought with them
– Diseases they acquired locally
– Diseases related to changes in their
circumstances
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What Health Services DoDisplaced Persons Need?
Treatment of diseases and injuries
Prevention of illness via medical means
Primary Prevention
Immunization against measles, meningitis, etc.
Secondary Prevention
Treatment of tuberculosis, leprosy, cholera, etc.
Tertiary Prevention
Rehabilitation of land mine injuries
Continued
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What Health Services DoDisplaced Persons Need?
Provision of health-related services
– Water, food, shelter
Identifying the vulnerable for improved
access to those at risk of disease
A major risk factor is forced dependency
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Section B
Disease Focus vs. Health Focus
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Disease Focus vs. Health Focus
Disease focus unable to address issues
Disease is not just the absence of correct
diagnosis and treatment
Disease is the absence of a correct public
health approach looking at all factors which
address health of a community
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Vicious Cycle of Health Care
Curative services futile if not coupled with
public health measures
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Section B
What Should a Health System Be Able to Do in Emergencies?
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What Should a Health System BeAble to Do in Emergencies?
Overall goals for the health system
– Reduce crude death rates to regional
levels
– Improve health status to regional norms
Continued
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What Should a Health System BeAble to Do in Emergencies?
1 Diagnose and treat common conditions,
especially if life-threatening
2 Active case-finding
3 Maintain adequate resources to sustain
health services
4 Prevention of diseases
5 Measure/analyze activities and results
6 Communicate with and train staff
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Specific Health Services:Child Health Care
Immunization (EPI) programs
Nutrition
– Promoting breastfeeding
– Growth monitoring
– Selective feedings if necessary
– Micronutrients – vitamin A, iron
Continued
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Specific Health Services:Child Health Care
Treat childhood illness (IMCI approach)
Standard treatment protocols
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Specific Health Services:General Curative Care
Common diseases
– Priorities, e.g.,
measles, ARI
– Trauma and
fractures
– Chronic diseases,
e.g. TB, asthma
In mid-level
development countries
– Diabetes,
hypertension, heart
disease, arthritis
Continued
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Specific Health Services:General Curative Care
Provision for outpatient and inpatient care
Prescription of drugs in an acceptable
manner
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Specific Health Services:Reproductive Health Care
Care during pregnancy
– Provide for safe delivery
Family planning
Care during delivery
Post delivery/post abortion care
STI treatment
HIV prevention
– Testing and counseling
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Developing the Program
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Setting of Mission
Identification of needs
– Should be specific and quantified
wherever possible
– Needs will serve as basis for monitoring
program impact
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Developing the Program
Continued
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Developing the Program
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Clear Objectives are Basis ofStrong Programs
Objectives must be measurable
– Indicators for each must be easily
assessed
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Developing the Program
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Developing the Program
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Strategies Formulated toImplement Objectives
Clear series of tasks set out
Required resources identified
Task A →Task B →Task C
↑ ↑
Input Input
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Developing the Program
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Developing the Program
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Evaluation Based on Objectives
Are the objectives the correct ones?
Have they been reached?
Is there clear evidence of impact?
How will the program be altered based on
the information?
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How to Establish Services for aDisplaced Population
Think through the development of health
system from the first
– “Since x is present, we will do y”
– “If f occurs then g will be needed”
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Apply the Planning Cycle
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Carry out aSystematic Assessment
Identify all obvious health problems
– Some for immediate attention
– Others for subsequent attention
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Decide on Immediate Prioritiesfor Treatment
High Low
High
Low
Risk of serious
illness or death
The 2 X 2 table:Frequency of disease
diagnosis
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Consider Consequences of NotAddressing the Problem
Consider the consequence of . . .
– Low immunization coverage for measles
– Low immunization coverage for BCG
– Large population in known cholera area
– Widespread scabies or lice
– Large adolescent population
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Involve Affected Community
Seek refugee community participation
– In priority selection
– In program design
This will promote program ownership
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Consider Alternatives and SelectAppropriate Solution
Use decision matrix to select the potentially
most feasible and effective solution
Solution A B C D
Feasibility
Acceptance
Cost
Sustainability
TOTAL SCORE
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Set Objectives to ReflectPossible Events
Set program objectives
for program monitoring
and evaluation
– Short-term
objectives
– Longer-term
objectives
Ensure objectives are
“SMART”
– Simple
– Measurable
– Attainable
– Realistic
– Time-bound
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Determine Strategy andEstablish Monitoring System
Determine strategy and methods
Implement program
Use information system to monitor process,
outputs and outcomes, as capacity allows
INPUTS → PROCESS → OUTPUTS → OUTCOME
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Section D
Manner of Providing Health Services
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In What Manner Should HealthServices Be Provided?
Health care is based on Primary Health Care principles
PHC seeks to do the following:
– Provide acceptable and affordable health
care
– Provide optimum rather than maximum
health care
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Themes of PHC
Education about main health problems
– Including prevention and control
Promotion of food supply and proper
Nutrition
Adequate supply of safe water and basic
Sanitation
Maternal and child health care, including
family planning
Continued
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Themes of PHC
Immunization against major diseases
Prevention and control of locally endemic
diseases
Appropriate treatment of common
diseases/injuries
Provision of essential drugs
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Different Levels of Health CareBy Frequency of Needs
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Resources Required to ProvideHealth Care
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Section E
Making Specific Decisions
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Specific Decisions to Be Made
Establish new services vs. augment existing services
Where possible, the choice is to strengthen
local services
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Deciding Whether to StrengthenLocal Services
Hospital Level New facilities very costly
Health Center Level New facilities often needed
Health Post New facilities usually needed
Community Services Specific for displaced populations
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Setting Staff Requirements
Staff requirements depend on the following:
– Skills and capacity
– Main tasks to be done
– Resource requirements for each
Selection of staff
– Refugee vs. National vs. Expatriate
– Seconded government staff
Continued
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Setting Staff Requirements
Need personnel policies for the following:
– Job descriptions
– Contracts
– Disciplinary procedures
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Establishing a Drug Program
Follow Essential Drugs Programme (1977)
Set drug procurement guidelines
Define drug selections for various levels of
health care
Promote “rational” prescribing habits
– Organizational practices
– Host country policy
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Drug Donations
Donated drugs often a disaster in
themselves:
– Inappropriate or unknown medications
– Outdated
– Unreadable instructions
– Clutter up warehouses, take up
personnel time
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New Emergency Health Kit
Contains drugs and medical supplies for
10,000 persons for three months
– 10 basic units for PHC workers
– One supplementary unit for higher-level
workers
Continued
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New Emergency Health Kit
Does not cover all drug requirements
– Chronic diseases
– Psychotropic drugs
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Section F
How Much of What is Needed?
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First Referral Hospital
Capacity—1:150,000–300,000
Services provided
– Emergency surgery
– Emergency obstetrical care
– Blood banking
– Basic laboratory
Continued
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First Referral Hospital
Key staff
– At least two medical officers
– Adequate nursing staff (20+)
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Health Center
Capacity—1:30,000 or 10 km radius
Staffing—health care workers, nurses,
±medical officer, ±simple laboratory
May have inpatient beds and a maternity unit
– Refer to 1st level hospital
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Health Posts or Dispensaries
Capacity—1:10,000 persons
Referral to the health center
Key staff—medical auxiliaries (primary
health care workers)
– Community Health Workers (CHWs) or
home visitors
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CHWs Work out of Health Posts
Often refugees—1:500 or 1:1000
Supervision from health post
Duties include the following:
– Health promotion
– Seek out and refer ill persons
– Treat common illness—
e.g., diarrhea
– Refer seriously ill to hospital
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How Health Services Are Utilized
Initially, may be a rush for treatment
– Pent-up demand
– Epidemics may be in progress
– 2–3% of population may use services/day
Continued
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How Health Services Are Utilized
Steady state usually 1% of population
visiting OPD services daily
– 1% of outpatient attendance will need
inpatient care
– 1% of inpatients will need hospital
referral
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Factors Affecting Utilization
Utilization by geographic location
– OPD attendance drops by 50% for every
three km
Continued
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Factors Affecting Utilization
Utilization by age
– Under-15s constitute 50% or more of
most developing country populations
– Under-5s constitute about 20%
and represent 50–60% of outpatients
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What Can Health Workers Do?
HEALTH WORKER POTENTIAL CAPACITYCHW or home visitor
(community-based)
30 persons per day
Medical assistant or nurse
(facility based)
50 persons per day
Medical Officer (doctor) 40 outpatients a day
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Source of Staff
Refugee and host country nationals wherever possible
– Have better understanding of refugee
experiences
Potential for conflicts over pay are great
Establishing credentials of refugee staff may
be difficult
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Consider “Down Time” for Staff
Remember “down time”
– Training
– Vacation time
– Sick leave and maternity leave
– Rest and relaxation for expatriate staff
– Consider staff turnover
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Handing Over of Programs
Common after early phase to close down or hand over health services
– To development-oriented NGOs
– Sometimes to host country MoH
Continued
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Handing Over of Programs
Imperative to design programs for long-term
efficiency from the beginning
Monitoring of program effectiveness
– Measured against set objectives
– Goal to contribute to development of
refugees and host country system
Copyright 2005, The Johns Hopkins University and Gilbert Burnham. All rights reserved. Use of these materials permitted only in accordance with license rights
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