IMPORTANCE OF PRIMARY HEALTH CAREDr Aslesh OPAssistant professor, Community Medicine, Pariyaram Medical College

Definition of health

Are we healthy?

Highest Life expectancy

Lowest child mortality

Lowest maternal mortality

Prevalence of Non communicable diseases

Diabetes

Comparison of current prevalence of diabetes in above 18 years

Kerala India world0

2

4

6

8

10

12

14

16 14.8

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Age standardized prevalence of di-abetes among >18 years

Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, et al. Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India. Indian J Med Res. 2010;131(1):53–63.

World Health Organization. Global Status Report On Noncommunicable Diseases 2014. 2014.

Diabetes in Kerala over last 25 year

27.3

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19.6

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1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

%

Year

Prevalence of diabetes

1999 20100

2

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6

8

10

12

14

3.4

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Prevalence of diabetes in age group 30-40 years

Kutty VR, Soman CR, Joseph A, Pisharody R, Vijayakumar K. Type 2 diabetes in southern Kerala: variation in prevalence among geographic divisions within a region. Natl Med J India [Internet]. Jan [cited 2015 Apr 23];13(6):287–92

Jose R, Manojan KK, Augustine P, Nujum ZT, Althaf A, Haran JC, et al. Prevalence of Type 2 Diabetes and Prediabetes in Neyyattinkara Taluk of South Kerala [Internet]. Academic Medical Journal of India. 2013 [cited 2015 Apr 23]. Available from: http://medicaljournal.in/prevalence-of-type-2-diabetes-prediabetes

Detection , treatment and control of diabetes in Kerala

Aware Treated Controled0

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8072

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Allmalesfemales

Hypertension

Trend in prevalence of hypertension in Kerala (above 30 year of age)

Detection , treatment and control of hypertension in Kerala

Aware Treated Controlled0

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15

20

25

30

35

40

45

50

37

27

9

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33

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Allmalesfemales

Coronary artery diseases

State reports a higher prevalence of coronary artery diseases when compared to other states in India 7.4% in rural (in 1991) 13.5% in urban(in 1995)

The estimated prevalence of coronary artery disease in the age group 20-69 years for 2015 is 10.1 %.(31)

*Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. Int J Cardiol [Internet]. 1993 Apr [cited 2015 Apr 24];39(1):59–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8407009**Begom R, Singh RB. Prevalence of coronary artery disease and its risk factors in the urban population of South and North India. Acta Cardiol [Internet]. 1995 Jan [cited 2015 May 7];50(3):227–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7676762***National Commission on Macroeconomics and Health. NCMH Background Papers·Burden of Disease in India. New delhi; 2005. p. 1–388. Available from: http://www.who.int/macrohealth/action/NCMH_Burden of disease_(29 Sep 2005).pdf

Stroke

Prevalence stroke among adults (>18 years ) in the state was 0.3%

The age adjusted annual incidence of stroke in Kerala in 2010 was 135 per 100,000 were more in males (143 )compared to females (128)

Ischemic stroke was the most common type of stroke ( 73 per 100000)

#Menon J, Joseph J, Thachil A, Attacheril T V, Banerjee A. Surveillance of noncommunicable diseases by community health workers in Kerala: the epidemiology of noncommunicable diseases in rural areas (ENDIRA) study. Glob Heart [Internet]. 2014 Dec [cited 2015 Apr 1];9(4):409–17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25592794

##Soman CR, Kutty VR, Safraj S, Vijayakumar K, Rajamohanan K, Ajayan K. All-cause mortality and cardiovascular mortality in Kerala state of India: results from a 5-year follow-up of 161,942 rural community dwelling adults. Asia Pac J Public Health [Internet]. 2011 Nov [cited 2015 Apr 23];23(6):896–903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20460280

Cancer

Incidence of cancer in Kerala

Kerala (1) India (2) World (2)0

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150

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1.Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from: http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm2 GLOBOCAN :Fact Sheets by Population [Internet]. [cited 2015 Apr 27]. Available from: http://globocan.iarc.fr/Pages/fact_sheets_population.aspx

Trend in incidence of cancer in Kerala

1991-92

1993-97

1998-02

2005-07

2009-11

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20

40

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100

120

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109.2

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*CI5 - Home [Internet]. [cited 2015 Apr 27]. Available from: http://ci5.iarc.fr/Default.aspx**Three Year Report of PBCR 2009-2011 [Internet]. [cited 2015 Apr 28]. Available from: http://www.ncrpindia.org/ALL_NCRP_REPORTS/PBCR_REPORT_2009_2011/ALL_CONTENT/Printed_Version.htm

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Chronic Lung diseases

Prevalence of chronic respiratory disease in Kerala

Kerala India0

2

4

6

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Chronic bronchitisAsthma%

Jindal SK. Indian Study on Epidemiology of Asthma , Respiratory Symptoms and Chronic Bronchitis ( INSEARCH ) A Multi ‐ Centre Study ( 2006 ‐ 2009 ) Department of Pulmonary Medicine [Internet]. 2010. Available from: http://icmr.nic.in/final/INSEARCH_Full _Report.pdf

Chronic Kidney disease

Age-adjusted incidence rate of ESRD in India to be 22.9 per lakh population. 7500 new chronic kidney diseases every year

in Kerala Prevalence in hospitalized patients is 17 %

33 % in Kerala Main causes are diabetes nephropathy

and hypertensive nephrosclerosis*Modi GK, Jha V. The incidence of end-stage renal disease in India: a population-based study. Kidney Int [Internet]. 2006 Dec 25 [cited 2015 May 2];70(12):2131–3. Available from: http://dx.doi.org/10.1038/sj.ki.5001958**Singh AK, Farag YMK, Mittal B V, Subramanian KK, Reddy SRK, Acharya VN, et al. Epidemiology and risk factors of chronic kidney disease in India - results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol [Internet]. 2013 Jan [cited 2015 Apr 22];14(1):114. Available from: http://www.biomedcentral.com/1471-2369/14/114***Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: first report of the Indian CKD registry. BMC Nephrol [Internet]. 2012 Jan [cited 2015 Apr 17];13:10. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3350459&tool=pmcentrez&rendertype=abstract

Emerging infectious diseases

Expenditure on health in Kerala

Out of pocket expenditure for health in Kerala is the highest

Is there a solution?

Prevention oriented health care

Levels of prevention

Levels of prevention

Primodial prevention

Primary prevention

Secondary and tertiary prevention

prevention

Levels of health care and the system in place

Tertiary careMedical college, special institutes

Secondary careCHC, TH, DH

Primary care_PHC , subcentre

Primary level

The “first” level of contact between the individual and the health system.

Essential health care (PHC) is provided. A majority of prevailing health

problems can be satisfactorily managed.

The closest to the people. Provided by the primary health centers.

WHAT IS PRIMARY HEALTH CARE

primary health care is essential health care made universally accessible to individuals and acceptable to them, through full participation and at a cost the community and country can afford

Secondary health care More complex problems are delt with. Comprises curative services Provided by the CHC, taluk district

hospitals The 1st referral level

Tertiary health care Offers super-specialist care Provided by regional/central level

institution. Provide training programs

Level of prevention and health care

Tertiary prevention

Secondary

prevention

Primary prevention

Tertiary

Secondary

Primary care level

PRINCIPLES OF PRIMARY HEALTH CARE

Equitable distribution

Community participation

Intersectoral coordination

Appropriate technology

Decentralisation

ELEMENTS OF PRIMARY HEATH CARE

Education concerning prevailing health problems and the methods of preventing an controlling them

Promotion of food supply and proper nutrition

An adequate supply of safe water and basic sanitation

Maternal and child health care including FP

Contd.

Immunization against major infections diseases

Prevention and control local endemic diseases

Appropriate treatment of common diseases

Provision of essential drugs

EXTENDED ELEMENTS OF PHC Expanded options of immunization Reproductive health needs Provision of essential technologies for

health Prevention and control of non

communicable diseases Food safety and provision of selected

food supplements.

FIVE COMMON SHORT COMINGS OF HEALTH CARE DELIVERY

Inverse care Impoverishing care Fragmented and fragmenting care Unsafe care Misdirected care

The Basic Requirements for Sound PHC (the 8 A’s and the 3 C’s)

Appropriateness Availability Adequacy Accessibility Acceptability Affordability

Assessability Accountability Completeness Comprehensivene

ss Continuity

Thank You

Strategies of PHC

1.Reducing excess mortality of poor marginalized populations:

PHC must ensure access to health services for the most disadvantaged populations, and focus on interventions which will directly impact on the major causes of mortality, morbidity and disability for those populations.

2. Reducing the leading risk factors to human health:

PHC, through its preventative and health promotion roles, must address those known risk factors, which are the major determinants of health outcomes for local populations.

Strategies contd.

3. Developing Sustainable Health Systems: PHC as a component of health systems must

develop in ways, which are financially sustainable, supported by political leaders, and supported by the populations served.

4. Developing an enabling policy and institutional environment:

PHC policy must be integrated with other policy domains, and play its part in the pursuit of wider social, economic, environmental and development

policy.

Contd.

Government funded and delivered services with a centralized

Management of growing scarcity and downsizing

Bilateral aid and technical assistance

Primary care as the antithesis of the hospital

PHC is cheap and requires only a modest investment

Guiding the growth of resources for health towards universal coverage

Global solidarity and joint learning

Primary care as coordinator of a comprehensive response

PHC is not cheap. It requires considerable investment .