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PLANNING AND ORGANIZING HEALTH PROGRAMS
SCREENING
WHY PRIMARY HEALTH CARE ASSISTANCE?
ILL INDIVIDUALSTERTIARY
PREVENTION
INDIVIDUALS WITH REVERSIBLE CHANGES,
SECONDARY PREVENTION
HEALTHY PERSONSPRIMARY PREVENTION
NO HEALTH PROGRAMS
ILL INDIVIDUALS↑↑
INDIDUALS WITHREVERSIBLE
CHANGES↑
HEALTHY PERSONS↓
Diagnostic of the Health Status of an Individual
Diagnostic of the Health Status of a Community = Population Group
- Identify the individual (name, gender, age, profession)
- Identification of the population group (age distribution, gender distribution, level of education, profession, etc..)
- Anamnesis = History- Clinical Examination- Investigations - The information is compared with
already known “models”= learned
- The data should be standardized, transformed into information , we do calculate the average, and we do compare with already existing reference models
- Diagnostic - Diagnosis of the health status of the population group
- Determining the etiology - Determining the most probable etiology- Etiological or symptomatic
treatment-” Treatment” in the form of a health program
which should target the etiological factors/risk factors/the disease
- Control - Control by monitoring the health status of the population group
COMMUNITY MEDICINE INDIVIDUAL MEDICINE
1. Well-defined, population and geographic, community;
2. Healthy individuals and families and/or ill individuals;
3. Team work, not only medical staff ;4. Integrated care, medical and social;5. General application in accord with the
needs expressed by the community; 6. Main interest for the environment:
physical, biological, psychological, social and economic;
7. Planning activities in accord with the problems and needs, epidemiology as the main “tool” and participation of the beneficiaries;
8. Results appreciated most by the healthy;
9. The “health” team must be in permanent contact with the community;
10. The medical and social prevention and health education are the priorities.
1. Isolated individuals which do ask for medical services;
2. Main concern=the ill;3. The health=illness, specialist does
work “alone”;4. Individualized diagnostic and
treatment; 5. Limited use, just for the ill person; 6. Secondary interest for the
environment of the ill; 7. No planning, no epidemiology,
without the involvement of the beneficiaries;
8. Results appreciated only by the ill;9. No relationship with the individuals if
they are not ill;10. The only priority = treatment of the
illness.
SCREENING
Definition:“Secondary prophylaxis action which targets the identification of the individuals with a potential health problem, unknown until that moment, using a test/examination/other investigation techniques, which can be applied fast at population level.”
World Health Organization Definition:
“Population exam which does consists in applying one ore more examination techniques on a population group, in order to “probably” identify a disease , an abnormality, or an risk factor.
Dana Mincă, MD. Ph.D, Professor of Public Health
SCREENINGHypothesis: 1. In a population there are unknown ill persons and unknown
diseases; 2. Identifying the disease during the precocious stages
increases the possibility of curing the disease;3. Treatment made during the early stages are cheaper and
with better chances of preventing premature deaths.
SCREENING GOALSMaintain health and preserving health when screening targets risk factors = primary prevention;
• Early stages diagnosis of disease;• Determining prevalence of a disease or risk factor = tool for
planning health programs oR health services;• Diagnosis of the health status of a community;• Evaluation of a health program;• Determining the presence of a possible association.
SCREENINGCRITERIA OF CHOOSING A DISEASE FOR SCREENING:1. Public Health Problem – high prevalence, severe
medical and social consequences, severe evolution, invalidity, occupational absenteeism;
2. Disease detectable in asymptomatic or early stages;3. Appropriate tests to detect the disease;4. Test accepted by the population;5. Natural history of the disease known and
understood;6. Adequate treatment for the individuals with the
disease;7. Treatment acceptable by the ill persons;8. National strategy for treatment and surveillance;9. Acceptable cost;• The starting point for a long medical surveillance.
SCREENINGGENERAL MODEL OF A SCREENING
TARGET POPULATION
SAMPLING +/-
TEST APPLIED
NEGATIVE RESULTSPROBABLY HEALTHY
INDIVIDUALS
POSITIVE RESULTSPROBABLY ILLINDIVIDUALS
DIAGNOSTIC TEST - CONFIRM
TREATMENT PHASE AND MEDICAL SURVEILLANCE
SCREENING“The precursory period”
Time
Biological début of the
diseaseDisease
detectable using a
screening test
Disease clinically manifest
Screening performed
Final result:
- Healthy
- Invalidity
- Death
Precursory period
SCREENINGMETHODS FOR SCREENING1. INTERVIEW OR QUESTIONNAIRE – used to
screen behavior risk factors, subject to errors in regard with the memory of the subjects;
2. MEDICAL EXAMINATION – clinical examination, laboratory tests, other investigation techniques; the examination must be standardized, simple to perform and cheap, if possible to detect not only a disease;
3. COMBINED METHODS – using the methods from the previous techniques together.
SCREENINGSCREENING TEST – DIAGNOSTIC TEST
CRITERIA SCREENING TEST DIAGNOSTIC TEST
OBJECTIVE PRESUMPTION CERTITUDE
TARGET GROUP
APPARENTLY HEALTHY
WITH SIGNS OR SYMPTOMS
TARGET POPULATION GROUP INDIVIDUALS
PRECISION SENSIBILITY ↑SPECIFICITY ↓
SPECIFICITY ↑SENSIBILITY↓
COST LOW COST,“SINE QUA NON”
FREQUENTLY EXPENSIVE
TREATMENT DECISION
NEVER MAJOR CONTRIBUTION
SCREENINGVALIDITY = the frequency of the confirmation of the screening test by the diagnostic test; measured with Sensibility Specificity.Sensibility = capacity of a test to correctly identify those who have the disease → a test with a high sensibility will determine a reduced percentage of the false-negative, and it will decrease the possibility to miss individuals with the disease;Specificity = the percentage of the negative results of the test in the population of all non-ill individuals → a test with a high specificity will determine a low percentage of false-positive results. Ideal is that specificity and sensibility to be high, but in the real world we do prefer tests with high specificity, because, due to the costs, we do not want to increase the amount spent for the diagnostic phase. Validity can be increased by using complementary tests → blood sugar level + urine sugar level.
SCREENINGREPRODUCIBLE Test = the degree of stability, capacity to obtain similar results when the test is applied on the same population group, by different investigators. ACURACY = how accurate the characteristic investigated is measured = the degree of“reality” of the measurement.Reproducible Test = standard test + trained staff + monitoring & control
THE PREDICTIVE VALUE OF THE TEST :1. Positive predictive value = the probability of
being ill if the test is positive;2. Negative predictive value = probability of
not being ill if the test is negative.
SCREENINGUL
CHARACTERITICS OF A SCREENING TEST:1. Not noxious;2. To be rapidly performed;3. Cheap;4. Simple;5. Acceptable by the population;6. Validity adequate;7. Reproducible = high degree of stability;8. High out-turn;9. Adequate predictive value.
SCREENINGULDISEASES SUITABLE FOR SCREENING:
Blood diseases : pregnant women and new-born anemia, Rh incompatibility;Infectious diseases: UTI’s – pregnant women, DM; VBH – pregnant women, blood donors, organ donors; HIV – pregnant women, medical marriage certificate; Rubella – pregnant women; Syphilis; TB; Genetic diseases: Fenilcetonuria, Congenital Goiter;Cardio-Vascular diseases: HT, Cholesterol level;Cancers: Breast, Cervix, Bowel and Rectum, Testicle;Other diseases: Glaucoma, Osteoporosis .
SCREENING
DISADVANTAGES:
1. False – Positive results – treatment in excess of all abnormalities, anxiety, morbidity, eventually mortality;
2. False - negative results → detecting the disease in advanced stages with therapeutic and cost consequences, false “safety” of the individual, with the possible “snow – ball” effect on the population.
HEALTH PROGRAMS“ My interest is in the future, because in the future I am going to live the rest of my life. This is an attitude which each of us should adopt, because the future is the real place where our thoughts should be. Those who are going to anticipate correct this, are going to have more benefit compared with those which are not doing this.”
Charles F. Kattering
HEALTH PROGRAMS
Definitions:Program =“An organized, coherent, and
integrated ensemble of activities and services, which are realized simultaneously or in succession, with the necessary resources, in order to achieve the objectives established according to the health problems of a well defined population.”Project = “Combination of human, material,
and time resources, gathered together in a temporary organization in order to achieve a certain goal.”
R. Pineault
HEALTH PROGRAMS
NECESSARY CLARIFICATIONSProject and Program are considered many times synonymous = this is NOT a major mistake, because the characteristics and the stages, of both projects and programs, are approximately the same; A program is more comprehensive in regard with scale of activities, and it is not necessarily limited in time; A program may contain several projects, in fact the projects are representing the very first partition of a program.
HEALTH PROGRAMS
WHY HEALTH PROGRAMS?1. They do start with the identification of the health
problems of the community;2. The health problems are specific, and the applied
programs do respond to the health needs of the population = community;
3. Rational and logic method to conceive, and realize activities and services of health;
4. The activities of a program do not take into account the administrative barriers;
5. May be applied both for prevention and curative services;
6. Do favor the permanent adapting of the health services to the changes of the environment.
HEALTH PROGRAMSSTAGES OF CONCEIVING A PROGRAM
SITUATION ANALYSIS
ESTABLISHING PRIORITIES
STAFF INVOLVEDDEFINNING THE GOAL
ASSUMING RESPONSABILITYDESIGNATE COORDINATOR
TRANSFERRING RESPONSABILITIES TEAM BUILDING
PLANNING –ACTION PLAN
PROJECT RESULT
CONTROL SYSTEM
DECISION FOR ACTION
PLANNING
HEALTH PROGRAMS
DOMAINS OF THE SITUATION ANALYSIS
POLICY, OBJECTIVES, SOCIAL, ECONOMIC,
HEALTH
HEALTHDETERMINANTS
HEALTH SYSTEM DEVELOPINGPOTENTIAL
CURRENT LAWS
SOCIAL & ECONOMICPOLICY
HEALTH POLICY
INDICATORS OF THE HEALTH OF THE
POPULATION
HEALTH DETERMINANTS
ORGANIZINGPRINCIPLES
ACCESS TOHEALTH SERVICES
UNITSPERSONNELSERVICES
INFORMATION DOCUMENTCOMPREHENSIVE
HUMAN, MATERIAL, FINANCIAL, RESOURCES
HEALTH PROGRAMS1. Indicators of Health:
- social & demographics – services and health needs characteristics of the population, social development which allows to detect the vulnerable population groups;- indicators of health : mortality, morbidity, risk factors, incapacity & invalidity due to disease;- indicators of using the health services;- indicators for human, material and financial resources .
2. Questionnaires – information from the beneficiaries of services and self perception about the health status;
3. Consensus – individuals which do know very well the community.
HEALTH PROGRAMS
CRITERIA FOR ESTABLISHING PRIORITIES:1. Importance of the problem – incidence,
prevalence, premature deaths, potential years of life lost, incapacity, invalidity, impact upon society, family, environment, the evolution in time without an intervention;
2. Capacity of solving the problem;3. Possibility of implementing the program –
economic access, acceptance by the population, available resources, etc.
There can not be more than 5 action priorities in any domain, > 5 = bad system, or bad managerial skills
HEALTH PROGRAMSPLANNING A PROGRAM
ACTUAL SITUATIONANALYSIS
DESIRED SITUATIONPLANNED
ACTUAL HEALTH STATUSOF THE
POPULATION GROUP
SERVICES AND PRODUCTS
USED
EXISTENT RESOURCES
HEALTH NEEDS
SERVICES NEEDS
RESOURCES NEEDS NECESSARY RESOURCESDEMANDED=NEEDED
NECESSARY SERVICESDEMANDED=NEEDED
DESIRED HEALTHSTATUS
R. PINEAULT
PROJECT GOAL
“need” = difference between the present situation and the aimed situation
Factors which do determine the need :Behavior – attitudes, practices, knowledge, etc;Medical – disease prevalence, existent services, resources, access, etc;Non-medical – social, economic, financial, geographical, educational, policy, religion, etc.
HEALTH PROGRAMS
RESOURCES: HUMAN, FINANCIAL, MATERIALCompulsory is to establish the team, as well as the SWOT analysis (Strengths, Weakness, Opportunities, Threats) of the organization;Key elements for building a TEAM: select staff, each member responsibility, and transfer of the responsibility.Planning the resources must start with the analysis of the existing resources and the way these are used.Action plan = budgetEVALUATION – to determine if the objectives were achieved, OBJECTIVE= SMART
1. Before intervention – what objective are we going to evaluate; choose the indicators; data source; evaluation staff; plan the using of the evaluation results;
2. During the intervention – collecting data; contingency plan if needed
3. After the intervention – interpret & communicate results; starting point for a new program.
HEALTH PROGRAMSCONTROL SYSTEM
MONITORING = systematic process of collecting data and analysis to transform it in information, in order to ensure that the activities of the program are realized, and in this way we can precocious identify the operational problems;Allows:
1. To determine if the activities are taking place as planned;
2. Precocious identify problems, even the potential ones;
3. Adequate response to donors/managers demand in order to answer about budget allocation.
NATIONAL HEALTH PROGRAM NO.3FAMILY PLANNING INTERVENTION
GOALINCREASE ACCESS AT FAMILY
PLANNING SERVICES AT THE LEVEL OF PRIMARY HEALTH
CARE ASSISTANCE
MATERNAL MORTALITY IN THE CANDIDATE COUNTRIES OF THE EUROPEAN UNION
43,9
34,0325,4323,91
19,0717,2215,6412,687,925,153,533,312,24
01020304050
Croatia Ce
hiaPol
onia
Ungar
iaEs t
onia
Li tuani
aSlo
va cia
Slove n
iaBul
garia
Ucrain
aLet
on ia
Roma
n iaMo
ldova
ABORTIONS IN ROMANIA UNTIL 2002
0
100.000
200.000
300.000
400.000
500.000
600.000
700.000
800.000
900.000
1.000.000
Avorturi
1970
1980
1989
1990
1995
1996
1997
1998
1999
2000
2001
2002
1,17 1,
24 1,3
3
1,37
1,69
0,84
0,66
0,6
0,53 0
,6
0,48
0,41 0,41 0,4
0,42
0,33
0,34
0,22 0,31
0,74 0,92 1
,12
1,18
1,47
0,58
0,41
0,38
0,34 0,38
0,25
0,22
0,21
0,18
0,19
0,16
0,17
0,09
0,130,
43
0,32
0,21
0,19 0,22 0,26
0,25
0,22
0,19 0,22
0,23
0,19 0,2
0,22
0,23
0,17
0,17
0,13 0,18
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
1 2 3 4 5 6 7 8 910111213141516171819Risc obstetrical
AvortGlobal
MATERNAL MORTALITY IN ROMÂNIA1970-2003
Risc obstetrical Avort Global
1970 1975 1980 1985 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
LA 1
000
DE
NA
SCU
TI V
II
date provizorii
YEAR 1999 2000 2001 2002 2003 2004
DEATHS OBSTETRICAL
RISK
54 39 38 27 38 31
DEATHS ABORTIONS
44 38 37 20 27 19
OTHER CAUSES 12 20 17 24 23 22
ABORTIONS DURING THE FERTILE AGE Rata Avorturilor
0
10
20
30
40
50
60
1 2
Romania 1999
Kazakhstan 1999
Ukraine 1999
Czech Republic 1999
PREVALENCE OF MODERN CONTRACEPTIVE METHODS USED
Prevalence of using modern contraceptive methods
OLANDAFRANTA
UNGARIA
BULGARIAROMANIA
0102030405060708090
100
OLANDA FRANTA UNGARIA BULGARIA ROMANIA
LEVELS OF INTERVENTIONS
LegislationManagementTraining of service providersBehavior change communication
PARTNERS
GUVERNMENTAL:Ministry of Health, County Health AuthorityNGO’s:SECS, PSI, IEESR, Tineri pentru Tineri, ARAS, UNOPA, AFER, Romani CRISS, Renaşterea, SRC, Accept
DONNORS: UN, UE, WB, USAID
THREE PILLAR APPROACH
DIPLOMAConsiliere
TehnologiaContraceptiei
Ingrijire pre/postnatala
ITS
LMIS
TRAINING OF PROVIDERS
LOGISTIC SYSTEMFREE CONTRACEPTIVES
BCC / SOCIAL MARKETING /SERVICES MARKETING
SERVICE COVER 2001
SERVICE COVER 2004
0
100.000
200.000
300.000
400.000
500.000
600.000
700.000
800.000
900.000
1.000.000
Avorturi
197019801989199019951996199719981999200020012002200320042005
ABORTION AT THE END OF 2005
FREE CONTRACEPTIVES CONSUMPTION IN IASI, BOTOSANI, SUCEAVA
0
50000
100000
150000
200000
250000
300000
350000
400000
2002 2003 2004 2005
COCInjectabilPrezervativeDIU
1999 2000 2001 2002 2003 2004
Nascuti viiAvorturi spontane
Avorturi la cerereTotal intreruperi de sarcina
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
NEW BORN AND ABORTIONS - Botosani
Nascuti vii Avorturi spontane Avorturi la cerere Total intreruperi de sarcina
1999 2000 2001 2002 2003 2004
Nascuti viiAvorturi spontane
Avorturi la cerereTotal intreruperi de sarcina
0
2000
4000
6000
8000
10000
12000
NEW BORN AND ABORTIONS - Suceava
Nascuti vii Avorturi spontane Avorturi la cerere Total intreruperi de sarcina
1999 2000 2001 2002 2003 2004
Nascuti vii
Avorturi spontaneAvorturi la cerere
Total intreruperi de sarcina
0
2000
4000
6000
8000
10000
12000
14000
16000
NEW BORN AND ABORTIONS - Iasi
Nascuti vii Avorturi spontane Avorturi la cerere Total intreruperi de sarcina
FINAL THOUGHTS
No matter how large amounts of money are going to be invested in the curative services of a health system this is not going to improve the population health.Health programs = viable option for the PHCA for preventive and curative services.
PLANNING AND ORGANIZING HEALTH PROGRAMS�WHY PRIMARY HEALTH CARE ASSISTANCE?NO HEALTH PROGRAMS SCREENINGSCREENINGSCREENINGSCREENINGSCREENING�“The precursory period”SCREENINGSCREENING SCREENINGSCREENINGSCREENINGULSCREENINGULSCREENINGHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMS HEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMSHEALTH PROGRAMS �CONTROL SYSTEMNATIONAL HEALTH PROGRAM NO.3�FAMILY PLANNING INTERVENTIONABORTIONS IN ROMANIA UNTIL 2002ABORTIONS DURING THE FERTILE AGE PREVALENCE OF MODERN CONTRACEPTIVE METHODS USEDLEVELS OF INTERVENTIONSPARTNERSTHREE PILLAR APPROACHSERVICE COVER 2001SERVICE COVER 2004FINAL THOUGHTS