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