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Resource manual: Page 20/01/2011PUB 122

DEPARTMENT OF COMMUNITY HEALTHDEPARTEMENT VAN GEMEENSKAPSGESONDHEID

PUB 304

RESOURCE MANUAL FOR THE COURSE/HULPBRON LER VIR DIE KURSUS

Department of Community Health/Departement van Gemeenskapsgesondheid

University of Free State/Universiteit van die Vrystaat


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PUB304 (Public health and compulsory residency)

LECTURE PROGRAM - 2011

Session * Lecturer Subject Date

Session 1 Prof. Kruger Principles of Public Health/Community

Health & PHC

20/01/11

Session 2 Prof Kruger Health care system in SA 27/01/11Session 3 Dr de Klerk Levels of Care and Prevention 3/02/11

Session 4 Dr de Klerk Multi-causality of disease 10/02/11

Session 5 Dr de Klerk Health Promotion and Health Education 17/02/11

Session 6 Prof. Kruger Community and community participation 24/02/11

Session 7 Dr de Klerk Community assessment 03/03/11

Session 8 Prof. Kruger Introduction to epidemiology 10/03/11

Session 9 Dr de Klerk Screening programs 17/03/11

Session 10 Prof. Kruger Disease surveillance 24/03/11

Session 11 Dr de Klerk Outbreak investigation 14/04/11

Session 12 Dr de Klerk Health personnel 5/05/11

Additional Prof. KrugerDr de Klerk

MAIN TEST 19/05/11

Additional Prof. KrugerDr de Klerk

Feedback test 1 26/05/11

Additional N Naicker/ MGRamonyai

Community-based Service LearningProject

AdditionalN Naicker /MGRamonyai &Community healthstaff

Submission of the report of Community-based Service Learning Project

Additional Optometry &Community healthstaff

Project presentation by students 16/09

*Please note that session schedule might change because of availability of lecturers

Lecture: Thursday 14h00-15h00

Place: Seminar room, Department of Community Health, University of Free State

Test 1: Sessions 1-11

Exam: See examination roster later this year sessions 1-12


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INTRODUCTION TO COMMUNITY/PUBLIC HEALTHINLEIDING TOT GEMEENSKAPS-/PUBLIEKE GESONDHEID

Session/sessie 1

Information and study materialsInformasie en studie materiaal

Compiled by:Opgestel deur:

Prof. WH KrugerChief Specialist/Hoof spesialis

Department of Community HealthDepartement van Gemeenskapsgesondheid

University of Free State


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A. INTRODUCTION TO COMMUNITY/PUBLIC HEALTH

1. DEFINITIONS

1.1 Definition of community:Dennill et al ( 1995:56) described a community in terms of its geographic boundariesor its social boundaries, or both. They define a community as a group of people who

live in a particular area and who have shared values, cultural patterns and socialproblems, as well as a group awareness which facilitates the residents interactingmore intensely with each other than they would with outsiders.

In respect of planned resources a community could also be defined geographically.Matters of culture, ethnicity and age, however, define, sometimes tightly andsometimes not, other communities, which are within the geographical community. Allof these have to be taken into account in respect of a service, which is deliveredsensitively, responsively and responsibly.

According to Hennessy (1997:5) a dictionary definition reads something like this:[Community is] a collection of individuals composing a community of living under the

same organisation or government, and the state or condition of living in association,company or intercourse with others of the same species; the system or mode of lifeadopted by a body of individuals for the purpose of harmonious co-existence or furmutual benefit (The Shorter Oxford English Dictionary on Historical Principles).

1.2 Definition of HealthThere are several familiar descriptions of health and the definition given by Hennessy(1997:6) is in line with the definition given by the WHO. The definition regard healthas a state of balance or harmony, of homeostasis between the emotional, mental,physical, social and spiritual aspects of a persons individual life.

1.3 Definition of Care:

According to Hennessy (1997:8) care is about having a concern for another/others;an appropriate regard; a preparedness to act; and, sometimes properly, not to act.Care, too, has to do with the balance, which assists in promoting independence andappropriate protection of the vulnerable form exploitation and abuse.

1.4 Definition of Community Health Care:Community Health Care is all about comprehensive health care provision in acommunity both by the primary health care team and others organisations/peoplesuch as dentists, dieticians, pharmacists, ophthalmic workers, continence advisers,ext. (Hennessy, 1997:10).

Hennessy (1997:11) also describe community health care as all the health care thatis taking place and developing at the interface of hospitals and communities, and alsoall health care provision outside hospitals.


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B. PRINCIPLES USED IN COMMUNITY HEALTH

1. 3 MAIN AREAS OF INTEREST

Community Health focuses on the following three areas:

1.1 HEALTH ADMINISTRATION

This is all about the health care systems including management of health care andhealth care institutions

1.2 COMMUNICABLE AND NON-COMMUNICABLE DISEASEFocus on epidemiology and prevention of the above-mentioned diseases/epidemics/endemicEnvironmental Health including water, sanitation, regulations, ext.Occupational Health including occupational medicine and hygiene

1.3 EPIDIOMOLOGY AND STATISTICSResearch

2. PRIMARY HEALTH CARE (PHC)

2.1 DEFINITION:

PHC represents essential health care which is widely accessible to the individual andtheir families in the community, in a acceptable way to the clients, with theircontinuous co-operation at an affordable cost for the community and the country.

It is also seen as part of the first contact a client or his family has with health caresystem (called primary care not the same as primary health care) that can berendered by health care workers inside and outside of the hospital in the community.

2.2 COMPREHENSIVE IN NATURE:

Essentially primary health care is part of a holistic approach to a patient and/or acommunity. Not only focusing on the problem but taking into consideration severalother issues at hand. Several frameworks could be used in this regard and the levelsof prevention is just one such an example:

2.2.1 Primary level of preventionHealth promotionSpecific prevention

2.2.2 Secondary level of preventionEarly diagnosis and treatmentLimitation of disability

2.2.3 Tertiary level of preventionRehabilitation


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2.3 THE KEY WORDS:

Key words use in PHC context as well as quality in health care are defined as follows:

2.3.1 Accessibility:Health care that is within easy reach of all citizens geographically, functionally,financially and culturally

2.3.2 Affordable:The level of health care which the community and authorities can afford

2.3.3 EquityThe absence of subgroup variability and discrepancy

2.3.4 AcceptabilityA level of health care which is acceptable to the community and other healthworkers

2.3.5 Availability

Services must be readily available to members of the community

2.3.6 EffectivenessIt is the extent to which a specific intervention when employed in the field, doeswhat is intended to do for a defined population

2.3.7 EfficiencyThe end results achieved in relation to the effort expended in terms of money,resource and time. It is a measure of the economy with which a procedure ofknown efficacy and effectiveness is carried out

2.4 PREREQUISITES:

2.4.1 Sufficient supportive and referral resources must exit2.4.2 It is a multi-professional team approach2.4.3 Environmental health plays an important role2.4.4 Although the medical practitioner fulfils the leading role in the team, the

community health nurse, in her extended role, bears the responsibility for thegreater workload

2.5 COMPONENTS OF PHC (ALMA ATA, WHO declaration):

2.5.1 Promotion of proper feeding2.5.2 Sufficient supply of safe water

2.5.3 Basic sanitation2.5.4 Mother and child care2.5.5 Family planning2.5.6 Immunisation2.5.7 Prevention and control of local endemic diseases2.5.8 Education with regard to health problems and ways of prevention and control2.5.9 Appropriate treatment for general diseases and minor injuries


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4. DETERMINANTS OF A DISEASE (see Figure 2 for more details)

HOST

AGENT

ENVIRONMENT

5. INFECTIOUS DISEASE PROCESS

5.1 AGENT BACTERIAL, VIRAL, FUNGI, PARASITES

5.2 RESERVOIR HUMAN, ANIMAL, ENVIRONMENT

5.3 PORTAL OF EXIT IN NORMAL BODY FUNCTIONS

5.4 MODE OF TRANSMISSION DIRECT(FROM ONE PERSON TO ANOTHER) INDIRECT(VECTOR, VEHICLE) AIRBORNE ROUTE

5.5 PORTAL OF ENTRY

THROUGH NORMAL BODY FUNCTIONS

5.6 SUSCEPTIBLE HOST IMMUNITY, LIFE STYLE, BARRIER, CHEMOPROPHYLAXIS

5.7 INCUBATION PERIOD TIME FRAME FROM INFECTION UNTIL SYMPTOMS/SIGNS APPEARED

DISCUSSION: BASIC CONCEPTS IN INFECTIOUS DISEASE EPIDEMIOLOGY

These concepts or framework are not unique to only infectious diseases. It could alsobe used in describing any other disease and to develop preventative programs. Someof the heading will then only be not applicable.

5.1 AGENT BACTERIAL, VIRAL, FUNGI, PARASITES

5.2 RESERVOIR HUMAN, ANIMAL, ENVIRONMENT

This is where the agent normally lives and multiplies and where it dependsmainly for survival. This may be man, e.g. chickenpox, animals, e.g.brucellosis, or the environment, e.g. tetanus. It is not necessarily the same asthe source of infection in a particular incident.


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5.3 SOURCE OF INFECTION: Infection may arise from the organisms normally living on the person, or from

another human being, an animal (zoonoses) or the environment. The source ofan infection may sometimes be different from its reservoir. For example, in anoutbreak of listeriois in Canada in 1981, the reservoir of infection was a flock ofsheep, from which manure was used as fertilizer on a cabbage field.Contaminated cabbages from the field were used to make coleslaw, whichbecame the source of infection for humans. When the source of infection isinanimate, e.g. food, water or fomites, it is termed the vehicle of infection

5.3 PORTAL OF EXIT FROM RESERVOIR: IN NORMAL BODY FUNCTIONS

5.4 MODE OF TRANSMISSION

The routes by which an infectious agent passes from source to host can beclassified as follows:

5.4.1 Food-, drink- or water-borne infection, e.g. typhoid and cholera. Theterm food poisoning is usually used of incidents of acute disease in

which the agent has multiplied in the food vehicle before ingestion, (e.g.salmonella food poisoning), and where it may have produced toxins, e.g.botulism. Other agent such as virus gastro-enteritis agents may becarried on the food but do not multiply in it.

5.4.2 Direct of indirect contact. This includes spread from cases or carriers,animals or the environment to other persons who are 'contacts'. (Acarrier is someone who is excreting the organism but who is not ill.)Within this category possible routes include:

Faeces to hand to mouth spread, e.g. shigellosis Sexual transmission, e.g. syphillis Skin contact, e.g. wound infection and cutaneous anthraz

5.4.3 Percutaneous infection. This includes:

Insect-borne transmission via the bite of an infected insect, eitherdirectly from saliva e.g. malaria, or indirectly from insect faecescontaminating the bite wound e.g. typhus.

Inoculation of contaminated blood or a blood product, either bytransfusion, by sharing intravenous needles, by contaminatedtattoo needles or acupuncture needles, e.g. hepatitis B.

The agent may pass directly through intact skin, e.g.schistosomiasis, or through broken skin, e.g. leptospirosis.

5.4.4 Air-borne: Infectious organisms may be inhaled as: Droplets and droplet nuclei, e.g. tuberculosis aerosols, e.g.

legionnaires' disease

Dust, e.g. ornithosis.

5.4.5 Mother to baby:

Organisms may pass from the mother across the placenta to thebaby before birth, e.g. rubella, or via blood at the time of birth e.g.hepatitis B.


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5.5 PORTAL OF ENTRY (HOST): THROUGH NORMAL BODY FUNCTIONS

5.6 SUSCEPTIBLE HOST: IMMUNITY, LIFE STYLE, BARRIER, CHEMOPROPHYLAXIS While the environment affects human health in general, environmental health

threats do not weigh evenly on all segment of the community. Unfortunately,

there are many populations that are more vulnerable to the environmentalhealth challenges than other. Among these populations are the following:

5.6.1 Children:Because of the childrens immature body organs and tissues, rapid changes indevelopment and growth, higher levels of exposure (eat, drink and breath moreair per pound of body weight), play more outside, and are less capable ofprotecting themselves.

5.6.2 The elderly:Because of their compromised immune system.

5.6.3 The immune-compromised: (e.g. HIV positive, people on steroids andchemotherapy, organ transplants, diabetes mellitus patients)Also because of their compromised immune system.

5.6.4 Minority populations & the Impoverished:

5.7 INCUBATION PERIOD:

This is the time from infection to the onset of symptoms. For each organismthere is a characteristic range within which the infection dose and the portal ofentry, as well as other host factors, e.g. age and other illness, give rise toindividual variability. For example, in rabies the incubation period is shorter thecloser the bite would is to the head. The virus travels up the nerves to the brain

and has less far to go the closer the bite to the head.

5.8 COMMUNICABILITY:

The infectious agent may be present in the host and passed to others over along period of time, the period of communicability. Some infections can bepassed on even when the host is well. These people are then known astemporary or chronic carriers e.g. typhoid carriers. In some diseases,transmission from person to person occurs before symptoms develop. Forexample, a person with hepatitis A is most infectious to others just before he orshe becomes ill.


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5.9 OCCURRENCE:

An infection that is always present in a population is said to be endemic. Anincrease in incidence above the endemic level is described as an epidemic orpandemic when the epidemic is world wide. Cases may be sporadic when theyare not known to be linked to other cases, or clustered in outbreaks when twoor more linked cases or infections occur, suggesting that there was a commonsource of there has been spread from person to person. Two commonly usedmeasures of occurrence of disease or infection are the incidence rate, thenumber of new cases occurring in a defined population for the total population,e.g. 10 cases per 100 000 persons per year/ and prevalence, the proportion ofthe population which is susceptible to infection. The resistance of a populationto the epidemic, because a sufficient proportion of the population is immune, iscalled herdimmunity.

The attack rate during an outbreak is the proportion of the population at riskwho was ill during the period of the outbreak. The secondaryattackrate isthe attack rate in the contacts of primary cases due to person -to-personspread.

Variables: Epidemiology involves measuring attributes or factors, which vary inquantity or character. Some variables are fixed, i.e. they are either present orabsent, e.g. sex. Occupation and nationality; or they may be continuous, beingpossessed in different amounts, e.g. age, height and weight. Analysis of thedistribution of fixed variables in a population will usually be by calculating theproportion of people who fall within certain categories, or the rates ofoccurrence of disease within sub-groups of the population, e.g. death rates byresidence or occupational group. Analysis of continuous variables is morecomplicated since values obtained from a population will lie along a range, andthese values are usually summarised by an average.

5.10 SURVEILLANCE:

The process of monitoring disease and infection in population is calledepidemiological or population surveillance. The stages of surveillance are:

5.10.1.1 systematic collection of data;5.10.1.2 analysis of the statistics to produce statistics5.10.1.3 interpretation of the statistics to provide information5.10.1.4 distribution of this information to all those who require it so that

action can be taken; and5.10.1.5 continuing surveillance to evaluate the action

Data maybe collected especially for surveillance purpose (active systems) or usemay be made of routine data (passive systems). Possible weaknesses in the qualityand completeness of the data should always be borne in mind.

Most active data collecting systems are based on a carefully designed standard casedefinition. Passive data collection systems are usually based upon a microbiologicalor clinical diagnosis, which is not precisely defined, and this may lead to problems ofinterpretation. Nevertheless, such data are invaluable for monitoring trends and fordetecting episodes or cases for further study.


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Resource Manual: Page - 13 - 20/01/2011PUB304

Period of pre-pathogenesis Period of pathogenesis

Death

ComplicationsChronicity

Agent Host Improvement anAdvanced rehabilitation.disease.

Interaction Early recognizable Temporary dis- disease. ability.

Environment

Stimulus Clinical horizon

Susceptible host and de-terminants. (Specific agent Early pathogenesis and contributing factors) including incubation

and latent period.

COURSE OF TIME

FIGURE 1: DEVELOPMENT OF A DISEASE


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DETERMINANTS OF DISEASE

In-transit Environment

R

e Housing, clothing, sport, recreation, hobbies, legislation, Climate, allergens and carcino

s lifestyle, family life, occupations, training, income taxes, rainfall, humidity, water, tem

i attitudes, beliefs, values, norms, socialization, politics, ozone, topography, ear

d war, unrest, violence, crime, overpopulation, slums, radio active radiatio

e squatting, theatres, prostitution, sexual offences, ventilation, dus

n suicide, welfare, divorce, family disinte- poisons, me

t gration Sosio-economical Physico thermal

i Environment chemical

a Environment l

Biological Environment

Viruses, bacteria, fungi, protozoa, worms, arthropoda, vegetative and animal food allergens a

alcohol, tobacco, dagga, opium, cocane, vaccines and antibiotics.

Occupational Environment]

/lb/vkg3les1

FIGURE 2: DETERMINANTS OF DISEASE


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Visiting doctor

Chief nursing service manager

ASenior nursing service manager

Nursing service manager

Decision-making level

Chief professional nurse (senior tutor)

BSenior professional nurse (tutor)

Professional nurse

Health adviser

C

Community

FIGURE 3: AN EXAMPLE OF A HEALTH CARE HIERARCHY IN A COMMUNITYChimere-Dan (1996:30)

Community levelworkforce

1

2

3

4

i

ii

iii


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REFERENCES:

Chimere-Dan, G. 1996. Community involvement in urban health programmes.Johannesburg : Thomson Publishing. 109p.

Dennill, K., King, L., Lock, M & Swanepoel, T. 1995. Aspects of primary health care.Halfway House : Southern Book Publishers. 146p.

Hennesy, D. 1997. Community health care development. Hampshire : MacmillianPress. 270p.

STUDY GOALS

A student should be able to:

1. Define certain concepts used in Community Health and apply the definitions inpractice

2. Understand and apply the concepts of primary health care in practice3. Have meaningful discussions with peers and patients using the various frameworks

used in Community Health


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HEALTH CARE SYSTEM IN SOUTH AFRICA/GESONDHEIDSORG SISTEEM IN SUID AFRIKA

PUB 304

Information and study materials for Session 2Informasie en studie materiaal vir Sessie 2


Dr GMC LouwagieSenior Specialist/Senior spesialis

& Dr A de la Querra

Registrar

Department of Community Health/Departement van Gemeenskapsgesondheid

University of Free State/Universiteit van die Vrystaat


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A. OVERALL STRUCTURE OF HEALTH AUTHORITIES AS ENVISAGEDIN NATIONAL HEALTH ACT, 2004 (Act no.61 of 2003)

(Note that some of these structures, e.g. the advisory councils are not yet in place)

1. NATIONAL LEVEL

National Cabinet

Minister of Health National Health Council (advisory)

Director General Health

National Health Departments

2. PROVINCIAL LEVEL (system of fiscal federalism). Free State Example

Provincial Cabinet

Member of Executive Council Health Provincial Health Council (advisory)

Provincial Head Health

Health support Cluster Clinical Cluster Financial Cluster(Health programs) (Hospitals and clinics) (Financial/strategic issues)

3. DISTRICT LEVEL (TYPE C AND A MUNICIPALITIES, with type B local municipalities)

MHS NON-MHS District Health Council: functionalintegration

District Councils (and for transitional period type B local municipalities) areresponsible for Municipal Health Services, defined as Envirornmental Health Services innew National Health Act, 2004.

The MEC Health establishes the District HEALTH Councils and ensures mutually agreedperformance targets are set.

Note that un the transitional period, many PHC services at clinics are rendered by type Blocal authorities. Some may be taken over by the province, others may continue to berendered by the local authorities if they have the capacity.


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The services provided by PHC workers include immunisation; communicable andendemic disease prevention; maternity care; screening of children; IntegratedManagement of Childhood Illnesses (IMCI) and child health care; health promotion;youth health services; counselling services; chronic diseases; diseases of olderpersons; rehabilitation; accident and emergency services; family planning; and oralhealth services.

Patients visiting PHC clinics are treated mainly by PHC-trained nurses, or at someclinics by doctors. Patients with complications are referred to higher levels of care,such as hospitals, if the conditions cannot be treated at PHC level.Persons who are members of a medical aid scheme are excluded from free services.The National Drug Policy is to a large extent based on the essential drugs concept,and is aimed at ensuring the availability of essential drugs of good quality, safety andefficacy to all South Africans.

The Essential Drug List (EDL) for all levels consists of 693 medicines. Provincialgovernments determine which of the medicines applicable to each level of care arestocked in the different facilities. The Standard Treatment Guidelines and EDL for thedifferent levels were developed using World Health Organisation (WHO) guidelines.

They will be revised regularly to include new developments in the medical andpharmaceutical fields.

5. DISTRICTS

The Department's health plan is based on the district model, which functionsaccording to the PHC approach and implies the establishment of health districts inevery part of the country. Forty-two health regions and 162 health districts have beendemarcated nationally. The health districts have been realigned with the newly-demarcated municipalities.

6. HEALTH POLICY

Some 40% of all South Africans live in poverty, and 75% of these stay in rural areaswhere health services are least developed. The core of government's health policy isto eventually provide health care that is affordable and accessible to all.In 1999, the Minister of Health published a reviewed strategic framework to guide workover the next five years. Relevant aspects identified in this 10-point plan are: reorganisation of support services improvements in the quality of care

revitalisation of public hospitals further implementation of the district health system and primary care a decrease in the incidence of HIV/AIDS, sexually-transmitted infections (STIs) and

tuberculosis (TB) resource mobilisation and allocation human resource development (HRD).


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In recent years, substantial developments took place in several of these areas: A unified National Health Laboratory Service (NHLS) was established to provide

laboratory services to the public health sector. It came into operation as a publicentity in the middle of 2001.

The National Planning Framework, provincial health plans and costing of serviceshave progressed substantially, enabling a longer-term focused rehabilitation andrevitalisation programme in the Department.

Significant progress in HRD included the submission to Cabinet of a draft humanresource plan for the sector and the negotiated abolition of rank and legpromotions. Community service was extended to dentists and pharmacists.

7. LEGISLATION

7.1 National health Act

The National Health Bill was passed by Parliament in 2003. The Act, which provides alegal framework for a national health system that encompasses public, private, non-governmental and other providers of health services, also sets out the rights andduties of health-care providers, health workers, establishments and users.

It aims to promote the progressive realisation of South Africans' rights to healthservices and an environment that is not harmful to their well-being. It will also promotethe right to basic health-care services for children.

7.2 Mental Health Act

The Act provides for the care, treatment, rehabilitation and administration of personswho are mentally ill. It also sets out the different procedures to be followed in theadmission of such persons.

7.3 Traditional Healers Bill

The Traditional Healers Bill was drafted in 2002. It will provide for the registration oftraditional healers and the establishment of a statutory body for the regulation of thisarea of practice.

7.4 Medicine and Related Substances Amendment Bill

The Bill makes provision for, among other things: the definition of the search-and-seizure powers of the inspectorate of the

Medicines Control Council in a way that is consistent with the Bill of Rights.

the appointment of a Deputy Registrar or Registrars for the Council to assist theRegistrar as the workload increases.

the extension of regulations applicable to pharmacists to cover other healthpractitioners licensed to dispense and compound medicines. These includeprofessional fees and the obligation to inform the patient about generic drugoptions.

The Bill further states that any party appealing against a decision of the Director-General on the granting of dispensing licences must approach the Minister directly.Any party appealing against a decision of the Council on medicine registration willhave recourse to an appeal committee established by the Minister.


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7.5 Other health legislation

The recommendations of a task team comprising the Department of Health andofficials from the HPCSA and the South African Nursing Council is expected to lead toamendments of the Health Professions Act, 1974 (Act 56 of 1974), and Nursing Act,1978 (Act 50 of 1978), in 2002/03.

The process of revising the regulations of the Medicines and Related SubstancesControl Amendment Act, 1997 (Act 90 of 1997), is almost complete. The regulationswere published for comment in the latter half of 2001.The Medical Schemes Amendment Act, 2001 (Act 55 of 2001), amended the MedicalSchemes Act, 1998 (Act 131 of 1998), to extend certain rights of members to theirdependants. In addition, the Act, among other things: broadens the definition of a complainant

explicitly prohibits discrimination on the basis of age regulates the practice of reinsurance regulates the circumstances under which waiting periods may be applied

improves the powers of the Council and the Registrar to act in the interest ofbeneficiaries

8. HEALTH CARE FACILITIES

8.1 Clinics

A network of mobile clinics run by government forms the backbone of primary andpreventive health care in South Africa. Clinics are being built or expanded throughoutthe country. Between 1994 and 2002, health services were brought within easierreach of about six million people through the building of some 500 clinics.

8.2 Hospitals

Provincial hospitals play a vital role in the training of physicians, nurses andsupplementary health personnel. According to the Department of Health there were357 provincial public hospitals in 2002.

Ongoing programmes are in place to improve the quality of hospital services. Acharter of patients' rights has been developed, as well as complaint and suggestionprocedures. A service package with norms and standards has been developed fordistrict hospitals and is being extended to regional hospitals. Funding for tertiaryhealth services has been reformed with the introduction of the new National TertiaryServices Grant, which will fund 27 hospitals in all the provinces in 2002/03. TheNational Planning Framework and provincial strategic position statements haveprogressed substantially, providing a sound basis for health service planning and afirmer base for the Health Facilities' Revitalisation Grant.

The Hospital Revitalisation Programme (with a budget of some R528 million) and theHospital Management Grant (amounting to R129 million) deal with some substantialelements of quality of care. It also targets the management systems and the skillsneeded by managers to drive a process of quality improvement.

By February 2002, the Revitalisation Programme had funded 936 projects aimed atphysical repairs and rebuilding. Four hundred and forty-four of these projects had


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been completed and 241 were on site. The Programme has R528,5 million to spend in2002/03, which will bring the total expenditure since 1998 to R1,2 billion.

According to the National Health Accounts (March 2001), there were 200 privatehospitals and a total of 23 076 beds in use in South Africa in 1999. Many of thesehospitals are owned and managed by consortia of private physicians or by largebusiness organisations. Private hospital fees are generally higher than those ofprovincial hospitals.

8.3 Emergency medical services

Emergency medical services, which include ambulance services, are the responsibilityof the provincial departments of health. Emergency care practitioners receivenationally standardised training through provincial colleges of emergency care. Sometechnikons also offer diploma and degree programmes in emergency care. Personnelcan receive training to the level of advanced life-support. These services also provideaero-medical and medical rescue services.

The national Department of Health plays a co-ordinating role in the operation

formulation of policy and guidelines, and development of government emergencymedical services. Private ambulance services also provide services to the community,mainly on a private basis. Some of these services also provide aero-medical servicesto the private sector. The South African Health Services of the South African NationalDefence Force plays a vital supporting role in times of emergencies or disasters.

8.4 National Health Laboratory Service

The NHLS is a single national public entity that consists of personnel from provincialPersonnel working in this field are required to register with the HPCSA, which has aProfessional Board for Emergency Care, health departments and from the SouthAfrican Institute for Medical Research's (SAIMR) laboratory service. Unification of

laboratories will provide cost-effective and efficient health laboratory services to allpublic-sector health-care providers, private health-care providers and to anygovernment institutions that may require such service.

8.5 South African Vaccine Producers and State Vaccine Institute

The South African Vaccine Producers and State Vaccine Institute play a crucial role inthe control and prevention of communicable diseases, by producing human vaccinesand antiserum against diseases affecting the developing world. At present, the SouthAfrican Vaccine Producers is not operational, owing to restructuring that aims for astrategic equity partnership with the private sector.


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9. THE ROLE OF LOCAL GOVERNMENT

Local government has been recognised as a separate sphere of government, therebyendorsing its constitutional status. Some of the services rendered at this level includethe following: preventive and promotive health, with some municipalities rendering curative care

environmental health services, including the supply of safe and adequate drinking

water, sewage disposal and refuse removal regulation of air pollution, municipal airports, fire-fighting services, licensing andabattoirs.

10. ANCILLARY SERVICES

Various independent organisations, most of them voluntary, also provide vital healthservices. The South African Red Cross renders emergency, health and communityservices and offers training in first aid and home-nursing. It also operates anambulance service, medical supply points, old-age homes, an air ambulance and air-rescue service, and comprehensive youth programmes.

The St John's Ambulance Foundation operates in major centres around South Africaand offers training in first aid and home care to individuals, schoolchildren, andcommerce and industry. It operates eye-care clinics around the country aimed atunderprivileged communities. Centres stock a range of first-aid kits for factory, officeand home environments, as well as hiring out mobility aids. Various communityservice projects in the field of PHC are undertaken.

Medic Alert is a world-wide medical identification system. All members wear anidentification emblem on which their medical condition and membership number areengraved. Health personnel have 24-hour telephonic access to this register. MedicAlert also serves as a register for organ, tissue and body donors, as well as for peoplewith pacemakers.

The South African First Aid League provides first aid at sports meetings, civilprotection and training in first aid. It also provides first-aid kits. Poison centres arestaffed 24 hours a day. These centres also provide vital advice on antidotes andtreatment for doctors, pharmacists, hospitals and the public. Life Line provides a 24-hour telephone counselling service for those in distress. Similar confidential servicesare Child Line, Rape Crisis and Suicides Anonymous. Alcoholics Anonymous is a non-profit organisation aimed at helping addicts deal with alcoholism.

Hospices improve the quality of life of the terminally ill through care, support andlove. Nursing staff look after the physical, social, emotional and psychologicalneeds of the patients and their relatives.


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Transnet's health-care train, known as Phelophepa (good health), offers a uniqueservice, bringing accessible and affordable health-care facilities to ruralcommunities. Since its inception five years ago, Phelophepa's educationprogramme has broadened existing services, which include eye, dental, health andpsychological clinics, and an X-ray and a pharmacy service. The train is run byqualified permanent staff. The basic health education programme gives volunteersfrom local communities the opportunity to enhance their basic health-careknowledge. Topics such as baby care, how to keep one's environment and bodyclean, and the prevention of STIs and AIDS, have been included in a five-daycourse presented weekly in the educlinic.

It is estimated that more than 25% of South Africa's population is in need of someform of primary eye care. The primary eye-care programme, Sight Africa, is thebrainchild of Lions Club International of South Africa and the South AfricanOptometric Association. It aims to provide primary eye care to disadvantaged orindigent people who are visually impaired.

The Bureau for the Prevention of Blindness performs 4 000 cataract operationseach year to restore eyesight.

11 COSTS AND MEDICAL SCHEMES

Tariffs for admission to private and provincial hospitals differ. Cost differences alsoexist between various provincial hospitals depending on the facilities offered. Allprovincial hospital patients pay for examinations and treatment on a sliding scale inaccordance with their income and number of dependants. If a family is unable tobear the cost in terms of the standard means test, the patient is classified as ahospital patient. His or her treatment is then partly or entirely financed by theparticular provincial government or the health authorities of the administrationconcerned.

By April 1999, 168 private medical schemes were registered in terms of theprovisions of the Medical Schemes Act, 1967 (Act 72 of 1967).The Medical Schemes Amendment Act, 2001 (Act 55 of 2001) improves theregulatory capacity of the Registrar for Medical Schemes and regulatesreinsurance. A review of medical schemes was published in the Registrar's annualreport. The complaints division of the Council for Medical Schemes dealt with 1327 complaints in 2000/01.

The Act seeks to strengthen the Medical Schemes Act, 1998 in the following ways:

improving protection for members. The Act addresses the problem area ofinsurance, by revisiting the provision on waiting periods, and specificallyprotecting against discrimination on grounds of age.

reducing unnecessary red tape that imposes unduly heavy conditions onmedical schemes.

promoting efficient administration and good governance of medical schemesby, among other things, insisting on the independence of individuals in keypositions.

introducing mechanisms to address problematic practices in the marketing ofmedical schemes and brokerage of services.

The consumer is further protected by additional powers that are assigned to theMinister in terms of the Act. These include the power to:


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In order to address the problems within the health sector the Department of Healthdeveloped policies on a wide range of issues that are contained in the White Paper forthe Transformation of the Health Sector in South Africa released in April 1997. The WhitePaper lays out the vision of the Department and the Ministry of Health. The White Paperpresents what needs to be done to correct the ills of the health system and proposes howthe Department intends to go about the process of reconstruction.

A significant departure from the past is the decision to create a unified but decentralisednational health system based on the DHS model. One of the main reasons for this is thebelief that this system is deemed to be the most appropriate vehicle for the delivery ofPHC. In addition, the decision to decentralise the delivery of health care is consistent withthe overall policy to decentralise government.

3. WHAT IS MEANT BY DECENTRALISATION AND THE DHS

3.1 Decentralisation and health sector reform

The Government of National Unity has adopted decentralisation as the model forboth governance and management. Decentralised governance is embodied in the

Constitution in the form of the powers and functions of the three spheres ofgovernment. The powers and functions of the local sphere of government bearstestimony to the importance of this sphere in particular.

In trying to understand what the concept 'decentralisation' means a definition isrequired. In general terms the concept implies the shift of power, authority andfunctions away from the centre. It is seen as a mechanism to achieve thefollowing: greater equity and efficiency; greater involvement of andresponsiveness to communities; the reduction in the size of the bureaucracy farremoved from the communities being served; and greater coordination betweensocial sectors. The World Bank views the decentralisation of public healthservices as potentially the most important force for improving efficiency and

responding to local health conditions and demands (World Bank, 1993).

According to Bossert (1996) decentralisation can take many forms. One set oftypologies is the following: Deconcentration: Deconcentration is defined by Bossert as 'shifting power from

the central offices to peripheral offices of the same administrative structure'

Devolution: Is the shifting of power and responsibility to separate administrativestructures but that are still within the public sector

Delegation: Represents the shifting of responsibility to semi-autonomous'agencies'

Privatisation: As a form of decentralisation

3.2 Rationale for and principles underlying DHS development in South AfricaUnger and Criel (1995) note that the ...district concept derives from tworationales:... the implementation of the PHC strategy, requiring a decentralisedmanagement, (and) the organisation of integrated systems which implies that onesingle team manages simultaneously the district hospital and the network ofdispensaries' (p. 125).

In terms of the developments post Alma Ata there was a clear recognition thatunless one creates a coherent vehicle to manage the delivery of PHC theobjectives set at Alma Ata would not be met. This recognition resulted in the


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development of the DHS concept that has been promoted by the World HealthOrganisation (WHO).

Tarimo (p. 4, 1991) defines a DHS as follows: 'A DHS based on PHC is a more orless self-contained segment of the national health system. It comprises first andforemost a well-defined population living within a clearly delineated administrativeand geographic area. It includes all the relevant health care activities in the area,whether governmental or otherwise'.

The WHO views the DHS as a vehicle for the delivery of integrated health care(WHO Technical Report Series, 1996). This is an important consideration given theDepartment of Health's policy decision, reflected in the White Paper on theTransformation of the Health System in South Africa, that service delivery must beboth integrated and comprehensive (p. 14).

The White Paper also notes that the establishment of the DHS is a key healthsector reform strategy that is also based on the Reconstruction and DevelopmentProgramme (RDP): 'The health system will focus on districts as the major locus ofimplementation, and emphasise the primary health care (PHC) approach' (p. 12).

There is national consensus on the principles underlying the establishment of theDHS and what the DHS should strive for. These include: overcomingfragmentation; equity; provision of comprehensive services; effectiveness;efficiency; quality; improved access to services; local accountability andcommunity participation; decentralisation; developmental and intersectoralapproach; and sustainability (White Paper, 1997, p. 28). The role of the DHS withinthe National Health System (NHS) is also spelled out in the White Paper:'This level of the health care system should be responsible for the overallmanagement and control of its health budget, and the provision and/or purchase ofa full range of comprehensive primary health care services within its area ofjurisdiction. Effective referral networks and systems will be ensured through co-operation with the other health districts. All services will be rendered in

collaboration with other governmental, non-governmental and private structures'(p. 30).

The following aspects of the role of the DHS in South Africa should beemphasised:

delivery of comprehensive and integrated services up to and including districthospital services;

decentralised management responsibility, authority and accountability;

the planning and management of services delivered at district level; the need for effective referral mechanisms within and between districts and

levels of care;

the need to deliver care in the most efficient and effective manner possible; the option of purchasing services; and the importance of utilising all district resources effectively, whether public,

private or non-government organisation (NGO).


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4. PROGRESS IN DHS IMPLEMENTATION IN SOUTH AFRICA

4.1 Implementing the DHS: achievements and challenges, 1994-2000

A formal study of the process and some of its outputs was conducted in 1995as part of a WHO multi-county study. This investigation identified the followingweaknesses (Gilson et al., 1995):

regions may become an obstacle to district development;

implementation strategies may have overlooked some critical groups; top-down implementation runs counter to the PHC approach; the linear strategy adopted is inflexible; there is little change in the management style of provincial and national

managers; lack of management capacity and skills; and there is no monitoring and evaluation system.

Despite barriers the Albany district in the Eastern Cape province, for example,has been able to document the processes and benefits of functional integrationwhich included:

curative services being introduced in all municipal clinics; staff redeployment strategies finalised; duplication of services rendered by both the province and the

municipality within a single clinic was rationalised; and all facilities,

Many barriers to the institutionalisation of the DHS remain. These include:

the determination of the health rendering function of municipalities;

the transfer of resources; and the building of capacity of municipalities to enable them to render

comprehensive health care.

Many organisations (NGOs and universities) have worked with the national andprovincial departments of health to implement the DHS. While an exhaustivelist of organisations and their areas of assistance is beyond the scope of thisdocument a few will be listed:

Health Systems Trust and the Initiative for Sub-district Support haveworked in several health districts in all nine provinces and produced anumber of publications which may be found on their website(www.hst.org.za);

The EQUITY Project which initially focused its efforts in the EasternCape Province but has since expanded to become a national project hasproduced a range of documents (www.msh.co.za);

The Centre for Health Policy and the Women's Health Project based inthe School of Public Health at the University of the Witwatersrand (Wits);

The Public Health Programme at the University of the Western Cape(UWC);

The Health Information System Project based at the Universities of theWestern Cape and Cape Town (UCT);

The various schools of public health and training programmes (MedicalUniversity of South Africa (MEDUNSA), University of Pretoria, Wits,UCT, UWC).


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The national Department of Health, with the concurrence of the Departments ofFinance and Provincial and Local Government have yet to define municipal healthservices as provided for in the constitution (see later sections for the decisionsadopted by the Health Ministers and nine Members of the Executive Council(MINMEC)). While the Department of Health favours a situation wheremunicipalities (district councils and metropolitan councils) take responsibility forrendering a comprehensive package of PHC services, the Departments of Financeand Provincial and Local Government appear to favour a narrow definition ofmunicipal health services. The latter argue that municipalities are currently not,and would not for the short term, doing a reasonably efficient and effective job ofrendering their core functions and that they should not be burdened with additionalresponsibility until they can demonstrate that they can perform their core functionsadequately.

While the national departments sort out their differences, municipalities areundergoing a process of restructuring following the determination of newboundaries and the election of a new set of councilors in December 2000. It maybe argued that this presents the country with a unique opportunity to obtainconsensus on the role of local government with respect to the delivery of health

services so that municipalities may plan accordingly.

The Department of Health has decided to reduce the number of health districts inline with the changes in the number of municipalities. Each metropolitanmunicipality and each district municipality would constitute a health district. Thisimplies that there will be 48 health districts a reduction from the 174 demarcated inearly 1999. It has also been proposed that local municipality boundaries may beused to designate sub-districts one or more local municipalities may thereforebecome sub-districts.

A few scenarios are possible with regard to the role of municipalities in the deliveryof health services. The scenarios are wholly dependent on how municipal health

services are defined. Firstly, municipal health services may be defined as thecomprehensive package of PHC services. If this is the case a further determinationneeds to be made, i.e., should metropolitan councils and district councils or localcouncils be responsible for the delivery of these services. A further issue thatwould need to be resolved is how these services will be funded would they befunded from the revenues generated by municipalities from rates and taxes, or bythe provinces or directly from the national fiscus?


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6. CRITICAL NEXT STEPS IN DHS DEVELOPMENT

The Health MINMEC meeting on 13 February 2001 took the following decisionsregarding the implementation of the DHS and the role of local government inhealth service delivery:

District and the Metropolitan Council areas shall be the focal point for theorganisation and coordination of health services.

Provincial Departments of Health will be responsible for coordinating the planningand delivery of district health services within the District and Metropolitan areas, incollaboration with local government

Each Member of the Executive Committee (MEC) for Health shall establish aProvincial Health Authority (PHA) in her/his province by the 30 June 2001 whosefunction will be to advise the MEC for Health;

The PHA shall comprise the MEC for Health and the councillors responsible forhealth for each District or Metropolitan Council in the province;

The Head of the provincial Department of Health will establish a Provincial HealthAdvisory Committee (PHAC) by 30 June 2001 whose functions will be tocoordinate the planning and delivery of health services and to advise the Provincial

Health Authority; The PHAC will be composed of the Heads of Health of the provincial Department

of Health and each District Council and Metropolitan Council;

The MEC for Health will facilitate the establishment of District Health Authoritiesand community health committees within the District municipalities andMetropolitan areas, using the criteria and guidelines agreed to by the PHA, withthe participation of local government;

District Health Services will be provided in every District municipality andMetropolitan area;

Although the long-term vision is to capacitate municipalities to delivercomprehensive PHC services, in the short-term, these services will excludeservices provided by district hospitals. Municipal Health Services should bedefined to include the following: environmental health services; provision of clean water and sanitation; prevention of infectious or communicable diseases; health promotion and education; provision of community rehabilitation services;

treatment of minor injuries and diseases; and provision of essential medicines for primary care.

After conducting an audit of services provided in each municipality, the MEC forHealth may delegate the delivery of PHC services to a Metropolitan or DistrictCouncil, a local municipality, or a group of local municipalities, with the appropriatecapacity, support and resources and this relationship will be managed through aservice agreement signed between the province and the municipality, with clearlyoutlined performance indicators.

The MINMEC has provided clear direction with regard to what needs to be doneand, in some instances, some timeframes. The task remains a large one whichmust be done in the context of limited financial and other resources. As expressed


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in numerous policy documents, the South African government is committed to theestablishment of the DHS but needs to provide clear leadership in a few areas sothat progress can be accelerated. There are many lessons from the internationalexperience in establishing decentralised system and South Africa is well placed tolearn from these experiences.

Suggested reading

Arden, N. African Spirits Speak: A White Woman's Journey into the Healing Traditionof the Sangoma. Rochester, Vermont (USA): Destiny Books, 1999.Baldwin-Ragaven, L., De Gruchy, J. and London, L. An Ambulance of the WrongColour: Health Professionals, Human Rights and Ethics in South Africa. Cape Town:University of Cape Town Press, 1999.Bayer, R and Oppenheimer G.M. AIDS Doctors: Voices from the Epidemic. CapeTown: Oxford University Press, 2002.Campbell, S. Called to Heal: Traditional Healing Meets Modern Medicine in SouthernAfrica. Halfway House: Zebra Press, 1998.Kibel, M. and Wagstaff, L. eds. Child Health for All: A Manual for Southern Africa. Cape Town: Oxford University Press, 1992.

Crewe, M. AIDS in South Africa: The Myth and the Reality. London: Penguin, 1992.De Haan, M. Health of Southern Africa. 6th ed. Cape Town: Juta, 1988.De Miranda, J. The South African Guide to Drugs and Drug Abuse. Cresta, Randburg:Michael Collins Publications, 1998.Dennil, K. and others. Aspects of Primary Health Care. Halfway House, Gauteng:Southern Book Publishers, 1995.Dreyer, M. and others. Fundamental Aspects of Community Nursing. 2nd ed. HalfwayHouse: International Thomson Publishing, 1997.Engel, J. The Complete South African Health Guide. Halfway House, Gauteng:Southern Book Publishers, 1996.Gumede, M.V. Traditional Healers: A Medical Doctor's Perspective. Johannesburg:Skotaville, 1990.

Hammond-Tooke, W.D. Rituals and Medicines: Traditional Healing in South Africa.Johannesburg: Donker, 1989.Hattingh, S. and others. Gerontology: A Community Health Perspective.Johannesburg: International Thomson Publishing, 1996.Holland, H. African Magic: Traditional Ideas that Heal a Continent. Sandton: Penguin,2001.Booysens S.W. ed. Introduction to Health Services Management. Kenwyn: Juta, 1996.Kok, P. and Pietersen, J. Health. Pretoria: Human Sciences Research Council, 2000.(National Research and Technology Project).Mashaba, T.G. Rising to the Challenge of Change: A History of Black Nursing inSouth Africa. Kenwyn: Juta, 1995.Mbuya, J. The AIDS Epidemic in South Africa. Johannesburg: The Author, 2000.

Mendel, G. A Broken Landscape: HIV and AIDS in Africa. Johannesburg: M & GBooks, 2002.Nadasen, S. Public Health Law in South Africa: An Introduction. Durban: Butterworths,2000.Reddy, S.P and Meyer-Weitz, A. Sense and Sensibilities: The Psychosocial andContextual Determinants of STD-related behaviour. Pretoria: Medical ResearchCouncil and Human Sciences Research Council, 1999.South African First Aid Manual: The Authorised Manual of the St John's Ambulanceand the South African Red Cross Society. 3rd ed. Cape Town: Struik, 1997.


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Felhaber, T. ed.South African Traditional Healers' Primary Health Care Handbook.Traditional aspects compiled by I. Mayeng. Cape Town: Kagiso, 1997.Couvadia, H. M. and Benatar, S. eds. Tuberculosis With Special Reference toSouthern Africa. Cape Town: Oxford University Press, 1992.Van Rensburg, H.C.J. Health Care in South Africa: Structure and Dynamics. Pretoria:Academica, 1992.Van Wyk, B.E. and Gericke, N. Medicinal Plants of South Africa. Pretoria: BrizaPublications, 1999.Webb, D. HIV and AIDS in Africa. London: Pluto; Cape Town: David Philip, 1997.Whiteside, A. and Sunter, C. AIDS: The Challenge for South Africa. Cape Town: Human& Rousseau, 2000.

REFERENCES

Abdel Rahim IM, Elkaki BA, Ali MMA, Elsayd AH, Nalder S and Gorosh M (1992)Smaller health areas for better service. World Health Forum, 13:31-37.

Ahmed AM, Desta A, Tekle K and Mweta E (1993) Pursuing better health caredelivery at district

STUDY GOALS

A student should be able to:

1. Explain the overall structure of health authorities in South Africa2. Discuss the functions of each level of authority as stipulated in the Health Act of South

Africa3. Explain the purpose of each health related Act4. Explain the concept of a district health system in South Africa


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LEVELS OF CARE AND PREVENTIONVLAKKE VAN SORG EN VOORKOMING

PUB 304

Information and study materials for session 3Informasie en studie materiaal vir sessie 3


Dr B de Klerk

PMO



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Levels of PreventionThe scope of prevention

The decline in death rates that occurred during the nineteenth century in the United Kingdom, wasprincipally due to a decrease in deaths from infectious disease. A similar decline is now beingseen in many developing countries, mainly as a result of general improvements in standards ofliving, especially in nutrition and sanitation. Significant control of certain diseases has been

achieved through specific preventive measures (for example, immunization against poliomyelitis),but in general the role of specific medical therapies has been less important.

Changes over time are influenced by the changing age structure of the population, as well as bythe waxing and waning of epidemic diseases. The changes in mortality rates over time indeveloped countries have been particularly dramatic in the youngest age groups, where infectiousdiseases used to account for most mortality; traffic accidents are now the leading cause of deathin children in many developed countries. The increase in proportionate mortality due to heartdisease, cancer and stroke is explained in part by an increase in the number of old people in thepopulation. An analysis of age-specific or age-standardized data is required in order to assesstrends properly.

The continuously changing patterns of mortality and morbidity over time in countries indicate that

the major causes of disease are preventable. Other evidence of this comes from geographicalvariation in disease occurrence within and between countries, and from the observation thatmigrants slowly develop the patterns of disease of host populations. For example, the rates ofstomach cancer in people born in Hawaii to Japanese parents are lower than those in Japan(Haenszel et aI., 1972). The fact that it takes a generation for the rates to fall suggests theimportance of an exposure, such as diet, in early life.

Epidemjology, by identifying modifiable causes of disease, can play a central role in prevention.The many epidemiological studies of coronary heart disease conducted over the past 50 yearshave identified the size of the problem, the major causes and the appropriate strategies for itsprevention and control, thereby contributing to decline in mortality in several countries. In a similarway, epidemiology has helped to reduce the incidences of occupational disease, food-bornedisease and injuries sustained in road accidents.

In addition to epidemiologists, other specialists are involved in prevention, among them sanitaryengineers, pollution control experts, environmental chemists, public health nurses, medicalsociologists, psychologists and health economists. The need for prevention is gaining acceptancein all countries as the limitations of modern medicine in curing disease become apparent and thecosts of medical care escalate.

Levels of prevention

Four levels of prevention can be identified, corresponding to different phases in the developmentof disease:

primordial;

primary;

secondary

tertiary.

All are important and complementary, 'although primordial prevention and primary preventionhave the most to contribute to the health and well-being of the whole population.


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Primordial prevention

This level of prevention, the most recent to have been recognized, was identified as a result ofincreasing knowledge about the epidemiology of cardiovascular diseases. It is known thatcoronary heart disease occurs on a large scale only if the basic underlying cause is present, i.e. adiet high in saturated animal fat. Where this cause is largely absent, as in China and Japan,coronary heart disease remains a rare cause of mortality and morbidity, despite the high fre-quencies of other important risk factors such as cigarette smoking and high blood pressure(Marmot & Smith, 1989). However, smoking-induced lung cancer is on the increase and strokesinduced by high blood pressure are common in China and Japan.

The aim of primordial prevention is to avoid the emergence and establishment of the social,economic and cultural patterns of living that are known to contribute to an elevated risk ofdisease. Mortality from infectious diseases' is declining in many developing countries and lifeexpectancy is increasing. Consequently, non-communicable conditions, especially unintentionalinjuries, cancer and coronary heart disease, take on a greater relative importance as public healthproblems even before the infectious and parasitic diseases have been fully controlled.

In some developing countries, coronary heart disease is becoming important in the urban middle-

and upper-income groups, which have already acquired high-risk behaviour. As socioeconomicdevelopment occurs, the risk factors can be expected to become more widespread, leading tomajor increases in cardiovascular disease.

Primordial prevention is also needed in respect of the global effects of air pollution (thegreenhouse effect, acid rain, ozone-layer depletion) and of the health effects of urban smog (lungdisease, heart disease). For example, the particulate matter and the sulfur dioxide concentrationsin the atmosphere in several major cities exceed the maximum recommended by the WorldHealth Organization and the United Nations Environment Programme (UNEP) (Fig. 6.3). Publicpolicies aimed at avoiding the underlying reasons for the development of these hazards areneeded in most countries to protect health.

Regrettably, the importance of primordial prevention has often been realized too late. In many

countries the basic underlying causes of specific disease are already present, even' though theresulting epidemics may still be developing. Cigarette smoking is increasing rapidly in manydeveloping countries, while the overall consumption of cigarettes in many developed countries isdropping. The epidemic of lung cancer may take 30 years to develop in countries newly exposedto cigarette sales promotion. It has been estimated that by 2010 there will be over two milliondeaths per year in China from smoking related diseases if a major effort is not made now toreduce smoking (WHO, 1997c).

Effective primordial prevention in this field requires strong government regulatory and fiscal actionto stop the promotion of cigarettes and the onset of smoking. Few governments have had thepolitical will to act to prevent epidemics caused by smoking. All countries need to avoid thespread of unhealthy lifestyles and consumption patterns before they become ingrained in societyand culture. The earlier the interventions, the more cost-effective they will be. (Manton, 1988).

Primordial prevention for coronary heart disease should include: national policies andprogrammes on nutrition involving the agricultural sector, the food industry, and the foodimport/export sector; comprehensive policies to discourage smoking; programmes for theprevention of hypertension; and programmes to promote regular physical activity. The example ofsmoking indicates that a high level of government commitment is required for effective primordialprevention.


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Primary prevention

The purpose of primary prevention is to limit the incidence of disease by controlling causes andrisk factors. The high incidence of coronary heart disease in most industrialized countries is dueto the high levels of risk factors in the population as a whole, not to the problems of a minority. Arelationship between serum cholesterol and the risk of coronary heart disease excist. Only a smallminority of the population have a serum cholesterol level above 8 mmol, i.e. a very high risk ofcoronary heart disease. Most of the deaths attributable to coronary heart disease occur in themiddle range of the cholesterol level, where the majority of the population lies. In this case,primary prevention depends on widespread changes that reduce the average risk in the wholepopulation. The most practical way to do this is to shift the whole distribution to a lower level. Thisapproach is supported by a comparison of the distributions of serum cholesterol in Japan andFinland. There is little overlap: people with high cholesterol levels in Japan would be consideredto have low levels in Finland; the death rate from coronary heart disease in Japan is about one-tenth of the rate in Finland. Practical targets for mean serum cholesterol for the purpose ofprimary prevention have been proposed.

Another example of primary prevention aimed at virtually the whole population is the reduction ofurban air pollution through limitation of sulfur dioxide and other emissions from cars, industry and

domestic heating. A series of air quality guidelines have been developed (WHO, 1987c) thatwould lead to primary prevention if enforced. In many cities the guideline values are exceeded.

A similar approach is applicable in industry, where primary prevention means the reduction ofexposure to levels that do not cause ill-health. Ideally, hazards should be totally eliminated; forexample benzene, a cancer-causing solvent, has been banned from general industrial use inmany countries. If this is not possible, maximum occupational exposure limits can be establishedand, indeed, have been in most countries.

Further examples of primary prevention are the use of condoms in the prevention of HIV infection,and the development of needle exchange systems for intravenous drug users to prevent thespread of hepatitis Band HIV infection. Education programmes to make people aware of how HIVis transmitted and what they can do to prevent its spread are an essential part of the primaryprevention of this disease. Another important way of preventing communicable diseases is toemploy systematic immunization, as hi the eradication of smallpox.

Primary prevention involves two strategies that are often complementary and reflect two views ofetiology. It can focus on the whole population with the aim of reducing average risk (thepopulation strategy) or on people at high risk as a result of particular exposures (the high-riskindividual strategy). Epidemiological studies have demonstrated that, although the high-riskindividual strategy, which aims to protect susceptible individuals, is most efficient for the people atgreatest risk of a specific disease, these people may contribute little to the overall burden of thedisease in the population. In this event the population strategy or a combination of both strategiesshould be applied. The advantages and disadvantages of the two strategies are summarized inTable 6.2.

The major advantage of the population strategy is that it does not require identification of the high-risk group. Its main disadvantage is that it offers little benefit to individuals because their absoluterisks of disease are quite low. For example, most people will wear a car seat-belt while driving fortheir entire life without being involved in a crash. The widespread wearing of seat-belts has pro-duced benefits to many societies but little apparent benefit to most individuals. This phenomenonhas been called the prevention paradox (Rose, 1985).


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With regard to the high-risk strategy, smoking cessation programmes are very appropriate sincemost smokers wish to abandon the habit and individual smokers and the physicians concernedare usually strongly motivated. The benefits of intervention directed at high-risk individuals arelikely to outweigh any adverse effects, such as the short-term effects of nicotine withdrawal. If thehighrisk strategy is successful it also brings benefit to nonsmokers by reducing their passivesmoking. The disadvantage of the high-risk individual strategy is that it usually requires ascreening programme to identify the high-risk group, something that is often difficult and costly.

.

Secondary prevention

Secondary prevention aims to cure patients and reduce the more serious consequences ofdisease through early diagnosis and treatment. It comprises the measures available to individualsand populations for early detection and prompt and effective intervention. It is directed at theperiod between onset of disease and the normal time of diagnosis, and aims to reduce theprevalence of disease.

Secondary prevention can be applied only to diseases in which the natural history includes anearly period when it is easily identified and treated, so that progression to a more serious stagecan be stopped. The two main requirements for a useful secondary prevention programme are asafe and accurate method of detection of the disease, preferably at a preclinical stage, andeffective methods of intervention.

Cervical cancer provides an example of the importance of secondary prevention and alsoillustrates the difficulties of assessing the value of prevention programmes.

Another example is screening for phenylketonuria in newborn children. If children with thiscondition are identified at birth they can be given a special diet that will allow them to developnormally. If they are not given the diet they become mentally retarded and require special carethroughout life. In spite of the low incidence rate of this metabolic disease (2-4 per 100000 births),secondary prevention screening programmes are highly cost-effective.

Other examples of secondary prevention measures that are widely used are: blood pressuremeasurements and treatment of hypertension in middle-aged and elderly people; testing forhearing loss and advice concerning protection against noise in industrial workers; skin testing and

chest X-rays for diagnosis of tuberculosis and subsequent treatment.

Tertiary prevention

Tertiary prevention is aimed at reducing the progress or complications of established disease andis an important aspect of therapeutic and rehabilitation medicine. It consists of the measuresintended to reduce impairments and disabilities, minimize suffering caused by departures fromgood health, and promote patients' adjustment to incurable conditions. Tertiary prevention is oftendifficult to separate from treatment since the treatment of chronic disease has; as one of itscentral aims, the prevention of recurrences.

The rehabilitation of patients with poliomyelitis, strokes, injuries, blindness and so on is of greatimportance in enabling them to take part in daily social life. Tertiary prevention can mean a greatimprovement in individual well-being and family income, in both developed and developing

countries.ScreeningScreening is the process by which unrecognized diseases or defects are identified by tests thatcan be applied rapidly on a large scale. Screening tests sort out apparently healthy people fromthose who may have a disease. Screening is not usually diagnostic and it requires appropriateinvestigative follow-up and treatment. Safety is of paramount importance, since the initiative forscreening usually comes from the health service rather than from the people being screened.


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There are- different types of screening, each with specific aims:

mass screeninginvolves the screening of a whole population;

multipleor multiphasic screeninginvolves the use of a variety of screening tests on the

same occasion;

targeted screeningof groups with specific exposures, e.g. workers in lead foundries, is

often used in environmental and occupational health; case-findingor opportunistic screening is restricted to patients who consult a health

practitioner for some other purpose.

The costs of a screening programme must be balanced against the number of cases detectedand the consequences of not screening. Generally, the prevalence of the preclinical stage of thedisease should be high in the population screened, but occasionally it may be worthwhile toscreen even for diseases of low prevalence which have serious consequences, such asphenylketonuria. The disease must have a reasonably long lead time, i.e. the interval between thetime when the disease can be first diagnosed by screening and that when it is usually diagnosedin patients presenting with symptoms. Hypertension has a very long lead time and so has noise-induced hearing loss; pancreatic cancer usually has only a short one. A short lead time implies arapidly progressing disease and treatment initiated after screening is unlikely to be more effectivethan that begun after the more usual diagnostic procedures.

Early treatment should be more effective in reducing mortality or morbidity than treatment begunafter the development of overt disease, as, for example, in the treatment of cervical cancer in situ.A treatment must be not only effective, but also acceptable to people who are asymptomatic, andit must be safe. If treatment is ineffective, earlier diagnosis only increases the time period duringwhich the participant is aware of the disease; this effect is known as length bias or length/timebias.

When targeted screening is carried out in groups with particular exposures, the criteria forscreening are not necessarily as strict as for general population screening. The health effect thatis prevented may be minor (for instance, nausea or headache), but screening may be of highpriority if the effect reduces the work capacity and well-being of the patient. This type of screening

is common in workplaces. In addition, many health effects arising from exposure to environmentalhazards are graded, and the prevention of a minor effect may at the same time prevent moreserious effects. Targeted screening is a legal requirement in many countries, for instance, forpeople working with lead or asbestos, miners, victims of major environmental pollution, and othergroups. After the initial screening process more precise tests are used as appropriate.The screening test itself must be cheap, easy to apply, acceptable to the public, reliable and valid.A test is reliable if it provides consistent results, and valid if it correctly categorizes people intogroups with and without disease, as measured by its sensitivity and specificity.

Sensitivity is the proportion of truly ill people in the screened population who areidentified as ill by the screening test.

Specificity is the proportion of truly healthy people who are so identified by the screeningtest.

Although it would obviously be desirable to have a screening test that was both highly sensitiveand highly specific, a balance has to be struck between the two.


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TABLE 1: THE LEVELS OF PREVENTION/INTERVENTION

LEVEL PRIMARY PREVENTION SECONDARY PREV

SUB-

LEVEL

HEALTH

PROMOTION

SPECIFIC

PREVENTION

EARLY

DIAGNOSIS ANDTREATMENT

LIM

OF D

Specificactivitiesand/oritemsrequiringattention

Natural environmentPopulation growthSocializationEducationDietHousingExerciseRest/RelaxationTransportOccupation

Protection of endangered speciesHealth education & Family planningPersonal hygiene & SanitationProtection against infectious diseasesFood hygiene & FoodstuffsProtection against allergensProtection against carcinogensWater purification & controlProtection against occupationaldiseases.

Prevention of accidents.

Periodic individualexaminations.Active diseasesurveillanceContinued diseasescreeningMass screening.Active personalsurveillance

Provisufficfacilittrainemanptreat compand death

Aims To obtain maximumphysical, social andpsychological well-being for all toimprove quality life.

Protect individuals and the communityagainst specific diseases.

To resist theduration anddegree of morbidity.Prevent spread ofcommunicablediseases.

To compdeathTo existidisab

Respon-sibility

The individualThe community,volunteers andpolitical associations

or bodies.Outside the publicsector.

The individual personally.All health workers at Primary HealthCare level and comprehensive healthcare.

(Environmental Health Officer)

Comprehensivehealth care inprivate and publicsector.

Comphealtprivatpublic

P R E P A T H 0 G E N E S I S P A T H O G E N E


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MULTI-CAUSALITY OF DISEASEMULTI-OORSAAKLIKHEID VAN N SIEKTE

PUB 304

Information and study materials for session 4Informasie en studie materiaal vir sessie 4


Dr B de Klerk

PMO



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MULTI-CAUSALITY OF DISEASE

Study goals

At the end of the session students must be able to do the following:

1. Understand the multi factorial factors that influence health (determinants of disease)2. Describe the interaction between environment, host and agent.3. Understand the guidelines to causation4. Understand the different factors such as predisposing, modulating and precipitating factors in the host,

which are related to illness.5. Explain why a factor is a cause of a disease6. Understand concept of macro and micro-environment

Lecture (1 hour)Multi-causality of disease

CausationIs a concept which is just as controversial in epidemiology as it is in other sciences.

Cause of a diseaseIs an event, condition, characteristic or a combination of these factors, which plays an important part in thedevelopment of disease. It is called sufficient when it inevitably produces or initiates disease. It is callednecessary if a disease cannot develop in its absence.

Kochs postulates for determining whether a specific organism caused a particular diseaseKoch stated that these postulates should be met before a causative relationship can be accepted between aparticular bacterial parasite or disease agent and the disease in question.1. The agent must be shown to be present in every case of the disease2. The agent must be able to be isolated and grown in pure culture3. Once isolated, the agent must be capable of reproducing the disease in susceptible animals.4. The agent must be recovered from this experimental animal.

Robert Koch (1843 1910) was one of the founders of microbiology and an important contributor towardsour understanding of infectious disease epidemiology. His major contributions were the life cycle of anthrax,the etiology of traumatic infection and the discovery of the tubercle bacillus.

Guidelines to causation

Temporalrelationship

Does the cause precede the effect? (essential)

Plausibility Is the association consistent with other knowledge? (mechanism of action;evidence from experimental animals)

Consistency Have similar results been shown in other studies?Strength ofassociation

What is the strength of association between cause and effect? (relative risk)

Dose-responserelationship

Is increased exposure to the possible cause associated with increased effect?

Reversibility Does removal of a possible cause lead to a reduction of disease risk?

Study design Is the evidence based on a strong study design?

Judging theevidence

How many lines of evidence lead to the conclusion?


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DETERMINANTS OF A DISEASE / DETERMINANTE VAN N SIEKTE

HOST/GASHEER

AGENT ENVIRONMENT/OMGEWING

THE PRESENT APPOACH: AGENT, HOST, AND ENVIRONMENT:

The present epidemiologic approach is based upon the interaction of the host, the causativeagent, and the environment. Among these factors there exists a dynamic situation in whichefforts to prevent and/or control disease are constantly challenged: populations are highly mobileand tend to live longer, thereby creating circumstances of increased risk of exposure andinfection; urbanization and sub-urbanization have exerted greater and greater pressures on theenvironment; biological agents of disease have shown remarkable adaptability to modern control

measures; non-biological agents are often introduced into the milieu despite precautions ofinterested groups.The science of epidemiology emerged and evolved from the study of infectious diseases.However, it application has extended to the study of noninfectious diseases and to the study ofhealth conditions in general. We may, therefore, speak of the apidemiology of heart disease,accidents, cancer, and hypertension. The same principles of interaction among the agent (s),host, and environment apply.

1. AGENT FACTORS

The current scope of epidemiology requires an expansion in perception of the causative agents ofdisease. Causative (etiologic) agents are not limited to biological agents; they may also bechemical or physical:

Biological Agents Chemical Agents Physical Agents

ProtozoaMetazoaBacteriaVirusesRickettisaFungi

PesticidesFood additivesPharmacologicsIndustrial chemicals

HeatLightIonizing-radiationNoiseVibrationSpeeding objects

2. HOST FACTORS

Host factors include a wide variety of characteristics.Examples of Host Factors

Predisposing factors(born with it) Modulating factors(change during life) Precipitating factors(push you over edge)SexRaceGenesEthnicBlood group

AgeMarital statusLifestyleMedicationNutritionImmunityPrevious diseasesSocio-economic status

Death partner / family etcOverdose medicationCrisis


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All of the preceding host factors, and some others, are important to the extent that they affect,first, the risk of exposure to a source of infection,, and second, the hosts resistance orsusceptibility to infection and disease.

Age usually is the single most important host factor related to disease occurrence. The influenceof malnutrition both under and over nutritionis gaining more importance even in the relativelyaffluent and apparently well-fed populations of the United States. The connection betweenmalnutrition and decreased general and specific host-resistance is slowly being disclosed.

3. ENVIRONMENT FACTORS

Micro environmenta.

20110120 pub304 public health resource manual draft 3 for 20

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