PRIMARY HEALTH PHYSICIAN /FAMILY DOCTOR

AND PUBLIC HEALTH

Sharon Gondodiputro dr., MARS.,MHDept. Of Public Health Faculty of

MedicineUnpad

JEJARING RUJUKAN PELAYANAN KESEHATAN

POSYANDU, POLINDES ,UKBM

RUJUKAN YANKES PERORANGAN

RUJUKAN YANKES MASYARAKAT

PERORANGAN/KELUARGA

PERORANGAN/KELUARGA

MASYARAKAT MASYARAKAT

STRATA 1, primer

STRATA 1

STRATA 2, sekunder

STRATA 2

STRATA

3 ,

tersier

STRATA

3

UPAYA KES KEL MANDIRI

UPAYA KES KEL MANDIRI

KADER ,PELATIH OR

POSYANDU, POLINDES

PRAKTIK DOKTER,PUSKESMAS, BP, BKIA , PRAKTEK BIDAN

PUSKESMAS , INSTANSI LAIN

RS UMUM/KHUSUS KAB/KOTA, BP4, BKMM, BKOM, BKTK , KLINIK SPESIALIS, SPESIALIS

DINKES KAB/KOTA ,DINAS LAIN ,BP4, BKMM, BKOM, BKTK

RS UMUM/KHUSUS PUSAT/PROPINSI

DINKES PROPINSI , DEPKES RI

VI.Primary health care is essential health care based on practical scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination

DECLARATION of ALMA ATAInternational Conference on Primary

Health Care, Alma-Ata, USSR, 6-12 September 1978

Primary health care characteristics:• community full participation and

at a cost that they can afford to maintain every stage of their development in the spirit of self-reliance and self-determination.

• forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community.

Primary health care

• It is the first level of contact of

individuals, the family and

community with the national

health system

• bringing health care as close as

possible to where people live

and work, and constitutes the

first element of a continuing

health care process.

3. Includes at least:• education concerning prevailing health

problems • the methods of preventing and controlling

them; • promotion of food supply and proper

nutrition; • an adequate supply of safe water and basic

sanitation; • maternal and child health care, including

family planning; • immunization against the major infectious

diseases; • prevention and control of locally endemic

diseases; • appropriate treatment of common diseases

and injuries; • provision of essential drugs;

VII.PRIMARY HEALTH CARE

Health care provider…… for the individual, family and

community

Family Physician

Community physician

Faculty of Medical Science University of Sri Javawardenepura

Professor Leela Karunaratne

Community/ target groupIndividual/ Family

the methods of preventing and controlling diseases

Communicable diseases:1.Tuberculosis2.DHF3.HIV4.Pneumonia5.Scabies6.ISPA

Noncommunicable diseases:1.Hypertension2.Diabetes mellitus3.Thallasemia4.Cancer

Tabel 1. 13 Proporsi Penyakit Dan Gejala Penyakit Pada Umur 0-7 hari di Kota Bandung Tahun 2008 dan 2009

No Penyakit Tahun 2008 Tahun 2009 Rata-rata

(%) Proporsi (%) Proporsi (%) 1 ISPA 85,62 48,6 67,11

2

Ggg lain pada kulit dan jaringan subkutan (diasumsikan sebagai dermatitis/eksema)

22,29 22,29

3 Diare dan gastroenteritis

13,01 13,93 13,47

4 Pneumonia 5,57 5,57

Total 98,63 90,39

Tabel 1. 17 Proporsi Penyakit Dan Gejala Penyakit Pada Umur 5-14 thn di Kota Bandung Tahun 2008 dan 2009

No Penyakit

Tahun 2008 Tahun 2009 Rata-rata

(%) Proporsi (%)

Proporsi (%)

1 ISPA 73,83 54,7 64,27

2 Diare dan Gastroenteritis 7,55 4,61 6,08

3 Demam 4,71 4,71

4 Gastritis/Tukak Lambung/Gastroduedenitis

3,89 3,89

5

Ggg lain pada kulit dan jaringan subkutan (diasumsikan sebagai dermatitis/eksema)

6,58 6,58

6 Karies gigi, Penyakit Pulpa jaringan periapikal dan jaringan penunjang

6,91 6,91

7 Conjunctivitis 2,36 2,06 2,21

8 Varicella/Cacar Air 2,97 1,34 2,16

9 Gangguan telinga lainnya 1,34 1,43 1,39

10 Abses, furunkel dan karbunkel

1,23 1,23

Tabel 1. 18 Proporsi Penyakit Dan Gejala Penyakit Pada Umur 15-44 thn di Kota Bandung Tahun 2008 dan 2009

No Penyakit Tahun 2008 Tahun 2009

Rata-rata (%) Proporsi

(%) Proporsi

(%) 1 ISPA 62,26 37,41 49,84

2 Gastritis/Tukak Lambung/Gastroduedenitis

12,14 12,14

3 Diare dan Gastroenteritis 8,31 4,12 6,22 4 Myalgia 5,19 5,19 5 Hipertensi Primer 6,94 2,96 4,95

6

Ggg lain pada kulit dan jaringan subkutan (diasumsikan sebagai dermatitis/eksema)

8,23 8,23

7

Karies gigi, Penyakit Pulpa jaringan periapikal dan jaringan penunjang

4,74 4,74

8 Sakit kepala 3,10 3,10 9 Demam 2,66 2,66 10 Conjunctivitis 3,65 1,94 2,80 11 Gangguan telinga lainnya 1,99 1,17 1,58 12 Arthritis dan Rheumatism 1,46 1,46

13 Asthma 1,29 1,29 14 Tuberkulosis 1,94 0,64 1,29

15 Scabies 1,10 1,10

IMCI (integrated management of childhood

illness) is •an integrated approach to child health•that focuses on the well-being of the whole child and aimed to reduce death, illness and disability, and •to promote improved growth and development among children 5 years of age.

maternal and child health care

COST SAVING/COST EFFICIENT

Why is IMCI better than single condition approaches ?

The most important realisation about child survival is that killer diseases operate in the same environtment of poor nutrition and lack immunisation to protect the child making a single diagnosis is impossible

IMCI - Integrated strategy which takes into account the variety of factors that put children at serious risk

- It Ensures The Combined Treatment Of The Major Childhood Illnesses, Emphasizing Prevention Of Disease Through Immunization And Improved Nutrition

{{

INTEGRATED MANAGEMENT OF CHILDHOOD INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) ILLNESS (IMCI) For Acute Respiratory InfectionFor Acute Respiratory Infection

SAVING COST ?SAVING COST ?

Septiani Susilowati Septiani Susilowati 11, , Sharon GondodiputroSharon Gondodiputro 22, Henni , Henni Djuhaeni Djuhaeni 22

An observasional study

Sample : 184 cases

Data were analyzed using chi square test and pooled t-test

14

1. Head of Puskesmas Kopo District Health Office Bandung Municipality, West Java, Indonesia

2. 2 Staf FS of Public Health Department, Faculty of Medicine , Universitas Padjadjaran Bandung , West Java, Indonesia

CAN

BE

PREVENTED

Children under 5 years of age Children under 5 years of age Death Ratio Death Ratio 1992-2001 in Indonesia1992-2001 in Indonesia

1998-19921992-1998

1998-2002

S1

78

63

46

0

10

20

30

40

50

60

70

80

Year

Children under 5 Death Ratio 1992-2001 in Indonesia 22.68 % IS CAUSED BY ARI

80-90 % IS CAUSED BY PNEUMONIA

Per

100

0 li

ve b

irth

s

Acute Respiratory Infections (ARI) prevalence in Indonesia , 2001

38.7

42.2

36

37

38

39

40

41

42

43

bayi <1 thn balita 1-4 thn

PNEUMONIA

PROPORTION

FROM

ALL ARI

IS 10 %

Infant < 1 year

Children 1-4 year

18

COUGHINGCOUGHING WITHOUT OTHER WITHOUT OTHER

SYMPTOMSSYMPTOMS

NON PNEUMONIA PNEUMONIA

• COUGHING AND OR

• DIFFICULTY IN BREATHING

• RESPIRATORY FREQUENCY :

2 MONTHS - < 1 YEAR : 40X/MINUTE,

1 YEAR - < 5 YEAR : 50X/MINUTE

THERAPY

CRITERIA

< 38.5OC ≥ 38.5OC < 38.5OC ≥ 38.5OC

NONE ANTIPYRETIC ANTIBIOTIC ANTIPYRETICANTIBIOTIC

184 NEW CASES OF ARI

184 NEW CASES OF ARI

7 PUSKESMAS IMCI

7 PUSKESMAS NON IMCI

NONPNEUMONIA

PNEUMONIA

< 38.5 C> 38.5 C < 38.5 C > 38.5 C

SORT OF DRUGS TOTAL COST OF DRUGS

NON PNEUMONIA

PNEUMONIA

< 38.5 C> 38.5 C < 38.5 C > 38.5 C

SORT OF DRUGS

PNEUMONIA

TEMP <38.5ºC TEMP >38.5ºC

IMCI (N=45)NON IMCI

(N=28)IMCI (N=29)

NON IMCI (N=9)

n % n % n % n %

~ NO DRUGS NEEDED

0 0.00 0 0.00 0 0.00 0 0.00

~ 1 SORTS 42 93.30 0 0.00 3 10.30 0 0.00

~ 2 SORTS 3 6.70 0 0.00 26 89.70 0 0.00

~ 3 SORTS 0 0.00 5 17.90 0 0.00 0 0.00

~ 4 SORTS 0 0.00 16 57.10 0 0.00 6 66.67

~ 5 SORTS 0 0.00 7 25.00 0 0.00 3 33.33

  45 100.00 28 100.00 29 100.00 9 100.0021

SORT OF DRUGS

NON PNEUMONIA

TEMP <38.5ºC TEMP >38.5ºC

IMCI (N=45)NON IMCI

(N=34)IMCI (N=43)

NON IMCI (N=9)

n % n % n % n %

~ NO DRUGS NEEDED

37 55.20 0 0.00 2 4.70 0 0.00

~ 1 SORTS 23 34.30 1 0.70 36 83.70 0 0.00

~ 2 SORTS 7 10.40 5 3.60 5 11.60 1 11.11

~ 3 SORTS 0 0.00 30 21.70 0 0.00 3 33.33

~ 4 SORTS 0 0.00 52 37.70 0 0.00 3 33.33

~ 5 SORTS 0 0.00 50 36.20 0 0.00 2 22.22

  77 100.0 166 100.0 45 100.0 9 10022

TOTAL COST -DRUGS (Rp)

PUSKESMAST NILAI P

IMCI NON IMCI

PNEUMONIA ,TEMP < 38.5C        

~ N 45 28

~ MEAN 3461.77 6230.93 3.105 P = 0.013

~ SD 1011.99 3498.22

~ MEDIAN 3463.00 5566.50

PNEUMONIA ,TEMP > 38.5C        

~ N 29 9

~ MEAN 5020.14 8195.94 4.084 P = 0.000

~ SD 1147.11 3001.55

~ MEDIAN 5663.00 7852

23

24

    

NON IMCI IMCI Nilai pt

PUSKESMASTOTAL COST – DRUGS (Rp)

5484.002200.00 ~ MEDIAN

3039.201157.48 ~ SD

P = 0.0412.4074821.162345.73 ~MEAN

943 ~ N

    NON PNEUMONIA,TEMP

> 38.5C

7259.0051.00 ~ MEDIAN

3711.271764.00 ~ SD

P = 0.00013.9766539.831195.18 ~ MEAN

13867 ~ N

    

NON PNEUMONIA,TEMP < 38.5C

284,138,042.06 1,320,433,174.56

1,036,295,132.50

524,965,852.84

1,039,832,301.86

514,866,449.02

-

200,

000,

000.

00

400,

000,

000.

00

600,

000,

000.

00

800,

000,

000.

00

1,00

0,00

0,00

0.00

1,20

0,00

0,00

0.00

1,40

0,00

0,00

0.00

CASES WITH TEMP< 38.5OC

CASES WITH TEMP ≥ 38.5OC

COST SAVED

TOTAL COST PUSKESMAS NON IMCI

TOTAL COST PUSKESMAS IMCI

25Rp

Primary prevention

increase a person’s ability to remain free of disease

Secondary prevention

is the early detection of disease/ precursors of disease , treatment can be started before irreversible damage

Tertiary prevention

is the management of established disease minimize disability

Health Enhancement Continuum

Primary prevention

increase a person’s ability to remain free of disease

Secondary prevention

is the early detection of disease/

precursors of disease , treatment can be

started before irreversible damage

Tertiary prevention

is the management of established disease

minimize disability

Family Physician

THE METHODS OF PREVENTING DISEASES

Level of Preventio

n

No Program Health Enhancement continuum

Primary 1 Health Promotion 1. Environmental and Social policies

2. 2.Assessment of General Resistance Resources (GRR)

3. Enhancement of GRR

2 Spesific Protection 1. Enhancement of GRR 2. Risk Assessment

Secondary

3 Early Detection/Screening

1. Risk Assessment 2. Risk Reduction 3. Presymptomatic diagnosis

4 Prompt Treatment Early Diagnosis

Tersiary 1 Disablility Limitation Early Diagnosis

2 Rehabilitation 1. Rehabilitation to enhance recovery

2. Care and support to maintain function and reduce further complications

THE METHODS OF PREVENTING DISEASES

No Health Enhancement continuum

Activities

1 Environmental and Social policies

1. Housing2. Electricity3. Clean water4. Park & recreation5. Nutrition education6. Food insp.7. Occupational health and safety8. Insect control9. Accident prevention10. Child support & protection11. Health education

2 Assessment of General Resistance Resources (GRR)

1. Self-assessed health status2. Confidence3. Coping ability4. Social support5. Family function6. Work Satisfaction7. Exercise8. Immunization status9. Income security10. Knowledge of hygiene

THE METHODS OF PREVENTING DISEASES

No Health Enhancement continuum Activities

3 Enhancement of GRR 1. Support2. Health education and counseling3. Immunization4. Family planning5. Prenatal care6. Child care

4 Risk Assessment 1. Smoking related disease2. Substance abuse3. Coronary heart disease4. Family violence5. STD6. Occupation7. Teenage pregnant

5 Risk Reduction 1. Smoking cessation2. Reduction alcohol intake3. Reduction of serum cholesterol4. Nutrition edu.5. Accident prevention6. Refer to social service

counseling

THE METHODS OF PREVENTING DISEASES

No Health Enhancement continuum Activities

6 Presymptomatic diagnosis Screening and case finding

7 Early Diagnosis Prevention of complication by early diagnosis of serious treatable disease

8 Rehabilitation to enhance recovery

9 Care and Support of Patients with Chronic Disease and their Families to Maintain Function and ReduceComplication