Health Care Services

Health care services are the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in citizens. Health care services are delivered by specialists in medicine, chiropractic, dentistry, nursing, pharmacy, associated health, and other care providers. The health care services represent the efforts put in delivering primary care, secondary care and tertiary care, as well as in public health.

Preventive Care Services

Preventive care refers to measures taken to prevent diseases, (or injuries) rather than curing them or treating their symptoms.

Immunization

Immunization is carried out under Expanded Program on Immunization which is a WHO and UNICEF assisted programme. The objective of the expanded Programme on Immunization (EPI) is to immunize children against vaccine preventable childhood diseases and women against neonatal tetanus. Immunization is done at the health facilities, outreach sites and through mobile teams to provide immunization services for children against Measles, Diphtheria, Tetanus, Polio, Tuberculosis, Pertussis, and Hepatitis-B. In addition to this, mothers of child bearing age receive 5 doses of TT or 2 doses during pregnancy. The current overall coverage in Punjab as per EPI CES for children 12 to 23 months was 77.0% and for mothers against Tetanus, it was 63% respectively73. Immunization coverage in Pakistan has improved in recent years but remains below the national targets. The programmatic aspects are fully decentralized to the District Governments for reaching the target population with a well-defined package of immunization services. A strategy to expand coverage through private health sector has not yet taken hold.

Maternal and Child Health Services (Including Family Planning)

Maternal and peri-natal conditions account for about 12 percent of the total BOD. This large disease burden is due to several causes. First presently, in the Punjab only 44% of the antenatal care is being provided by a skilled birth attendant and only about 33% percclass="ImmP"ent of women are assisted by an appropriately trained provider during delivery. Secondly, one-third of births occur less than two years apart, which doubles the mortality risk of newborns as compared to a more normal spacing. Third, about one-third of pregnant women are underweight, which is correlated with low birth weight –a risk factor for the newborn. Basic new born care should also be provided at all levels and comprehensive EMonC should be available at THQ and DHQ hospitals.

The above factors explaining poor reproductive health in Pakistan are in turn largely explained by poor consumer education. There is a massive information deficit concerning reproductive health, and consequence has been the weak demand for family planning services for spacing (although this is changing) and for pre- and post-natal and delivery services by qualified personnel. A second explanation for poor reproductive health in many rural areas is prohibition placed on women seeking care from male providers, in a situation where qualified female providers are often not within reach.

The information deficit and restrictions on women justify government interventions in the reproductive health area. In this intervention, government must also make reliable services available, especially in rural areas, where qualified private providers are generally not present. In addition to front-line services provided by community health workers and staff of first level care facilities, referral services for serious cases (e.g., obstetric emergencies) should be made available at all Tehsil and District Headquarters hospitals.

Prevention and management of STIs and RT

Stigma associated with sex and STIs/RTIs is a major hindrance to prevention efforts and early treatment, therefore to understand STIs, it is important to take into account social, economic, cultural and other factors that pave the way for the infected organism to enter the human body. Treatment of the infection would cure a single episode of STI, but simultaneously addressing other determinants of STIs empowers the community to lessen the chances of getting infected. STIs are predominantly linked to poverty. Currently there is not enough information available on STIs and on their prevention. There is also a requirement for provision of information and treatment of patients at all levels, according to WHO protocols of Syndromic Case Management.

Major Micronutrient Deficiencies

Current status shows that there is 9.9% and 3.0% deficiency of Vitamin A among mothers and children under five respectively. Iodine deficiency among mothers is 21%, and among school age children 6.6%, Iron deficiency among children below 5 years is 64% and mothers of under 5 years of age is 45%. Currently there are programmes such as fortification of salt for Iodine, vegetable oils for Vitamins A & D, wheat for Iron and folic acid which can reduce these deficiencies at both national and provincial level. There is requirement of developing and launching media campaigns that would bring awareness to the population at large.

Promotive Services

These services are defined as "The process of enabling people to increase control over their health and its determinants, and thereby improve their health".

Health Education and Promotion

Many of health problems in Pakistan and Punjab are the result of very poor consumer education. Health education is a classic example of a public good; the government must take responsibility for it and fund it. Some of the most important types of health education needed in Pakistan are as follows:

• Creation of greater awareness of, and demand for:
  (i)immunization of infants and tetanus toxoid vaccination for women of reproductive age;
  (ii)pre- and post-natal checkup and deliveries by trained health care providers;
  (iii)the health benefits of proper spacing of children through family planning; and
  (iv)good nutrition practices, not only for pregnant women and young children, but also for adults
  (so as to prevent cardiovascular disease)
• Basic hygienic practices to prevent various types of communicable diseases (personal hygiene, proper cleaning of kitchen utensils, boiled water, proper disposal of human waste, etc)
• Education about HIV/AIDS and other sexually transmitted diseases and their prevention
• Anti-smoking campaigns, to lower the incidence of cardiovascular diseases and other diseases associated with smoking
• Education of people as health consumers to enable them to develop a better understanding of service quality. Consumers should be educated as to what they should expect and demand from a health care provider, public or private. They should also be educated to be able to distinguish among various types of health care providers, and especially to create awareness about the dangers of seeking care from untrained providers

An important point to note is that there is a great deal of synergy between general education levels and specific health education efforts. The efficacy of health education is likely to rise as education levels rise. Nevertheless, health education efforts can have a significant effect even under present low levels of general education. For example, levels of immunization in Pakistan and Punjab have risen in the past when information, education and communication activities related to the immunization programme were stepped up. Another example of a successful and recent (information, education and communications) campaign in Pakistan is the campaign associated with the Green Star Network of private family planning clinics.

Curative Care Services

Curative care is the kind of health care traditionally oriented towards seeking a cure for an existent disease or a medical condition

Communicable Diseases Control

Communicable diseases still account for 38 percent of the total burden of disease in Pakistan. The main ones, in terms of their disease burden, include diarrhoeal diseases (12.5 percent of total BOD), respiratory infections (8 percent of BOD), tuberculosis (5 percent of BOD), the childhood cluster of immunizable diseases (measles, pertussis, poliomyelitis, diphtheria, tetanus; 6.7 percent of BOD), and sexually transmitted diseases (2.2 percent of BOD). Diarrhoeal diseases, respiratory infections, and the childhood cluster of immunizable diseases, take their greatest toll from young children (under five years of age). Tuberculosis affects both children and adults.

Integrated Management of Childhood Illness (IMCI) approach was piloted in a few Districts of Pakistan and has been proved to be a cost effective strategy. This could be scaled up in the whole province of the Punjab.

The government should adopt a very proactive stance on preventing and treating communicable diseases. An important part of this effort should be health education together with public health measures. Government also should seek actively to identify and treat those already affected by communicable disease, and to maintain high levels of immunization coverage on a sustained basis. Government’s health staff should take advantage of all available opportunities. For instance, when a mother brings her sick child to an outpatient facility for treatment, the staff should seize the opportunity to find out whether the child has been fully immunized.

Presently only 33% of the natal care is being provided by a skilled birth attendant. 15% of the pregnant women suffer from pregnancy related complications and only 5% of these reach a health facility (UNFPA: CPA Report 2000). Therefore, RHCs should be equipped to provide Basic EmONC and comprehensive EmONC services should be provided at THQ and DHQ hospitals.

Most interventions to address communicable diseases, and maternal and child services, would be provided most cost effectively at the lower levels of the health system (in the household themselves, in the communities, and at first-level health care facilities). However, reliable referral services are also needed to handle emergencies and more serious cases. For most people in the Punjab, the first level of referral is Tehsil and District Headquarters hospitals.

Prevention and Treatment of Non Communicable Diseases

Cardiovascular diseases account for another 10 percent of the total BOD. Other important problems are Diabetes Mellitus, cardiovascular diseases, Rheumatoid arthritis, and different causes of blindness, Obesity, Mental and conditions associated with aging (geriatric problems). These diseases are less easily treatable; the most promising approach would be health education campaigns to prevent their onset and promoting healthy life style behaviours. Anti-smoking campaigns and nutrition education to promote a healthier diet would be the main types of health education aimed at preventing cardiovascular diseases. Also important are injuries, which account for about 11 percent of the total BOD. Their incidence could be reduced through public education programs on accident prevention, better work safety requirements, better automobile safety requirements, and other similar preventive measures.

Emergency Services

Timely availability of emergency services and critical care can prevent and reduce number of deaths. Comprehensive emergency services should be available at RHC and above. BHUs should have a proper referral and transport system to carry patients to the higher facility. There is a need to increase capacity and to develop emergency services supporting critically ill patients throughout RHC and higher health care facility. Comprehensive information and data collection is required to support emergency services unit.

Strengthening of Emergency Services at SHC and SHC like Tertiary care hospitals is needed; in terms of physical infrastructure, human resource deployment and provision of drugs and supplies.

Dental Care

Oral health is very important and is a crucial aspect of maintaining general health. Problems in the mouth may be the first symptom of diseases like HIV infection and can also signify clinical progression. Open sores and exposed tissue is a potential entrance for infections into the body and proper dental care can reduce the presence of bacteria. Regular dental visits allow for early identification of conditions and infections. This allows for early treatment of these issues before they develop into serious problems. Specialist dental care both medical and surgical should be provided at RHC and above. THQ and DHQ Hospitals should be well equipped to deal with dental emergencies and surgeries.

Medical and Surgical Care (Out Patient Services and In Patient Services)

Basic medical and surgical care will be available at BHU and RHC. Specialist medical and surgical care and advice for proposed specialties will be available at THQ and DHQ hospitals.

Diagnostic Services

Basic diagnostic services that include Routine Blood and Urine examination, Malarial Parasite, X-ray, and Ultrasound should be provided at BHU and RHC. Advance services including sophisticated tests, Ultrasound, Gastroscopy, and Endoscopy will be provided at THQ and DHQ levels and CT scan at DHQHs only.

Rehabilitation Services

Rehabilitative services can help people, with disabilities, to get gainfully employed and do away with reliance on others. This includes meeting the physical, psychosocial, emotional and spiritual needs of patients and their families while incorporating the nursing and rehabilitative processes. Such Services should be provided to all patients in both inpatient and outpatient settings at all levels of care. The importance of Rehabilitative Services should not be under emphasized. These Services are part and parcel of any type of treatment and most of the time are indistinguishable as separate entities. It should be kept in mind that patients are receiving some type of rehabilitation during treatment or interaction with health care providers, as for example while receiving treatment for typhoid fever he/she is also being rehabilitated psychologically/nutritionally. Putting this in another way, it goes without saying that health care providers must avail all opportunities to provide right type of the rehabilitative services according to prevailing circumstances and level of care.

Outreach and Community Based Services

Immunization

Immunization is carried out under Expanded Program on Immunization which is a WHO and UNICEF assisted programme. The objective of the expanded Programme on Immunization (EPI) is to immunize children against vaccine preventable childhood diseases and women against neonatal tetanus. Immunization is done at the health facilities, outreach sites and through mobile teams to provide immunization services for children against Measles, Diphtheria, Tetanus, Polio, Tuberculosis, Pertussis, and Hepatitis-B. In addition to this, mothers of child bearing age receive 5 doses of TT or 2 doses during pregnancy.

Following are the main outreach activities being done for health care

Visits of the Consultants/Specialists

All Specialists from THQH pay one visit every month at Rural Health Center to provide services to the population and capacity building of the medical staff. At least Specialists of the essential specialties(Physician, Surgeon, Pediatrician and Gynecologist) should provide services at RHC

Women Medical Officer (WMO)

Other than their other responsibilities WMOs also visit from RHC to BHU for Obstetrics, Gynaecology Problems and technical/clinical support to LHVs. WMO spends atleast 20% of her working hours for visits to BHUs (without WMOs) to provide consultation for Obstetrics, Gynaecology problems and technical/clinical support to LHVs

Lady Health Visitor (LHV)

PHC to community Home visits of Lady Health Visitor (LHV) for Health Education, antenatal care, postnatal care, nutritional advice, family planning services and provision of newborn and early childhood care. LHVs conduct at least 2 visits a week to provide MCH services at the door steps of the community. LHV tries to provide at least 80% of women of child bearing age of the catchment area with these services. The level of care provided by LHV is at all levels of care and community based.

Midwife

Home visits of Midwife for antenatal care planned domiciliary. Natal care, Post Natal care, nutritional advice, FP services, and provision of newborn and early childhood care.

Midwife should conduct 4 visits a week to provide MCH services at the door steps of the community. They will work with close liaison with LHWs.

Primary Health Care

Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

Essential Components of Primary Health Care

There are eight essential components of Primary Health Care (PHC)approach. These are given below:

• Education concerning prevailing health problems and the methods of preventing and controlling them.
• Promotion of safe food supply and proper nutrition.
• An adequate supply of safe water and basic sanitation.
• Maternal and child health care, including Family Planning.
• Immunization against major infectious diseases.
• Prevention and control of locally endemic diseases.
• Appropriate treatment of common diseases and injuries.
• Provision of essential drugs.

Following health facilities are mainly working to provide Primary Health Care(PHC)

Basic Health Unit (BHU)

The BHU is located at a Union Council and serves a catchment population of up to 25,000. Services provided at BHU are promotive, preventive, curative and referral. Outreach/community based services are part of package provided by the BHU. BHU provides all PHC services along with integral services that include basic medical and surgical care, CDD, CDC, ARI, malaria and TB control. MCH services are also part of the services package being provided at BHU. BHU provides first level referral to patients referred by LHWs. BHU refers patients to higher level facilities as and when necessary.

The BHU also provides clinical, logistical and managerial support to the LHWs. It also serves as a focal point, where community and the public sector health functionaries may come together to resolve issues concerning health.

Rural Health Centre (RHC)

The RHCs have 10-20 inpatients beds and each serves a catchment population of up to 100,000 people. The RHC provides promotive, preventive, curative, diagnostics and referral services along with inpatient services. The RHC also provides clinical, logistical and managerial support to the BHUs, LHWs, MCH Centers, and Dispensaries that fall within its geographical limits. RHC also provides medico-legal, basic surgical, dental and ambulance services.

Secondary Health Care

Hospital at the first referral level serving a district or a tehsil. Secondary Health Care is an intermediate level of health care, that is concerned with the provision of specific technical, therapeutic or diagnostic services. Specialist consultation procedures and hospital admissions fall into this category of care. These services are episodic and usually focused on a particular health problem.

Continuity of care is less critical.The role of a district hospital in primary health care has been expanded beyond being dominantly curative and rehabilitative to include promotional,preventive and educational roles as part of a primary health care approach.

Following health facilities are mainly working to provide Primary Health Care(PHC)

Tehsil Head Quarter

Tehsil Head Quarter (THQ) hospital is located at each THQ and serves a population of 0.5 to 1.0 million. At present majority of THQ hospitals have 40 to 60 beds. The THQ hospital provides promotive, preventive, curative, diagnostics, in patients, referral services and also specialist care. THQ hospitals are supposed to provide basic and comprehensive Emergency Obstetric and New born Care (EmONC). THQ hospital provides referral care to the patients including those referred by the Rural Health Centers, Basic Health Units, Lady Health Workers and other primary care facilities.

District Head Quarter

The District Head Quarters (DHQ) Hospital is located at District headquarters level and serves a population of 1 to 3 million, depending upon the category of the hospital. The DHQ hospital provides promotive, preventive, curative, advance diagnostics, inpatient services, advance specialist and referral services. All DHQ hospitals are supposed to provide basic and comprehensive EmONC. DHQH provides referral care to the patients including those referred by the Basic Health Units, Rural Health Centers, Tehsil Head Quarter hospitals along with Lady Health Workers and other primary care facilities.

Tertiary Care

Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, some problems which fall in tertiary care are:

• Head and neck oncology
• Perinatology (high-risk pregnancies)
• Neonatology (high-risk newborn care)
• PET scans
• Organ transplantation
• Trauma surgery
• High-dose chemotherapy for cancer cases
• Growth and puberty disorders
• Neurology and neurosurgery

Following two types of hospitals fall in this category A major hospital that usually has a full complement of services including pediatrics, general medicine, various branches of surgery and psychiatry.

A specialty hospital dedicated to specific sub-specialty care (pediatric centers, Oncology centers, psychiatric hospitals). Patients will often be referred from smaller hospitals to a tertiary hospital for major operations, consultations with sub-specialists and when sophisticated intensive care facilities are required.:

General Terms

Admission

Formal acceptance, by a health facility, of a patient who is to receive medical or paramedical care while occupying a health facility bed. Healthy babies born in hospital should not be counted if they do not require special care.

Antenatal care

Includes recording medical history, assessment of individual needs, advice and guidance on pregnancy and delivery, screening tests, education on self care during pregnancy, identification of conditions detrimental to health during pregnancy, first-line management and referral if necessary.

Antenatal care coverage at least one visit

Percentage of women who utilized antenatal care provided by skilled birth attendance for reasons related to pregnancy at least once during pregnancy as a percentage of live births in a given time period.

Antenatal care coverage at least four visits

Percentage of women who utilized antenatal care provided by skilled birth attendants for reasons related to pregnancy at least four times during pregnancy as a percentage of live births in a given time period.

Beds

The number of beds regularly maintained and staffed for the accommodation and full-time care of a succession of inpatients and which are situated in wards or a part of the hospital where continuous medical care for inpatients is provided. The total number of such beds constitutes the normally available bed complement of the hospital. Cribs and bassinets maintained for use by healthy newborn babies who do not require special care are not included.

Discharges (including deaths)

The number of persons, living or dead, whose stay in a health care facility has terminated and whose departure has been officially recorded.

Emergency

A state in which normal procedures are suspended and extraordinary measures are taken in order to avert the impact of a hazard on the community. Authorities should be prepared to respond effectively to an emergency. If not managed properly, some emergencies will become disasters.

Hazard

A dangerous phenomenon, substance, human activity or condition that may cause loss of life, injury or other health impact, property damage, loss of livelihoods and services, social and economic disruption, or environmental damage.

Health infrastructure Public facilities

Physicians

Graduates of any faculty or school of medicine, licensed or registered to work in the country as medical doctors who apply preventive or curative measures and/or conduct research. Also expressed as number of physicians per 1000 population. Disaggregated by gender, area and sector.

Dentists

Graduates of any faculty or school of dentistry, odontology or stomatology, duly licensed or registered to practise dentistry, and actually working in the country in any dental field to apply medical knowledge in the field of dentistry and/or conduct research. Also expressed as number of dentists per 1000 population. Disaggregated by gender, area and sector.

Pharmacists

Graduates of any faculty or school of pharmacy, duly licensed or registered to practice pharmacy and actually working in the country in pharmacies, hospitals, laboratories, industry, etc. applying pharmaceutical concepts and theories by preparing and dispensing or selling medicaments and drugs. Also expressed as number of pharmacists per 1000 population. Disaggregated by gender, area and sector.

Nurses

Persons who have completed a programme of basic nursing education and are qualified and registered or authorized to provide responsible and competent service for the promotion of health, prevention of illness, care of the sick, and rehabilitation, and are actually working in the country. Also expressed as number of nurses per 1000 population. Disaggregated by gender, area and sector.

Midwives

Persons who have completed a programme of midwifery education and have acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery, and are actually working in the country. The persons may or may not have prior nursing education. Also expressed as number of midwives per 1000 population. Disaggregated by sex, gendera and sector.

Paramedical staff

Health care assistants, laboratory technicians, technologists, therapists, nutritionists, sanitarians, among others, who are actually working in the country and are graduates of 2- to 5-year health courses in recognized health training institutions. Also expressed as number of paramedical staff per 1000 population. Disaggregated by gender, area and sector.

Community health workers

Lay members of communities who have a period of on-the-job training, sometimes formalized in apprenticeships, who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. Also expressed as number of community health workers per 1000 population. Disaggregated by gender, area and sector.

Urban Area

Those working in urban areas or in planned metropolitan communities in developed areas designed to be self-sufficient, with their own housing, education, commerce and recreation.

Rural Area

Those working rural areas or in areas outside cities and metropolitan areas generally regarded as underdeveloped in terms of infrastructure and specialized services.

Public Sector

Those who are employed in the public sector, which is the portion of society controlled by national, state or provincial and local governments.

Private Sector

Those who are employed in the private sector, which comprises private corporations, households and non-profit institutions serving households.

Immunization coverage for infants

Percentage of children under one year of age who have received immunization against tuberculosis (BCG), diphtheria, pertussis, tetanus (DTP3 and DTP1), poliomyelitis (POL3), measles (at least one dose and two doses) and hepatitis B3 and HepB birth dose. Also includes coverage with vitamin A1.

Inpatient

A person admitted to a health care facility and who usually occupies a bed in that health care facility.

Neonatal period

Commences at birth and ends 28 completed days after birth.

Outpatient

A person who goes to a health care facility for consultation, is not admitted to the facility and does not occupy a hospital bed for any length of time.

Population

All the inhabitants of a given country or area considered together. Estimates are based on a recent census, official national data. Presented in thousands or actual value. Disaggregated by gender.

Population density

Population per square kilometer.

Population growth rate

The average exponential population growth of the population in a given period of time. Expressed as a percentage. Disaggregated by gender.