Organization of work of treatment-and-prophylactic establishments at different stages of medical aid FOR rural population.
Organization of emergency medical care (EMC).
Content of work of EMC, accounting and analysis of ITS activity.
The organization of public health services and medical сare
It is necessary to distinguish two concepts if we are talking about public health services: “public health services” and “medical care”.
“Public health services” may be defined as follows:
Public health services is a system of state, public, individual actions and means which assist health, prevention of diseases and the prevention of premature death, maintenance of persons active ability to live and work .
Definition of “medical care” is the following:
medical services – is a system of special medical actions and means which assist health, prevention of diseases and the prevention of premature death, maintenance of persons active ability to live and work .
So, the concept of “public health services” is universal, it includes everything, that concerns the health of people: state policies, social and economic conditions of people, environment of conditions, behaviour of people or their way of life, etc.
“Medical care” – is a component of public health services, which covers special activity of medical institutions.
Main principles on which the public health services and medical care in
– The state character with equal rights for the existence of public and private ownership;
– Decentralization of management;
– Socially focused availability;
– Economic efficiency;
– A preventive orientation;
– A free choice of the doctor;
– Scientific maintenance;
– Wide participation of the public in public health services;
– The international cooperation;
These bases are proclaimed in “Bases of the legislation of
Also we should stop on the following major aspects of this act on which public health services and medical care in
The law proclaims the right of each person on public health services.
The right on public health services provides:
1. High standard of life, including clothes, dwelling, medical care both social service and the maintenance, necessary for health of the person;
2. Environment safe for life and health ;
3. Sanitary – epidemic well-being of territory and settlement where the citizen lives;
4. Safe and healthy working conditions, life and rest;
5. The qualified health care, including free choice of the doctor and establishment of public health services;
6. The authentic and up-to-date information about the condition of the health of all people, including existing risk factors and their degree;
7. Participation in discussion of projects of acts and offers concerning formation of a state policy in the field of public health services;
8. Participation in management of public health services and carrying out public examination on these questions in the order, stipulated by the legislation;
9.
10. Legal protection from any illegal forms of discrimination connected with personal state of health;
11. Compensation of the harm caused to health;
12. The appeal of wrongful decisions and actions of workers, establishments and bodies of public health services;
13. Opportunity of carrying out of independent medical examination in case of disagreement of the citizen with conclusions of the state medical examination, application to him of compulsory treatment and in other cases if actions of the worker of public health services can be the humiliate of human and civil rights;
At the same time, the law also regulates duties of citizens in the field of public health services, namely:
1. Duty to take care of the health and health of children, not to be harmful to health of other citizens;
2. In the cases stipulated by the legislation to pass preventive medical examinations reviews and to do inoculations;
3. To live the emergency care to other citizens who are in menacing for a life or health ;
4. To execute other duties stipulated by the legislation concerning public health services;
State, public and other organs, enterprises, organizations, officials and citizens are obliged to provide priority public health services in their own activity, not to damage the health of the population and separate persons, in borders of the competence to live the care to patients, invalids and suffering from accidents, to assist the activities of the workers of medical organs and establishments of public health services, and also to execute other duties stipulated by the legislation on public health services.
According to the law the state policy of public health services is provided with budgetary assignations in volume according to its scientifically-grounded based needs, but not less than 10 % of the national income.
The law stipulates the financing of departmental and other establishments of public health services which serve only separate categories of the population, at the expense of the enterprises, establishments and organizations to which they serve.
The law stipulates gradual creation of the system of medical insurance.
Then budgetary funds, means of the enterprises, establishments and the organizations, and also the personal means of citizens will be gathered by insurance organizations which start to finance giving of medical care.
It is supposed to develop the special law concerning medical insurance. Government organizes material support of the public health services in the volume necessary for giving for the population of the guaranteed level of the health care.
All establishments of public health services have the right to solve questions of the material support independently.
The law regulates professional rights, privileges and duties of medical workers.
Rights and privileges:
1) Occupation with medical and pharmaceutical activity according to a specialty and qualifications;
2) Appropriate conditions of professional work;
3) Improvement of professional skills, retraining not less than once in five years in the corresponding establishments;
4) Free choice of the approved forms, methods and means of activity, introduction of modern achievements of a medical and pharmaceutical science and practice;
5) Gratuitous age of the social and special medical informatioecessary for realization of professional duties;
6) Obligatory insurance at the expense of the proprietor of establishment of public health services in case of causing harm to their life and health in connection with performance of professional duties in the cases stipulated by the legislation;
7) The social care of the state in case of disease, invalidity or in other cases of disability which were caused by performance of professional duties;
8) To fix in official bodies of public health services average rates and official salaries at the level, which not lower from average wages of industry workers;
9) The reduced working day and additional payment rest in the cases established y the legislation;
10) Concessionary terms of a provision of pensions;
11) Preferential providing with dwelling and phone;
12) Gratuitous using an apartment with heating and lighting by those who live in a countryside, giving of privileges concerning payment of the land tax, crediting, providing the a facilities and construction of own house, purchase of auto and motor-transport;
13) Prime reception of the treatment-and-prophylactic care and provision with medical and orthopedic means;
14) Creation of scientific medical societies, trade unions and other public organizations;
15) Legal protection of the professional honor and dignity.
Besides, other rights and privileges for medical and pharmaceutical workers can be stipulated. By the legislation privileges, which are established for the workers by the enterprises, also can be distributed to them by establishments and the organizations to which they give the health care.
Duties:
1) To assist protection and strengthening of health of people, prevention and treatment of the diseases, to give qualified medical care;
2) Free-of-charge emergency call service to citizens in case of accident and other extreme situations;
3) To distribute scientific and medical knowledge among the population, to propagandize, including own example, a healthy way of life;
4) To keep the requirement of a professional etiquette and of a deontology, to save medical secret;
5) To raise constantly the level of a professional knowledge and skills;
6) To live the advisory care to the colleagues and other workers of public health services.
The basic principles, which underlie medical care in
The first principle, on which the public medicine was created, was its availability to people. There was an idea to divide territory administrative unit (district, province) on so-called districts and to employ the doctor so that he gave inhabitants of that district accessible medical service.
At first, the doctor has driven around district (so-called traveling system of public medicine), and then the system has been replaced by stationary one which essence was, that in the territorial center of a district the hospital was situated where the doctor stayed constantly.
Districts gradually became smaller and at the moment of apogee of public medicine (1913) have achieved the following middle parameters: radius of a district –
The Soviet medicine has borrowed a district of the organization as the basic and with the end of its existence has finished normative parameters of districts to the following figures: a rural medical district – radius of
So-called therapeutic district for adult population was limited to 1700 inhabitants, pediatric – to 800 infants.
In the independent
The principle of availability was united with a principle of qualification of medical care.
Therefore, near to development of districts, there was a superstructure above them, all over again as district hospitals (since the twentieth years), and then district hospitals (since the fortieth years). The district doctor also specializes, dividing into divisional of the pediatrist and the therapist (from the end of the fortieth years).
Medical districts should give the primary health care, regional and city hospitals – specialized and areal establishments – highly specialised care.
So there is a three-level system of medical care. Each following level should give not only higher degree of the specialized care, but also to supervise over lower levels.
By volume medical service was distributed as following: a primary level – 5-20 %, secondary – 40-70 %, tertiary – 10-20 %.
Meanwhile, world experience proves, that the primary level can concentrate up to 90 % of all volume of medical care (as it was during the period of public medicine) and narrow specialists should concentrate on giving the more complex care which demands application of high medical technologies.
The basic quantity indices of the network of medical institutions in
Bases parameters of system of medical care in
|
1. |
Number of hospital establishments |
3122 |
|
2. |
Number of establishments which give the out-patient – polyclinic help |
6429 |
|
|
|
|
|
3. |
The general number of hospital beds |
444495 |
|
4. |
Total number of doctors (including dental) |
205759 |
|
5. |
Total number of nurses |
498845 |
|
6. |
Number of doctors on 10 thousands people |
41,6 |
|
7. |
Number of nurses on 10 thousands people |
100,9 |
|
8. |
Number of hospital beds on 10 thousand people |
89,9 |
|
9. |
Average capacity of hospital establishments: |
|
|
|
Areal hospital |
837 |
|
|
City hospital |
190 |
|
|
Regional hospital |
230 |
|
|
District hospital |
73 |
|
|
Local hospital |
16 |
The doctor of the general practice or the family doctor can make a basis of a primary level of medical care. He caot be appointed, but selected by patients. His financial state can be determined by number of patients which have selected him.
He should not enter structure of city or central district hospital, and have administrative, financial and legal independence.
Place of its work can be a separate medical ambulance station.
Directing patients to narrow specialists or to a hospital, the family doctor, unlike modern district doctor, does not finish his function, but together with the narrow expert or the doctor of a hospital continues supervision over the patient and giving him the care.
After long years of discussions family medicine in
It is still not enough if to take into account, that the number of medical districts in
The Soviet medicine has saved a principle of gratuitousness of medical care for patients and considerably it has developed, having passed medicine completely in duties of the state. It was a significant step forward which had huge global consequences. The state maintenance of medicine was gradually distributed in the world, and now there is no civilized country where the part of the state in financing of medicine would be smaller than 75 % (besides of the
However the state maintenance of medicine, besides doubtless positive advantages, has also the essential lacks.
First, always it is not sufficiently provided with means.
According to recommendations of WHO (the World Health Organization), on medical care the state can allocate not less than 6,5 % of the total internal product.
If it is less allocated it will inevitable result in an impoverishment and backlogs of medicine.
The second lack is that the means are irrationally spent. It has lead to upset of the display ratio of factors of medical care :a lot of medical workers were trained but medical technologies were not developed .
Besides state source of financing, which can remain the basic (not less than 80 % from needs), in conditions of the market should exist other sources of financing: public and private.
The public medicine has introduced a preventive orientation of medicine .As a preventive direction; the Soviet medicine has proclaimed an ambulance station and a polyclinic.
The basic method of work of ambulance stations and polyclinics became dispensary, which essence has consisted in active revealing of patients and their active improvement. Complex and target routine examinations of the population have been introduced.
Rationality dispensary method did not cause doubt and due to them indisputable successes in revealing a lot of diseases, first of all infectious, a tuberculosis, venereal, malignant, etc. have been achieved.
For years of independence of the basic changes in a preventive orientation of system of medical care in
The dispensary method from obligatory has passed to the category of desirable.
Here still much should be corrected and finished.
Organisation features of treating-and-prophylactic care to urban population, workers of the industrial enterprises and constructions.
The basic organizational form of giving medical care to the population in city is versatile city hospital. It consists of the following departments: polyclinics, hospital, auxiliary diagnostic-medical service and administrative service. The object of activity of hospital is the population of all cities or its certain part district. City hospitals are of two types: for adults and children.
The primary goals of city hospital are the following:
1. Giving of the inhabitants of the fixed district the primary health care.
2. Giving to inhabitants the specialized medical care from the basic structures.
3. Preventive services of the population.
4. Expertise of temporary disablement.
5. Maintenance of sanitary – epidemiological well-being in area of activity.
6. Educative activities .
7. The organization of the public activity for participation in business and improvement of medical care.
The territory of activity is divided into medical districts which are headed by district doctors. Those are leading specialists of the city hospital. The district nurses help them.
Besides district doctors, narrow specialists work in the structure of polyclinics. Their number is determined in each polyclinic according to the needs, but the total number does not exceed the limits of the specification authorized by store department of Ministry of public health services (MPHs) of
The modern city polyclinic, as a rule, gives the specialized out-patient care of 15-35 specialties.
Narrow specialist consult patients who are sent to them by district doctors, and also conduct independent reception of patients. Dispensary patients, who need the specialized care, are under supervision of the narrow expert.
The polyclinic spends anti-epidemic actions.
First of all, they are carried out by district doctors.
Besides, in structure of a polyclinic there is a cabinet of infectious diseases where all patients with the fever and suspicion on an infectious disease must go. The cabinet of infectious diseases carries out necessary inoculations according to the established norms and requirements.
First of all, it concerns children.
In structure of polyclinics the Day – hospitals and hospitals in – home are organized recently. Day – hospitals are opened in the specially equipped rooms and can have several or tens beds.
Patients are sent by district doctors and narrow specialists for carrying out medical actions which are taken from morning till evening according to an individual plans.
We speak about chronic patients who need scheduled anti-relapse and precautionary treatment. The patient is sent home for night.
A hospital at home is carrying out the certain diagnostic and medical actions to the patient at his place. As a rule, it deals with chronic patients who can be examined and treated by portable equipment.
In
For optimization of streams of patients that go to a polyclinic, departments of preventive maintenance are organized. They consist of such subdivisions: a room of pre-medical reception, rooms of the therapist and the basic specialists (the neurologist, the oculist, the otholaryngologist, the surgeon), a fluorographic room, clinical laboratory. In the room of premedical reception medical workers work.
Here medium level a blood pressure, visual acuity and hearing are measured to patients, ЕCG and some other simple examinations are being made, the patients are sent to X-ray and laboratory examining. By results of these previous examinations a patient is directed to doctors rooms. The department of preventive maintenance allows to order the carrying out of preventive examinations and to rationalize the further reception of patients in the polyclinic.
In structure of polyclinics the departments of rehabilitation are organized recently.
Patients are sent for renovated treatment after the end of an acute disease period.
The basic contingent of departments of rehabilitation–orthopaedical, traumatological, neurological and cardiovascular patients. Here the wide spectrum of renewal means is used: physiotherapy, balneology, work therapy.
In the polyclinic patients are selected for hospitalization.
Patients from district doctor’s room and doctors of a narrow specialty are sent to a reception department. Here the patient is examined; the primary medical document is filled in patient’s card and the goes to the special department.
City hospitals contain, as a rule, 5-10 specialized stationary departments of therapeutic and surgical character.
Capacity of departments changes from 20 up to 80 beds. In a hospital all store of diagnostic and medical actions and means for complete examination and treatments of patients is used.
Besides dispensary and hospital care, the people may receive an emergency care, that is given by emergency stations.
They include the general and specialized brigades equipped with special diagnostic means and transport. This emergency care is given twenty-four-hour. The care is given at home, in case of need the patient is hospitalized to a hospital. In the big cities special hospitals of emergency care are organized which accept patients in acute states all day and night.
In cities the care to inhabitants is organized not only by territorial, but also by an industrial principle. The essence of last the one is, that at the enterprises medical care centres (MCC) are developed .If there are more than 4 thousand workers on the enterprise, MCC consists of a polyclinic and a hospital. Besides it may include dietary dining room and dispensaries.
For smaller numbers of workers, МCC consists only of a polyclinic and if the number of workers less than 1000, medical or medical assistant’s stations are created.
МCC may be of closed (treat only workers of the enterprise and their family) and open types (treat also the population of district which adjoins). Main principle of Primary care center is working the same, district. But the districts here are the shops of the enterprise. The doctor is called as the shop doctor. He observes 2 thousands of workers.
Periodically, depending on available industrial harmfulness, the shop doctor or the medical assistant organizes routine examinations of workers.
By results of the examination chronic patients are taken on dispensary registration. Special attention is preventive of industrial traumatism.
By results of state of workers health, every year physicians MCC together with trade union and administration of the enterprise make a comprehensive plan of the sanitary measures aimed at improvement of working conditions and life of workers and improvement of their health.
Maternity care and childhood
In
The law ” About the state help to families with children ” establishes a level of material support of families with children guaranteed by the state by giving the state help with due regard for family, its structure incomes, age, a health ,state help of children, etc.
The following kinds of the state help are stipulated:
1) Monetary payments on pregnancy and child birth. The size of the care makes, as a rule, 100 % of earnings;
2) A lump sum allowance at a birth of the child. This care is given to families in the quadruple number of the minimal wages. To mothers, who was registered in medical institution in early terms of pregnancy (till 12 weeks), on a regular basis of attendance and carried out the recommendation of doctors, at a birth of the child the additional care in the double size of the minimal wages is given;
3) Monetary payments of the child till his three-year old age is given to working women (or to other members of family) at a rate of the minimal wages irrespective of work experience;
4) Monetary payments to mothers (parents) occupied care with three and more infant by age till 16 years; are appointed at a rate of the minimal wages at presence of three infant and double minimal wages at presence of four and more infant;
5) Monetary payments of the child – invalid till his reaching 16-years old age (him) at a rate of the minimal wages;
6) Monetary payments on temporary disablement in connection with care of the ill child till the age of 14 years.
7) Monetary payments on infant in the age till 16 years (pupils – till 18 years) is given at a rate of 50 % of the minimal wages on each child if the monthly average cumulative income on each member of family for previous year does not exceed the triple number of the minimal wages;
8) Monetary payments on infant to single -unmarried mothers, iumber half or complete minimal wages on each child age till 16 years (pupils – till 18 years);
9) Monetary payments on infant of military men of emergency service are given at a rate of the minimal wages on each child;
10) Monetary payments on infant who are under somebody’s guardianship (trusteeship) or care; is given at a rate of double minimal wages on each child;
11) The temporary monetary payments for minor infant under age whose parents evade from payment of the alimony or if collecting of the alimony is impossible; it is given at a rate of 50 % of the minimal wages on each child.
In
It is the important program, which purpose is the coordination of actions connected with the performance of directions of Conference UNO about the rights of infant, according to the Decree of the President of Ukraine it should provide social protection of infant, create favourable conditions for their physical, intellectual and spiritual development.
It is already emphasized in the introduction to the Program in the primary school, 60 % of infant have diseases of immune system, chronic inflammatory diseases of some bronchi-lung systems, bodies of digestion, urinogenital ways and a thyroid gland.
The objective reasons of acute decrease in the level of health of rising generation is deep social and economic crisis, environmental problems, critical condition concerning provision of infant with a balanced diet, weak material base of system of medical care and education.
The program “Children of Ukraine” should be a reference point for taking measures concerning improvement of infant health. In particular, the question is in prophylaxis of disease and providing infant most with the effective medical care, means of treatment and restoration; carrying out radical actions on prevention of infectious and parasitic diseases; introduction of the scientific inventions aimed at on the solution of actual problems of the childhood.
It is necessary to emphasize, that in the Basic directions of the Program is the great role of family is emphasised in particular.
The family remains the best natural environment for physical, mental, social and spiritual development of infant.
The organization of public health services and medical сare
It is necessary to distinguish two concepts if we are talking about public health services: “public health services” and “medical care”.
“Public health services” may be defined as follows:
Public health services is a system of state, public, individual actions and means which assist health, prevention of diseases and the prevention of premature death, maintenance of persons active ability to live and work .
Definition of “medical care” is the following:
medical services – is a system of special medical actions and means which assist health, prevention of diseases and the prevention of premature death, maintenance of persons active ability to live and work .
So, the concept of “public health services” is universal, it includes everything, that concerns the health of people: state policies, social and economic conditions of people, environment of conditions, behaviour of people or their way of life, etc.
“Medical care” – is a component of public health services, which covers special activity of medical institutions.
Main principles on which the public health services and medical care in
– The state character with equal rights for the existence of public and private ownership;
– Decentralization of management;
– Socially focused availability;
– Economic efficiency;
– A preventive orientation;
– A free choice of the doctor;
– Scientific maintenance;
– Wide participation of the public in public health services;
– The international cooperation;
These bases are proclaimed in “Bases of the legislation of
Also we should stop on the following major aspects of this act on which public health services and medical care in
The law proclaims the right of each person on public health services.
The right on public health services provides:
1. High standard of life, including clothes, dwelling, medical care both social service and the maintenance, necessary for health of the person;
2. Environment safe for life and health ;
3. Sanitary – epidemic well-being of territory and settlement where the citizen lives;
4. Safe and healthy working conditions, life and rest;
5. The qualified health care, including free choice of the doctor and establishment of public health services;
6. The authentic and up-to-date information about the condition of the health of all people, including existing risk factors and their degree;
7. Participation in discussion of projects of acts and offers concerning formation of a state policy in the field of public health services;
8. Participation in management of public health services and carrying out public examination on these questions in the order, stipulated by the legislation;
9.
10. Legal protection from any illegal forms of discrimination connected with personal state of health;
11. Compensation of the harm caused to health;
12. The appeal of wrongful decisions and actions of workers, establishments and bodies of public health services;
13. Opportunity of carrying out of independent medical examination in case of disagreement of the citizen with conclusions of the state medical examination, application to him of compulsory treatment and in other cases if actions of the worker of public health services can be the humiliate of human and civil rights;
At the same time, the law also regulates duties of citizens in the field of public health services, namely:
1. Duty to take care of the health and health of children, not to be harmful to health of other citizens;
2. In the cases stipulated by the legislation to pass preventive medical examinations reviews and to do inoculations;
3. To live the emergency care to other citizens who are in menacing for a life or health ;
4. To execute other duties stipulated by the legislation concerning public health services;
State, public and other organs, enterprises, organizations, officials and citizens are obliged to provide priority public health services in their own activity, not to damage the health of the population and separate persons, in borders of the competence to live the care to patients, invalids and suffering from accidents, to assist the activities of the workers of medical organs and establishments of public health services, and also to execute other duties stipulated by the legislation on public health services.
According to the law the state policy of public health services is provided with budgetary assignations in volume according to its scientifically-grounded based needs, but not less than 10 % of the national income.
The law stipulates the financing of departmental and other establishments of public health services which serve only separate categories of the population, at the expense of the enterprises, establishments and organizations to which they serve.
The law stipulates gradual creation of the system of medical insurance.
Then budgetary funds, means of the enterprises, establishments and the organizations, and also the personal means of citizens will be gathered by insurance organizations which start to finance giving of medical care.
It is supposed to develop the special law concerning medical insurance. Government organizes material support of the public health services in the volume necessary for giving for the population of the guaranteed level of the health care.
All establishments of public health services have the right to solve questions of the material support independently.
The law regulates professional rights, privileges and duties of medical workers.
Rights and privileges:
1) Occupation with medical and pharmaceutical activity according to a specialty and qualifications;
2) Appropriate conditions of professional work;
3) Improvement of professional skills, retraining not less than once in five years in the corresponding establishments;
4) Free choice of the approved forms, methods and means of activity, introduction of modern achievements of a medical and pharmaceutical science and practice;
5) Gratuitous age of the social and special medical informatioecessary for realization of professional duties;
6) Obligatory insurance at the expense of the proprietor of establishment of public health services in case of causing harm to their life and health in connection with performance of professional duties in the cases stipulated by the legislation;
7) The social care of the state in case of disease, invalidity or in other cases of disability which were caused by performance of professional duties;
8) To fix in official bodies of public health services average rates and official salaries at the level, which not lower from average wages of industry workers;
9) The reduced working day and additional payment rest in the cases established y the legislation;
10) Concessionary terms of a provision of pensions;
11) Preferential providing with dwelling and phone;
12) Gratuitous using an apartment with heating and lighting by those who live in a countryside, giving of privileges concerning payment of the land tax, crediting, providing the a facilities and construction of own house, purchase of auto and motor-transport;
13) Prime reception of the treatment-and-prophylactic care and provision with medical and orthopedic means;
14) Creation of scientific medical societies, trade unions and other public organizations;
15) Legal protection of the professional honor and dignity.
Besides, other rights and privileges for medical and pharmaceutical workers can be stipulated. By the legislation privileges, which are established for the workers by the enterprises, also can be distributed to them by establishments and the organizations to which they give the health care.
Duties:
1) To assist protection and strengthening of health of people, prevention and treatment of the diseases, to give qualified medical care;
2) Free-of-charge emergency call service to citizens in case of accident and other extreme situations;
3) To distribute scientific and medical knowledge among the population, to propagandize, including own example, a healthy way of life;
4) To keep the requirement of a professional etiquette and of a deontology, to save medical secret;
5) To raise constantly the level of a professional knowledge and skills;
6) To live the advisory care to the colleagues and other workers of public health services.
The basic principles, which underlie medical care in
The first principle, on which the public medicine was created, was its availability to people. There was an idea to divide territory administrative unit (district, province) on so-called districts and to employ the doctor so that he gave inhabitants of that district accessible medical service.
At first, the doctor has driven around district (so-called traveling system of public medicine), and then the system has been replaced by stationary one which essence was, that in the territorial center of a district the hospital was situated where the doctor stayed constantly.
Districts gradually became smaller and at the moment of apogee of public medicine (1913) have achieved the following middle parameters: radius of a district –
The Soviet medicine has borrowed a district of the organization as the basic and with the end of its existence has finished normative parameters of districts to the following figures: a rural medical district – radius of
So-called therapeutic district for adult population was limited to 1700 inhabitants, pediatric – to 800 infants.
In the independent
The principle of availability was united with a principle of qualification of medical care.
Therefore, near to development of districts, there was a superstructure above them, all over again as district hospitals (since the twentieth years), and then district hospitals (since the fortieth years). The district doctor also specializes, dividing into divisional of the pediatrist and the therapist (from the end of the fortieth years).
Medical districts should give the primary health care, regional and city hospitals – specialized and areal establishments – highly specialised care.
So there is a three-level system of medical care. Each following level should give not only higher degree of the specialized care, but also to supervise over lower levels.
By volume medical service was distributed as following: a primary level – 5-20 %, secondary – 40-70 %, tertiary – 10-20 %.
Meanwhile, world experience proves, that the primary level can concentrate up to 90 % of all volume of medical care (as it was during the period of public medicine) and narrow specialists should concentrate on giving the more complex care which demands application of high medical technologies.
The basic quantity indices of the network of medical institutions in
Bases parameters of system of medical care in
|
1. |
Number of hospital establishments |
3122 |
|
2. |
Number of establishments which give the out-patient – polyclinic help |
6429 |
|
|
|
|
|
3. |
The general number of hospital beds |
444495 |
|
4. |
Total number of doctors (including dental) |
205759 |
|
5. |
Total number of nurses |
498845 |
|
6. |
Number of doctors on 10 thousands people |
41,6 |
|
7. |
Number of nurses on 10 thousands people |
100,9 |
|
8. |
Number of hospital beds on 10 thousand people |
89,9 |
|
9. |
Average capacity of hospital establishments: |
|
|
|
Areal hospital |
837 |
|
|
City hospital |
190 |
|
|
Regional hospital |
230 |
|
|
District hospital |
73 |
|
|
Local hospital |
16 |
The doctor of the general practice or the family doctor can make a basis of a primary level of medical care. He caot be appointed, but selected by patients. His financial state can be determined by number of patients which have selected him.
He should not enter structure of city or central district hospital, and have administrative, financial and legal independence.
Place of its work can be a separate medical ambulance station.
Directing patients to narrow specialists or to a hospital, the family doctor, unlike modern district doctor, does not finish his function, but together with the narrow expert or the doctor of a hospital continues supervision over the patient and giving him the care.
After long years of discussions family medicine in
It is still not enough if to take into account, that the number of medical districts in
The Soviet medicine has saved a principle of gratuitousness of medical care for patients and considerably it has developed, having passed medicine completely in duties of the state. It was a significant step forward which had huge global consequences. The state maintenance of medicine was gradually distributed in the world, and now there is no civilized country where the part of the state in financing of medicine would be smaller than 75 % (besides of the
However the state maintenance of medicine, besides doubtless positive advantages, has also the essential lacks.
First, always it is not sufficiently provided with means.
According to recommendations of WHO (the World Health Organization), on medical care the state can allocate not less than 6,5 % of the total internal product.
If it is less allocated it will inevitable result in an impoverishment and backlogs of medicine.
The second lack is that the means are irrationally spent. It has lead to upset of the display ratio of factors of medical care :a lot of medical workers were trained but medical technologies were not developed .
Besides state source of financing, which can remain the basic (not less than 80 % from needs), in conditions of the market should exist other sources of financing: public and private.
The public medicine has introduced a preventive orientation of medicine .As a preventive direction; the Soviet medicine has proclaimed an ambulance station and a polyclinic.
The basic method of work of ambulance stations and polyclinics became dispensary, which essence has consisted in active revealing of patients and their active improvement. Complex and target routine examinations of the population have been introduced.
Rationality dispensary method did not cause doubt and due to them indisputable successes in revealing a lot of diseases, first of all infectious, a tuberculosis, venereal, malignant, etc. have been achieved.
For years of independence of the basic changes in a preventive orientation of system of medical care in
The dispensary method from obligatory has passed to the category of desirable.
Here still much should be corrected and finished.
Organisation features of treating-and-prophylactic care to urban population, workers of the industrial enterprises and constructions.
The basic organizational form of giving medical care to the population in city is versatile city hospital. It consists of the following departments: polyclinics, hospital, auxiliary diagnostic-medical service and administrative service. The object of activity of hospital is the population of all cities or its certain part district. City hospitals are of two types: for adults and children.
The primary goals of city hospital are the following:
1. Giving of the inhabitants of the fixed district the primary health care.
2. Giving to inhabitants the specialized medical care from the basic structures.
3. Preventive services of the population.
4. Expertise of temporary disablement.
5. Maintenance of sanitary – epidemiological well-being in area of activity.
6. Educative activities .
7. The organization of the public activity for participation in business and improvement of medical care.
The territory of activity is divided into medical districts which are headed by district doctors. Those are leading specialists of the city hospital. The district nurses help them.
Besides district doctors, narrow specialists work in the structure of polyclinics. Their number is determined in each polyclinic according to the needs, but the total number does not exceed the limits of the specification authorized by store department of Ministry of public health services (MPHs) of
The modern city polyclinic, as a rule, gives the specialized out-patient care of 15-35 specialties.
Narrow specialist consult patients who are sent to them by district doctors, and also conduct independent reception of patients. Dispensary patients, who need the specialized care, are under supervision of the narrow expert.
The polyclinic spends anti-epidemic actions.
First of all, they are carried out by district doctors.
Besides, in structure of a polyclinic there is a cabinet of infectious diseases where all patients with the fever and suspicion on an infectious disease must go. The cabinet of infectious diseases carries out necessary inoculations according to the established norms and requirements.
First of all, it concerns children.
In structure of polyclinics the Day – hospitals and hospitals in – home are organized recently. Day – hospitals are opened in the specially equipped rooms and can have several or tens beds.
Patients are sent by district doctors and narrow specialists for carrying out medical actions which are taken from morning till evening according to an individual plans.
We speak about chronic patients who need scheduled anti-relapse and precautionary treatment. The patient is sent home for night.
A hospital at home is carrying out the certain diagnostic and medical actions to the patient at his place. As a rule, it deals with chronic patients who can be examined and treated by portable equipment.
In
For optimization of streams of patients that go to a polyclinic, departments of preventive maintenance are organized. They consist of such subdivisions: a room of pre-medical reception, rooms of the therapist and the basic specialists (the neurologist, the oculist, the otholaryngologist, the surgeon), a fluorographic room, clinical laboratory. In the room of premedical reception medical workers work.
Here medium level a blood pressure, visual acuity and hearing are measured to patients, ЕCG and some other simple examinations are being made, the patients are sent to X-ray and laboratory examining. By results of these previous examinations a patient is directed to doctors rooms. The department of preventive maintenance allows to order the carrying out of preventive examinations and to rationalize the further reception of patients in the polyclinic.
In structure of polyclinics the departments of rehabilitation are organized recently.
Patients are sent for renovated treatment after the end of an acute disease period.
The basic contingent of departments of rehabilitation–orthopaedical, traumatological, neurological and cardiovascular patients. Here the wide spectrum of renewal means is used: physiotherapy, balneology, work therapy.
In the polyclinic patients are selected for hospitalization.
Patients from district doctor’s room and doctors of a narrow specialty are sent to a reception department. Here the patient is examined; the primary medical document is filled in patient’s card and the goes to the special department.
City hospitals contain, as a rule, 5-10 specialized stationary departments of therapeutic and surgical character.
Capacity of departments changes from 20 up to 80 beds. In a hospital all store of diagnostic and medical actions and means for complete examination and treatments of patients is used.
Besides dispensary and hospital care, the people may receive an emergency care, that is given by emergency stations.
They include the general and specialized brigades equipped with special diagnostic means and transport. This emergency care is given twenty-four-hour. The care is given at home, in case of need the patient is hospitalized to a hospital. In the big cities special hospitals of emergency care are organized which accept patients in acute states all day and night.
In cities the care to inhabitants is organized not only by territorial, but also by an industrial principle. The essence of last the one is, that at the enterprises medical care centres (MCC) are developed .If there are more than 4 thousand workers on the enterprise, MCC consists of a polyclinic and a hospital. Besides it may include dietary dining room and dispensaries.
For smaller numbers of workers, МCC consists only of a polyclinic and if the number of workers less than 1000, medical or medical assistant’s stations are created.
МCC may be of closed (treat only workers of the enterprise and their family) and open types (treat also the population of district which adjoins). Main principle of Primary care center is working the same, district. But the districts here are the shops of the enterprise. The doctor is called as the shop doctor. He observes 2 thousands of workers.
Periodically, depending on available industrial harmfulness, the shop doctor or the medical assistant organizes routine examinations of workers.
By results of the examination chronic patients are taken on dispensary registration. Special attention is preventive of industrial traumatism.
By results of state of workers health, every year physicians MCC together with trade union and administration of the enterprise make a comprehensive plan of the sanitary measures aimed at improvement of working conditions and life of workers and improvement of their health.
Maternity care and childhood
In
The law ” About the state help to families with children ” establishes a level of material support of families with children guaranteed by the state by giving the state help with due regard for family, its structure incomes, age, a health ,state help of children, etc.
The following kinds of the state help are stipulated:
1) Monetary payments on pregnancy and child birth. The size of the care makes, as a rule, 100 % of earnings;
2) A lump sum allowance at a birth of the child. This care is given to families in the quadruple number of the minimal wages. To mothers, who was registered in medical institution in early terms of pregnancy (till 12 weeks), on a regular basis of attendance and carried out the recommendation of doctors, at a birth of the child the additional care in the double size of the minimal wages is given;
3) Monetary payments of the child till his three-year old age is given to working women (or to other members of family) at a rate of the minimal wages irrespective of work experience;
4) Monetary payments to mothers (parents) occupied care with three and more infant by age till 16 years; are appointed at a rate of the minimal wages at presence of three infant and double minimal wages at presence of four and more infant;
5) Monetary payments of the child – invalid till his reaching 16-years old age (him) at a rate of the minimal wages;
6) Monetary payments on temporary disablement in connection with care of the ill child till the age of 14 years.
7) Monetary payments on infant in the age till 16 years (pupils – till 18 years) is given at a rate of 50 % of the minimal wages on each child if the monthly average cumulative income on each member of family for previous year does not exceed the triple number of the minimal wages;
8) Monetary payments on infant to single -unmarried mothers, iumber half or complete minimal wages on each child age till 16 years (pupils – till 18 years);
9) Monetary payments on infant of military men of emergency service are given at a rate of the minimal wages on each child;
10) Monetary payments on infant who are under somebody’s guardianship (trusteeship) or care; is given at a rate of double minimal wages on each child;
11) The temporary monetary payments for minor infant under age whose parents evade from payment of the alimony or if collecting of the alimony is impossible; it is given at a rate of 50 % of the minimal wages on each child.
In
It is the important program, which purpose is the coordination of actions connected with the performance of directions of Conference UNO about the rights of infant, according to the Decree of the President of Ukraine it should provide social protection of infant, create favourable conditions for their physical, intellectual and spiritual development.
It is already emphasized in the introduction to the Program in the primary school, 60 % of infant have diseases of immune system, chronic inflammatory diseases of some bronchi-lung systems, bodies of digestion, urinogenital ways and a thyroid gland.
The objective reasons of acute decrease in the level of health of rising generation is deep social and economic crisis, environmental problems, critical condition concerning provision of infant with a balanced diet, weak material base of system of medical care and education.
The program “Children of Ukraine” should be a reference point for taking measures concerning improvement of infant health. In particular, the question is in prophylaxis of disease and providing infant most with the effective medical care, means of treatment and restoration; carrying out radical actions on prevention of infectious and parasitic diseases; introduction of the scientific inventions aimed at on the solution of actual problems of the childhood.
It is necessary to emphasize, that in the Basic directions of the Program is the great role of family is emphasised in particular.
The family remains the best natural environment for physical, mental, social and spiritual development of infant.
The basic methods of preservation and strengthening of health in family conditions are prophylaxis of diseases and keeping the certain hygienic rules in everyday life, optimum physical activity, body training, a balanced meal, prevention of the harmful phenomena and habits.
As for tasks of the state, the subject of its special attention is reduction of negative influence of surrounding natural environments on a state of health of infant, development of services of planning family, the genetic centers, establishments of out-patient – polyclinic network and giving of the specialized medical care to each child who needs it.
It is possible from the program on expectancy the consecutive reduction of mortality rate of infants up to 12 on 1000 born alive.
Realization of the bases actions on improvement of health of infant, decrease in infant’s disease and mortality rate is assigned by Ministry of public health services of
The question is introduction of modern methods of antenatal diagnostics and treatment genetic disorders; creation of district sanatoria – dispensaries for pregnant women the basis of district sanitary establishments and district centers are opened in Kyiv, Lviv and Donetsk for support of women lactation .
It is supposed to create in Kyiv the Ukrainian children centers of chronic hemodialysis and methods of treatment; to base the center of treatment of the newborn having a retinopathy, to develop the program of development of the city of
The questions of infant’s food will be solving consistently and persistently.
For example, it is planned to organize the manufacture of products of a infant’s meal with pertinacious additives for prophylaxis of diseases of children injured by
Realization of the state program “Children of Ukraine” will allow to improve the demographic situation will provide strengthening of health of children will protect them from consequences of social and economic crisis and will strengthen position of woman in the society.
All these measures will assist realization in Ukraine a state policy of the complex solution of problems of the childhood in complete conformity with the international strategy accepted by the United Nations Organization and with the Convention on the rights of the child, will enable to create conditions for realization in Ukraine the World declaration on maintenance of survival, protection and development of children.
Especially medical actions maternity care and childhood are covered two basic units:
1. The obstetrical – gynecologic care;
2. The treatment-and-prophylactic infant care.
The basic obstetrical-gynecologic establishments in cities are delivery homes and obstetrical-gynecological departments of the hospitals, in villages – obstetrical-gynecological departments of the central district hospitals.
Delivery homes (departments) must be provided with the qualified medical service of pregnant women, postpartum women and gynecologic patients. Delivery homes consist of two structural parts – antenatal clinic and a hospital.
Antenatal clinic is a main subdivision of delivery home. It can exist also as an independent medical institution. Antenatal clinic gives this kind of the preventive and medical care both to pregnant and gynecologic patients.
Doctors of antenatal clinic and their assistants – nurses work according to a district principle.
Antenatal clinic starts working from active revealing of pregnant women in early terms of pregnancy (on 2-3 month).
Further pregnant women are under dynamic dispensary supervision.
Early revealing and supervision are aimed at giving the necessary medical care, finding by pregnant women of hygienic habits, mental prophylactic training for the prevention of complications of pregnancy, prophylaxis of a prematurely, giving a maternity leave to the pregnant woman.
Antenatal clinic carries out also supervision delivery’s women, controlling their keeping observance hygienic recommendations, corrects bringing up of the child, etc.
The area of activity of antenatal clinic is divided on obstetrical districts which have the district into obstetrical-gynecologist and the nurse. They work in close contact with district therapists and other specialists.
During the first attendance of the clinic a pregnant woman is registered and is completely examined monthly, and during one and a half month – not less than once in two weeks. These terms can be changed in special cases, depending on a state of health of a pregnant woman.
The special attention is give to pregnant women with wrong position of a fruit, with a narrow pelvis, and also with inauspicious obstetrical outcome complicated previous labors.
All pregnant women are examined by therapist, and also narrow specialists if they need. Blood, urine is regularly analysed, arterial pressure is measured, and the Ultrasonic research is carried out.
In the first and second half of pregnancy blood on presence of syphilis is investigated. In case of a pathology the woman is hospitalized, or sent to a special sanatorium, solve questions of employment, improving procedures, a dietary meal, etc.
Pregnant women and postpartum omen is subject of obligatory nursing supervision at home. It is carried out by nurses and visiting nurse under the doctor control.
Regular prophylactic and medical attendance is aimed at:
1. Helping pregnant women in observance of the existing legislation concerning protection of their health and other rights;
2. Examination of the general state of the pregnant woman, control over her way of life, regular attendance of the hospital;
3. Training the rules of personal hygiene and care of newborns.
The first patronage attendance is carried out not later after two weeks when the pregnant woman is registered. If need, patronage attendance is carried out by the doctor.
The important task of antenatal clinic is prophylaxis of abortions, wide propagation of modern contraceptive means and training of women to use them.
Childbirths in a maternity hospital – the closing stage of long and many-sided work of antenatal clinic.
The delivery hospital consists of the following structural parts:
1. The casualty ward;
2. Physiological obstetrical department;
3. Observational (second) obstetrical department;
4. The department of pathologies of pregnancy;
4. The department for newborn;
5. Gynecologic department.
In the casualty ward which consists of reception room, the filter, separate examination showers rooms and both for physiological and observational departments, the women are coursing their sanitary treatment. The filter serves for interrogation and previous examination of the women after delivery and sent to physiological or observation departments.
The physiological department accepts healthy postpartum women, to observation one – the women with a fever, skin diseases, those who had contact to infectious patients etc.
From physiological department are sent the postpartum women with the complicated postnatal course (fever, an influenza etc.).
Physiological and observation departments have identical structure: sanitary room (for examination), delivery room, postnatal rooms, and the department for newborns. They differ in capacity; observation department is smaller than physiological one. Both departments are completely separated one from another.
Department of a pathology of pregnancy is used for women with the complicated pregnancy, which needs constant medical supervision (toxics of pregnancy, disease of heart and vessels, etc.), and also for prophylaxis of probable complications at a narrow pelvis, wrong position of a fruit, average abortions and other pathological states.
In small maternity hospitals for pathology of pregnancy separate rooms are in structure of physiological department.
The gynecologic department is used for hospitalization of women which suffer of diseases of female genitals. It is isolated from the obstetrical department.
Average being of postpartum woman in delivery hospital after normal delivery is 7-8 days. In case of any complications or diseases – till complete recovery.
After leaving in delivery hospital postpartum women is cared by the antenatal clinic observes.
In department of newborns medical supervision and care of newborns is carried out. It is the doctor – pediatrist and nurses. Physiological and observation department have separate department for newborns.
In observation department for newborns should be kept separate room.
In any of two obstetrical departments special rooms for prematurely born and weakened infant who need in particular careful treatment are separated.
Infant who were ill, and also infant of sick mothers should be isolated in isolation wards. Quality of care has great importance for health of newborns bringing up, observance of requirements of personal hygiene the medical personnel and mothers.
Every newborn is made preventive and antitubercular vaccination if there are no contra-indications.
Only healthy infant leave from delivery home. Children polyclinic is informed on the day of their leaving.
Results of delivery and consequences of medical supervision are put down by the doctor in a history of development of infant.
Children consultation informs the delivery home of all diseases revealed by it. In delivery home constant struggle against infections is conducted.
The sanitary regimen, correct organizational structure of delivery home, high culture of care by the pregnant women, postpartum women and newborns must be strictly kept.
The current and scheduled preventive sanitary processing of bed, linen, and rooms is made. During a year for three months the hospital is closed for preventive actions. Effective preventive action is system of cyclic filling of parent and infant’s rooms with the purpose of their periodic cleaning and disinfection.
A personnel of the hospital is periodically examined on presence of the bacilloses.
It is necessary to pay attention to education of personal hygiene at women, to an explanation of hygiene of application of contraceptive means, to training a future mother to look after the baby, to bring up and feed him correctly.
The final results of activity of obstetrical-gynecologic service are parameters of mortality, stillbirth, early neonatal rate, perinatal mortality rate .
The typical treatment-and-prophylactic establishment for children is independent children hospital or children departments in structure of big hospitals.
There are also children polyclinics and children consultations or children departments in the independent polyclinics.
These establishments provide children with all kinds of medical care and constant survey in the polyclinics, at home, in the hospitals, in the day kindergartens, schools.
The basic structural subdivisions of children hospital are the polyclinic and hospital. The general hospitals for adults can give the medical care to children.
The children polyclinic is the base part in treatment-and-prophylactic medical care of children. It takes care of healthy children, carries out preventive actions, provides the qualified medical care in the polyclinic and teaches mothers to take care of the child. The polyclinic at home works according to a district principle.
A district podiatrist – services 800 children in the cities and 1200 children in the villages.
The child polyclinic has consists of two basic parts: department for healthy children and the departments of medical care with separate filters, isolation wards, medical rooms.
Prophylaxis is the basic part of work of the children’s polyclinic.
First of all, it deals with home nursing of infants that begins in the antenatal period.
As soon as infant consultation obtains the first data on the future child from maternity hospital her visiting nurse of children’s polyclinic attends a future mother, talks to her ,teaches key rules of take care of the child and his bringing up, explaining her rights and a privileges. The mother’s schools are organized.
On day when the infant leaves the delivery hospital he is visited by the district pediatrist and visiting nurse giving all necessary care. If necessary attendance may be repeated. Further monthly the child is examined by the pediatrist in the polyclinic and visiting nurse at home.
At last during the first year of infant life.
Then patronage attendance becomes different – once a quarter on the second year of life, once a half-year – on the third and further annually.
On the third and sixth years of life the careful examination of the child by so-called narrow specialists – the neuropathologist, the surgeon, the oculist, the oto-laryngologist is made.
During the first patronage visiting on the first year of life the special attention is preventive to bringing up of the child, his regimen, his physical training.
The basic positive results of home nursing of infant are continuity and absence of illnesses. Found sick infant are being taken on dispensary registration.
The necessary medical care, is given these infant, as a rule, at home.
In case of need ill infants are hospitalized to children hospitals.
The first task of hospitalization is not to allow infant infections to be brought in the hospital.
With this purpose precautionary measures are taken – the careful examination, isolation at the least suspicions on infectious disease, the information of the district doctor on epidemiological conditions of a house and in infant establishments which child (a day nursery, school) is visiting.
Infant with infectious and infectious diseases are separated.
They stay in the infant box. Infants are hospitalized together with mothers.
In case of need, joint hospitalization is applied to children.
Medical process is united also with educational and pedagogical ones.
It is necessary to fill in leisure of infant with interesting with stimulating actions, entertainment’s for infant of school age.
All actions on home nursing infant and their treatments will put down in a history of development of infant.
On its basis quantitative and quality indices of work of children hospital are calculated – completeness and a continuity of home nursing, conditions of bringing up, morbidity of infant, completeness of scope by preventive inoculations, frequency of complications of diseases, fatality , in particular at hospital.
In public health care of children – children preschool establishments play the important role.
Here children are brought up, they are provided with appropriate health care.
Medical care is given by children’s hospital on which district children preschool establishment is situated.
For each children establishment the doctor – pediatrist who organizes patronage, preventive and medical work activity, control establishment’s sanitary – anti-epidemic conditions, and medical regimen. Nurses help doctors in their work.
WHO report calls for new approach to save lives of mothers and children
10.6 million children die before age five, and half a million women die in childbirth
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7 APRIL 2005 GENEVA/NEW DELHI — Hundreds of millions of women and children have no access to potentially life-saving care with often fatal results, the World Health Organization (WHO) says in a report published today. The report says the resulting death toll could be sharply reduced through wider use of key interventions and a “continuum of care” approach for mother and child that begins before pregnancy and extends through childbirth and into the baby’s childhood.
About 530 000 women a year die in pregnancy or childbirth, more than three million babies are stillborn, more than four millioewborns die within the first days or weeks of life, and altogether 10.6 million children a year die before their fifth birthday, according to WHO’s latest figures.
In The World Health Report 2005 – Make every mother and child count, WHO estimates that out of a total of 136 million births a year worldwide, less than two thirds of women in less developed countries and only one third in the least developed countries have their babies delivered by a skilled attendant. The report says this can make the difference between life and death for mother and child if complications arise.
World health report 2005 Make every mother and child count |
Make every mother and child count is being launched on World Health Day, which shares the report’s main theme. The event is being marked in many countries, with a major launch in
According to the report, almost 90% of all deaths among children under five years of age are attributable to just six conditions. These are: acute neonatal conditions, mainly preterm birth, birth asphyxia and infections, which account for 37% of the total; lower respiratory infections, mostly pneumonia (19%); diarrhoea (18%); malaria (8%); measles (4%); and HIV/AIDS (3%). Most of these deaths are avoidable through existing interventions that are simple, affordable and effective. They include oral rehydration therapy, antibiotics, antimalarial drugs and insecticide-treated bednets, vitamin A and other micronutrients, promotion of breastfeeding, immunization, and skilled care during pregnancy and childbirth. To reduce the death toll, the report calls for much greater use of these interventions, and advocates a “continuum of care” approach for mother and child that begins before pregnancy and extends through childbirth and into the baby’s childhood. This in turn requires a massive investment in health systems, particularly the deployment of many more health professionals, including doctors, midwives and nurses. “For optimum safety, every woman, without exception, needs professional skilled care when giving birth,” the report says, adding that continuity of care for the newborn in the following weeks is vital.
“This approach has the potential to transform the lives of millions of people,” says Dr LEE Jong-wook, WHO Director-General. “Giving mothers, babies and children the care they need is an absolute imperative.”
The report focuses on those developing countries where progress in maternal and child health is slow, stagnating or has even gone into reverse in recent years. Within such countries, less than half of mothers and newborns receive care, but by no means the full range of what they need. Make every mother and child count is a wide-ranging study of the obstacles to health facing women before and during pregnancy, in childbirth, and in the weeks, months and years that follow for them and their children. It pays particular attention to the plight of newborns, whose specific needs have “fallen between the cracks” separating maternal and child care programmes.
It is being published in the “report card year” of the United Nations’ Millennium Development Goals (MDGs), two of which are to improve maternal and child health drastically by the year 2015. The latest available data show that total public health expenditure for the 75 countries with the biggest problems amounts to US$ 97 billion per year. The report calculates that this amount needs to be increased by an average of US$ 9 billion a year for each of the next ten years in order to increase access to care in those countries to a level that would permit them to move towards and even beyond the MDGs.
Exclusion from maternal, newborn and child health care is a key feature of inequity as well as a crucial obstacle to progress towards the MDGs, the report says. The health of mothers and children “is at the core of the struggle against poverty and inequality, as a matter of human rights”.
Lack of access to skilled care and to major obstetric interventions is the prime reason why large numbers of mothers in rural areas are excluded from life-saving care at childbirth. For example, in a study of 2.7 million deliveries in seven developing countries, only 32% of women who needed a major life-saving intervention received it.
More than 18 million induced abortions each year are performed by people lacking the necessary skills or in an environment lacking the minimal medical standards, or both, and are therefore unsafe. As a consequence, 68 000 women a year die.
In many countries, “numerous women and children are excluded from even the most basic health benefits: those that are important for mere survival”. Some countries, often the poorest, show a pattern of massive deprivation, with only a small minority, usually the urban rich, enjoying reasonable access to health care, while an overwhelming majority is excluded.
Among those left out, women and their children suffer most. “Being poor or being a woman is often a reason for being discriminated against, and may result in abuse, neglect and poor treatment, poorly explained reasons for procedures, compounded by views sometimes held by health workers that women are ignorant. The care that women are offered may be untimely, ineffective, unresponsive or discriminatory,” the report says.
The report adds that putting in place the health workforce needed for scaling up maternal, newborn and child health services towards universal access is the first and most pressing task. The extra US$ 9 billion a year that is required to scale up maternal, newborn and child health includes US$ 3.5 billion in additional costs for human resources. Making up for the huge shortages and imbalances in the distribution of health workers in many countries will remain a major challenge for years to come. WHO is currently assessing the need for a massive scale-up in the numbers of health workers of all categories, not just maternal and child care, in the coming decade. The human resources crisis relates not just to shortages of people but also to issues such as pay and working conditions. WHO is developing a series of policy actions for each of the areas covered in the report and is encouraging governments and other stakeholders to introduce recommended interventions and scale up maternal, newborn and child health programmes. WHO will monitor and evaluate progress in these programmes.
Organization of country population medicare
1. The conception about medicare
Medicare according to the village population appears on general bases, however complicated realization of medical and prophylactic measures in an optimal volume and at sufficient level is by the row of circumstances, which are needed to take into account during its organization
It is possible to select among them;
• social-economic terms;
• medically-demographic features;
• state of morbidity and disability;
• natural terms;
• development of infrastructure on the whole and networks of medical establishments in particular.
Availability of prophylactic treatment aid in complicated by the features of settling apart of village population, which stimulate the low levels of morbidity from data of appeals. The number of visits of doctor and level of general morbidity diminished at the increase of distance from a village to the village district hospital (out-patient’s clinics). At the same time the indices of the “exhausted” morbidity, set as a result of the deep special selective researches, are considerable enough.
The network of prophylactic treatment and establishments was folded during great while. As above all things the specific of the system of settling apart of village population was taken into account with its geographical, economic and social features.
Gradually to the extent of alteratioetworks and growth of material well-being by a medical personal in its forming went into effect principle of staging:
I-st stage is a village hospital provides the primary medical sanitary aid.
ІІ stage are district medical establishments which give secondary (specialized) medical aid mainly (the primary aid on this stage appears only to the habitants of district center and villages adjoining to him – registered in hospital).
ІІІ stage are regional hospitals and dispensaries provide the highly-specialized aid.
The IV stage, which is represented by the inter-regional and state specialized centers which formed in modern terms. In addition, in the grant of medicare to the village population take considerable part and city hospital.
Consequently, on every next stage the population gets medicare higher after the degree of complication.
Bringing in to the medical providing of village population in cities and regional hospital allows to a certain extent to decrease disagreements in the levels of material well-being of villagers (especially it is up to the stationary aid).
It is considerably more difficult to provide the village population by the ambulatory-policlinic aid, as in her acted noticeable part and continue to play medical workers.
From the commoumber of visits by the villagers of medical establishments on the II-nd stages (7,4 on one habitant) on the first are only 2,3, that is not sufficient.
It testifies to the urgent necessity of the PMSA (primary medically-sanitary aid) strengthening, is necessary of more active introduction of bases of domestic medicine.
A village medical hospital plays important role in the grant of population medicare, conducting of prophylactic and health measures.
For the organization of village hospitals are taken into account:
• quantity of population;
• features of settling apart;
• hospital of district;
• distance between the settlements;
• state of ways.
On the end of 1999 year the 3300 village medical hospitals were counted in
The average quantity of population on hospital in 1991-1997 years made a 4,7 and 4,4 thousand accordingly, middle radius a 7,2-
On considerable part of the PMSA hospitals and medical out-patient’s clinics are given, and on the third are district hospitals, which medical out-patient’s clinics enter in the complement of.
Above all establishment are the district hospitals or independent medical out-patient’s clinics.
Basic tasks of district hospital:
• providing of village population by the ambulatory and sanitary medical aid;
• realization of prophylactic treatment and general health measures for the health protection of mother and child;
• organization and conducting of prophylactic measures and to decrease of morbidity indices and cases of traumatism;
•to advance the modern methods of prophylactics, diagnostics and treatment;
•Organization of medical guidance and control by activity of health protection establishments.
A volume and types of stationary aid is determined, coming power of hospital from full strength by the proper specialists. Regardless of power of permanent establishment in some village hospitals the aid must appear to the therapeutic and infectious patients.
Its must to adopt the cases of births, to provide surgical and prophylactic treatment and medical aid for the children.
The positions of the trained nurses (chamber) are set from a calculation of the one round-the-clock post on 25 therapeutic beds and on 20 pediatric beds (but not less than one post).
2. District hospitals
For providing of treatment and care of patients, except for doctors, foreseen positions of medical sisters.
In district hospitals to treat mainly the sick by therapeutic type. Considerable part of them are hospitalized not so much after medical, as after social testimonies (old people, that need examination and conducting of supporting treatment). During great while the particle of such sick hesitated within the limits of 40-60%.
The district hospitals are low-powered, their logistical support were skilled and insufficient. As a result of growth of requirements to quality of medicare the population gravitates to establishments, which give specialized and more high-quality aid.
In accordance with the volume of medicare quality for village population of stationary aid considerably diminished exactly at primary level that in district hospitals.
The ambulatory aid is the important section of work of village medical hospital.
Village out-patient’s clinic carries out:
• to early exposure of diseases and risk factors;
• timely treatment of patients in out-patient’s clinic and at home;
• selection of persons which need clinical observation, timely their inspection, treatment and to make here healthy;
• organization of urgent medical aid;
• direction of consultations and preparation to the review by the doctors, specialists of district establishments in their planned departure on village medical hospitals;
• timely hospitalization of patients;
• examination of patients with temporary disability;
• direction on the medically-social expert commission (МSЕC) of the patients with the signs of proof disability;
• dynamic observation by the state of women and children’s health;
• planning of the graphs and conducting of consultative receptions of patients on territory of the activity;
• conducting of health and anti-epidemic measures.
The structure of out-patient’s clinic, as component part of hospital, enter register office, cabinets of doctors, manipulation, bandaging cabinets.
If the independent medical out-patient’s clinic operates on region, medically-auxiliary and diagnostic subsections are also to enter to its composition (cabinets of physical therapy, scanography functional diagnostics, and also clinical laboratories).
The ambulatory aid in village medical out-patient’s clinics is given by doctors – interns, pediatricians, stomatologists. Some out-patient’s clinics are made by family doctors (general practice).
In accordance with the order of Health Ministry of Ukraine № 33 from 23.02.2000 on a 1000 adult population reference 0,6 positions of therapeutics and 0,25 positions of stomatologist, on 1000 children population – 1,25 positions of pediatrician and 0,25 positions of stomatologist.
Positions of obstetricians-gynecologists and surgeons are set on condition that the quantity of population on the region will exceed a 10 thousand.
Today, taking into account concrete terms, it is possible to create medical out-patient’s clinics in village settlements with a quantity over 1000 habitants, providing for necessarily, except for an internist, yet and position of pediatrician.
In accordance with positions of doctors by the same order the foreseen positions of district medical sisters for maintenance of adult population and children.
Position of medical assistant is foreseen in every out-patient’s clinic, position of midwife is entered on 2000 persons of population (but not less than one position on out-patient’s clinic).
One position of medical sister on 10 beds of daily primary hospitals during of work in one change is entered.
A volume and quality of ambulatory aid on a village hospital to depend from the complex of permanent positions, qualification of medical personal, logistical support, adjusting of intercommunications from the hospitals of the next stages.
Important part in the medical providing is acted by ambulatory points, the amount of which in 2000 made almost 16200.
The medical personnel ambulatory gives prophylactic treatment aid for the population, carries out of the complex of prophylactic, health, anti-epidemic measures, carries out of the current sanitary observation, provides the early exposure of infectious diseases.
This list testifies that exactly they begin to give the primary medically-sanitary aid, as considerable part of villagers is served – 33-37%.
At forming of the ambulatory network the quantity of population is taken into account in the concrete settlement, and also distance from it to the stationary village.
Pursuant to operating norms there is introduction of such positions:
Position of manager (medical assistant, midwife, medical sister) is entered in every ambulatory station.
3. The norms and notes.
There are the following norms and notes:
1. Regulary norms are used at the calculation of the states of the ambulatory points located in the distance anymore as a
Their application to the ambulatory points, which are created in the settlements located in the distance to a
However many these norms must not restrain development of the ambulatory network subject by the condition are existents or possible in future diminishment of quantity of population. Actually in the modern terms ambulatory or points medical assistants can be created in the settlements, where less than 200 habitants. For example, in the Zhytomir region 12,7% ambulatory function exactly in such villages, here about 51 % their remote on a
The ambulatory work to carry out by medical workers consists of two sections and represented on a picture (1).
Pursuant to the proper level of preparation and position, the duties of the ambulatory manager and midwifes differ, although there are functions inherent to both these workers.
Main tasks of the ambulatory manager:
• conducting of ambulatory reception and maintenance of calls;
• implementation of setting of doctors, conducting of certain physical therapy procedures and laboratory researches;
• participation in organization of prophylactic medical reviews, by the selection of persons for the clinical observation;
• organization of transportation of patients to the general medical establishments, accompaniment the sick children who lived more than 1 year;
• early exposure of infectious patients; providing of isolation, and if necessary – hospitalization of these patients;
• realization of patronage of patients with tuberculosis, psychical disorders; there is participation in their ambulatory treatment;
• conducting of inoculations;
• conducting of anti-epidemic measures in the cases of infectious diseases;
• conducting of current sanitary observation from the proper objects and territory of settlement;
• conducting of prophylactic measures of agricultural traumatism;
• medically-hygienic learning of population; drafting of plans of the ambulatory work;
• filling of registration documents and drafting of report of ambulatory point (f.024);
• to delivery of sheets of disability (pursuant to the proper order of regional department (management) of health protection.
The main functions of the ambulatory midwife:
• annual census of children more than 15 years;
• conducting of ambulatory reception of children, pregnant, gynecological patients and quality of medicare at home;
• organization of consultations at the diseases of children (especially early age) of district doctor (pediatrician), timely hospitalization to the general hospital;
• conducting of prophylactic reviews of all women;
• patronage of pregnant women and children;
• if necessary the direction of women to the gynecologist;
• implementation the children of settings to the doctors, pregnant and gynecological patients;
• conducting of certain physical therapy procedures and laboratory researches;
• quality of medicare at the acute diseases and accidents;
• conducting of inoculations;
• medically-hygienic education of women and children.
A medical assistant and midwife have a rights:
• to conduct the inspection within the limits of the jurisdiction , combination of diagnosis, appoint treatment;
• to execute necessary manipulations;
• to write recipes (except for strong and poisonous remedies);
• to give the certificates.
The important role in the ambulatory activity is taken to the prophylactic of traumatism and providing of sanitary-epidemic prosperity. For that the medical workers carry out the current sanitary observation after educational establishments, farms and processing productions, sources of water-supply and others like that, the inoculation is conducted in accordance with an operating calendar and after epidemiology testimonies.
From the data of the research conducted in the Zhytomir region, on prophylactic work of ambulatory outlay of about 30 % working hours.
Considerable enough part of working day is occupied by the ambulatory reception of patients and grant to them medicare at home.
From data of 1997, 68 % of patients, which have medicare on ambulatories and one third (32%) – at home, loading on one concerned position achieves 2900 visits almost.
The middle medical workers of ambulatories to fill numerous enough registration documents.
From the data of registration documents “Report of ambulatory patient” (f. № 024) is filled, ratified by the order of Statutory Broker of Ukraine and Health Ministry of Ukraine № 256/184 from 31.07.2000.
The secondary specialized prophylactic treatment for the village population appears is in district medical establishments.
A central district hospital is leading establishment of the II-nd stage (CDH-central district hospital). There is the fourth of bed fund of country on these hospitals.
CDH provides the quality of the specialized aid for the population of district and is the center of organizationally-methodical work, as carries out guidance by all prophylactic treatment establishments on territory of district, to carry responsibility for organization and quality of medicare.
Positions of doctors in hospitals establishment to depend with the amount of beds and type of separations. In accordance with it the states of middle medical workers are formed.
Basic tasks of CRH (central regional hospital).
• direct grant of primary ambulatory-policlinic aid for the population of village and district;
• quality of the specialized ambulatory-policlinic and stationary aid to all population of district;
• providing by quickly and exigent medicare of district population ;
• introduction into practice the modern methods of work in district hospital and facilities of prophylactic, diagnostics and treatment;
• organization of consultative work;
• organizationally-methodical guidance by work of all district hospital, and also control after its activity;
• development and introduction of measures directed by medical providing;
• development, organization and realization of measures on the in-plant and rational uses of medical personnel’s and material and technical resources training of medical personnel’s;
• planning, financing and organization of logistical support of establishments of health protection district.
Implementations of these difficult tasks are fixed on the proper structural subdivisions in a hospital.
In the cases when power of some CRH does not allow creating the specialized separations (ophthalmology, urology, traumatology), the inter-district separations are created.
In permanent establishments of central district hospitals the norms of establishment of positions of medical sisters (chamber) practically do not differ from the norms foreseen for permanent establishments of city hospitals.
The important part in organization of the CRH work is acted by the organizationally-methodical cabinet headed the duty of doctor by medical service of district population. In for some time past in place of these cabinets the informational-analytic separations are created in the CRH сomposition.
In this position of doctors-methodists, medical assistants, midwifes, medical statisticians, operators of the personal computers and others like that are regular (depending on the quantity of population).
Organizationally-methodical work to assignment.
• analysis of indices of population health;
• analysis of indices of work of the district hospital;
• study and distribution of experience;
• planning and organization of departures of the specialists hospitals on village hospitals for the consultative aid between the population and doctors;
• planning and providing of conducting of prophylactic medical reviews;
• planning and organization of the in-plant training of medical workers of district;
• development of measures on the improvement of the medical providing of population of district.
The important role in organization of medicare for the children in village society belongs to the district pediatrician.
The main functions of pediatrician:
• consultative aid of the district center hospital, village medical hospitals from the questions of organization of medicare for children;
• the ambulatories visit and village hospitals (out-patient’s clinics), review of healthy and consultation of sick children, verification of timeliness of conducting of prophylactic inoculations and sanitary-anti-epidemic measures;
• control after conducting of clinical observation by children, above all things in the first year of life; after conducting of prophylactic inoculations to the children;
• drafting jointly with the sanitary-epidemiology station (SES) of the plan of the anti-epidemics measures directed on the fight against children’s infectious diseases;
• providing of the in-plant training from pediatrics for the doctors of village hospitals, medical workers of child’s preschool establishments and schools, health-visitors, medical personnel ambulatories;
• visit of children’s preschool establishments, control after their activity;
• analysis of reports of children’s prophylactic-treatment establishments, study and estimation of the state of children’s health of village, district and the hospital activity, generalization of findings and development of concrete measures of medicare;
• bringing in of representatives of local organs of power, public organizations, assistance of Society of Red Cross to conducting of the measures directed on the improvement of medical care to the children.
Regional hospitals are leading establishments of the third stage of the medical providing of region population. The amount of them makes
Next to direct participation in providing of stationary and consultative polyclinics aid, a regional hospital coordinates prophylactics-treatment and organizationally-methodical work which is carried out by hospitals and dispensaries in towns and district centers, regions. This establishment is a base for the in-plant training of doctors and middle medical personnel.
4. Basic tasks of regional hospital
They are the following ones:
• providing of population of region by the high specialized stationary and polyclinic aid;
• organization and grant of urgent and consultative medicare on region;
• introduction into practice the modern methods of hospital work and facilities of diagnostics, treatment, experience;
•training of doctors in-plant and middle medical personal of region establishments;
• organization, guidance and control by a statistical account and accounting, drafting of the taken reports, analysis of performance indicators of prophylactic-treatment establishments of region;
• development of measures, directed on medical providing and on the improvement of population’s health.
A consultative polyclinic is important structural subdivision of regional hospital, which functions are belong:
• grant of highly specialized consultative aid for the patients by directions of region establishments;
• decision of questions about subsequent treatment of the consultative patients with determination of medical technology and place;
• bringing into consultation of highly skilled doctors– specialists of hospital and other, and also workers of research institutes and medical institutes;
• direction for hospital, which sent on consultation of patients, conclusions with pointing of the diagnosis, set in a polyclinic, conducted and recommended treatment;
• development for the hospital region of suggestions (sights) about an order and testimony for direction of patients to the polyclinic;
• organization and conducting (together with the separation of urgent and medically-sanitary aid) of departure consultations of specialists of districts, and also extra-mural consultations of the doctors;
• systematic analysis for the districts of region (the cases of diagnoses disagreements between hospitals), in which the patients sent consultation in polyclinic;
• error assumed by hospital doctors at the inspection and treatment of patients before direction of them to the polyclinic analysis;
• drafting looked over informative sheets about the state and level of medically-diagnostic work in districts.
One of tasks of regional hospital is organization and grant of urgent and planned-consultative aid. This work is planned and is executed by independent subsection-separation with a similar name. It will organize round-the-clock controller’s service (medical assistant) of reception and registration of calls from the hospitals of districts, bridge of region and provides the timely grant of urgent and planned-consultative aid for the population. Before the work the specialists of regional hospital are attracted, other hospital regions, employees of medical institutes of higher, research institutes on the concordance with the general establishments and establishments, pursuant to the order of the proper management of health protection.
After the grant of necessary medicare in place, in the case of necessity, the separation provides transporting of patients to the regional center, on occasion outside a region to the proper hospitals.
To that end it uses both sanitary aviation and ground vehicle, depending on the state of patient, distance, meteorological terms, season, time of days and others like that.
In the feature of different regions it is needed here and there at reduction of bed fund of district hospitals of replacement of the usual three-staging system of grant of stationary aid (district, regional hospitals) by two-staging (district, regional hospitals).
Reduction of beds in district hospitals can be compensated definitely due to the sanitary-replacing aid – daily permanent establishments. It is expedient also to have the certain amount of beds in village out-patient’s clinic (3-5 beds) for temporal hospitalization of patients which need stationary treatment on next stages.
Reduction of stationary aid on the first stage is to be compensated by the increase of volume of medical ambulatory aid and its approaching to the villagers, that is possible on condition of careful replacement of establishments medical assistants medical.
Needs urgent decision of realization of complex of measures on the improvement of conducting of the centre system health and making healthy of village population. With the purpose of upgrading prophylactic reviews and development of prophylactic-treatment measures clinical patients are foreseen to engage in this work not only the specialists CRH but also regional hospitals (pursuant to the order of Health Ministry of Ukraine № 261 from 29.10.99).
The improvement of quality of prophylactic-treatment aid requires subsequent development of quick and exigent aid, which is provided on the second stage by district hospitals.
The administrative decisions must be directed on saving of network of establishments of medical aid, as its availability depends from it.
Reorganization of the system of prophylactic-treatment aid to the village population must take place gradually. The beds of district hospitals can be used as medico-social and for the separations of sisterly examination that the question is not about mechanical reduction of stationary aid on the first stage, and about its pre-orientation oew organizational forms expedient from the point of view economic efficiency and socially-psychological positions. With it attitude of population is linked toward reorganization of the medical providing, perception by him changes in the system of health protection.
Emergency medical services
Emergency medical services (abbreviated to the initialism EMS in some countries) are a type of emergency service dedicated to providing out-of-hospital acute medical care, transport to definitive care, and other medical transport to patients with illnesses and injuries which prevent the patient from transporting themselves. The use of the term emergency medical services may refer solely to the pre-hospital element of the care, or be part of an integrated system of care, including the main care provider, such as a hospital.
Emergency medical services may also be locally known as a first aid squad, emergency squad, rescue squad, ambulance, squadambulance service, ambulance corps, or life squad.
The goal of most emergency medical services is to either provide treatment to those ieed of urgent medical care, with the goal of satisfactorily treating the presenting conditions, or arranging for timely removal of the patient to the next point of definitive care. This is most likely an emergency department at a hospital. The term emergency medical service evolved to reflect a change from a simple system of ambulances providing only transportation, to a system in which actual medical care is given on scene and during transport. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.
In most places in the world, the
In some parts of the world, the emergency medical service also encompasses the role of moving patients from one medical facility to an alternative one; usually to facilitate the provision of a higher level or more specialised field of care but also to transfer patients from a specialized facility to a local hospital or nursing home when they no longer require the services of that specialized hospital, such as following successful cardiac catheterization due to a heart attack. In such services, the
In some jurisdictions,
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, where a man who was beaten is cared for by a Samaritan. Luke 10:34 (NIV) – “He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him.” Also during the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield.
A 1973 Cadillac Miller-Meteor ambulance. Note the raised roof, with more room for the attendants and patients
The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte‘s chief physician. Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. These ‘flying ambulances’ were first used by Napoleon’s Army of the
In civilian ambulances, a major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in
The first known hospital-based ambulance service operated out of
In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modelled on a military-style command and discipline structure.
The earliest emergency medical service was reportedly the rescue society founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ring Theater in 1881. Named the “Vienna Voluntary Rescue Society,” it served as a model for similar societies worldwide.
A 1948 Cadillac Meteor ambulance
Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. This was followed in 1900 by
American historians claim that the first component of pre-hospital care on scene began in 1928, when “Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia,
During World War One, further advances were made in providing care before and during transport – traction splints were introduced during World War I, and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Shortly before World War II, then, a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses – the only available vehicle that could carry a recumbent patient – and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.
Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.
Advances in the 1960s, especially the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. One well-known report in the ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.
In 1971, after release of the National Highway Traffic Safety Administration‘s study, “Accidental Death and Disability: The Neglected Disease of Modern Society”. A progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study a “superb white paper” that “jolted and wakened the entire structure of organized medicine. This report was the “prime mover” and made the “single greatest contribution of its kind to the improvement of emergency medical services”. Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting. Such advancements included Dr. R Adams Cowley creating the country’s first statewide EMS program, in Maryland.
Service providers
Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.
· Government Ambulance Service
Operating separately from (although alongside) the fire and police service of the area, these ambulances are funded by local, provincial or national government. In some countries, these only tend to be found in big cities, whereas in countries such as
· Fire or Police Linked Service
In countries such as the
· Volunteer Ambulance Service
Charities or non-profit companies operate ambulances, both in an emergency and patient transport function. This may be along similar lines to volunteer fire companies, providing the main service for an area, and either community or privately owned. They may be linked to a voluntary fire service, with volunteers providing both services. There are charities who focus on providing ambulances for the community, or for cover at private events (sports etc.). The Red Cross provides this service in some parts of the world on a volunteer basis (and in others as a Private Ambulance Service), as do other smaller organisations such as St John Ambulance and the Order of Malta Ambulance Corps. These volunteer ambulances may be seen providing support to the full time ambulance crews during times of emergency. In some cases the volunteer charity may employ paid members of staff alongside volunteers to operate a full time ambulance service, such in some parts of
· Private Ambulance Service
Normal commercial companies with paid employees, but often on contract to the local or national government. Private companies may provide only the patient transport elements of ambulance care (i.e. non urgent), but in some places, they are contracted to provide emergency care, or to form a ‘second tier’ response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the ’emergency’ cover, whilst a private firm may be charged with ‘minor injuries’ such as cuts, bruises or even helping the mobility impaired if they have for example fallen and just need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available all the time for genuine emergencies. These organisations may also provide services known as ‘Stand-by’ cover at industrial sites or at special events.
· Combined Emergency Service
these are full service emergency service agencies, which may be found in places such as airports or large colleges and universities. Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where size or budget does not warrant separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.
· Hospital Based Service
Hospitals may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Their use would be dependent on using the services of the providing hospital. Most Advanced Life Support (Paramedic) services in the
· Charity Ambulance
This special type of ambulance is provided by a charity for the purpose of taking sick children or adults on trips or vacations away from hospitals, hospices or care homes where they are in long term care. Examples include the
· Company Ambulance
Many large factories and other industrial centres, such as chemical plants, oil refineries, breweries and distilleries have ambulance services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion
Purpose
Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery.
This common theme in medicine is demonstrated by the “star of life”. The Star of Life shown here, where each of the ‘arms’ to the star represent one of the 6 points. These 6 points are used to represent the six stages of high quality pre-hospital care, which are:[40]
1. Early detection
Members of the public, or another agency, find the incident and understand the problem
2. Early reporting
The first persons on scene make a call to the emergency medical services and provide details to enable a response to be mounted
3. Early response
The first professional (
4. Good on-scene care
The emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident
5. Care in transit
The emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
6. Transfer to definitive care
The patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians
Levels of care
Emergency Medical Service is provided by a variety of individuals, using a variety of methods. To some extent, these will be determined by country and locale, with each individual country having its own ‘approach’ to how
A category of emergency medical service which is known as ‘medical retrieval’ or rendezvous MICU protocol in some countries (Australia, NZ, Great Britain) refers to critical care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in regionalised systems of hospital care where intensive care services are centralised to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service in
Generally speaking, the levels of service available will fall into one of three categories; Basic Life Support (BLS), Advanced Life Support (ALS), and care by traditional healthcare professionals, meaning nurses and/or physicians working in the pre-hospital setting and even on ambulances. In some jurisdictions, a fourth level, Intermediate Life Support (ILS), which is essentially a BLS provider with a moderately expanded skill set, may be present, but this level rarely functions independently, and where it is present may replace BLS in the emergency part of the service. When this occurs, any remaining staff at the BLS level is usually relegated to the non-emergency transportation function. Job titles typically include Emergency Medical Technician, Ambulance Technician, or Paramedic. These ambulance care givers are generally professionals or paraprofessionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an ‘EMT’ or a ‘paramedic’, regardless of their training, or the lack of it.[41] In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as ‘Wilderness’, ‘Tactical’, and so on.
According to the European Society for Emergency Medicine:
“Emergency Medicine is a specialty based on the knowledge and skills required for the prevention, diagnosis and management of urgent and emergency aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural disorders. It is a specialty in which time is critical. The practice of Emergency Medicine encompasses the pre-hospital and in-hospital triage, resuscitation, initial assessment and management of undifferentiated urgent and emergency cases until discharge or transfer to the care of another physician or health care professional. It also includes involvement in the development of pre-hospital and in-hospital emergency medical systems”.
More specifically, out-of-hospital emergency medical services (O-H-EMS), also known as pre-hospital EMS, typically refer to the delivery of medical care at the site of the adverse medical event. These complex systems include different services, from health-care posts or emergency points attended by medical staff, to a call centre (dispatch centre) that is able to answer emergency calls, provide medical advice to the caller and, if necessary, dispatch a mobile medical care unit. The latter includes a vehicle that is able to transport medical staff (car, motorbike, boat, etc) and equipment, or alternatively a vehicle that can adequately transport the patient to a health-care facility (typically named “ambulance”: car, helicopter, airplane, boat etc). Ambulances are the means of transport most commonly used and the coordination and organization of all transport is usually carried out by one or more dispatch centres (DCs), which may receive calls from a bystander, a patient, a medical care institution or other emergency service (i.e. police or fire brigade) and provide directions to ambulances to reach the site of the emergency. In general, then, all actors and services involved in the provision of emergency medical care in an out-of-hospital setting are included in this definition.
In-hospital emergency medical services (IN-H-EMS) refer to all those subsets of medical institutions and hospitals that have the capacity to deliver uninterrupted emergency care on a 24 hours a day, 7 days a week basis. By definition, the medical institution should have the catering and bed capacity necessary to admit patients who need medical care for longer than 24 hours. All units, departments, wards etc. that provide continuous care should be considered part of an in-hospital medical service. For example, a neurosurgical clinic staffed by professionals (surgeons and nurses) and providing full-time (24 hours a day, 7 days a week) specialized care (diagnostics, operating theatre, etc.) should be considered a component of IN-H-EMS.
Thus, the complete set of out-of-hospital and in-hospital EMS constitutes the wider EMS system. In addition, a broader spectrum of services can contribute to providing, ameliorating and supporting EMS. For example, primary health-care services often share responsibilities with EMS, by directly delivering emergency care to patients. Conversely, EMS, either in-hospital or out-ofhospital, are often requested by patients to provide primary care. EMS also has an important role in public health and preventive care, either in times of disaster or during day-to-day work.
Thus a complete separation of distinct health services is impossible and the tendency is to consider health systems as a whole, within the framework of an organized set of “integrated health care”.
Historically, EMS was principally identified as the “out of hospital transportation system” and rooted in the development of such services in the United States of America. The Pan American Health Organization/WHO has reviewed this concept in a recent publication:
“…the term EMS customarily refers to only the ambulance services component that responds to the scene of a medical or surgical emergency, stabilizes the victim of a sudden illness or injury by providing emergency medical treatment at the scene, and transports the patient to a medical facility for definitive treatment. The phrase “Emergency Medical Services System” here refers to a comprehensive integrated public safety and health care system model. It consists of mechanisms for accessing the system and reporting an emergency; pre-hospital service delivery and transport mechanisms; definitive, specialty, and rehabilitative care facilities; public education, participation, and prevention processes; educational programming and institutions; integrated medical and administrative direction and oversight organizations and processes; resource allocation and financing structures; coordinating the role of collaborating organizations; etc. The EMS System is part of a larger system, the Emergency Health Services System. The EHS System encompasses an even larger domain that includes the consequence management of disasters; unsafe housing, food, or water conditions; mental health effects of war, civil unrest, and terrorism; epidemiological infectious outbreaks in the community, and other health care issues that require swift resolve to maintain the health of the public. The EHS System is a subset of the public health care system”.
Objectives of the study
At present, no single region-wide EMS model exists for EU Member States. In general, the EMS status of a country depends on its peculiar geographic, political, cultural, linguistic, historical and medical setting. Given this heterogeneity, it was considered important to collect data on various EMS components from EU Member States in order to allow comparisons, to observe the level of progress of EMS in different locations, and to simply disseminate data to health professionals and policy-makers. This point is especially important in times of crisis and disaster, where information flow between countries is vital for cross-border EMS interoperability and an effective coordinated crisis response. The overall objective of the project is to improve EU Member States’ understanding of EMS structures and organizational arrangements within the EU and their link to national crisis management systems. In particular, the project aimed to: (1) Develop a standardized template to be used as a data collection tool to allow country comparisons and the compilation of an essential information package. (2) Map current EMS preparedness within EU Member States including existing institutional, educational, operational and human resource capacity. (3) Collect data on existing crisis management mechanisms intended to manage health threats.
Description and methodology
Close collaboration with the 27 EU Member States was considered a prerequisite for successful implementation of the project. Therefore, WHO formally requested the appointment of a national representative (NR) from the Ministries of Health in each State. All 27 NRs participated actively and contributed constructively to the project. A group of EMS experts with knowledge and expertise on the subject was also selected. Efforts were made to respect the geographic spread of the project and to reflect national differences in conceiving and developing EMS. The first phase of the project involved the development of a standardized template to collect general information and data on EMS across EU Member States. The template, initially proposed by WHO experts, was reviewed, discussed and finally approved at a dedicated workshop held in Bratislava, Slovakia in June 2007. This gave the project strategic momentum and the template became the key element from which all subsequent work evolved. For those EU Member States not represented in Bratislava, ad hoc missions were arranged and carried out, in order to involve them in the project and clarify issues in the proposed questionnaire. In general, participants showed a high level of interest in assessing EMS from its most basic elements such as patient care, specialty and academic requirements, information, management and financing systems, to more specific aspects such as EMS links and interrelations with the overall crisis management system. Following the Bratislava meeting and feedback from the NRs, the template was finalized in July 2007 (see Annex 2: Questionnaire). It is composed of five main sections with a total of 39 questions. A description of the sections is given in Table 1.1.
NRs were requested to complete the questionnaire online: this electronic tool rendered the collection of data easier and user-friendlier. On a daily basis, WHO supervised the completion of data and ensured finalization.
Data collection was finalized in October 2007. The data analysis that followed proved to be the most challenging aspect of the project. Some ambiguities in the questionnaire became evident and rendered the analysis complicated e.g. some data provided by the NRs were unclear, or in some cases, incoherent. To overcome this problem, a process of continuous communication was initiated with the NRs to clarify these ambiguities. As a result, a new simplified country profile was created containing a selection of the most relevant information and finally submitted for revision and approval to each NR. Data from the 27 countries were compared and matched with the aim of finding common features or possible gaps in the organization of EMS in EU Member States. A report, containing recommendations for future improvements, was drafted.
A second workshop was held with all NRs in December 2007 and hosted by the Portuguese Presidency of the Council of the EU in Lisbon. The meeting provided an opportunity to review progress in data analysis and to agree conclusions for the final report. Through a process of extensive debate, potential misunderstandings were clarified and results validated. Recommendations for improvements in the field of EMS were also discussed and voted on. They are mentioned at the end of each chapter of this document and in a separate section (see Annex 1: Recommendations).
Subsequent to the discussions held in Lisbon, the report and conclusions of the project were finalized in the early months of 2008. The following chapters represent the final output of this extensive and demanding work and have emerged from collaboration between 27 NRs and WHO.
Constraints and opportunities of the project
Given the time frame, project objectives were very ambitious and EU Member States and various stakeholders raised this concern. The difficulty of assessing EMS links with national crisis management systems in the absence of any previous EU-wide study of these national systems was highlighted. Therefore, instead of focusing mainly on EMS crisis preparedness and links with national crisis management systems, the project had to attempt to fill this information gap first. The report thus devotes much space to explaining the structure and organization of the European EMS system and reserves only one chapter to the role of EMS withiational crisis management systems.
Another major limitation of this process is that all data have come from NRs, appointed by Ministries of Health. This sometimes proved to be a constraint, especially in those EU Member States where the organization and management of health-care provision are delegated to sub-national authorities (federal states, regions, etc.); although NRs had the opportunity to consult with local stakeholders when any doubts arose. This fact must be taken into consideration when reading the document.
A constraint was also encountered in the attempt to promote a standardized study, seeking comparable data using unique and common definitions. Problems arose where concepts had different meanings in different countries and, in some cases, resulted in difficulties and misunderstandings. While this could have generated some incoherence in the data, the problem was overcome by further communication and clarification between WHO and the NRs.
On the positive side, the project has followed a highly participatory methodology with reasonable levels of interest and motivation from the majority of participants. Moreover, the project utilized experts in the field of EMS to peer review the work carried out.
An important element of the project has been its dissemination strategy as the project and its preliminary results have been repeatedly presented at major European conferences on emergency medicine (EM). Special attention has been given to European scientific societies of emergency medicine, whose representatives have always been invited as external observers.
The most important outcome of the project has been the creation of the European Inter-Ministerial Panel on Emergency Health Care, a group of experts in the field of EMS, appointed by all concerned Ministries of Health. It is hoped that this group will continue to meet on a regular basis, constituting an important “political platform” that may provide the point of contact between policy decision- makers and EMS professionals in the EU.
