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MEDICAL CARE (classification)

Types
1. Primary Health Care
2. Specialized, including high technological medical care
3. Emergency, including specialized medical care
4. Palliative medical care

Conditions of rendering:
 outside medical establishment
 outpatient
 Inpatient
 in Day hospital

Forms:
 emergency
 urgent
 Planned

Primary health care (PHC) is

"essential health care based on practical, scientifically sound and socially

acceptable methods and technology made universally accessible to individuals and
families in the community through their full participation and at a cost that the
community and the country can afford to maintain at every stage of their
development in the spirit of self-determination"(Alma Ata international conference
definition)

It was a new approach to health care that came into existence following this
international conference in Alma Ata in 1978 organized by the World Health
Organization and the UNICEF.
Primary health care was accepted by the member countries of WHO as the key
to achieving the goal of Health for all.

Essential components of primary health care

The Declaration of Alma Ata outlined the 8 essential components of primary

health care such as principles of,
1) Equitable distribution
Health services must be shared equally by all people irrespective of their ability
to pay and all (rich or poor, urban or rural) must have access to health services.
Primary health care aims to address the current imbalance in health care by shifting
the centre of gravity from cities where a majority of the health budget is spent to
rural areas where a majority of people live in most countries.
2) Community participation
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There must be a continuing effort to secure meaningful involvement of the

community in the planning, implementation and maintenance of health services,
beside maximum reliance on local resources such as manpower, money and
materials.
3) Intersectoral coordination
Primary health care involves in addition to the health sector, all related sectors
and aspects of national and community development, in particular agriculture,
animal husbandry, food, industry, education, housing, public works,
communication and other sectors.
4) Four Cornerstones in primary health care
 Active community participation
 Intra and Inter-sectoral linkages
 Use of appropriate Technology
 Support Mechanism made Available
5) Elements of PHC
E-education for health L-locally endemic disease control E-expanded program of
immunization M-maternal and child health E-essential drugs N-nutrition T-
treatment of communicable disease s-safe water and sanitation.

Primary health care is the integral part of the national health system. It`s the
main component of the overall social and economic development of society. It is
the first level of contact between individuals, family, community and national
health care system. PHC as much as possible approaches medical care to a
residence place and work and forms first element of the continuing health
protection process.
The central element of the PHC conception is social justice – placing at
everyone equal physical, financial and social access to primary medical care to
reduce differences in levels of health of various socio-economic groups.
PHC is directed to the solution of main problems of public health and includes
measures to improve health, prevention and rehabilitation. The system of primary
health care must include:
- Help in rational nutrition and sufficient high quality water supply;
- Basic sanitary-hygienic measures;
- Maternal and children`s health protection, including family planning;
- Vaccination against basic infectious diseases;
- Prevention of local endemic diseases and fight against them;
- Health education of actual health protection problems and methods of their
solutions, including prevention;
- Treatment of widespread diseases and traumas.

According to WHO recommendations, primary care service must meet the

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following requirements:
- Generality - to include healthy life promotion, prevention, control and
rehabilitation.
- Holistic - to engage the person as a whole in the context of family and
community.
- Continuity - to ensure regular monitoring of the patient and monitoring of
medical care efficiency.
Features that distinguish primary care from other types of medical care
include:
1. Availability 24/7.
2. Initial estimation and decision of further actions depending on patient`s
complaints, based on his individual characteristics and nature of his / her problem.
3. Rendering the aid to the small and constant group of people.
4. Dependence of primary care approaches on the type and nature of diseases
and conditions of patients, as well as needs of each particular group of patients.
5. Possibility of long-term and continuous care receiving.
Availability of PHC is the consecutive and organized providing with medical
care without obstacle in territorial, financial, cultural and functional plans for all
population.
Territorial availability is acceptability of distance till medical establishment,
travelling time and expenses for population.
Financial availability: irrespectively of payment system for health care costs of
medical services should not be more as population capabilities both all country.
Cultural availability: used technical and organizational methods answer the
cultural way of the population.
Functional availability: required type of medical service is available to those
who need it, on a permanent basis at any time by the health team efforts, properly
prepared for this work.

The leading experts proved that the most effective way of PHC providing is
general practice - family medicine with a central figure of a general practitioner
(family doctor).
Subject and tasks of general (family) medicine.
General (family) medicine is a long-term medical care of healthy and sick
people, regardless of age and sex, which focuses on a comprehensive study of the
patient’s personality, his family and social environment.

General practice can be developed in different health care systems, but it is

characterized by the following features:
1. Universality Care is provided to everyone regardless of age, sex, social class,
race or religion. Not one patient`s complaint or any medical problem cannot be
ignored.
2. Availability Free access to services of general practice (geographically,
culturally and without limitation of financial factors) with a minimum waiting
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period.
3. Integration It includes medical and rehabilitation care as well as health
improvement and diseases prevention.
4. Permanent basis It is not limited with a particular case of aid rendering or any
disease, but provides for patients individual long-term medical care for a long
period of their lives.
5. Team approach Family doctor should work as part of a well-functioning, multi-
disciplinary team.
6. Integrity Medical problems of individuals, families and society should be
considered in the aspect of physical, psychological and social perspectives.
7. Personal character It is oriented to person, and then to disease, based on the
personal relationship between patient and physician.
8.Orientation to family Problems are studied in the context of family and social
person`s contacts.
9.Orientation to serviced contingent Patients` problems should be considered in
the context of life in local conditions. Family doctor should know problems of the
served population at the local level, to collaborate with other professionals and
services of other sectors as well as self-help groups to resolve local problems of
health plan.
10. Co-ordination Family physician should inform of patients about results of
specialist advices, all services and best way of their use and also be the coordinator
for all advices and prescriptions that the patient receives.
11. Confidentiality Patients should expect full confidentiality from their family
doctors including all information about them.
12. Lawyer function Family physician should always be the «advocate» of the
patient in all health questions, as well as in its relations with all other providers of
medical care.

General Practitioner (family doctor) is a licensed graduate of medical

higher education institution which provides individual primary and continuing
medical care for individuals, families and population, regardless of age, sex or type
of a disease.

Family medicine in PHC system

Introduction of family medicine in Russian Federation is connected with

following conditions:

1) Necessities in state and patient`s economy of means

2) Specialization of medical care causes of physician`s responsibility increasing for

patient
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3) Family doctor works for a long time with constant contingent and can take into
account the affect of different factors on patient1s health (first, life style). He
studies a personality, her family and social surrounding taking into account
medical, psychological and social aspects of health state.

4) Family doctor helps patients in case of disease, decides their social problems.
So, he can affect on different parts of population`s life.

Principles of family medicine:

 To observe stable population group taking into account medical-social

problems of family;
 To provide free, available, current, continuous PHC;
 Free choice of family doctor by patient;
 Central figure of PHC is a district physician (family doctor);
 Main form of work organizing is a group practice of physicians, nurses and
others specialists.

Functions of district physician (family doctor)

Family doctor is a certificated medical specialist who personally renders

primary health care and continuous aid to separate patients, families and district
population independently on age, sex and disease.
He provides medical aid to patients in a consulting room, at a residence
place and sometimes in a hospital. He has priority to decide all patient`s problems.
Family doctor continuously observes under patients with chronic, recurrence
and incurable diseases.
Responsibility of family doctor for all population is based on cooperation
with medical and non-medical colleagues.

Models of family practice in Russian Federation

Individual practice in Group practice Unity of several Individual or group

independent in family group practice in practice in polyclinics
establishments ambulatories health centers

Individual medical practice is only useful in areas with low population

density, where the functioning of physicians group is economically unprofitable.
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Group practice is the union of two or more general practitioners. Association

of physicians in group practice has several advantages in comparing with
individual practice:
• Effective use of limited resources (combined rent of premises and medical
equipment);
• Ability to employ support personal pluralistically: social worker,
psychologist, manager, accountant, lawyer;
• More opportunities for diagnostics and treatment due to concentration of
funds to purchase equipment;
• Possibility of interchangeability of medical personnel during the day and in
case of long-term absence (vacation, training);
• Opportunities for professional dialogue, mutual consultation, training, etc.
• Opportunities for a particular specialization within general medicine
• Joint realization of some administrative functions.
The practice can have any form of ownership: state, municipal, private,
collective.

Physician of general practice (family doctor) independently starts and

finishes treatment of basic part of patients. If it`s necessary he consults with
specialists or decides question about plan or urgent hospitalization.

Practical functions of family doctor:

 Diagnostics
 Emergency aid
 Urgent hospitalization
 Consultations with specialists
 Independent treatment and treatment according to specialists` advices
 Plan hospitalization

Family doctor provides:

 Realizing ambulatory reception and visits at home

 Realizing preventive, medical, diagnostic and rehabilitative measures in
the cases envisaged by the qualification characteristics
 Rendering emergency aid
 Organizing day and home hospitals
 Decision of medical-social problems in a family (help)
 Realizing antiepidemical measures in an infectious disease seat
 Informing about infectious diseases cases (SES and infectionist)
 Temporal disability examination
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 Preventive work among population

 Working out plans and realization of patients` dispanserization and
rehabilitation
 Realization the most spreading manipulations.

Basic medical documents of a general practitioner (family doctor):

 Outpatient card
 History of Child Development
 Control card of dispensary observation
 Card of patient of day, home hospital
 Card of preventive vaccinations
 Statistical coupon for registration of final (exacted) diagnoses
 Emergency notification of infectious disease, food, acute occupational
poisoning, an unusual reaction to the vaccine
 Journal of infectious diseases registration

Structure of family medicine ambulatory (approximate)

Family doctor

Registry
Rooms

Manipulation Physiotherapy
Inspection Physician

Day hospital wards

Express laboratory
GP`s
interactions with non-medical services
General practitioner should decide not only medical problems of their
patients, but also a number of social problems. To do this he needs knowledge of
health regulations and other spheres of human activity, ability to cooperate with
the following services:
• Service of Social Welfare;
• The service of charity;
• Law bodies;
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• Sanitary and Epidemiological inspection services;

• Public funds;
• Insurance companies.