Integrated Primarycare:

Integrating Vertical Programmes for

effectiveness in delivery of service

DR. SAFURAH JAAFAR

Director Family Health Development Division
fh.moh.gov.my
The Journey in History
The 1950s: emphasis on technology
and disease-specific campaigns
• Series of major drug research breakthroughs that
produced an array of new antibiotics, vaccines and
other medicines in this period – attending to Disease
Control
• Creation of National Health Systems - acknowledged
the need to extend services to rural and
disadvantaged populations,
but in practice the bulk of government and international donor
funding for health continued to flow to urban-based curative
care.

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The 1950s: (Remains)
• International public health this period characterized
by proliferation of "vertical" programs - narrowly
focused, technology-driven campaigns targeting
specific diseases such as malaria, smallpox, TB and
yaws.
• The vertical campaigns begun in this period
generated a few notable successes, most famously
the eradication of smallpox.

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The 1960s and early 70s: the rise of
community-based approaches
• By the mid-1960s Problems:
– dominant medical and public health models were
not meeting the most urgent needs of poor and
disadvantaged populations (the majority of people in
developing countries).
• High-end medical technology downplayed,
• Reliance on highly trained medical professionals was
minimized.
• Locally recruited community health workers assist their
neighbors in confronting the majority of common health
problems.
• Health education and disease prevention were at the heart of
these strategies

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1970s

• Malaysia – “Klinik Bidan, Dresser, Gedong Ubat”

• China's "barefoot doctors”
• These were diverse array of village health workers
who lived in the communities they served, stressed
rural rather than urban health care, preventive rather
than curative services, and combined western and
traditional medicines.

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The crystallization of a movement:
Alma-Ata and primary health care
• September 1978 - International Conference on Primary Health Care,
3,000 delegates from 134 governments and 67 international
organizations participated in the Alma-Ata conference, destined to
become a milestone in modern public health.

• The conference declaration embraced Mahler's goal of “Health for

All by the Year 2000”, with primary health care (PHC) as the means.

– The PHC model as articulated at Alma-Ata “explicitly

stated the need for a comprehensive health strategy that
not only provided health services but also addressed the
underlying social, economic and political causes of poor
health” (original emphasis)

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The Alma-Ata declaration presented
PHC in a double light:
1. PHC was "the first level of contact of individuals, the
family and community with the national health
system“.
2. PHC was also a philosophy of health work as part of
the "overall social and economic development of the
community“.

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 PHC
• Logically, PHC included among its pillars intersectoral
action to address social and environmental health
determinants.
• The Alma-Ata declaration specified that PHC
"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; and
demands the coordinated efforts of all these sectors".

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1980s
• Mid-1980s,
– Social Determinants of Health given prominence in the
emerging health promotion movement. The First
International Conference on Health Promotion -cosponsored
by the Canadian Public Health Association, was held in
Ottawa in 1986.
– Focus Eight key determinants of health:
peace, shelter, education, food, income, a stable eco-
system, sustainable resources, social justice, and equity.

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The rise of selective primary health
care
• From early on, both the potential costs and the
political implications of a full-blown version of PHC
were alarming to some population.
• Selective PHC was rapidly proposed in the wake of
the Alma-Ata conference as a more pragmatic,
financially palatable and politically unthreatening
alternative.

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Selective primary health care SPHC
Critics of selective PHC, Magnussen et al.:
• "the selective approach ignores the broader context of
development and the values that are imbued in the
equitable development of countries.
• It does not address health as more than the absence of
disease; as a state of well-being, including dignity; and as
embodying the ability to be a functioning member of society.
• In conjunction with the lack of a development context, the
selective model does not acknowledge the role of social
equity and social justice for the recipients of technologically
driven medical interventions".
• Cueto summarizes that, for its critics, SPHC was a "narrowly
technocentric" strategy that turned away from the underlying
social determinants of health, ignored the development
context and its political complexities, and resembled vertical
programs.
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Selective PHC created
Vertical Programmes
• Strength? Yes
– Best way to fight disease!
– Vertical line of command
– Visibility to Donor
– Ease of Monitoring
– Programmes :
• Yaws, TB, Malaria, Leprosy …
• Growth monitoring, oral rehydration, immunisation, family planning….
Selective PHC created
Vertical Programmes
• Shortcomings? Yes
– Lose track broader context of health development
• Equity, well-being, dignity, community social function
– Donor Driven
– Creates own bureaucracy
– Inefficient facility use
– Gaps in Care
– Divert skill brain drain across several programmes
– Fighting one disease at a time
– Issue of coverage
The Social / Public Approach
vs Disease Approach
• Primary Health Care
• Health For All
• Ottawa Charter
• New Public Health
• Agenda 21
• Healthy Cities
• MDGs
• Social Determinants for Health
MOVING TOWARDS AN
INTEGRATED SERVICE
“R.E.A.P W.I.S.E.LY
 Definition
PRIMARY CARE AT FIRST
POINT OF CONTACT
From the policy perspective:
• Delivering Health Care
– between levels of Care
– between different providers
– across care settings,
– across episodes of care
– provided throughout one’s life
• Efficient
• Effective
• Greatest Cost - Benefit

safurah jaafar qatar2010 17

 What types of co
co--morbidity present
among diabetic patients?

safurah jaafar qatar2010 18

Prevalence of NCD Risk Factors in
Malaysia (1996-2006)
NHMS II MANS MyNCDS-1 NHMS III
(1996) (2003) (2005) (2006)
Age group ≥18 years ≥18 years 25-64 years ≥18 years
Smoking 24.8% N.A. 25.5% 21.5%
Physically Inactive 88.4% 85.6%* 60.1% 43.7%
Unhealthy Diet N.A. N.A. 72.8 N.A.
Overweight
16.6% 27.4% 30.9% 29.1%
(BMI ≥25 & <30 kg/m2)
Obesity (BMI ≥30 kg/m2) 4.4% 12.7% 16.3% 14.0%
Hypercholesterolaemia N.A. N.A. 53.5% 20.6%

In 2006, there is an estimated 2.8 million Malaysians age 18 years

and above are current smokers, 5.5 million physically inactive, 3.6
million overweight and 1.7 million Malaysians obese.

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 Eight Health Service Goals of MOH

1. Wellness focus
2. Personalised information
3. Person focus
4. Self-care
5. Seamless care
6. Customised care
7. High quality care
8. Care close to home

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safurah jaafar qatar2010
 Growing Scope of Services in
Primary Care
Mother and Child
Mother and Child Family Planning
Family Planning Outpatient 2010
Outpatient Home Visits
Home Visits Dental
Dental
2000 Pharmacy
1980 Pharmacy Lab
Child w
Mother and Child Lab Special
Needs

1960 Family Planning

Child w
Special
Needs
Reproductive
Clinic
Outpatient Reproductive Elderly
Diabetic
Clinic
Clinic
Adolescent
Mother and Child Home Visits Elderly
Diabetic
Clinic
Occupational
Health Clinic
Geriatric
Adolescent
Family Planning Dental Occupational
Health Clinic Emergency
Geriatric
Outpatient Pharmacy Emergency Health informatics
Metadon NSEP
Lab Health informatics National Service students
safurah jaafar qatar2010 Special groups :detention 21
centre, prison, drug rehab
 Mapping PRIMARYCARE
Services @ District
cc
cc cc
KK cc H cc
cc cc
“Universal” 4000 C
CC
cc
level CC 10 -20,000 SCHOOLS Private GPs
4000

cc cc
KK
cc
4000 HC 4000
“Advance”
HC
4000
CC
level
cc
CC
4000 50,000 - 4000
KK 4000 10 -50,000 100,000

“Intermediate”
level
safurah jaafar qatar2010 22
 High worrying load of repeat/
chronic cases … vs staff strength
Malaysia population 28million Annual attendance :
40 million

Staff strength
No of Patients

Repeat Attendances

New Attendances 1
1

Year

safurah jaafar qatar2010 23

 From Acute Management to include:
“Upstream Care”
HEALTHY LIFE EXPECTANCY

Blood Sugar Test

AGE BLOOD PRESSURE UPSTREAM CARE
and Control
Raised
Periph Diabetic Foot
AGE
Blood Sugar Diabetes /amputation
Neuro AGE

safurah24
jaafar qatar2010
 “UPSTREAM CARE”
SCREEN YOUNGER!! – MANAGE EARLIER
 Blindness, Deaf, Learning Disabilities, Autism, Dyslexia
 Vision, Hearing, Cognitive
 IHD, CVD, HT, STROKE
 Blood Pressure, Nutrition, Exercise
 Diabetes
 Blood Sugar, Nutrition, Exercise,
 Depression and Anxiety
 Relaxation and Coping
 Infectious Disease
 Hygiene, Sanitation, Univ Precaution, Isolation

safurah25
jaafar qatar2010
Identifying Key-Risks Parameters and
Managing
Healthy Healthy Healthy Healthy Healthy
Ante- Child Adolescent Adult Elderly
Mother
Body Weight Cognitive Physical Physical Physical

Blood Devp Growth Growth Growth

Pressure Social Devp Body weight Body weight Body weight

Blood Hb Physical Bld Pressure Bld Pressure Bld Pressure

Urine Alb & Growth Bld sugar Bld sugar Bld sugar
Sugar … Mental Mental Mental
Fetal Kicks … Health Health Health
.. Sexual & Rep Sexual & Rep

.. Health Health

“UNIVERSAL COVERAGE “ “UNIVERSAL COVERAGE “

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R.E.A.P W.I.S.E ly
• REAP – REVIEWED APPROACH
• W - wellness
• I - illness
• S - support services
• E - emergency
information

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 Screening of Integrate
patients
Services
(starts with
opportunistic)

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WHO Steps Approach –
“MODIFIED”
• Mod. Step 1 – questionnaire to
patients/client
• Mod. Step 2 – Examination of
patients
• Mod Step 3 – Biochemical
measurements
• Mod Step 4 – Management and
Follow-up

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Step 1
• Patients who are registered are
selected to fill up questionnaire
(identification of Risks)
– BSSK (Health Screening Form)
• Adolecence- BSSK /R/1/2008
• Adult
– female - BSSK/W/1/2008
– Male - BSSK/L/1/2008
• Elderly - BSSK/WE/1/2008
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Step 2
At the Clinic Triage – Self measure
• Take Your Weight
• Take your Blood Pressure
• Measure your BMI

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 Step 3
• Clinical assessment
– Doctors
– Assistant Medical Officers
1. Take clinical history and complaints
2. Explain the BMI reading
3. Examine the BSSK forms
4. Examine patients clinically
5. Intervention or further biochemical tests
safurah jaafar qatar2010 37
 Step 4
Manual Data Collection at point of care
Non TPC clinics

safurah jaafar qatar2010 38

safurah jaafar qatar2010 39
"five shared social and political
factors" of special importance to
better assured health of population:
• Historical commitment to health as a social goal;
• Social welfare orientation to development;
• Community participation in decision-making
processes relative to health;
• Universal coverage of health services for all social
groups (equity);
• Intersectoral linkages for health

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 Clinic Base and Population
Integrated Management
• Identification of population / patients
with risks
• Population-based risk management
• Early intervention
• Quality Management
– QA Indicators : Diabetes and Asthma
– Performance output
• CVD -
• Diabetes –
• Cancer –
• Renal -
• Vision and Hearing
• Smoking
• STD/HIV/TB (MDG)

safurah jaafar qatar2010 46

ALL FOR HEALTH AND
HEALTH FOR ALL

THANK YOU