9 Rural and community medicine Sudan rural health and community

medicine

Dr. Siham GritlyUniversity of Bahri

Definition of rural communities

• There is no international standard for defining rural areas, and standards may vary even within an individual country (WHO).

• The most commonly used methodologies fall into two main camps:

• population-based factors

• and geography-based factors.

• The methodologies used for identifying rural areas include;

• population size, • population density, • distance from an urban center,• settlement patterns,• labor market influences,

Rural area

• English dictionary defined rural area as a geographic area that is located outside cities and towns

• Usually those areas having fewer than 1000 persons per square mile and less than 20,000 people

• The rural poor depend largely;

• on agriculture,

• fishing

• and forestry,

• and related small-scale industries and services.

• rural areas are different from those in urban areas,

• These differences are the result of• geographic, • demographic, • socioeconomic,• workplace, • and personal health factors.

• People living in rural areas also have;• poorer socioeconomic conditions, (high rates

of poverty amongst)• • less education,

• higher mortality rates when compared to their urban counterparts

Why rural areas characterized by poverty

• How rural poverty is created

• Numerous characteristics of a country's economy and society, as well as some external influences, create rural poverty

• political instability and civil war;

• systemic discrimination on the basis of gender, race, ethnicity, religion, or class

• ill-defined property rights or unfair enforcement of rights to agricultural land and other natural resources;

• high concentration of land ownership and irregular rental arrangements;

• corrupt politicians

• economic policies that discriminate against or exclude the rural poor from the development process

• market imperfections owing مديون to the high concentration of land and other assets and imperfect public policies;

• natural causes (for example, climatic changes)

• The right to adequate land and water is importance in reducing rural poverty in many developing countries.

• large and rapidly growing families

• Basic health care • immunization, • provision of clean water, • and family planning • and education (literacy, schooling, and

technical training)—particularly for women and children—are essential building blocks and should be accessible at reasonable cost.

characteristics of rural life

• More space; greater distances between residents and services

• Cyclic/seasonal work and vacation activities

• Informal social/professional interactions

• Access to extended relationship systems

• Residents are related or acquainted

• Small enterprises• fewer large industries• Economic orientation to land and nature (e.g.,

agriculture, mining, fishing) • High-risk occupations are more prevalent• schools are social organizations • Preference for interacting with localities• Mistrust of newcomers to the community

Rural health or rural medicine

• In medicine, rural health or rural medicine is

the interdisciplinary study of health and health

care delivery in rural environments.

• The concept of rural health incorporates many fields, including;

• geography,• midwifery, • nursing, • sociology, • economics, • telemedicine

Sudan rural areas often suffer from a lack of access to healthcare.

• Poor coverage in rural areas

• Health threats

• Common illnesses include malaria, measles, and tuberculosis.

• In areas with poor sanitation to the south and west, water-borne diseases like cholera are a threat.

Difficulties in health care delivery

• The problems of receiving adequate health care are particularly high in rural regions, which lack trained staff and facilities.

• Recruiting and retaining qualified health professionals in rural communities is difficult

• In some areas, people also suffer from lack of food.

• In South Kordofan, for example, four in ten households do not have enough food.

• This compares to wealthier states such as Khartoum, where less than one in ten households have a poor diet.

• Infant mortality rates among children are high in some regions.

• Some factors that influence where health care providers work are

• 1) geographic location,

• 2) population density, and• • 3) distance from an urban center.

Factors that prevent women in developing countries from getting the health care they need include

• -distance from health services,

• -cost (direct fees as well as the cost of transportation, drugs, and supplies),

• multiple demands on their time,

• -women’s lack of decision-making power within the family

• -poor quality of services, including poor treatment by health providers, also that almost 50% of the births in developing countries take place without a skilled attendant (UNICEF).

The services needed are include:

• *Routine maternal care for all pregnancies, including a skilled attendant (midwife or doctor) at birth

• *Emergency treatment of complications during pregnancy, delivery and after birth

• *Postpartum family planning and basic neonatal care

• *Educating women and their communities about the importance of maternal health care,

• *Research on social and psychological factors affecting maternal health

• *Development of better interventions (and evaluations of interventions) for complex problems (e.g., behavioral, social, biological

Health system in Sudan

• The design of the health care system in Sudan is based on primary health care which is considered as a decentralized health care system able to integrate, the existing programmes, including;

• preventive, • curative • promotional activities

• For provision of service, health care is organized at three levels:

• 1- primary health care,

• 2- secondary level

• 3- tertiary level

primary health care,

• The “first” level of contact between the individual and the health system.

• Essential health care (PHC) is provided.

• A majority of prevailing health problems can be satisfactorily managed.

• The closest to the people.• Provided by the primary health centers.

2- secondary level

• More complex problems are dealt with.

• Comprises curative services

• Provided by the district hospitals

• The 1st referral level

3- tertiary level

• Offers super-specialist care

• Provided by regional/central level institution.

• Provide training programs

Primary Health Care,

• a basic level of health care that includes programs directed at;

• the promotion of health,

• early diagnosis of disease or disability,

• prevention of disease.

Definition of PHC

• Primary health care is essential health care

made universally accessible to individuals and

acceptable to them, through full participation

and at cost the community and country can

afford

The ultimate goal of primary health care is the attainment of better health services for all.

• World Health Organization (WHO), has identified five key elements to achieving this goal;

• reducing exclusion and social disparities in health

(universal coverage reforms);

• organizing health services around people's needs and

expectations (service delivery reforms);

• integrating health into all sectors

• pursuing collaborative models of policy dialogue (leadership reforms);

• increasing stakeholder participation.

Elements of primary health care

• 1. Health Education

• 2 Promotion of food supply and proper nutrition

• 3 An adequate supply of safe water and basic sanitation

• 4 Maternal and child health care, including family planning

• 5 Immunization against the major infectious diseases

• 6 Prevention and control of locally endemic diseases

• 7 Appropriate treatment of common diseases and injuries

• 8 Basic laboratory services and provision of essential drugs.

• 9 Training of health guides, health workers and health assistants.

• Referral services

Principle of PHC

• The guiding principles of primary health care include

• Accessibility, • Public Participation,• Health Promotion, • Appropriate use of Technology • Inter-sectoral Collaboration

Philosophy of PHC:

• 1-Health is fundamental related to availability & distribution of resources

• not just health resources such as doctors, nurses, medicines but also by; other socioeconomic resources such as;

• education, • water supply, & food supply

• 2-PHC is concerned with equity to ensure that the available health& social resources are distributed equal

• 3- Health is an integral part of the overall development, thus factors which influence health care are social, cultural, economic as well as biological & environmental.

• 4- To achieve better health, requires much more development by people themselves as

• individuals & families,• communities • in taking action on their own behalf adapting

health behavior & ensuring healthy environment

efficient PHC services must be :

• Accessible • Acceptable • Affordable • Efficient administrative, professional and

technical procedures.• Community participation • Comprehensiveness • Continuity

Rural and primary health care

• At village level, primary health care units represent the first level of contact between the community and the health services.

• Secondary health care is available in small towns through rural hospitals and urban health centres

Promoting access to high quality primary health care services in Sudan,

ref. World Health Organization, regional office for Eastern Mediterranean and Sudan Ministry of Health 2012

• Access to high quality PHC services is one of the major problems of Sudan’s health system, in term of the following three main factors:

• • 1. The burden of communicable and non-

communicable diseases is rising which put more demand on PHC services.

• 2. PHC minimum package is below the standard that most of the needy do not have access to it.

• 3. the current health system governance, financing and delivery practices do not support best access to high quality PHC services.

Barriers to Option Implementationref. World Health Organization, regional office for Eastern Mediterranean and Sudan Ministry of Health 2012

• 1. Small size of health insurance pool and low revenue to health due to lack of unified health financing policy.

• 2. “Hospital centrism” approach of health system and lack of PHC oriented policies and laws jeopardize access to good quality PHC services.

• 3. PHC standards are not comprehensive and its implementation is not enforced.

• 4. Low resources are directed to peripheries and remote areas which hinder the expansion of PHC in these settings.

Implementation Strategies:ref. World Health Organization, regional office for Eastern Mediterranean and Sudan Ministry of Health 2012

• The overall strategies to deal with the above-mentioned barriers are:

• 1. Development of national health system financing policy supported by the necessary health system reform.

• 2. Shift of health system orientation towards PHC through development of PHC supporting policies and laws and support PHC management capacity.

• 3. Development of comprehensive PHC accreditation system while ensuring resources for its implementation.

• 4. Reform of PHC implementation policies and financing scheme as well as mobilization of resources.

references• 1. How healthy are Rural Canadians? An Assessment of Their Health Status and

Health Determinants. Ottawa: Canadian Institute for Health Information. 2006.ISBN 978-1-55392-881-2. Archived from the original on 2008-06-20.

• 2. Healthy Horizons- Outlook 2003-2007: A Framework for Improving the Health of Rural, Regional, and Remote Australians". Australian Health Ministries’ Advisory Council’s National Rural Health Policy Sub-committee and the National Rural Health Alliance for the Australian Health Minister’s Conference. 2003. ISBN 07308 56844.

• 3 Ministerial Advisory Council on Rural Health (2002). "Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities". Ottawa: Health Canada.

• 4. Population density and urbanization". United Nations Statistics Division.

references

• Declaration of Alma-Ata International conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978

• World Health Organization (2005). Sustainable health financing, universal coverage and social health Insurance. Ninth plenary meeting, Eighth report 2005.

• World Health Organization (1978), Declaration of Alma Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, 1978.

• Park's Textbook of Preventive and Social Medicine 21 Edition, by K. PARK

• World Health Organization, regional office for Eastern Mediterranean and Sudan Ministry of Health 2012; An Evidence-Based Policy Brief Promoting access to high quality primary health care services in Sudan