Health Care System S5 - 2024 PDF

S5 - 2024 UIDE Health Care System Zagazig faculty of medicine S5 - 2024  Community medicine 1. Overview of health care system 2. Levels of health care 3. PHC 4. UHO 5. Reproductive health 6. MCHC 7. Vulnerable groups health programs 8. Occupational health services...

S5 - 2024 UIDE Health Care System Zagazig faculty of medicine S5 - 2024  Community medicine 1. Overview of health care system 2. Levels of health care 3. PHC 4. UHO 5. Reproductive health 6. MCHC 7. Vulnerable groups health programs 8. Occupational health services and programs 9. Ergonomics 10.Health management 11.Health Quality 12.Accreditation 13.Audit 14.Health economics 15.Demography 16.Vital indices 17.Sources of data collection 18.SDGs GUIDE 1  Health Care Systems ❑ The World Health Organization (WHO, 2007) defines a health system as follow: - A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.  This includes efforts to influence determinants of health as well as more direct health-improving activities.” - A health system is therefore more than the framework of publicly owned facilities that deliver personal health services. - It includes, for example: Quiz 1- a mother caring for a sickchild at home 2- private providers 4- vector-control campaigns 3- behavioral change programs 5- health insurance organizations, 6- occupational health and safety legislations. - It include inter-sectoral action by health staff, for example, through encouraging the Ministry of Education to promote female education, which is a well- known determinant of better health. - Every nation must design and develop a health system in accordance with its needs and resources. - The common elements in all health systems are primary health care and public health measures. Pillars of the health-care systems VIQ - These are essential elements that enable the healthcare system to function. 1- Providers: ▪ Institutions include hospitals, clinics, and medical laboratories. ▪ These may be operated by the government or by nonprofit or for-profit organizations. ▪ Individuals include: Doctors Pharmacists Midwives others. Dentists Nurses dietitians GUIDE 2 2- Finance: ▪ Sources of health funding/pay include national or private health insurance, out of-pocket payment, donations, or charity. ▪ Salary for governmental or organizational providers allows funders to control health-care costs directly; however, it may lead to under-provision of services. 3- Information: ▪ plays an increasingly critical role in the delivery of modern health care and the efficiency of health systems. ▪ It includes clinical guidelines, medical terminology, patients’ medical records, human resources information, and so forth. 4- Management: includes policies and plans adopted by the government. 5- Performance: ▪ depends on indicators adopted by the providers for both time and place comparisons, which enable monitoring of progress and differences. Health sector reform in Egypt ❑ Reform: is to improve the quality of health services offered to consumers. - All national resources (governmental and non-governmental) are emphasized in the health reform process. ❑ Its objectives are: 1. Provision of good quality services that should be: Accessible Efficient CAES Acceptable Ensures equity Continuous Ensures respect and caring Competent Safe Effective Sustainable services with continuous quality improvement. GUIDE 3 2. Complete coverage of the whole citizens by health insurance.  Expanding the social health insurance coverage from 47 % of the population (in 2003) to universal coveragebased on the “family” as the basic unit.  It will afford cost effective package of basic health services based on the priority health needs of the population through a holistic family health approach.  Provision of the basic package will be based on competition and choice among the different public and private service providers, under a single Public and Health Insurance Fund (PHIF).  Provision of holistic, comprehensive, and integrated basic benefit package (BBP). 3. Upgrading PHC to provide family care with increasing the preventive role. 4. Increasing capacity of health providers through training and new medical information. 5. Motivation of community participation in healthcare.  Motivation of active involvement of the local community is also needed through sharing in payment of healthservices fees, in planning and in evaluation of services. 6. Decentralization of decision making, strengthening management systems and developing a regulatory framework and institutional relationships to ensure quality of care. 7. Developing the domestic pharmaceutical industry and reducing government involvement in the production of pharmaceuticals while strengthening its role as a financier. Organization of the Ministry of Health and Population in Egypt - The organizational structure of the MOHP consists of two functional structures: 1- The administrative structure 2- the service delivery structure. 1- Administrative Structure:  The administrative organization of the MOHP comprises: VIQ a- The central headquarters. b- The governorate level health directorates and districts. GUIDE 4   The main functions of the higher administrative structure include: 1) Planning 2) Supervision 3) Program management  in five areas namely: a. Central administration for the minister’s office. b. Curative health services. c. Population and family planning. d. Basic and preventive health services. e. Administration and finance. 2- Service Delivery Structure: - The MOHP is the major provider of primary, preventive, and curative care in Egypt, with nearly 5,314 PHC facilities and 521 hospitals nationwide. - The MOHP service delivery units are organized along a number of different dimensions. - These include: geographic (rural and urban) structural (health units, health centers, and hospitals) functional (maternal child health centers) programmatic (immunization and diarrheal disease control). - This PHC network allows for more than 95% geographical coverage of the population. - The MOHP is the largest provider of inpatient health-care services in Egypt, and services are provided through the following types of facilities. a) Integrated hospitals: ▪ are small hospitals providing PHC and specialized medical services in the rural areas. ▪ Integrated hospitals contain: well-equipped surgical theatres X-ray equipment laboratories ▪ they are responsible for serving a catchment population of between 10, 000 and 25, 000 people. b) District hospitals: ▪ are 100-to 200-bed hospitals that provide more specialized medical Services and are available in every district GUIDE 5 c) General hospitals : ▪ contain more than 200 beds and contain all medical specialties. ▪ General hospitals are available in every governorate. d) Specialty hospitals: ▪ are located in urban areas and have a particular focus, such as: Psychiatry Cardiology Gynecology Chest Ophthalmology and obstetrics Fever Oncology ▪ Specialty hospitals are available in all governorates. Table (1):Health System in Egypt: Three sectors in health services delivery Management Governmental Sector Semi- Governmental Private Sector Items Sector Type of health - MOHP facilities, - Health Insurance - Private practice facilities - University facilities, Organizations and doctors, /providers - Teaching hospitals Curative Care - pharmacists, - hospitals affiliated Organization. - nongovernmental with the Ministries of organizations Defense and Interior. clinics in mosques VIQ and churches. Source of - Ministry of Finance - Ministry of Finance User fees funds and self– funding and cost- from the economic recovery. departments. Served - Low-and middle- - Middle-and high- - Low-, middle- Population income population. income people. and high-income people. - MOHP, Registration - MOHP - MOHP - Medical Syndicate - Ministry of Social Solidarity. GUIDE 6  Strategic plan of MOHP for health care reform A- Development of infrastructure: both in quality and in quantity. 1- Establishing new services to slum areas and deprived areas in the form of health units or mobile clinics. 2- Renovation of the existing units. 3- Developing a separate system for financial needs of the health care services. 4- Application of family medicine program in all health units. 5- Providing all equipment and materials to improve performance whenever there is financial support. 6- Supporting transportation and communication networks to upgrade the efficiency of referral system. 7- Developing health information systems from central to peripheral levels and between public and private health services to ensure the flow of accurate reliable data of different health problems. B- Development of human resources: 1- Expansion and support of family medicine program application through medical school’s curriculum, continuous training of physicians, nurses and technicians. 2- Continuous training in preventive and clinical medicine through fellowship programs. 3- Development of managerial capabilities of physicians. 4- Application of quality assurance system according to fixed standards to evaluate the performance of health team.  Military hospitals serve military and public sectors (provide all levels of care). GUIDE 7  Levels of Health Care Item Primary health care Secondary health care Tertiary health care Level - The PHC is the first point of - Secondary health care provides a higher - Tertiary health care provides contact between the community level of curative care than PHC. an advanced level of health- and the health-care sector. care and technology Coverage - It covers almost 80 % of - It covers 15 % of the community needs. - It covers 5 % of the community needs. community health needs. Services - Health services are provided by: - Health services are provided by: - through specialized hospitals provided general practitioners (new specialists in general and district hospitals and institutions and graduates) through urban and and polyclinics. distinguished health-care by rural health facilities. specialists. Cost - The PHCis cost effective and is - Secondary level of care is more costly. - Tertiary level of care is the least expensive level of expensive. health care. Additional - A referral system exists between primary character care and secondary care facilities. - Feedback of information and follow-up are essential elements of the referral system. 8  Primary Health Care - Primary health care is often abbreviated as "PHC", has been defined as:  Essential health care based on practical, scientifically sound and socially acceptable methods andtechnology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self- determination. - This ideal model of health care was adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata in1978, and became a core concept of the World Health Organization's goal of Health for all. Goals and key elements VIQ - The ultimate goal of primary health care is better health for all. - The WHO has identified five key elements to achieving that goal: 1. Reducing exclusion and social disparities in health (universal coverage reforms). 2. Organizing health services around people's needs and expectations (service delivery reforms). 3. Integrating health into all sectors (public policy reforms). 4. Pursuing collaborative models of policy dialogue (leadership reforms). 5. Increasing stakeholder participation. Principles VIQ - Behind these elements lies a series of basic principles identified in the Alma Ata Declaration that should be formulated in national policies in order to launch and sustain PHC as part of a comprehensive health system and in coordination with other sectors: 1- Equitable distribution of healthcare:  primary care and other services must be provided equally to all individuals irrespective of their gender, age, color, urban/rural location and social class. GUIDE 9 2- Community participation:  in order to make the fullest use of local, national and other available resources. 3- Health workforce development:  comprehensive health care relies on adequate numbers and distribution of: a- trained physicians b- nurses c- allied health professions d- community health workers and others working  as a health team and supported at the local and referral levels. 4- Use of appropriate technology:  medical technology should be provided that is: a- accessible b- affordable c- feasible d- culturally acceptable to the community  (e.g. the use of refrigerators for vaccine cold storage). 5- Multi-sectional approach:  recognition that health cannot be improved by intervention within just the formal health sector; other sectors are equally important in promoting the health and self- reliance of communities.  These sectors include: a- agriculture (e.g. food security) b- Education c- communication (e.g. concerning prevailing health problems and the methods of preventing and controlling them) d- Housing e- public works (e.g. ensuring an adequate supply of safe water and basic sanitation); f- rural development g- industry h- community voluntary organizations. 6- Availability: the service must be available 24 hours. GUIDE 10 7- Accessibility: a- Geographical accessibility: ▪ i.e. PHC services should be near to people as possible (not more than1-hour travel). ▪ There must be a road and a mode of transportation available to the service. b- Social accessibility: ▪ i.e. services should be available to all population irrespective of socio-economic or cultural barriers. ▪ Outreach services (mobile PHC units) are done for: people in far areas (desert, mountain) for continuously moving groups (nomads). c- Functional accessibility i.e. kind care, good quality health care. 8- Affordability:  PHC services are to be provided within the available resources of the country.  It is offered through governmental and non-governmental services. 9- Acceptability:  services should be acceptable by people.  Customer's satisfaction is essential. 10- Appropriateness:  PHC should be based on scientifically sound and use acceptable technology. 11- Comprehensiveness:  PHC should include promotive, preventive, curative and rehabilitative health care services. 12 Continuous:  PHC should care for people from the intrauterine life to terminal care (from womb to tomb). GUIDE 11  Approaches: - Primary health care approaches have evolved in different contexts to account for disparities in resources and local priority health problems. ❑ GOBI-FFF: VIQ  One selective PHC approach is referred to collectively under the acronym GOBI-FFF.  These are strategies that are being adopted to improve maternal and child health as partof primary care, especially in low income countries burdened with high infant and child mortality.  They include: 1. Growth monitoring: to prevent most child malnutrition before it begins. 2. Oral rehydration therapy: to combat dehydration associated with diarrhea. 3. Breast feeding. 4. Immunization. 5. Family planning (birth spacing). 6. Female education. 7. Food supplementation: for example, iron and folic acid fortification/supplementation to prevent deficiencies in pregnant women. ❑ Essential Health Services in Primary Health Care (ELEMENTS): 1) E–Education for Health. VIQ 2) L–Locally endemic disease control. 3) E–Expanded program for immunization. 4) M –Maternal and Child Health including responsible parenthood. 5) E–Essential drugs. 6) N–Nutrition. 7) T– Treatment of communicable and non-communicable diseases. 8) S - Safe water and sanitation. GUIDE 12  PHC in Egypt - It started since 1942 through maternal health centers and endemic diseases units. - These services expanded to cover all governorates in both urban and rural areas. - It ensures coordination with other health related sectors. - It is subjected to continuous upgrading and reform now (as mentioned before). Levels of care provided through PHC VIQ 1- Preventive services: 1) The Health education 5) family planning 2) Counseling 6) support environmental sanitation 3) growth monitoring 7) vaccination of compulsory vaccines 4) supplementing micronutrients to infants 8) food safety 9) early detection and screening tests for: neonatal anomalies risky pregnancy tuberculosis malignant tumors. 2- Curative services: 1) Treatment of communicable and non-communicable diseases 2) control of epidemics and endemic diseases 3) first aid and emergency care 4) provision of some drugs 5) referral of needy cases to higher care level.  Actually, PHC provides: comprehensive, promotive, protective, preventive, and curative care.  Curative services constitute 20% only of primary health care.  This concept must be practiced and understood by all health care providers. GUIDE 13  Criteria of effective and successful PHC VIQ 1) Coordination of PHC with different related sectors as: Education Agricultural organizations Social organizations Environmental organizations  as they share in people's health. 2) Community participation in : PHC management setting priorities in needs assessment helping in resources in evaluation of activities. 3) Customer's satisfaction must be the ultimate and remote objective of PHC providers, through providing quality health care and by meeting people's needs. 4) Health provider satisfaction by: continuous education motives continuous training promotion. 5) Continuous monitoring and evaluation of services by: collection and analysis of data follow up of performance assessment of output indicators. GUIDE 14  GUIDE 15  Universal health coverage (UHC) ❑ WHO (2010) has defined UHC: - as “UHC is about ensuring all people and communities have access to quality health services where and when they need them, without suffering financial hardship". UHC objectives 1- Equity in access to health services Quiz 2- To ensure good quality of health service 3- People should be protected against financial hardships ❑ Reform strategy for Health Insurance Organization (HIO) in Egypt: principles underlying the reform strategy Principles of the New Universal Health Insurance System 1- Separation of functions VIQ 2- Family is the basic unit 3- Social Solidarity 4- Mandatory 5- Presence of basic benefit package. GUIDE 16  Understanding free VS Universal Health care - Free healthcare is also different from universal health care. - The terms are often used interchangeably but there are differences. a- Free Health care: means that all citizens receive health care at no cost or at avery minimal cost. b- Universal Health care: means that there is a health care system that provides coverage to at least 90% of citizens. ❑ The Beneficiaries of the New Universal Health Insurance System: 1- Subscribing to the new health insurance system will be mandatory for 90% of Egyptians residing within the Arab Republic of Egypt (excluding military personnel); while enrolment remains optional for Egyptians working or staying with their families aboard.  The government has committed to provide the policy free of charge to approximately 25% of the population who cannot afford it. 2- In addition, the UHIL allows coverage for all foreign residents, subject to reciprocal agreements with their respective countries. ❑ The Regulatory Authorities of the New Universal Health Insurance System: a- The Universal Health Insurance Organization (UHIO) b- The Healthcare organization c- The Accreditation and Supervision Organization A- Universal Health Insurance Organization (UHIO): - The Universal Health Insurance organization will replace the current General Authority for Health Insurance in all its rights and obligations. - responsible for: 1- Financing the services by contracting healthcare providers, therapeutic systems, etc.and pricing medical services. 2- Determining which level of service each patient should receive. GUIDE 17 B- Health Care organization: - A public services authority with an independent budget, which is subject to the supervisionof the Ministry of Health and Population. 1) It has regulatory role for the health services provided. 2) It will also provide health and therapeutic services to all insured people through the Ministry of Health facilities. 3) Providing primary, secondary, and tertiary health care services through contract swith accredited providers ❑ WHO uses 16 essential health services in 4 categories as indicators of the level and equity of coverage in countries: VIQ A- Reproductive, maternal, newborn and child health: 1- Family planning. 3- Full child immunization. 2- Antenatal and delivery care. 4- Health-seeking behavior for pneumonia. B- Infectious diseases: 1- Tuberculosis treatment. 2- HIV antiretroviral treatment. 3- Hepatitis treatment. 4- Use of insecticide-treated bed nets for malaria prevention. 5- Adequate sanitation C- non-communicable diseases: 1- Prevention and treatment of raised blood pressure. 2- Prevention and treatment of raised blood glucose. 3- Cervical cancer screening. 4- Tobacco smoking. D- Service capacity and access: 1- Basic hospital access. 2- Health worker density. 3- Access to essential medicines. 4- Health security: compliance with the International Health Regulations. GUIDE 18  - Each country is unique, and each country may focus on different areas, or develop their own ways of measuring progress towards UHC. - But there is also value in a globalapproach that uses standardized measures that are internationally recognized so that they are comparable across borders and over time. - Please note:  Not all citizens or residents receive free healthcare in all of these countries.  In many of these countries, employers and individuals share in the cost of healthcare through contributions, cost-share arrangements, co-pays, and other related fees.  However, the goal with these programs is to make healthcare as affordable and accessible as possible for the largest number of people – “Universal Care”. Table (2): Comparison Between the Old and the New Health Insurance System: Old Health Insurance System New Health Insurance System - HIO performs three functions: - The new system depends on separation of 1) managing the fund functions through its three independent 2) providing health care services organizations 3) and act as supervisor on its provided VIQ services - An individual acts as the systems unit - A family acts as the systems unit - Mandatory: - Allow for opting out  all Egyptians will be part of this pool, except for staff and families of the military - In adequate risk pooling due to the - Adequate risk pooling solidarity asit aims to uninsured sectors of the population and cover all sectors of the population and it opt out allowance does not allow opting out. - Contribution rates in the old lawbased on - Contribution rates in the new law will be the basic salary based on the total salary - Incomplete population coverage - Various population groups in the informal sector, who are ineligible to exemption criteria will be subject to mandatory contribution. GUIDE 19 ❑ Examples of countries with Universal Healthcare: Australia, Japan, Bahrain, Kuwait, Italy, Canada, Germany, Denmark, New Zealand, and France. GUIDE 20 1) Concept of family medicine 2) Basic Benefit Package (BBP) 3) Family in family medicine 4) Family health team 5) Family health records 6) Referral system GUIDE 134  Concept of Family Medicine ❖ Instructional objectives: ­ Define family medicine. ­ Demonstrate the family medicine model of care and its principles. Quiz ­ Compare between the family medicine model of care and specialist care. ­ Apply family medicine model on clinical cases. Definition of Family Medicine ▪ According to the American Academy of Family Physician (AAFP) in 1995, Family Medicine is the medical specialty, which provides continuing, comprehensive healthcare for the individual in the context of the family and for the family in the context of the community. ▪ It’s the scope encompasses all ages, both sexes, each organ system & every disease. ▪ It integrates all aspects of patient care including the physical, psychological, social and cultural aspects. Principles of Family Medicine VIQ 1) Person-centered rather than disease-centered care: ▪ The family physician is committed to the person, rather than to a particular body of knowledge, group of diseases or special technique.  This commitment is open-ended in two senses: 1. First, it is not limited by the type of health problem. The family physician is available for any health problem in a person of either sex or any age. 2. Second, the commitment has no defined end point. It is not terminated by cure of an illness, or by the end of a course of treatment, or by the incurability of an illness. In many cases the commitment is made while the person is healthy, before any problem has developed. GUIDE 135  ▪ The family physician demonstrates an understanding of patient’s experience of illness particularly ideas, concern & expectations & impact of illness on patient’s life. ▪ The family physician practices a total person approach, assessing the individual from the bio-psycho-social aspects (Holistic approach), avoiding the case approach which is concerned with the presenting condition only. 2) Continuous care: ▪ Family physician has continuing responsibility for individual over long periods of time, over many episodes of health and illness, typically from intrauterine life to death (from womb to tomb). ▪ This continuity allows family physicians to increase their knowledge of the patient at each office visit, reducing the need to have the patient recite past medical history, social history, etc. at each clinical encounter. ▪ It also enables doctor and patient to form relationship which is deepened and strengthened by time.  This relationship is an important element in the healing process as it enables family physicians to understand how the patient's problem is related to his personality and life experience and provides them with methods of diagnosis and therapy that are not available to other types of physicians. 3) Comprehensive care: ▪ It involves full-service health care of both sexes and all ages. ▪ It is bio-psycho-social, promotive, preventive, curative and rehabilitative care at the individual, the family and the community levels. 4)Coordinated care: ▪ It means the harmony of delivery of care at different levels. ▪ Family physician emphasizes that the patient should receive appropriate care at the right place and at the right time i.e., when referral is indicated, the family physicians should ensure appropriate and timely referral of the patient to specialist services but remain the coordinator of the patient’s health care through follow up which necessitate better record keeping. This prevents fragmentation of that care. GUIDE 136  ▪ This coordinated care has made family physicians the ideal primary health care physicians, serving as “conductor” of an orchestra of limited specialists or the “Gatekeeper” of health system. 5)Collaborative care: ▪ Family physicians should be prepared to work with other medical, health and social care providers delegating to them the care of their patient whenever appropriate. ▪ They should actively participate in multidisciplinary team as team members or team leaders. 6)Competent care: ▪ Family physicians are skilled clinicians. ▪ They properly apply knowledge and skills to solve wide range of health problems based on evidence- based medicine. 7)Compassionate care: ▪ The doctor-patient relationship is central to family medicine. ▪ Therefore, family physician is sensitive and aware of patient’s feelings and skillful in building an effective doctor-patient relationship based on partnership, friendship with patient, and mutual respect. ▪ This relationship is important for continuity of care allowing a family physician to be “a member of the patient’s family.” 8)Community oriented care: ▪ Family physicians should see the patient’s problems in the context of his/her life in the local community. ▪ They should be aware of the health needs of the population living in this community and able to respond to people’s changing needs and adapt quickly to changing circumstances. ▪ They should see themselves as part of a community network of health care providers & should be skilled at collaborating with other professionals, agencies from other sectors and self-help groups to initiate positive changes in local health problems. GUIDE 137 9)Family oriented care: ▪ Family physicians deal with all age groups and therefore tend to care for family units. ▪ This enables the physician to acquire knowledge of a family's relationships which can enrich his understanding of an individual's problems and increase his therapeutic range. 10) Preventive attitude: ▪ Family physician sees every contact with his patients as an opportunity for practicing preventive measures in addition to curative care services. ▪ Family physician views his practice as a population at risk.  It implies a commitment to maintain health in the members of his practice, whether or not they are attending the office. ▪ To do so requires a record system that is able to identify groups of patients in the practice who are in need of special attention e.g., adult patients whose blood pressure has never been recorded; children who have not been immunized. 11) Resource Management: ▪ The family physician is a manager of resources. ▪ As a generalist and first-contact physician, he is able, within certain limits, to control admission to hospital, use of investigations, prescription of treatment and referral to specialists. ▪ In most parts of the world, resources are now limited. ▪ It is, therefore, the family physician's responsibility to manage these resources for the maximum benefit of his patients. Settings of Family Medicine Family medicine can be practiced in the following settings: 1. In Primary health care (PHC) facilities. 2. In the hospital. 3. In private clinics. GUIDE 138  Family Medicine’s basket of services Family physician provides full range of health services at the level of the individual, the family and the community.  At the individual level: 1) Health promotion services: ­ directing individuals to healthy lifestyle e.g., proper nutrition, healthy environment especially in the house, quitting bad habits especially smoking, practicing appropriate level of physical activity, etc. ­ Health education is an important intervention in this respect. 2) Preventive services: can be summarized in the mnemonic (RISE): R: risk assessment. I: immunization (passive, active) and chemoprophylaxis. S: screening for early detection of diseases. E: education: about prevention of health problems & healthy lifestyle practices. 3) Curative services: ­ family physicians able to manage wide range of health problems (80- 90% of cases) including common acute and chronic problems, rare but life-threatening emergencies, complex biopsychosocial problems, undifferentiated problem. ­ Curative services also include provision of emergency services, referral and follow-up service. 4) Rehabilitative services. 5) Counseling services. 6) Home care services. 7) All activities of special programs as Maternal and Child Health (MCH), Reproductive Health and Family Planning (RH/FP), School Health services, etc. 8) Palliative care to people with terminal disease. GUIDE 139  At the family level: ▪ This level requires a well-integrated team, a family health file & a proper record system. ▪ The family physician should be alert to the specific needs of very family and apply comprehensive care at the family level according to these needs.  At the community level: the health services provided to the community should be appropriate to address the health needs of that particular community, to promote health and wellbeing, to prevent and control priority health problems and to treat any disease conditions. VIQ (Table 3): Differences between Family Medicine Model & Hospital / Specialist Model of Care: Family Medicine Model Hospital/Specialist Care Model Structure Cares for small, registered population Cares for large, unregistered population Patients have direct access Access usually via FP/ GP Situated close to patient’s home Situated far from most patients’ homes Huge variability between practices (e.g., Hospitals exhibit far less variability age, social class of patients, geographical distribution) Function Responsibility for all presenting Responsibility for specialty-related problems irrespective of age, sex or problems only: restricted by age (e.g., morbidity pediatrics) or sex (Obs & Gynae) Presented with undifferentiated Presented with more organized disease problems/diseases Deals with common diseases and social Deals mainly with rare diseases or problems atypical versions of common diseases GUIDE 140 Makes infrequent and highly Makes frequent and less selective selective use of ‘high technology’ use of ‘high technology’ Continuing responsibility for Episodic responsibility for patients patients (Continuous care) (Fragmented care) Multidisciplinary team is the Specialist is the source of care source of care (coordinated care). (uncoordinated work). Evidence based care Experience based care Purposeful, organized chronic disease Non organized chronic disease management. management. Responsibility for all health care for Responsibility for specialty-related patient including. medical care including. 1. Patient education 1. Drugs 2. Appropriate reassurance 2. Surgery 3. Lifestyle modification 3. Specific intervention 4. Empowering self- responsibility 5. Proper prescription 6. Consultation and referrals 7. Follow-up 8. Prevention 9. Family and social support Attitudes Whole person’ oriented: uses ‘triple/ Disease oriented: usually either physical Bio-psychosocial diagnosis’ or psychological Biological (etiology of disease) Psychological effect (stress, anxiety, abnormal illness behavior, sleep, depression) Social (effect of illness on the GUIDE 141  family, work and sexuality) Individual, family & community oriented Individual patient oriented Prepared to use time as diagnostic Little use of time as diagnostic tool tools (nice to know) (need to know) Importance of doctor-patient Doctor-patient relationship less well relationship & its uses recognized & demonstrated or used valued If no cure, recognizes need for If no cure, the patient is often discharged continuing care and support Patient’s viewpoint and autonomy Less recognition of patient’s recognized viewpoint and autonomy Preventive attitude i.e., care is Care is mostly reactive both proactive and reactive GUIDE 142  Forensic medicine 1- Identification 2- Death 3- Postmortem changes 4- SND 5- Asphyxia 6- Crime scene GUIDE 181  IDENTIFICATION ❑ Definition: - Identification is the recognition (‫ )التعرف‬of an unknown person (living, dead or body remains as bone, hair, and nail) through certain characters, which differentiate him from others. Identification of Bones - The medicolegal report that identifies a collection of bones must contain the following points. Are the bones human or not? Are the bones belonging to one person or more? Identification of sex. Identification of age. Identification of race. Are the bone human or not? 1- Visual identification: in case of complete bone as skull. 2- Precipitin test:  in case of bone fragments, we can know the origin of the bone either human or animal. Are the bone belonging to one person or more? 1- Repetition of the same bones: more than one skull, more than one right femur… 2- Different bones of different ages and sexes. Identification of sex: - Identification of sex from bones occurs usually after puberty. GUIDE 182 A- Identification of sex from skull: VIQ Parameters Male Female Parietal and frontal eminence Prominent Smooth Superciliary ridges Prominent Less prominent Frontonasal junction Angular Smooth Mastoid processes Long Short Occipital condyles Long narrow Short, broad B- Identification of sex from sternum: Parameters Male Female Size Longer and broader Shorter and narrow Relation between The body is more than double The body is less than double the body and the the length of the manubrium the length of the manubrium manubrium C- Identification of sex from hip bone: Parameters Male Female Iliac crest More curved Less curved Greater sciatic notch Narrow & deep Wide & shallow Obturator foramen Oval Triangle Acetabulum Deep & wide Shallow & narrow Ilio-pectineal line Sharp Smooth Body of the pubis Long & narrow Short & square Preauricular sulcus Shallow and ill-defined Deep in multipara Subpubic arch Inverted V-shaped Inverted U-shaped Pelvic cavity Deep & narrow Shallow & wide D- Identification of sex from sacrum: Parameters Male Female Shape Long, narrow and curved Short, wide and straight Promontory Projected Less projected Sacroiliac joint Reaches the 3rd sacral piece Reaches to the 2nd sacral piece Coccyx Less movable More movable GUIDE 183  Identification of age from bones: A) Identification of age from skull: 1. Dimension: Head circumference of full term = 13 inches its length = 5 inches its width = 4 inches. 2. Fontanels ‫اليافوخ‬ Posterior fontanel close at full term. Anterior fontanel closes at 2 years. 3. Sutures: Frontal suture: close at 2 years. Coronal suture: close at 40 years. Sagittal suture: close at 25-30 years. Lambdoid suture: close at 50 years. Basi-occipital bone unites with basi-sphenoid at 23 years. 4. Mandible: Identification of age from mandible depend on the angle between the body of the mandible and the ramus: ▪ Infant: the angle is obtuse. ▪ Middle age: the angle is right. ▪ Old age: the angle is obtuse and the alveolar margins become absorbed. 5. Teeth: Milk dentition: ▪ Central incisor: 6 months. ▪ Lateral incisor: 9 months ▪ First milk molar: 12 months ▪ Canine: 18 months. ▪ Second milk molar: 24 months. Permanent dentition: ▪ First molar: 6 years. ▪ Central incisor: 7 years. ▪ Second bicuspid: 10 years. ▪ Lateral incisor: 8 years ▪ Canine: 11 years. ▪ First bicuspid: 9 years. ▪ Second molar: 12 years. ▪ Third molar (wisdom tooth): 18-25 years. GUIDE 184 B) Appearance of ossific centers (‫)مراكز التعظم‬: 1- During intrauterine life: Age Ossific center 5 months Calcaneus 7 months Talus 8 months Lower end of femur 9 months (full term) Cuboid, upper end of the tibia and the lower end of the femur reach 0.5 cm in diameter. 2- After birth: Age Ossific center 1 year Head of femur and humerus 2 years Lower ends of radius, tibia and fibula 6 years Lower end of ulna, upper end of radius and medial epicondyle 12 years Upper end of ulna and lateral epicondyle C) Union of epiphysis: 1- Upper limb: Age Union of epiphysis 14 years Trochlea with capitulum of humerus 15 years Trochlea and capitulum with the shaft of humerus 16 years Lateral epicondyle and upper end of ulna 17 years Medial epicondyle and upper end of radius 18 years Metacarpal and phalanges with shafts 20 years Head of humerus and lower end of radius & ulna 23 years Sternal end of the clavicle 2- Lower limb: Age Union of epiphysis 16 years Lesser trochanter of femur 17 years Greater trochanter of femur 18 years Head of femur and lower ends of tibia and fibula 21 years Lower end of femur and upper end of tibia GUIDE 185 3- Hip bone: Age Union of epiphysis 6 years Pubic ramus unites with ischial ramus 15 years Ileum, ischium and pubis unite at the acetabulum (y shaped suture disappears) 21 years Ischial tuberosity 23 years Iliac crest 1. Sternum: xiphoid process unites with the body at 40 years and the manubrium unites with the body at 60 years. 2. Hyoid bone: the greater cornu unites with the body at 40 years. 3. Medullary cavity of the humerus: it reaches the surgical neck at 30 years and reaches the anatomical neck at 33 years. N.B.: The above-mentioned ages are those for male, but in females union occurs 1-2 years earlier. Identification of race - The most important points of differentiation are present in skull. General characters of Negroid skull: VIQ 1- Persistent frontal suture. 2- Absence of H-shaped suture (the four bones of the skull meet at one point). 3- Flat nasal bridge with wide nasal apertures. 4- Flat palate with prognathism (protrusion of upper jaw). 5- Dolichocephaly (elongation of the antero-posterior diameter of the skull). 6- Small mastoid process. GUIDE 186  Identification of the dead - Identification of dead body can be established by examination of: 1. Clothes: are examined for: tailor’s labels identity cards books… etc. tears letters missing buttons pocket 2. External appearance: color of skin, hair, eyes, shapes of nose, mouth, ears…etc. 3. Sex: - External examination - Internal examination: e.g. uterus, ovaries, undescended testis…etc. - Cell sexing: Sex chromatin test:  female cells show Barr body in the form of chromatin mass attached to the inner surface of the nuclear membrane, but male cell do not show that Barr body. Davidson body test:  white blood cells of females show a thin stalked drum-stick projection in the polymorph nucleus. 4. Age ▪ During the first 2 years of life: a) Milk dentition. b) Bone. c) Body weight: ▪ At birth → 3-3.5 kg ▪ At 12 month → 9 kg ▪ At 6 month → 6 kg ▪ At 2 years → 12 kg ▪ Between 2-6 years: a. Body weight: age in years = (weight in kg-8)/2. b. Ossification centers. ▪ Between 6-25 years: a. Union of epiphysis. c. Signs of puberty. b. Ossification centers. GUIDE 187  ▪ Above 25 years: a. Skull sutures. b. Sternum and hyoid bone. c. Signs of senility: grayness of hair, wrinkles of skin, etc… 5. Race: Race can be determined from: color of skin, hair, iris, skull features…etc. 6. Finger print: it is the most accurate method for identification. 7. Social status and occupation may be identified from the clothes or stain on the fingers 8. Examination for presence of congenital malformation: birth marks operations tattoo marks scars, …etc. Identification of living persons - Identification of a living person is very important in civil cases as marriage, inheritance or in case of people impersonating somebody else to obtain unlawful property. - Identification of living body follows all the points mentioned for the dead with the addition of certain features particular to living as: 1. Character of voice. 4. Manner of speech. 2. Gait. 5. Hand writing 3. Degree of education. Table (18): Ages of Medicolegal Importance: Age Medicolegal importance Identification - Eruption of first permanent molar. - Pubic ramus unites with ischial ramus. 6 years - Age of starting education - Appearance of ossific centers of upper end of radius, lower end of ulna & medial epicondyle - Age of discrimination - Eruption of permanent central incisor 7 years and between right wrong - Ossific center occupies 2/3 of the breadth of lower end of radius GUIDE 188  - Under this age the boy 14 cannot commit the crime - Trochlea units with the capitulum years of rape 15 - Age of end of maternal - Union of y-shaped suture between ileum, years custody. ischium and pubis of hip bone. - Age of getting identity cards. - Union of trochlea and capitulum with the shaft of humerus 18 - Legal age of marriage of - In male: years male and female - The age of female consent  union of epiphysis of metacarpal and phalanges, head of femur and lower ends in rape. of tibia & fibula. - Age of getting driving license. - In female: - Age of governmental  union of epiphysis of head of humerus & employment. lower end of ulna and radius. - Voting in election. - Criminal responsibility. - First military call. 21 - Age of full civil rights - In male: years - Age of recruitment of  union of epiphysis of lower end of femur military service and upper end of tibia & ischial tuberosity. - In female:  union of sternal end of clavicle, epiphysis of iliac crest, basi-occiput with basis phenoid. 30 - Age for being a member of - Closure of sagittal suture but coronal suture is years people assembly still open 35 - Legal age of being president - As age 30 years 60 - Pension age ‫سن المعاش‬ - Manubrium & the body of sternum years GUIDE 189  Identification of Hair and Fibers A. Medicolegal importance of hair examination: 1- Personal identification from colour and distribution of hair. 2- Identification of the suspected assailant: - by comparing the hair present at the scene of the crime or in the hand of the victim with the hair of the suspected assailant. 3- In case of rape: the assailant may have some hair of the victim in his private parts. 4- Differentiation of incised wound in scalp (hair is sharply cut) and lacerated wound (hair is crushed). 5- Differentiation between dry burn (hair is singed and coma shaped) and scald (hair is wetted). 6- Diagnosis of firearm injuries and estimation of the distance of firing (singed hair). 7- Diagnosis of poisons as heavy metals by chemical analysis of hair. 8- Identification of disputed child from the color and form of hair. 9- Identification of the race by the color and form of the hair (black & pepper corn in Negroid, black & straight in Indian and silky & light brown in Europeans). 10- Identification of the source of hair by the presence of vaginal, seminal or nasal secretion sticking to it. 11- Examination of the hair tip gives an idea about the time since it has been cut: a- Acute angle → recently cut. b- Round end → few days. c- Tapering end → 2 weeks. 12- Examination of the hair root denotes whether it has fallen by itself (degenerated root) or has been pulled out by force (healthy root with rupture sheath). GUIDE 190 ❑ Difference between human hair and animal hair: Human hair Animal hair Cuticle Regular, formed of one cell Irregular, formed of more than one layer with no scales cell layer with scales Cortex Broad without transverse Narrow with transverse striation striation Medulla Narrow, interrupted and may Broad and continuous be absent B. Certain fibers must be differentiated from hair as: 1. Cotton fibers → flattened twisted ribbons. 2. Silk fibers → regular, cylindrical and retractile. 3. Linen fibers → linear, segmental with swellings (like bamboo). 4. Wool fibers (animal hair) → wavy with irregular thickness. GUIDE 191