Community MedicineCommunity MedicineA system of delivery A system of delivery

of comprehensive health of comprehensive health care to the people by a care to the people by a health team in order to health team in order to

improve the health of the improve the health of the communitycommunity

..

Clinical MedicineClinical Medicine Community MedicineCommunity Medicine

AimAim

To shorten morbidity and To shorten morbidity and prevent mortality in a ill or prevent mortality in a ill or diseased person Explore diseased person Explore methods which would methods which would reverse or eliminate disease reverse or eliminate disease statesstates

To reduce unnecessary To reduce unnecessary morbidity and premature morbidity and premature mortality in the whole mortality in the whole population Explore greatest population Explore greatest potential health potential health improvementimprovement

ObjectiveObjective Cure patient of diseaseCure patient of disease Improve health status of a Improve health status of a communitycommunity

Information Information requiredrequired

Clinical history, Physical Clinical history, Physical examination and laboratory examination and laboratory teststests

Population data, Health Population data, Health problems, disease pattern, problems, disease pattern, availability of health services. availability of health services. Felt needs of the Community.Felt needs of the Community.

DiagnosisDiagnosis Differential diagnosis and Differential diagnosis and probable diagnosisprobable diagnosis

Community DiagnosisCommunity Diagnosis

Action PlanAction PlanTreatment & rehabilitation Treatment & rehabilitation Community health ProgramCommunity health Program

EvaluationEvaluation Follow up and assessmentFollow up and assessment Evaluation of change in health Evaluation of change in health statusstatus

Health IndicatorsHealth Indicators

To measure Health status of a Community / To measure Health status of a Community / countrycountry

Comparison of health status between two Comparison of health status between two communities/Countries.communities/Countries.

Assessment of health care needsAssessment of health care needsAllocation of scare resourcesAllocation of scare resourcesMonitoring & Evaluation of health services, Monitoring & Evaluation of health services,

activities & programmes.activities & programmes.The extent to which the objectives & targets are The extent to which the objectives & targets are

being attained.being attained.

Indicator:Indicator:Indicators are an indication of a given Indicators are an indication of a given situation or a reflection of a situation.situation or a reflection of a situation.

Variable:Variable:A characteristic of interest in a study that A characteristic of interest in a study that has different values for different objects has different values for different objects and subjects.and subjects.

- which helps to measure changes- which helps to measure changes- These can indicate direction and - These can indicate direction and speed of change speed of change- Serve to compare different areas or - Serve to compare different areas or groups of people at the same time. groups of people at the same time.

Characteristics of an indicator:-Characteristics of an indicator:-

i. Validi. Valid ii. Reliableii. Reliable

iii. Sensitive iii. Sensitive iv. Specificiv. Specific

v . feasiblev . feasible vi. Relevant.vi. Relevant.

Health IndicatorsHealth Indicators

Mortality indicatorsMortality indicators Morbidity indicatorsMorbidity indicators Disability ratesDisability rates Nutritional status indicatorsNutritional status indicators Health care delivery indicatorsHealth care delivery indicators utilization ratesutilization rates Indicators of social and mental healthIndicators of social and mental health Environmental indicatorsEnvironmental indicators Socio-economic indicatorsSocio-economic indicators Health policy IndicatorsHealth policy Indicators Indicators of quality of lifeIndicators of quality of life other indictorsother indictors

Mortality IndicatorsMortality Indicators

Crude death rate (CDR)Crude death rate (CDR) Expectation of lifeExpectation of life Infant mortality rate (IMR)Infant mortality rate (IMR) Child mortality rate (CMR)Child mortality rate (CMR) Under -5 Mortality rate (U5MR)Under -5 Mortality rate (U5MR) Maternal mortality rate (MMR)Maternal mortality rate (MMR) Disease specific mortality rate (DSMR)Disease specific mortality rate (DSMR) Proportional mortality rateProportional mortality rate

Morbidity IndicatorsMorbidity Indicators

– Incidence and PrevalenceIncidence and Prevalence– Notification ratesNotification rates– Attendance rates at out-patient departments, Attendance rates at out-patient departments,

health centers, etc.health centers, etc.– Admission, readmission and discharge ratesAdmission, readmission and discharge rates– Duration of stay in hospital andDuration of stay in hospital and– Spells of sickness Spells of sickness – Absence from work or school.Absence from work or school.

Disability IndicatorsDisability Indicators

a) Event-type indicators:a) Event-type indicators:i) Number of days of restricted i) Number of days of restricted

activityactivityii) Bed disability daysii) Bed disability daysiii) Work-loss days iii) Work-loss days

iv) School loss days within a iv) School loss days within a specified specified period period

b) Person-type indicators:b) Person-type indicators: i) Limitation of mobilityi) Limitation of mobility ii) Limitation of activityii) Limitation of activity

Nutritional Status IndicatorsNutritional Status Indicators

a)a) Anthropometric measurements ofAnthropometric measurements of

preschool children, e.g., weight and height, preschool children, e.g., weight and height, mid-arm circumference;mid-arm circumference;

b) Heights (and sometimes weights ) ofb) Heights (and sometimes weights ) of

children at school entry; and children at school entry; and

c) Prevalence of low birth weight – LBWc) Prevalence of low birth weight – LBW

(less than 2.5 kg).(less than 2.5 kg).

Health Care Delivery indicatorsHealth Care Delivery indicators

a) a) Doctor-population ratioDoctor-population ratio

b) Doctor-nurse ratiob) Doctor-nurse ratio

c) Population –bed ratioc) Population –bed ratio

d) Population per health center /subcentred) Population per health center /subcentre

e) Population per traditional birth attendante) Population per traditional birth attendant

f ) Availability of health servicesf ) Availability of health services

g) Accessibility of health care servicesg) Accessibility of health care services

h) Utilizationh) Utilization

I ) Quality of health care deliveryI ) Quality of health care delivery

Utilization ratesUtilization rates

Proportion of infants who are “fully immunized” against Proportion of infants who are “fully immunized” against the 7 EPI diseases.the 7 EPI diseases.

Proportion of pregnant women who receive antenatal Proportion of pregnant women who receive antenatal care, or have their deliveries supervised by a trained birth care, or have their deliveries supervised by a trained birth attendant.attendant.

Percentage of the population using various methods of Percentage of the population using various methods of family planning.family planning.

Bed-occupancy rate (i.e., average daily in-patient Bed-occupancy rate (i.e., average daily in-patient /average number of beds)./average number of beds).

Average length of stay (i.e., days of care rendered / Average length of stay (i.e., days of care rendered / discharges).discharges).

Bed turn-over ratio (i.e., discharges/average beds).Bed turn-over ratio (i.e., discharges/average beds).

Socio-economic indicatorsSocio-economic indicators Rate of population increaseRate of population increase Per capita GNPPer capita GNP Level of unemployment Level of unemployment Dependency ratioDependency ratio Literacy rates, especially female literacy rateLiteracy rates, especially female literacy rate Family size.Family size. Housing: the number of persons per roomHousing: the number of persons per room Per capita “calorie” availabilityPer capita “calorie” availability Working conditionsWorking conditions Income distributionIncome distribution

SOCIAL INDICATORSSOCIAL INDICATORS

1.POPULATION2.FAMILY FORMATION & HOUSEHOLD3.EDUCATIONAL OPPORTUNITIES4.EARNING ACTIVITIES5.SOCIAL SECURITY & FAMILY WELFARE6.HEALTH SERVICES7.NUTRITION 8.INCOME DISTRIBUTION9.ENVIRONMENT 10. PUBLIC ORDER & SAFETY11.TIME USE AND LEISURE, RECREATION12.SOCIAL STRATIFICATION AND MOBILITY

Selected health and socio-economic indicatorsSelected health and socio-economic indicators

Least developed Least developed countriescountries

Developing countriesDeveloping countries Developed countriesDeveloped countries

1. Life expectancy at birth (2002)1. Life expectancy at birth (2002) 4949 6262 7878

2.IMR (per 1000 live births)(2002)2.IMR (per 1000 live births)(2002) 9999 6262 55

3. Under 5 mortality per 1000 live 3. Under 5 mortality per 1000 live births (2002)births (2002)

158158 9090 77

4. Maternal mortality Rate per 4. Maternal mortality Rate per 100,000 live births (2002)100,000 live births (2002)

890890 440440 1313

5. Doctor-population ratio per 5. Doctor-population ratio per 10,000 (2002)10,000 (2002)

1.41.4 8.48.4 25.225.2

6.Nurse-population ratio per 6.Nurse-population ratio per 10,00010,000

2.22.2 9.69.6 74.274.2

7. GNI, per capita (US $ ) (2002)7. GNI, per capita (US $ ) (2002) 277277 11541154 2821428214

8. Per capita public expenditure 8. Per capita public expenditure on health, US $ in% of GDP on health, US $ in% of GDP

55 44 1414

9. Adult literacy rate (%) (2002)9. Adult literacy rate (%) (2002) 53.353.3 74.574.5 9797

10. Per Capita calories10. Per Capita calories 20992099 26632663 33713371

11. Access to safe water (2002)11. Access to safe water (2002)

% population.% population.

6262 7878 100100

12. Access to adequate 12. Access to adequate sanitation (2002) % population.sanitation (2002) % population.

4444 5252 100100

Health Policy IndicatorsHealth Policy Indicators

Political commitment to health for allPolitical commitment to health for all Resource allocation, GNP spentResource allocation, GNP spent Degree of equity distribution of health Degree of equity distribution of health

services.services. Community InvolvementCommunity Involvement Organization frame workOrganization frame work Managerial Process.Managerial Process.

LIFE EXPECTANCY84.7

82.480.4

76 75.5

82.279.7

63 64

77.7 77.475.4

7369.6

75.8 74

6162.8

0

10

20

30

40

50

60

70

80

90

J apan Sweden UK Kwiat Srilanka Switzer land USA Pakistani India

COUNTRY

YEAR

S

WORLD POPULATION (MILLIONS)

791978

1262

1650

2526

3037

3696

4066

4432

5000

5385

58846054

6225

0

1000

2000

3000

4000

5000

6000

7000

Y 1750 Y 1800 Y 1850 Y 1900 Y 1950 Y1960 Y1970 Y1975 Y1980 Y1987 Y1991 Y1998 Y2000 Y2002

YEAR

POPU

LATI

ON

POPULATION OF PAKISTAN (MILLIONS)

28.28233.817

42.978

65.341

84.254

113.78

130.58

154.794

0

20

40

60

80

100

120

140

160

180

1941 1951 1961 1972 1981 1991 1998 2006

YEAR

POP.

IN M

ILLI

ONS

MILLENNIUM DEVELOPMENT MILLENNIUM DEVELOPMENT GOAL INDICATORSGOAL INDICATORS

Eradicate extreme poverty and hungerEradicate extreme poverty and hunger Reduce Child MortalityReduce Child Mortality Improve Maternal HealthImprove Maternal Health Combat HIV/AIDS, malaria and other diseasesCombat HIV/AIDS, malaria and other diseases Ensure environmental sustainabilityEnsure environmental sustainability Develop a global partnership for development Develop a global partnership for development

Comparison of Kerala and all-India Health StatisticsComparison of Kerala and all-India Health Statistics

KeralaKerala All-IndiaAll-India

Death rate/1000(2002)Death rate/1000(2002) 6.46.4 8.18.1

Rural birth rate(2002)Rural birth rate(2002) 16.816.8 25.025.0

Infant mortality rate (2002)Infant mortality rate (2002) 1010 6464

Annual growth rate, per cent Annual growth rate, per cent (2001)(2001)

0.90.9 1.931.93

Life expectancy at birth 2001-06 Life expectancy at birth 2001-06 (Projection)(Projection)

MaleMale

FemaleFemale

66.566.5

71.771.7

7575

61.561.5

64.164.1

65.465.4

Literacy rate, percent(2001)Literacy rate, percent(2001) 90.9290.92 65.3865.38

Female literacy rate (2001)Female literacy rate (2001) 87.8687.86 54.1654.16

Mean age at marriage females Mean age at marriage females (1999)(1999)

22.122.1 19.519.5

Per capita income (2000-01)Per capita income (2000-01) Rs. 21046Rs. 21046 Rs. 16707Rs. 16707

Doctor-population ratio (1991)Doctor-population ratio (1991) 1: 72131: 7213 1:21481:2148