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FOUNDATION OF NURSING

Health Care Delivery System

### Lecturer: AJIBADE O.S

Structure of Primary, Secondary and Tertiary Facilities and Social Services

Learning Outcomes

At the end of this lecture/discussion, learners should be able to:
- Define health care delivery system.
- Identify factors influencing the health care delivery system.
- Understand the different levels of the health care delivery system, globally and specifically in Nigeria.
- Describe services provided at each level of the system.

- Describe the role of nursing at each level of the health care system (HCS).

What Is Health Care?

Health care is an organized way of medical care concerned with the maintenance of the health of the whole body.
It is delivered by healthcare providers or professionals in various fields such as:
- Nursing
- Pharmacy
- Medicine
- Dentistry
- Psychology
Influential aspects include:
- Social conditions
- Economic conditions
- Health policies of the place

- Healthcare varies across different countries, individuals, and groups.

Types of Health Care

Primary Health Care

Primary health care aims to provide local and basic care to patients.

Secondary Health Care

Provided by medical specialists.
Patients require a referral from primary care professionals to proceed further for secondary care, which depends on the country.

Tertiary Health Care

- Known as specialized consultative healthcare, typically for in-patients referred from primary and secondary healthcare for advanced medical investigation and treatment.

What Is Health Care System?

A health care system encompasses the totality of services offered by all health disciplines.

- It is recognized as one major industry in all societies (Berman, Snyder, Kozier, & Erb, 2008).

Factors Influencing Health Care System

Various factors influence the healthcare system and its operations:
- Educational system
- Socio-demography of the population
- Political system/law
- Economics of the nation
- Technological advancements

- Training of professionals at different levels

Levels of Health Care System

Primary Health Care System

First level of contact for individuals, families, and communities.
Provides primary prevention services.

Secondary Health Care System

Focuses on secondary prevention, primarily in hospitals and clinics.
Provides resources for patients requiring emergency, intensive, and acute care, as well as promotion and illness prevention.

Tertiary Health Care System

Goals include providing tertiary prevention in the form of rehabilitation, health restoration, and palliative care.

- Tertiary prevention aims to help individuals regain their previous level of health or achieve the highest level they can, given their current health status.

Structure of Primary, Secondary, and Tertiary Facilities

Health care provision in Nigeria operates under the functions of the three tiers of government:
- Federal Government
- State Government
- Local Government
According to the Nigerian constitution, each level shall support a coordinated three-tier system of health care:
- Primary Health Care (Local Governments)
- Secondary Health Care (State Governments)

- Tertiary Health Care (Federal Governments)

Organizational Pyramid of the Nigerian Health Services Structure

Administrative Levels

Federal Government
State Government
Local Government Areas

Service Structure

Tertiary Health Services: Managed by the Federal Ministry of Health.
Secondary Health Services: Managed by the State Ministry of Health.
Primary Health Services: Managed by Local Government Areas.

- Private Sector: Includes private services and providers.

Structure of Primary Facility: History and Conceptualization of PHC

The concept of Primary Health Care (PHC) was formulated at the Alma Ata conference on 12th September 1978, with participation from 134 countries organized by WHO and UNICEF.

- In Nigeria, PHC was adopted in the National Health Policy of 1988 to improve equity in access to basic health services.

Stages of PHC Development in Nigeria

First Stage (1975-1980): Introduction of the Basic Health Services Scheme (BHSS).
Second Stage (1986-1992): Development of model PHC in 52 pilot local government areas focusing on implementing all eight components of PHC.
Third Stage: Establishment of National Primary Healthcare Development Agency (NPHCDA) in 1992, with the Ward Health System (WHS) instituted as the basic operational unit for primary health care delivery.

4. PHC Under One Roof Policy: Introduced in 2011 to address fragmentation and ensure integration of PHC services under one authority.

Levels of Operation at PHC

Level 5

Medical Officer of Health (MOH): Supervises a group of PHC centres in each Local Government.

Level 4

Nurse/Midwife: Heads a PHC centre and consults with the supervisory MOH in difficult cases.
If there are no medical officers, the most senior nurse acts as supervisor.

Level 3

Community Health Officers (CHOs): Head a PHC centre in the absence of a nurse and have received additional training beyond Community Health Extension Workers (CHEWs).

Level 2

Community Health Extension Workers (CHEWs): Trained for three years in Schools of Health Technology and qualify with a diploma.

Level 1

- Volunteer Health Workers (VHWS) and Traditional Birth Attendants (TBAs): Informally trained staff aiding PHC centres in case finding and community engagement.

Secondary Level of Health Care

- Managed by the State Ministry of Health, providing specialty services and accepting referrals primarily from primary care.

Tertiary Health Care System

Provided by teaching hospitals and specialist hospitals.
Chief Medical Director (CMD) or Medical Director (MD) manages the hospital.
Staff organization includes:
- Doctors under the Chairman of the Medical Advisory Committee (CMAC).

- Nurses under the Director of Nursing Services.

Hospital and Ward Organizations

Learning Outcome

Define hospitals.
Describe a ward.
Enumerate classifications of hospitals.
Explain various hospital dimensions.

- Describe admission, discharge, and referral processes.

Hospital Definition

Hospitals are institutions providing medical and surgical treatment and nursing care for sick or injured individuals.
A ward is a room with bed(s) where patients are admitted.
Types of hospital entrances:
- Patient/Visitor entrance
- External Clinics entrance
- Service entrance

- Mortuary entrance

Classifications of Hospitals

By Level of Care

Secondary Hospitals: district and specific hospitals.
Tertiary Hospitals: specialized and educational hospitals.

By Size

Mini size: < 50 beds
Mid size: 50-250 beds
Large: 250-500 beds
Huge: >500 beds

By Size of Medical Specialists

Specialists
General

By Ownership

Private

- Public

Elements and Divisions of the Hospital

Main Divisions

Admission Division:
- Reception hall, waiting area, registration, accounts, staff offices, general managers' offices, staff lounge, toilets.
- Should be located near hospital entrance.
Out-patient Division:
- Consists of outpatient clinics and pharmacy with consultation, examination and treatment rooms, waiting areas, staff room, toilets.
- Located near main entrance, close to pharmacy and diagnostic services.
Emergency Reception Components:
- Entrance/waiting area, registration, staff room, mini surgery, test room, medical utilities room, mini sterilization room.
- Located close to emergency area, radiology, laboratories, and sterilization.
Diagnostic Services:
- Laboratories include work area, waiting area, sample room, cleaning room, and staff offices.
- Radiology includes X-ray rooms, control room, waiting area, staff offices, utility room, dark room, film view and store, ideally placed close to emergency.
Therapeutic Services Division:
- Includes physical therapy with waiting area, office, hydrotherapy, exercise room, toilets, ideally located on the ground floor.
Internal Medical Treatment Division:
- Comprises operating theatres, intensive care unit, maternity section, central sterilization department, needing close proximity to emergency unit.
Inpatient Division:
- Patient wards, nurses' wards, inpatient services, mortuary, and security, focusing on accommodating 60 patients with sufficient space for beds, treatment, and nursing facilities.
General Service Division:
- Storage room, kitchen, preparation area, and clean-up area, needing direct access to service entrance.
Housekeeping Division:
- Includes office, dirty linen room, storage, laundry, requiring proximity to central storage on ground floor.
Mortuary Division:

- Should be located on the ground or basement floor with exits to emergency and service entrance.

Reception and Admission Procedures

Admission Definition

Admission refers to allowing a patient to stay in the hospital for observation, investigation, and treatment of disease.
Procedures may vary depending on facility, patient condition, and diagnosis.
Types of admission include:
- Emergency admission
- Routine admission
- Transfer between units.

Outpatient Admission

Initial patient greeting to ensure comfort.
Critical treatment initiation in emergency situations.
Gather social and medical data for patient identification.

- Includes collecting medical history, physical examination, checking vital signs, and laboratory investigations.

Inpatient Admission

Nurse's demeanor is crucial for patient cooperation.
Severely ill patients placed in beds immediately.
For less ill patients, a tour of the unit/ward is provided.

- Collect and record patient data and explain hospital policies, check orders, and commence care.

Transfer Admission Procedure

Involves reassuring patients and relatives about transitions.

- Introduce the patient to the new ward staff.

Admission Procedure Materials

Patient registration card
Admission application form
Hospital wear

- Health insurance card (if available).

Common Patient Questions

Duration of hospital stay?
Expectations during hospitalization?
Discharge plans?
Follow-up care requirements?

- Special equipment or care needed at home?

Referral Process

Definition

Referral in health care delivery is transferring responsibility for care to another health worker/facility with appropriate skills in managing the condition (Price & Adomakoh, 2006).

Types of Referral Systems

Referrals can be from lower to higher levels for effective management, or vice versa for continuity and follow-up care.

Reasons for Referral

Promotes relationships between health system levels.
Ensures quality services and optimal care.
Enhances utilization of primary health services.
Facilitates decision-making at lower levels (Asfar & Younnus, 2004).

Components of Referral System

- Comprises health system issues, initiating facility, referral practicalities, receiving facility, supervision and capacity building, continuous quality improvement (WHO, 2004).

Discharge Procedures

Definition

Discharge planning prepares a client to leave one level of care for another within or outside the current health agency, typically focusing on home discharge.

- It needs to begin upon admission to ensure comprehensive assessments throughout the stay.

Key Items in Discharge Planning

Evaluation by qualified personnel.
Discussion with the patient or representative.
Planning for homecoming or transfer to another facility.
Determining caregiver training needs.
Referrals to home care agencies.

- Arranging follow-up appointments/tests.

Nurse's Responsibilities

Assess client data and capabilities for daily activities.
Evaluate caregiver responses, financial resources, and community supports.
Identify home hazards and the need for health assistance.
Teach clients coping skills and self-care practices.

- Provide written and verbal information on medication, dietary restrictions, activity limitations, warning signs, and follow-up plans.

Common Care Responsibilities Following Discharge

Personal care: bathing, eating, dressing, toileting.
Household care: cooking, cleaning, laundry, shopping.
Healthcare: medication management, physician’s appointments, physical therapy, wound treatment, injections, medical equipment handling.

- Emotional care: companionship and meaningful activities.

Health Maintenance Agencies: National/International

Health Maintenance Organizations (HMOs) provide maintenance and treatment services to enrollees for a predetermined fee, regardless of the services provided.

Origin of the Term HMO

Coined by Dr. Paul Elwood in the 1970s during the evolution of Private Provider Group Practice in California, USA.

Value-driven System of Managed Care

Focuses on delivering affordable health services while bearing the risk of utilization costs, governed by explicit and implicit rules. ---

Mode of Operation

Use of exclusive provider networks.
Primary care providers (PCP) can act as gatekeepers for specialist referrals.
Open access plans allow choosing any PCP or specialist without referral.

Provider Contracting

HMOs may contract directly with physicians or have network arrangements (IPA model) or staff-model HMOs (in-house or salary arrangement).
This limits client choices but offers reduced healthcare costs. ---

Characteristics of HMOs

Contractual responsibility for the delivery of a defined range of services, including in-patient care.
Serve a voluntarily enrolled population.
Fixed premiums regardless of service utilization, with possible co-payments for certain services.

Nigerian Health Insurance Scheme (NHIS)

Establishment

Created in 2005 under Decree 35 of 1999, initially proposed in 1962, aimed at ensuring access to good healthcare, protecting from financial burdens of medical expenses.

Objectives

Limit costs of health services while maintaining efficiency and equitable distribution.
Improve private sector involvement, ensuring a balanced distribution of health facilities.
Secure funding availability for enhanced health services. ---

Roles of HMOs in Nigeria

Collection of employer-employee contributions
Registration and quality assurance of service providers.
Providing health promotion and educational initiatives.
Facilitating a quality assurance system for effective healthcare services.

Responsibilities

Process claims, market health plans to public/private employers, and engage in effective marketing strategies. ---

Major International Health Agencies

Multilateral Agencies

Significant contributors include organizations like WHO, which aims at universal health improvements and coordinates international health activities on global health concerns.

The World Bank

Focused on lending to low-income countries under favorable conditions which are not competitive in commercial markets.

UNICEF

- Allocates substantial resources to healthcare, prioritizing the world's most vulnerable children, dedicating a significant proportion of its budget to healthcare initiatives.

Bilateral Agencies

Governmental agencies from individual countries (example: USAID) that provide aid determined often by political/historical factors.

Non-governmental Organizations (NGOs)

Known as private voluntary organizations (PVOs), providing about 20% of all external health aid.
Example includes Project Hope, a notable NGO focused on international health. ---

References

Asfar, H.A., & Younnus, M. (2004). Patient Referral at the Grass –roots level in Pakistan, Nature and Science, vol.2, no.4, pp18-27.
Berman, A., Snyder, J.S., Kozier, B., & Erb G. (2008). Fundamentals of Nursing: Concepts, Process and Practice 8th edition, Pearson Education, Inc.
Health Insurance (2015). What is the Role Of Health Maintenance Organizations In Nigeria.
WHO, 2004. Referral Practices in Health Services.

- Obawale, R. (2015). HMO characteristics and operations.

Note: References provided for additional study & verification.