Levels of care
Paper for discussion
1st level
BHU/dispensary
Vision
- Easy access (geographical, financial, timely) for people/patients
- Comprehensive service from one point with 90% of health care needs taken care, patients do
not need to seek or travel to other facilities in majority of cases
- Close relationship between doctor/nurse and patient/family
- Decent/nice facilities
- People aware of the BHU work and role, happy to go there
Tasks
- First point of contact for patients (including community health workers)
- Diagnosis and treatment
- Gatekeeper for the rest of the system, referral to next levels of care
- Coordination of care across levels of care (responsible for patient pathway)
- Chronic disease management
- Prevention and health promotion activities like vaccination and lifestyle counselling
- Population outreach (active) for identification of persons at risk (e.g. for NCDs)
- Monitoring of population health status (e.g. levels of blood pressure or overweight in the
population served or sub-population at risk for certain diseases)
- Training centre for family medicine specialists (doctors and nurses)
Description
- 1 per 10 000-20 000 (?) population depending on population density (serving more population in
areas with higher population density)
- Lists of attached patients (catchment area possibly across administrative borders)
- Geographically close to patients
- Defined service package that integrates services from Essential Service List, vertical programs,
LHW activities and other related services
- 1-3 family medicine physicians (FMP) per BHU
- Team-based approach – 4-6 nurses and other ancillary staff per physician
- Nurses perform triage of patients, and provide services to majority (60-70%?) of the patients
with only complicated cases seeing the doctor
- Potentially specialised nurses with individual consultations e.g.
o diabetes nurse
o public health nurse (prevention and health promotion)
- Integration of vaccination specialist and other professionals from vertical programs into BHU
team
- Inclusion of a social care worker in the team/BHU ???
- Managerial autonomy under supervision of DHO/authorities with potentially a dedicated
financial/managerial officer in the BHU
o Prepare budget requests and planning
o Can procure consumables etc inside the agreed/approved budget
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Coordination of community health workers (LHW and potentially others) in the area with
medical advice/support as necessary
Basic equipment to be defined but include:
o EKG
o possibility to take samples for laboratory tests,
o measurement of blood pressure, height and weight
o basic surgical equipment to treat minor wounds
o equipment for monitoring normal pregnancies
o equipment for monitoring child development for all ages
o IT equipment and work stations for doctors and nurses with access to e-Health services
Room for procedures
Potentially 1-2 rooms for specialist consultations on a rotation basis from the next level
(RHC/dispensary)
Referral to next level
o RHC – outpatient specialist care
o Hospitals – (highly) specialised outpatient consultation and inpatient care
2nd level
Rural health centre and their equivalent in urban areas,
Vision
- Easy access (geographical, financial, timely) for people/patients
- Support to facilities/professionals on the first level
- Coordination of work between facilities on the first level
- Diagnostic centre for the area
- First level of specialist consultation
- ??? Training platform for the health professionals in the area for mandatory trainings (delivered
by external teachers e.g. from universities)
Tasks
- First point of referral from BHU/dispensaries
- Diagnostic centre for BHUs in the area (CT, ultrasound, X-ray, laboratory, etc.)
- Specialised outpatient services (consultations)
- Potentially specialist consultations in the BHUs/dispensaries on the rotational basis
- Consulting family medicine specialists to support BHUs/dispensaries on complex cases and
organisation of work there
- Consulting of BHU/dispensary staff on complex cases there
- Referral to inpatient care
- Training centre for nurses and doctors
Description
- Per 30 000-80 000 population (?), per 3-5 BHU/Dispensary
- Small number of beds for patient status monitoring and recovery after procedures (no overnight
stay)
- Geographically relatively close to the patients and BHUs/dispensaries in the area, easy access
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Defined service package that integrates services from Essential Service List and potentially also
some activities from vertical programs that are suitable for this level of care
1-2 consulting family medicine specialists
3-5 (?) specialists per speciality (depending on the disease profile of ICT/area)
o Gynaecology/obstetrics + midwives
o Cardiologists
o Internists
o Infectionists
o Traumatologist (?)
o General surgeon
o Ear, throat, nose
o Pulmonologist
o Physiotherapists and rehabilitation specialists
o ???
Team-based approach – if a patient has several health complaints, diagnosis and care/treatment
plan prepared/agreed by team of specialists across specialities
??? Number of nurses and ancillary staff ???
Laboratory for the population in the area
Diagnostics
o X-ray
o CT?
o Ultrasound
o ???
Rooms for minor surgery, wound cleaning
??? Room for normal birth deliveries ???
Foot clinic for diabetes patients?
Patient education centre for cancer, diabetes (e.g. cooking classes) and other patient groups???
Rooms for physiotherapy and rehabilitation ???
Long-term care facilities and hospices???
For elderly and disabled who need 24/7 medical supervision or terminal patients
??? Or should these be on the next level and attached to hospitals…
3rd/4th level
Tasks
- Specialist outpatient care for (highly?) complex cases
- Inpatient care