In Turkey - World Bank
Transkript
In Turkey - World Bank
12-13 October 2010 Ankara Prof. Dr. Recep AKDAĞ Human First: “Let Man Flourish and the State will also Flourish!" 2 Health Transformation Program "Mother and Children" It was included in a governmental emergency action plan for the first time. 3 Tunceli Burdur Artvin Uşak Giresun Isparta Sinop Çanakkale Amasya Gümüşhane Erzincan Muğla Trabzon Rize Bingöl Kırşehir Kastamonu Bolu Karabük Balıkesir Bartın Ordu Kırıkkale Erzurum Karaman Denizli Malatya Aydın Tokat Kütahya Zonguldak Niğde Eskişehir Edirne Bitlis Iğdır Bayburt Bilecik Mersin Kırklareli Ankara Ardahan Elazığ Afyon Çankırı Osmaniye Manisa Samsun Nevşehir Sivas Çorum Muş Yozgat Kars Bursa Ağrı Yalova Hakkari Kocaeli Antalya TÜRKİYE Kilis İzmir Tekirdağ Sakarya Konya Siirt Adıyaman K.Maraş Kayseri Aksaray Diyarbakır Şırnak Gaziantep Hatay Mardin Adana Düzce Batman Şanlıurfa Van İstanbul Population per Nurse-Midwife Change by province 2002-2010 2,500 2.090 2,000 1,500 1,000 1.102 500 284 0 December 2002 Aralık 2002 Eylül 20102010 September 4 2,000 Burdur Karabük Artvin Bayburt Sinop Aydın Bolu Erzurum Yozgat İzmir Bartın Kırıkkale Elazığ Tunceli Uşak Isparta Rize Kırşehir Çorum Nevşehir Karaman Bilecik Balıkesir Gümüşhane Amasya Kırklareli Eskişehir Kastamonu Edirne Samsun Çanakkale Giresun Denizli Manisa Erzincan Trabzon Kilis Yalova Çankırı Iğdır Osmaniye Malatya Niğde Muğla Konya Tokat Düzce Sivas Aksaray Kütahya Afyon Adıyaman Sakarya Ardahan Adana Mersin Antalya Bingöl Bursa Kayseri Zonguldak Hatay Diyarbakır TÜRKİYE Ordu Tekirdağ Kocaeli Gaziantep Batman Muş K.Maraş Ankara Kars Mardin Siirt Van Bitlis Ağrı Şırnak Şanlıurfa İstanbul Hakkari Population per general pratitioner change by province 2002-2010 9,000 8.401 8,000 7,000 6,000 5,000 4.209 4,000 3,000 1.677 1,000 0 December 2002 Aralık 2002 September Eylül 2010 2010 5 0 Ankara İzmir Artvin Bolu Isparta Trabzon Tunceli Gümüşhane Edirne Sinop Bayburt Erzurum Burdur Karabük Kırıkkale Elazığ Kilis Aydın Çanakkale Eskişehir Ardahan Sivas Bilecik Rize Erzincan Bartın TÜRKİYE Samsun Kütahya Kırşehir Manisa Zonguldak Iğdır Balıkesir Denizli Niğde Çankırı Giresun Amasya Kastamonu Antalya Karaman Nevşehir Kocaeli İstanbul Sakarya Muğla Bursa Uşak Kırklareli Yalova Konya Ordu Malatya Çorum Hakkari Aksaray Yozgat Mersin Tekirdağ Kayseri Bingöl Düzce Adıyaman Adana Tokat K.Maraş Şırnak Afyon Osmaniye Bitlis Hatay Mardin Gaziantep Kars Siirt Van Şanlıurfa Batman Muş Diyarbakır Ağrı Population per specialist physician change by province 2002-2010 30,000 26.883 25,000 20,000 15,000 10,000 5,000 2.017 4.012 1.342 Aralık 2002 December 2002 Eylül 2010 September 2010 6 5th and 6th Changes in the Number of Healthcare Personnel Serving in Region Provinces 6000 5190 5000 3951 4000 3107 3000 2000 1764 1000 0 Specialist Physician 2002 General Practitioner 2009 7 5th and 6th Changes in the Number of Healthcare Personnel Serving in Region Provinces 90000 85579 80000 70000 60000 50000 42725 40000 30000 20000 18418 12847 10000 0 Nurse-Midwife Total Healthcare Personnel 2002 2009 8 Improvements in the Health Facilities Number of Active Healthcare Centers and Family Physician Units Number of Active Health Houses 6.000 5.268 7.216 7.500 5.000 4.000 5.000 5.055 3.000 2.000 2.500 1.572 1.000 0 0 2002 2009 2002 2009 9 112 Emergency Healthcare Services x Thousands 2500 2.000 2250 1.800 2000 1,9 Milyon 1.600 1460 1500 1.400 1.200 1.000 1000 800 618 481 500 600 400 0 350 Thousand 200 Number of Ambulances 2002 Number of Stations 0 Number of 112 Cases 2009 2002 2009 10 112 Emergency Help and Rescue Services Today... 11 112 Emergency Help and Rescue Services Today... 12 Air Ambulance Services 13 Ministry of Health Newborn Intensive Care Services Present Status of Newborn Units Number of Newborn Centers Number of Newborn Intensive Care Beds Number of Portable Incubators Number of Medical Ventilators Number of Personnel Who Received Newborn Resuscitation Training Number of Newborn Specialist Working in Newborn Unit Number of Nurses Working in Newborn Unit 2.002 2.009 39 116 665 2.140 115 555 406 3.148 4.005 26.572 5 43 654 3.000 14 Changes in General Intensive Care Units Number of Intensive Care Beds 8000 7351 7000 6000 Ninefold 5000 4000 3000 2000 1000 869 250 0 1993 19 years 2002 7 Years 2009 15 Success= Determination Monitoring and Assessment 16 Best Decrease Rates of Last Years in Maternal and Infant Mortality in Turkey and in the World 17 Researchs and Records Related to Maternal Mortality •Turkey Demographic Research (1974-75) –State Statistical Institute (Dual Record System) –208 in one hundred thousand live births •Turkey Demographic Research (1988) –State Statistical Institute (Sister Method –132 in one hundred thousand live births •Maternal Mortality and its Causes (1998) –Ministry of Health Mother-Child Health and Family Planning (Hospital Records) –49 in one hundred thousand live births (projection to the total of births is 70) •National Maternal Mortality Study (2005) –Ministry of Health General Directorate of Mother-Child Health and Family Planning-Hacettepe Institute of Demographic Studies –29 in one hundred thousand live births •Ministry of Health Records(Active surveillance is conducted since 2007.) -2007 21.75 in One Hundred Thousand Births -2008 21.75 in One Hundred Thousand Births -2009 21.75 in One Hundred Thousand Births 18 Maternal Mortality by Year IN HUNDRED THOUSANDS Maternal Mortality 2015 Target 120 100 100 80 70 60 40 25 28,5 20 19,4 0 1990 1998 2006 2008 18,6 2009 Source: 1990 State Planning Organization Projection, 1998 Hospital Research Projection, 2006 National Maternal Mortality Study, 2008-2009 Ministerial Records 19 Millennium Development Goals in the WHO European Region A situational analysis at the end of the five-year countdown 20 Trends in maternal mortality: 1990 to 2008 Estimates developed by WHO, UNICEF, UNFPA and The World Bank Authors: World Health Organization, UNICEF, UNFPA and The World Bank Publication date: 2010 Languages: English ISBN: 978 92 4 150026 5 21 Where is Turkey among the Other Countries in Maternal Mortality (World Health Organization Estimates) World Average (In Hundred Thousand) Low Income Group Lower Middle Income Group Upper Middle Income Group High Income Group Turkey 260 580 230 82 15 23 Turkey is in Upper Middle Income Group. Source: WHO Trends in MM 1990 to 2008 22 1990-2008 Maternal Mortality Rates (First 10 Countries with Most Decreasing) Country Maldives Romania Iran Bhutan 1990 2008 310 170 150 37 27 30 940 48 1,000 200 12 280 Poland China 930 17 110 280 6 38 Turkey 68 23 Estonia Equatorial Guinea Eritrea Source: WHO Trends in MM 1990 to 2008 Change Rate (%) -93 -84 -80 -79 -76 -73 -69 -67 -66 -66 23 Under Five Mortality Rates by Year IN THOUSANDS 80 60 40 Infant Mortality 61 2015 Target 52 37 20 22 20 17 0 1993 1998 2003 2008 2009 Source: 1993, 1998, 2003, 2008 Turkey Demographic and Health Survey Results; 2009 Ministerial 24 Records Under Five Mortality Rates 2007 (First 10 Countries by Annual Decrease Rates) Countries Thailand Peru Maldives Portugal Vietnam Turkey Lichtenstein San Marino Luxembourg Estonia Under Five Under Five Mortality Rate Mortality Rate 1990 2007 Average Annual Decrease Rate 1990-2007 Improvement with Respect to 1990 (%) 31 78 111 15 56 7 20 30 4 15 8.8 8.0 7.7 7.8 7.7 77 74 73 73 73 82 23 7.5 72 10 13 23 18 3 4 9 6 7.1 6.9 6.5 6.5 70 69 67 67 Source: 2009 The State of the World's Children UNICEF 25 Infant Mortality Rates by Year IN THOUSAND 80 0-11 Months Infant… 77 53 60 43 40 29 17 20 13 10 0 1988 1993 1998 2003 2008 2009 2010 * Source: 1993, 1998, 2003, 2008 Turkey Demographic and Health Survey Results; 2009 Ministerial 26 Records, 2010 Ministerial Records for the First Eight Months Turkey among the Other Countries in Maternal Mortality in 2009 World Average (In Hundred Thousand) Low Income Group Lower Middle Income Group Upper Middle Income Group High Income Group Turkey 45 76 44 19 6 13 Turkey is in Upper Middle Income Group. Source: 2010 WHO Statistics 27 Improvements in Infant Mortality Rate Decrease rate of Infant Mortality Rate in 1988-1993: 31.2% Decrease rate of Infant Mortality Rate in 1993-1998: 18.9% Decrease rate of Infant Mortality Rate in 1998-2003: 32.6% Decrease rate of Infant Mortality Rate in 2003-2008: 37.9% Decrease rate of Infant Mortality Rate in 2008-2010: 41.2% As maternal and infant mortality rate decrease, it is difficult to decrease it more. Nevertheless, our success is very important. We want to sustain this success with you. 28 Decreasing the Maternal and Infant Mortality • Our aim for the end of 2010 to decrease the Maternal Mortality under 16/100,000 the Infant Mortality under 10/1,000 • Our ultimate aim is not to lose any mother or infant because of reasons that can be prevented. 29 In Turkey, health system is the only system that provides services for diagnosis, treatment and rehabilitation of biological, psycho-social and developmental problems and through which every child is monitored in the pre-school period. 30 We monitor Every Infant 9 times until the first year, and 7 times after the first year, 16 times in total. 31 Monitoring Protocols Flowchart 5a (FC 5a) ASK AND CHECK THE RECORDS Ask the mother: How is the breastfeeding going? Was the baby breastfed in the previous hour? Is the baby happ with breastfeeding? Did you give any other type of nutrition to the baby? Do you have any problem with your breasts? Do you have any concerns? If the baby is more than one day old: How many times was the baby breastfed in the last 24 hours? INDICATIONS Monitor thebreastfeeding: If the baby wasn’t breastfed in the last hour, make the mother breastfeed the baby and watch for 5 minutes. Watch: Does the baby grip the breast well? Is the baby in the right position? Does the baby suck well? If the baby was breastfed in the last hour, tell the mother to wait for the baby to wake up for breastfeeding. CLASSIFICATION TREATMENT AND ADVICES Nurses well. Nurses 8 times a day, WELL-FEEDING day and night. BABY More than one day old baby urinates six or more times a day. Courage the mother to breastfeed the baby when the baby wants (P1-FC 5b) Hasn’t nursed yet. (in first hours of the baby’s life) Doesn’t grip well. Doesn’t nurse well. Nurses less than 8 times a day. Takes additional food. Several days old and took insufficient weight. Support the breastfeeding. Help the mother for the first breastfeeding. Teach the mother how to put the baby into the right position and how to make the baby grab. Advise her to breastfeed more frequently day and night. Convince her that she has enough milk. Advise the mother to cut the additional foods. Assess the case again at the next breastfeeding or the monitoring examination. Doesn’t nurse (less than 6 times a day) Doesn’t nurse at all. FEEDING DIFFICULTY UNNOURISHED Transfer the baby and the mother to a hospital İmmediately. 32 Monitoring Protocols Flowchart 5a (FC 5a) Birth Trauma and Congenital Anomalies INDICATIONS Swelling and cyanosis on the thighs. Swelling on the head at one side or both Sides Abnormal positioning of the legs (after a breech birth) Asymmetrical arm movements, arm(s) not moving CLASSIFICATION BIRTH TRAUMA Pes equinovarus Cleft palate-cleft lip MALFORMATION Distinguishing features, abnormal Appearance Tissues on the head, abdomen or back not covered with skin. Additional anomalies TREATMENT AND ADVICES Tell the mother and the father that these will not harm the baby and will get better in 1-2 weeks Don’t try to get the legs into a different position BY FORCE. Hold the immobile extremity gently, don’t pull Transfer the baby to the hospital Help the mother to breastfeed the baby, if the baby don’t nurse, teach her alternative feeding methods Direct the baby to surgical correction when the baby is a few months old Direct the baby to the institution specialized in the related field Befor the transfer, cover the open tissues with strerile dressings saturated with normal saline Transfer the baby to the hospital SEVERE MALFORMATION 33 Flowchart 1(FC1) Examine infants of 1 week to 2 months of age according to the diagram below: EVALUATION ASK THE MOTHER ABOUT THE BABY’S PROBLEMS • Define if this is the first examination for the problem or they come for control − If they come for control, apply the instructions at the bottom of this chart − If it is the first examination, examine the baby according to the instructions below LOOK FOR THE POSSIBLE BACTERIAL INFECTION ASK: • Have the baby had a convulsion? WATCH, LISTEN; FEEL: • Measure the respiration rate. If it is too high, measure again. • Check if the baby has chest shrinkage. • Check if there is nose wing respiration • Check for any groaning. • Check for any fontanel bulging. • Check if there is any pus leaking from the ears. • Check if there is any pus leaking from the eyes. • Examine the navel. Is there any Rubescence or any pus leaking? Does the rubescence expanding to the skin around the navel? • Measure the body temperature (or check with your hand). Is it high or low? • Check for any pustule on the skin. Are they more than 5 or heavy? • Check for any candidiasis or diaper dermatitis • Check if the baby is lethargic or unconscious • Examine the baby’s movements. Are they less than normal? CLASSIFY BABY ALL THE INFANTS SHOULD BE CALM WHEN CHECKING FOR THESE CLASSIFICATION CLASSIFY THE BABY’S DISEASE BY USING ALL THE BOXES RELATED TO THE BABY’S PROBLEMS AND INDICATIONS INDICATIONS CLASSIFICATION • Convulsion or • Rapid respiration (60/min or higher) or •Heavy chest shrinkage or • Nose wing respiration or • Groaning or • Fontanel bulgingor • Pus leakage from the ears or • Rubescence expanding over the skin around the navel or • Fever (at 37.5°C or higher or feels hot) or low body temperature (under 35.5°C or lower or feels cold) or • Heavy or more than 5 pustules or • Lethargic or unconscious or • Movements less than normal. • Reddened or inflamed navel or • Less than five pustules or • Pus leakage from the eyes. • Candidiasis or diaper dermatitis. •None of the above. POSSIBLE SEVERE BACTERIAL INFECTION OR SERIOUS DISEASE LOCAL BACTERIAL INFECTION LOCAL FUNGAL INFECTION PROBABLY NO INFECTION DETERMINING THE TREATMENT TREATMENT (Emergency treatments before the transfer are in bold.) Treat the baby if it is having a convulsion. Give the baby the first dose of intramuscular antibiotic. Take precautions against the hypoglycemia. Inform the mother on how to keep the baby warm on the road to the hospital. TRANSFER the baby immediately to a hospital.** Teach the mother how to treat local infections at home. Teach the mother how to care for the baby at home. Tell the mother to come again for control 2 days later. Give the baby local antifungal. Teach the mother how to treat local infections at home. Teach the mother how to care for the baby at home. Tell the mother to come again for control 2 days later. Teach the mother how to care for the baby at home. 34 Gelişimi İzleme Rehberi QUESTIONS 2 MONTH 4 MONTH 6 MONTH 9 MONTH 12 MONTH 15 MONTH 18 MONTH 1. “Ali’nin gelişmesi, öğrenmesi yani konuşması, sesler çıkarması, duyması, dinlemesi, başkaları ile ilişkisi, anlaşması, isteklerini anlatması, ellerini, parmaklarını, kollarını, bacaklarını kullanması, oyun oynaması gibi konularda sizi düşündüren neler var?. 2.”______şimdi istediklerini size nasıl anlatır?” Kucaklandığında rahatlar, mutluluk, açlık, huzursuzluk durumunda farklı sesler çıkarır. Mutluluk, üzüntü gibi duygularını gösterir, kahkaha atar, “aa,uu” sesleri çıkarır. “Agu”lar, sesli harfler ile sessizleri birleştirir. “Ga-ga”“Da-da” gibi heceleri birleştirir. İşaret eder, gösterir. Başını sallar. Değişik heceleri birleştirir, işaretlerle anlatır. Bir anlamlı sözcük söyler (anne, baba, mama, su). “Anne, baba, mama”dan başka bir anlamlı sözcük, işaretle istediklerini gösterir. 3. “______ şimdi neleri anlayabiliyor?” Konuşulduğunda, gülündüğünde yüzü değişir, dinler, ilgilenir. Konuşulduğunda ağıza bakar, “anne” nin sesini tanır Kendi adını tanır, bakar, sese döner, konuşulduğunda seslerle yanıt verir. “Mama”,”hayır” gibi sık tekrarlanan basit sözcükleri anlar. Tanıdığı kişi ve nesnelerin adını, ”ver, gitti, al” gibi komutları anlar. “Git ayakkabılarını getir” gibi basit komutları “Anne nerde?” gibi basit soruları anlar. Veda eder, el sallar. Yüzüstüyken başını kaldırır, çevirir, kol bacaklarını oynatır, yandan sırta döner, ellerini genelde açık tutar. Başını dik tutar, yüzüstüyken başını 90 derece kaldırır, ellerini açık tutar, birleştirir. Destekle oturur, önden arkaya, arkadan öne döner, elleriyle uzanır, tutar, bacaklarına ağırlık verir basar. Desteksiz oturur Elden ele geçirir, üzüm gibi küçük taneleri yerden alır. Elleriyle tutunup ayağa kalkar, “taytay” durur, tutarak adımlar, işaret parmağını kullanır. Yardımsız yürür. Yüze bakar, izler, ağlarken kucaklansa kucağa yerleşir, susar, konuşulsa dikkat verir, dinler, ilgilenir, karşılıklı gülümser. Onunla oynanırsa dikkatli, canlı bakar, “anne”sine döner, güler. “Anne” si ve yakın bakım veren diğer kişileri tanır, kendisi onlara uzanır, güler, yüzlerini inceler agular, heyecanını, öfkesini belirtebilir. İstemli, amaçlı ilişki kurar. Oyuncu yüz takınır, “anne”nin yüzüne uzanır, bu sırada güler, öfkeli ifadeyle yemeğini dökebilir, korkmuş ifadeyle yabancıdan uzaklaşabilir. Yakınlık, sıcaklık, mutluluk, kendini gösterme, araştırma, karşı gelme, öfke, korku, çekinme gibi birçok duygusunu düzenleyebilir, davranışları ile gösterebilir. Örn: Anneye sarılır, öper, yeni bir oyuncağı birlikte araştırır, yabancı ortamda sokulup arkasına saklanabilir, annenin kızgınlığına protesto ederek, öfke ile karşılık verebilir. Yakınlarının davranışlarını taklit eder (babasının şapkasını giyip gururla baba gibi yürümek gibi), söz ve işaret kullanarak istediklerinin çoğunu ailesine anlatır. Gözleri ile her yönü izler, birçok sese cevap verir, dinler, kucaklanınca rahatlar, oyunlara gülümser. Onunla oynandığında sesler çıkarır, oyuncağı, elini, ağzına götürür, sesleri taklit eder, oyuncaklara uzanır, çıngırağı yakalar. Ağzına götürür, ellerine bakar, oyuncakları sallar, “cee” oyununa şaşkınlıkla tepki verir, aynada yüzüne bakar, güler. Ağzına götürür, yeni oyuncağı merakla araştırır, atar, vurur, arar, “tel sarar, cee” oynar, taklit eder. Ağzına götürür, atar, vurur, kap-kacak doldurur boşaltır, çeker, sürür, araba sürer, oyuncak nasıl işliyor araştırır, çizgi çizmeyi taklit eder. Telefonla konuşma, tarakla tarama, bebeği besleme, uyutma gibi çok basit hayali oyunlar kurar, öykü dinler. 4.”______ şimdi bedenini nasıl hareket ettiriyor?” 5. “_______şimdi sizinle, aile bireyleri ile nasıl ilişki kuruyor?” 6. “________nin şimdiki oyunlarını bana anlatır mısınız?” En az 3 anlamlı sözcük kullanır. Ailesi onu anlayabilir. İleri ve geri-geri yürür, yürürken topu atabilir, kalem tutar, çizgi çizer. 35 Supporting of the Psycho-social Development of the Child (SPDC) • First step healthcare facilities and family physicians, • Regular monitoring of the psycho-social development of the expecting mother and children of 0-6 years of age, • Supporting of healthy development, • Early determining of the risk factors/pathologies that can prevent the healthy development of the child, • Early intervention to the risk factors/pathologies, The Psycho-social Development Support Program is started to be expanded nationwide in 2005. 36 Why SPDC? • The structuring of first step healthcare services is a structuring that enables access to the expecting mothers and children of 0-6 years of age in a wide and regular way. • Midwives and nurses monitor the physical development of the expecting mothers and children of 0-6 years of age and also their psycho-social development. 37 Monitored Risk Factors • Poverty in a level of malnutrition, • Developmental delays depending on the environmental factors, • Maternal/paternal mental disorders, • Violence, • Abuse/Neglect, 38 In the cases the risk is detected, • Midwife and physician handles the case together. • Family is guided to the institutions where they can receive support if needed. These institutions are as follows • Social Assistance and Solidarity Foundations • Social Services and Child Protection Agency • Turkish Employment Organization • Metropolitan and District Municipalities • Governorate Women's Status Unit • Directorate of National Education • Turkish Red Crescent Society 39 Interviews with Fathers In Turkey, interviews with fathers are first started to be follows thanks to the SPDC program. Information on the expecting mother/mother support, Alcohol and tobacco use, Healthy diet and family planning is given to the fathers and factors seen as risk factors to the violence are examined. Cases considered necessary are closely monitored. 40 • Trained Personnel Number of Physicians 8,374 Number of Midwifes/nurses 22,023 • Within the scope of the program in the first six months of 2010, the following is monitored: Pregnant: 296,029* Infant: 332,393* Child: 275,055* Father: 76,441* • The coverage of the Program will be expanded to all provinces in 2011. * January-July 2010 (data from 68 provinces) 41 Independent Effectiveness Survey (UNICEF) • Raising the understanding of healthcare personnel and mothers about child's development, • Increasing the number of early interventions by detecting the risks earlier, are the strong aspects of the Program. • The expansion of the Program will contribute greatly to the health and development of our children. 42 United Nations General Assembly 1959 Declaration Every child has the right to reach its full potential. Principle 2: The child shall enjoy special protection, and shall be given opportunities and facilities, by law and by other means, to enable him to develop physically, mentally, morally, spiritually and socially in a healthy and normal manner and in conditions of freedom and dignity. 43