PRIMARY HEALTH CARE

PHC
 Introduction
• Health status of hundred of millions of people
in the world at 1978 and before, was
unacceptable, particularly in the developing
countries. More than half the population of
the world does not have the benefit of proper
health care.
• In view of the magnitude of health problems and
inequitable distribution of health resources between
and within countries, and believing that health is a
fundamental human right and worldwide social goal,
a new approach to health and health care to close
the gap between the “ haves” and “have-nots”,
achieve more equitable distribution of health
resources, and attain a level of health for all the
citizens of the world that will permit them to lead a
socially and economically productive life.
 Alma Ata declaration (1978)
• An international conference in Alma Ata
(UUSR) issued declaration which stated that
“primary health care” is the key to attain HFA:
and the global strategy of WHO for the goal of
HFA was endorsed by the world health
assembly in 1981.
 Goals of Alma Ata

• The global goal as stated in the Alma Ata Declaration is Health for
All by the year 2000. through self-reliance.
• Health begins at home, in schools and in the workplace because it
is there where people live and work that health is made or broken.
• It also means that people will use better approaches than they do
now for preventing diseases and alleviating unavoidable disease
and disability and have better ways of growing up, growing old and
dying gracefully.
• It also means that here will be even distribution among the
population of whatever resources for health are available.
• It means that essential health services will be accessible to all
individuals and families in an acceptable and affordable way.
 Principles and Strategies of Alma Ata :

1- Accessibility, Availability, Affordability and

Acceptability of Health Services
– Strategies:
• Health services delivered where the people are
• Use of indigenous/resident volunteer health worker as
a health care provider with a ratio of one community
health worker per 10-20 households
• Use of traditional (herbal medicine) with essential
drugs.
2- Provision of quality, basic and essential health
services
– Strategies:
• Training design and curriculum based on community
needs and priorities.
• Attitudes, knowledge and skills developed are on
promotive, preventive, curative and rehabilitative health
care.
• Regular monitoring and periodic evaluation of community
health workers performance by the community and health
staff.
3- Community Participation
– Strategies:
• Awareness, building and consciousness raising on health and
health-related issues.
• Planning, implementation, monitoring and evaluation done
through small group meetings (10-20 households cluster)
• Selection of community health workers by the community.
• Formation of health committees.
• Establishment of a community health organization at the parish
or municipal level.
• Mass health campaigns and mobilization to combat health
problems.
4- Self-reliance
– Strategies
• Community generates support (cash, labor) for health
programs.
• Use of local resources (human, financial, material)
• Training of community in leadership and management
skills.
• Incorporation of income generating projects,
cooperatives and small scale industries.
5- Recognition of interrelationship of health and
development
– Strategies:
• Convergence of health, food, nutrition, water, sanitation
and population services.
• Integration of PHC into national, regional, provincial,
municipal and barangay development plans.
• Coordination of activities with economic planning,
education, agriculture, industry, housing, public works,
communication and social services.
• Establishment of an effective health referral system.
6- Social Mobilization
– Strategies
• Establishment of an effective health referral system.
• Multi-sectoral and interdisciplinary linkage.
• Information, education, communication support using
multi-media.
• Collaboration between government and non-
governmental organizations.
7- Decentralization
– Strategies
• Reallocation of budgetary resources.
• Reorientation of health professional and PHC.
• Advocacy for political and support from the national
leadership down to the grass root level.
 Health for all
• In developed countries the rate of infectious
diseases decreased through the 20th century largely
due to broad public access to water and sewage
systems, sanitation, immunizations and economic
prosperity.
• Public health then began to put more focus on
chronic diseases such as cancer and heart disease.
However, in developing countries people remain
plagued by largely preventable infectious diseases,
exacerbated by malnutrition and poverty.
 Health for all

means that health is to be brought within the

reach of every given community that is to say to
eliminate poverty, ignorance, malnutrition,
diseases, contaminated water supply, unhygienic
housing, etc. it depends on continued progress
in medicine and public health.
 What is health?
• Health as defined by World Health
Organization (WHO), it is a "State of
complete physical, mental, and social well
being, and not merely the absence of disease
or infirmity."
 Levels of Care

• Primary health care

• Secondary health care
• Tertiary health care
Primary health care

• The “first” level of contact between the individual

and the health system.
• Essential health care (PHC) is provided.
• A majority of prevailing health problems can be
satisfactorily managed.
• The closest to the people.
• Provided by the primary health centers.
Secondary health care
• More complex problems are dealt with.
• Comprises curative services
• Provided by the district hospitals
• The 1st referral level

Tertiary health care

• Offers super-specialist care
• Provided by regional/central level institution.
• Provide training programs
 Primary health care
Definition WHO 1978:
• Primary health care is defined as “essential health
care based on practical, scientifically sound and
socially acceptable methods and technology, made
universally accessible to individuals and families in
the community through their full
participation and at a cost that the community and
country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-
determination”.
• It is the first level of contact of individuals, the
family and community with the national health
system bringing health care as close as
possible to where people live and work and
constitutes the first elements of a continuing
health care process.
• Primary Health Care was identified as the key
measure through which HFA was to be
achieved.
 Primary Health Care
It includes the following:
 health promotion
 illness prevention
 care of the sick
 advocacy
 community development
 Primary Health Care

Preventive services Curative services

Outpatient clinic (referral)

General services Care of vulnerable groups
Laboratory services
Pharmacy
Health education Maternal &child health s.
Monitoring of environment First aid and emergency
School health services
Prev.&control of endemic diseases
services
Geriatric health services
Health office services Occupational health services
 Characteristics of Primary Health Care
These are :
(a) Stresses prevention rather than cure.
(b) Relies on home self-help, community participation and technology
that the people find acceptable, appropriate and affordable.
(c) Combines modern, scientific knowledge and feasible health
technology with acceptable, effective traditional healing practices.
(d) Should be shaped around the life patterns of the population.
(e) Should both meet the needs of the local community and be an
integral part of the national health care system.
(f) Should be formulated and implemented with involvement of the
local population.
 Primary Health Care (ELEMENTS)
Essential Health Services in Primary Health Care (ELEMENTS)
• E – Education for Health
• L – Locally endemic disease control
• E – Expanded program for immunization
• M – Maternal and Child Health including responsible parenthood
• E – Essential drugs
• N – Nutrition
• T – Treatment of communicable and non-communicable diseases
• S - Safe water and sanitation
 
 Core Activities for PHC

There is a set of CORE ACTIVITIES, which were

normally defined nationally or locally. According to
the 1978 Declaration of Alma-Ata proposed that
these activities should include:
1. Education concerning prevailing health
problems and the methods of preventing and
controlling them
2. Promotion of food supply and proper
nutrition
3. An adequate supply of safe water and basic
sanitation
4. Maternal and child health care, including
family planning
5. Immunization against the major infectious
diseases
6. Prevention and control of locally endemic
diseases
7. Appropriate treatment of common diseases
and injuries
8. Basic laboratory services and provision of
essential drugs.
9. Training of health guides, health workers and
health assistants.
10. Referral services
 SPECIAL CONSIDERATION TO:

• Mental health
• Physical handicaps
• Health and social care of the elderly
 WHO Strategies of PHC
1. Reducing excess mortality of poor marginalized populations:
PHC must ensure access to health services for the most
disadvantaged populations, and focus on interventions which
will directly impact on the major causes of mortality,
morbidity and disability for those populations.

2. Reducing the leading risk factors to human health:

PHC, through its preventative and health promotion roles,
must address those known risk factors, which are the major
determinants of health outcomes for local populations.
3. Developing Sustainable Health Systems:
PHC as a component of health systems must develop in ways,
which are financially sustainable, supported by political
leaders, and supported by the populations served.

4, Developing an enabling policy and institutional environment:

PHC policy must be integrated with other policy domains, and
play its part in the pursuit of wider social, economic,
environmental and development
policy.
 PHC principles
The PHC elements should be organized and
delivered on the basis of principles which are:
1. Equity in distribution.
2. Appropriate technology.
3. Multi- sectoral approach.
4. Community participation.
 Equity in distribution
• Equity means services to all, and more services to the
needy and vulnerable i.e. while continuing to provide
essential health care for all population irrespective of
social, economical, and cultural preferences, extended
care is to be provided to high risk groups.
• To ensure equity accessibility has to be improved either by
increasing the number of health facilities, improving
transport condition, or by organizing out- reach services.
So bring health services as near people homes as
possible. It may also be supported by higher level service
as referral system for extended care.
 Appropriate technology
• “PHC requires development, adaptation, and
application of technology that the people can use and
afford” Alma Ata 1978.
• The word technology is a total sum of materials,
methods, techniques considered in association with
the person who is using it, which is potentially capable
of solving health problem.
• Health technologies required are not only for
diagnostic and therapeutic maneuvers, but also for
disease prevention, control and health promotion.
 Multi- sectoral approach
• The developmental efforts of each sector is
complimentary to other and hence, individual
sectors can not function in isolation.
( ministry of education and school health)
 Community participation
• Social awareness and community self reliance are the
key factors in human development, so the people have
both the right and duty to participate in the process of
improvement and maintenance of health.
• PHC providers make the necessary arrangement for
the individuals, families and communities to assume
responsibilities for their health.
• The scope of involvement is unlimited, by involving
them in all spheres of PHC activity as planning,
implementation, and evaluation.
The Basic Requirements for Sound PHC (the 8
A’s and the 3 C’s)
• Appropriateness • Assessability
• Availability • Accountability
• Adequacy • Completeness
• Accessibility • Comprehensiveness
• Acceptability • Continuity
• Affordability
 Appropriateness
• Whether the service is needed at all in
relation to essential human needs, priorities
and policies.
• The service has to be properly selected and
carried out by trained personnel in the
proper way.
 Adequacy

• The service proportionate to requirement.

• Sufficient volume of care to meet the need
and demand of a community
 Affordability

• The cost should be within the means and

resources of the individual and the country.
 Accessibility

• Reachable, convenient services

• Geographic, economic, cultural accessibility
 Acceptability

• Acceptability of care depends on a variety of

factors, including satisfactory communication
between health care providers and the
patients, whether the patients trust this care,
and whether the patients believe in the
confidentiality and privacy of information
shared with the providers.
 Availability

• Availability of medical care means that care

can be obtained whenever people need it.
 Assessability

• Assessebility means that medical care can be

readily evaluated.
 Accountability

• Accountability implies the feasibility of regular

review of financial records by certified public
accountants.
 Completeness

• Completeness of care requires adequate

attention to all aspects of a medical problem,
including prevention, early detection,
diagnosis, treatment, follow up measures, and
rehabilitation.
 Comprehensiveness

• Comprehensiveness of care means that care is

provided for all types of health problems.
 Continuity

• Continuity of care requires that the

management of a patient’s care over time be
coordinated among providers.
 Health for all
• The world health assembly decided in 1977
that the main social targets of the
governments and WHO in the decades should
be the attainment of “health for all” by the
year 2000AD”.
• The attainment by all people of the world “ a
level of health that permit them to lead
socially and economically productive life”.
• Concurrently, a few intermediate goals for HFA
were defined such as:
i. Ensure the right kind of food for all by 1986.
ii. Provide an adequate supply of safe drinking
water and basic sanitation for all by 1990.
iii. Immunizing children against six common
diseases: measles, whooping cough, tetanus,
polio, diphtheria and tuberculosis by 1990.
 Interpretation
• Primary medical care and primary care are often
mistaken for primary health care, refers mainly to
those personal services provided by the physician
directly or on his instructions. Thus, the primary
care would indicate the first contact or immediate
care of a clinical condition, or a pathological state of
an organ in a “case” e.g. primary coronary care,
primary eye care or a similar care given by a specific
specialist group e.g. primary pediatric care.
 Millennium Development Goals
• The Millennium Development Goals derive out
of the eight chapters of the United Nations
Millennium Declaration, which were officially
established at the Millennium Summit in
September 2000, where 189 world leaders
adopted the United Nations Millennium
Declaration.
The Millennium Development Goals, place
health at the heart of development and
represents commitments by governments
throughout the world to do reduce poverty and
hunger, and tackle ill-health, gender inequity,
lack of education , access to clean water, and
environmental degradation.
 To Summarize
Primary care is an approach that:
• Focuses on the person not the disease,
considers all determinants of health
• Integrates care when there is more than one
problem
• Uses resources to narrow differences
• Forms the basis for other levels of health
systems
• Addresses most important problems in the
community by providing preventive, curative,
and rehabilitative services
• Organizes deployment of resources aiming at
promoting and maintaining health.