In this site you will learn about the
concept of primary health care, which is considered to be an essential care,
which is acceptable, accessible and affordable to an individual, community and
the country as a whole. You will also learn about Alma Ata Declaration and the
components of primary health care. The principles of primary health care are
also explained.
Primary Health Concept
You have heard and learnt about primary health care and all
of you are providing this care in the areas of your practice i.e. hospital,
clinic or community setting. Before we start the discussion on this concept,
you should try to decide which kind of care in the situation described below.
If you think for a while, you will be able to realize that
the female Community Health Extension Worker is providing primary health care.
Primary health care is now a widely disseminated concept, but
most of us are still not clear as to its current meaning. We shall, therefore,
try to explain how the concept of PHC has evolved.
You know when a new progamme or technology
in any area is implemented, it becomes imperative to evaluate its
effectiveness. It is the same with health care approaches. Primary health care
has evolved from e-examination and evaluation of existing health care
approaches and assimilation of new experiences. The implementation of new
knowledge and technology in terms of vertical programme, for eradication of
disease did not achieve expected results' and it was realized that there was a
need for establishment of permanent health services in rural areas to deal with
the day-to-day work in the control and prevention of diseases and promotion of
health.
It was realized that the world's priority health problems
required development of new approaches for their solution. Hence the approach in
health services was shifted from curative to a preventive approach; from urban
to rural populations; from privileged to the underprivileged; from unipurpose
to multipurpose workers and from vertical mass campaigns to a system of
integrated health services forming a component of overall social and economic
development.
Based on this, a shift in emphasis on health services to
Basic Health Services Approach was conceptualized in 1970. This concept focused
on increasing accessibility and availability of health services to the rural
populations of developing countries. It was conceived as first level care or
first contact care. Now the concept of Basic Health Services paved the way for
Primary Health Care; the ideas contained in Basic Health Services were further
expanded to cover accessibility, availability, acceptability, affordability and
appropriateness of health services.
In May 1977, the Thirtieth World Health Assembly adopted a
resolution in which it was decided that the main social target of Governments
and of the World Health Organization in coming decades should be
"Health for All" by the year 2000 AD. The basis of "Health for
All" strategy is the Primary Health Care. In 1978, an international
conference on primary health care was held at Alma Ata in the then USSR jointly
by WHO and UNICEF. This led to the concept of Primary Health Care. This concept
of PHC was recommended by various health committees including Nigeria.
This clearly indicates that PHC concept has
its roots in the initial stages of our national health care approach.
Ultimately, after reviewing the health situation from time to time, World
Health Assembly, in its meeting in May 1977 decided that in coming decades the
slogan for all the countries should be to achieve the goal of 'Health For All
(HFA) by 2000 AD'. It was only after that the Primary Health Care (PHC) was
considered to be the strategy to achieve this goal. Later on, in 1978 an
International Conference on PHC was organized at Alma Ata in USSR, addition to
defining Primary Health Care (PHC).
Definition of Primary Health Care
Primary Health Care is defined in Alma-Ata Declaration
(19768). The Alma Ata Declaration states:
Primary Health Care is 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 state of their development in the spirit of
self-reliance and self-determination.
If you look at the definition, you will find that it involves
accessibility, which means, continuing and organized supply of care which is
geographically, financially, culturally within easy reach of the whole
community.
Acceptability implies
that care has to be appropriate and adequate in quality and quantity to satisfy
the health needs of people and has to be provided by methods acceptable to them
within their socio-cultural norms;
Affordable implies
that whatever the methods of payment used, the services should be affordable by
community and country.
Appropriate technology which
means using appropriate methods, techniques and locally available supplies and
equipment which together with the people using them can contribute
significantly to solving a health problem.
Primary health care is based on socially accepted methods
which the country can afford. Thus self-reliance and self-determination are
emphasized.
Thus we can say primary health care is a practical approach
to make essential health care universally accessible to individuals, families
and community in an acceptable and affordable way and with their full
participation.
The significance of PHC is to have contract
with members of the community for providing continuing health care in the light
of national health system. PHC focuses on promotive, preventive, curative,
rehabilitative and emergency care to meet the main health problems in the
community, giving special attention to the vulnerable groups such as mother and
child.
Element of Primary Health Care
We hope our discussion on concept and definition of PHC may
have benefited you. Now you will be interested to know what does this Primary
Health Care include or what type and what level of care is involved. The eight
essential elements or components of Primary Health Care as outlined in the
Alma-Ata Declaration are:
Education concerning prevailing health problems and the
methods of preventing and controlling them;
Promotion of food supply and proper nutrition;
An adequate supply of safe water and basic sanitation;
Maternal and child health care including family planning; Immunization against
major infectious diseases;
Prevention and control of locally endemic disease;
Appropriate treatment of common diseases and injuries.
Provision of essential drugs.
Dental & Mental Health are now added
Principles of primary health care
The description and meaning of the five basic principles which provide the framework of the primary health care approach can be summarized as follows:
ii.
Manpower development
iii.
Community involvement or participation
iv.
Appropriate technology
v.
Intersectoral coordination
i. Equitable distribution of resources
As you know, the attainment of a high level of health is the
fundamental right of an individual or you can also say that all human beings
have an equal right to health. You will be interested to know how people can
ensure this right. The answer is that all the people of the world/country
should be provided with equal opportunities to develop health to the fullest
and maintain it. So we can say that equitable distribution means that health
services must be shared equally by all people irrespective of their ability to
pay; and all the people -rich or poor, rural or urban -must have access to
health services.
If
we look at health statistics, you will find that the health situation as
indicated by health status indicators, e.g. infant mortality rate (IMR),
maternal mortality rate (MMR), birth rate (BR), death rate (DR), etc.
is lower in urban areas than in rural areas. Why this difference? It is because
health services are mainly concentrated in cities and towns, thus resulting in
inequality of care for rural people. These statistics reflect how
health-related resources are distributed with the countries - including access
to health services, education and income-earning opportunities. This is called
social injustice.
The
inability to receive health care services by majority of rural people and those
living in urban slums is inaccessibility.
The
aim of PHC is to bridge this gap by shifting this concentrated health care
system from cities or urban areas (where three quarters of health budget is
spent) to the rural areas (where three quarters of the people live) and bring
the services as near as possible to them.
The
other feature of health equity in society is health status of women and the
disparity in health between genders which indicates that women suffer more from
health problems than men. This is a critical indication of health inequality.
What can you, as a health care provider do? You can only provide care to an
individual, diseased or healthy, irrespective of any disparity; but in general,
these facts call for explicit policies and strategies to reduce inequalities in
health.
ii. Manpower development
The
manpower development in the context of health includes both professional and
auxiliary health personnel, members of community and supporting staff.
Primary
health care, aims at mobilizing the human potential of the entire community by
making use' of all available resources. This can only be achieved if the
individuals and families accept greater responsibility for their health.
The
requirement of health manpower will vary according to the varying needs of
groups of the population and desired outputs.
Primary
health care focuses on:
·
Education and training of health workers to
perform functions relevant to countries health problems
·
Reorientation of health personnel.
·
Planning health manpower according to the
needs of health system, in terms of the right kind of manpower, the right
number, at the right time and in the right place.
At
the first level of contact between individual and health care system, primary
health care is provided by community health workers acting as a team. These
workers have to be trained and retrained so that they can play a progressive
role in providing primary health care.
The second categories of health personnel are traditional
medical practitioners and birth attendants. They are often part of the local
communities, culture and traditions and exert influence on local health
practices. Therefore these indigenous practitioners need to be trained
accordingly for improving the health of the community.
Lastly
we can say that family members are often main providers of health care, mainly
women play an important role in promoting health, thus they can contribute
significantly to primary health care, especially in ensuring the application of
preventive measures. Women's organization can be taught and encouraged to
discuss on question as nutrition, child care, sanitation and family planning.
School teachers and adolescent girls can be trained on human sexuality and home
nursing. Similarly young people can be educated on health matters. They can be
effective in carrying these messages to their homes thus promoting primary
health care.
iii. Community participation
We
now come to the most essential and sensitive principle of PHC, i.e. community
participation. Community participation is the process by which individuals,
families and communities assume the responsibility in promoting their own
health and welfare. By their own health decisions, they develop the capacity to
contribute to their own and the community's development. Realizing the fact
that a community can become the agent of its own development, a continuous
effort should be made towards the involvement of the local community in planning,
implementation and maintenance of health services.
The term community involvement in health describes a process
in which partnership is established between government and local communities in
planning and implementation of health activities. It aims at building local
self-reliance and gaining social control over primary health care
infrastructure and technology. For example, one such approach which is followed
in our country (Nigeria) is training of village health workers and aides. They
are selected by the local community and are trained locally in the delivery of
primary health care and are involved in planning the care for the community.
This concept is an essential feature of PHC. The individuals in the community
know their own situation better and are motivated to solve their common
problems. Thus it can be stated that involvement of community in health matters
will require attainment of capacity by individuals to appraise a situation,
weigh the various possibilities and estimate what can be their own contribution.
Your contribution in community participation, as a member of the health system,
is to motivate the community to learn and solve their own health problems,
explain, advise and provide clear information about favourable and adverse
consequences of the health interventions proposed as well as their relative
cost.
Having
understood the idea of community participation, you will be interested to know
about the areas in which individuals, families and communities can participate.
Involvements of these are:
·
Involvement of the community in assessment
of the situation,
·
Definition of the problem and setting of
priorities.
· Planning of the primary health care
activities and subsequently cooperating fully when these activities are carried
out.
All these mean acceptance of a high degree of responsibility
by the individuals for their own health care, for example, by adopting a
healthy life style, by applying principles of good nutrition and hygiene and by
making use of immunization services.
iv. Appropriate technology
Appropriate
technology means the technology that is scientifically or technically sound,
adaptable to local needs, culturally acceptable (i.e. acceptable to those who
apply it and for whom it is used) and financially feasible.
This
implies that technology should be in keeping with the local culture. It must be
capable of being adapted and further developed, if necessary.
In
addition, it should be easily understood and applicable by the community.
The
Health for all target requires first and foremost scientifically sound health
technology that people can understand and accept and which the non-expert can
apply. It also implies use of cheaper, scientifically valid, acceptable and
available equipment, procedures and techniques rather than those costlier and
non-affordable and non-accessible to the community. For example, oral
rehydration fluid, locally prepared weaning food and stand pipes rather than
house to house connection, cooperative food stores.
It
is socially, economically and professionally acceptable to take the technology
closer to the people, consumer, wherever possible. For example, making
rehydration salts for babies available to mothers in every home is likely to be
more useful than expecting the mothers to take the baby to the special center.
We cannot afford to continue the use of sophisticated
technology which is appropriate for meeting the local health needs of people.
For example, we know that expensive hospitals which are inappropriate to local
needs are being built. These absorb a major part of the national budget,
thereby affecting the improvement of general health services.
The concept of appropriate technology can further be explained by taking the example of ORT (oral rehydration therapy). The ORT packets, for diarrhoea, prescribed by WHO cannot be made available to each home; so the community is taught how to prepare sugar and salt solution to combat dehydration in a child with diarrhoea. With these concepts in mind, we shall discuss the principles of intersectoral coordination.
v. Intersectoral coordination
We
now come to the principle which focuses on the concept that health of an
individual, family and community is affected by other sectors in addition to
health sector. Let us now try to learn more about this principle.
It is now realized that health cannot be attained and/or
primary health care PHC) cannot be provided by the health sector alone. PHC
requires the support of other sectors; these sectors serve as entry points for
the developments and implementation of PHC. In our country the sectors responsible
for economic development, antipoverty measures, food production, water
purification, sanitation, housing, environmental protection and education all
contribute to health. Development of PHC will rest on proper coordination at
all levels between the health and all sectors concerned.
Declaration of Alma-Ata states that:
Primary Health Care involves in addition to the health sector
all related services and aspects of national and community development; in
particular, agriculture, animal husbandry, food, industry, education. Housing,
public works, communication and other sectors," WHO (1978, HFA Series
No.1).
We shall now explore the importance of these related sectors in providing PHC. We shall first discuss the importance of agriculture sector, water supply, sanitation and housing, then, we will talk about public works, communication and education sector and mass media. So let us begin with agriculture sector first.
Agriculture
sector ensures the production of food for family consumption.
Also nutritional status can be improved through programmes in agriculture, e,g.
'grow more food' and 'kitchen garden projects'. Similarly you know that water
supply is very important for household use. A regular supply of clean water
helps to decrease mortality and morbidity, in particular among infants and
children. You are aware that many diseases like cholera, typhoid, diarrhoea,
viral hepatitis are waterborne. Safe disposal of wastes and excreta also has a
significant influence on health.
Housing
has
a positive' aspect on health, provided it is properly adapted to local climatic
and environmental conditions. Housing needs to be proof against insects and
rodents that carry diseases.
We have so far discussed the effect of agriculture sector,
water supply and sanitation and housing on primary health care, now we shall
discuss public works, communication, education sector and mass media. Certain
aspects of public works and communication are of strategic importance to
primary health care. Feeder roads not only connect people to the market but
make it easier for them to reach other villages, bringing in new ideas and also
the supplies needed for health. TV and radio communication serve as important
vehicles for learning regarding health and health practices. Mass media can play
a supportive educational role by providing valid information on health and ways
of attaining it, and depicting the benefits to be derived from improved health
practices. It could help to create awareness regarding various health
programmes, i.e. family planning, immunization, growth monitoring, diarrhoeal
disease and ORS etc. in the people isolated. We all know that various messages
are carried on TV or radio, regarding FP, ORS, nutrition, diarrhoeal diseases
etc.
Now we come to educational sector which has
a vital role to play in development and operation of PHC. Community education
helps people to understand their health problems, possible solutions to them
and the cost of different alternatives. Instructional material/literature can
be developed and distributed through the educational system. Associations of
parents and teachers can assume certain responsibilities for primary health
care activities within schools or the community: such as sanitation programmes,
food for health campaigns or Courses on nutrition and first aid, adult literacy
programmes, kitchen garden projects, Courses on human sexuality and home
nursing.
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