Primary Health Care: Definition, Element and Principles...


Primary Health Care: Definition, Element  and Principles...

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:

 i. Equitable distribution of resources

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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