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PRIMARY HEALTH CARE

Suryani Tawali

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May 1988

In a huge conference hall in Washington DC, overa thousand participants listen with rapt attentionto Muktabai Pol, a village health worker fromJamkhed, India. The listeners include officials

from WHO and UNICEF, ministers of health,health professionals and representatives ofuniversities from many part of the world.Muktabai shares her experience of providing

primary health care in remote Indian Village

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Cont’  

She concludes her speech by pointing tothe glittering lights in the hall.

“This is a beautiful hall and the shiningchandeliers are treat to watch,” shesays. “One has to travel thousands of

miles to see their beauty. The doctorare like these chandeliers, beautifuland exquisite, but expensive and

inaccessible”.

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Cont’  

She then pulls out two wick lamp from herpurse. She lights one. „This lamp isinexpensive and simple, but unlike thechandeliers, it can transfer its light to

another lamp.” she lights the other wicklamp with the first. Holding up both lampsin her outstretched hands she says, “ I amlike this lamp, lighting the lamp of better

health. Workers like me can light anotherand another and thus encircle the wholeearth. This is Health for All.

The audience rises to its feet in a standing

ovation

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Primary Health Care

(PHC)

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History of PHC

PHC is a relatively modern approach tohealth care

The term officially coined in 1978

PHC is not a template but a mixture ofstrategy, philosophy, and list of

priority health actions  

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In 1978 at Alma Ata in what is nowKazakhstan, WHO adopted PHC as thepolicy vehicle by which it would

achieve its goal of “ Health for all bythe year 2000”. 

PHC: an idea whose time has come

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Primary Health Care

In its most basis form, PrimaryHealth Care is:

……essential health care madeuniversally accessible toindividuals and families in thecommunity by means acceptableto the, through their fullparticipation and at a cost that thecommunity and country can afford

(WHO,1998)

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The broad principles of

PHC Equity in relation to need, including making

essential health care accessible to entirepopulation

Participation by communities andindividuals in their own health, in somecases linked to community empowerment

Intersectoral approaches addressing

social determinants of health andempasising health promotion and diseaseprevention

Integrated approaches for efficiency andquality 

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Two misconceptions

PHC is not the same as “primary care”  

Primary care refers to first-contact

health service delivery

PHC is not second-rate care for thepoor

PHC aims to use available resources inthe most appropriate, equitable, andeffective way possible

Usually low tech, but not always

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Using a PHC lens

PHC can be viewed from threeperspectives:

 A health-oriented approach forcommunity development

 An approach to delivering health

services, particularly at the local (ordistrict) level

 A system form organising national

health systems

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Using a PHC lens

PHC implementation is complex and and mustviewed in context and so any description of

PHC must distinguish PHC principles aswell as PHC elements (or actions)

The PHC principles can be used as a PHCanalytical framework which can be used to

test and improve initiatives in communityhealth, health services delivery or healthpolicy

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Four pillars of PHC-the

most important principles Participation

Equity

Inter-sectoral collaboration with othersectors

Integration-within the health sector)

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Main elements of PHC

Promotion of nutrition

Provision of adequate supply of safe water

Provision of basic sanitation

Maternal and child care including family planning

Immunisation against major infectious diseases

Prevention and control of locally endemic diseases(such as malaria, TB, HIV)

Education concerning prevalent health problemsand the methods of their prevention and control

 Appropriate treatment for common diseases andinjury

Provision of essential drugs and treatments

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Main elements of PHC-2

Provision of adequate supply of safewater

 –   Gravity fed from streams or springs,tube wells or reticulated systems

 – Clean and safe

 – Education and ownership Provision of basic sanitation

 – VIPs, septics etc

 – Culturally appropriate acceptable

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Main elements of PHC-3

Maternal and child care

 – Antenatal and perinatal care

 – Family planning

 – Immunisation for children

 – Child nutrition and case management of

illness A move to integration-especially with

sexual and reproductive health

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Main elements of PHC-4

Immunisation against major infectiousdisease

 – EPI‟s six target  – Newer vaccines (HepB, HiB, men,

pneumo)

Prevention and control of locallyendemic diseases, often diseases ofpoverty or under development

TB, Malaria, HIV, local priorities eg.

Dengue, filariasis or thachoma

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Main elements of PHC 5-6

Education concerning the prevalenthealth problems and the methods of

their prevention and control as well aseducation in general developmentterms

 Appropriate treatment for commondiseases and injuries

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PHC health sector

activities Basic infrastructure, Some basic health

facility should be established within reach ofevery family. This distance will depend onterrain, roads and available transport, butan acceptable average walking distance isusually taken to be 5 kilometres

Referral system. Health facilities need tobe connected with each other through areferral mechanism that commences atprimary health care level and proceeds rightup to tertiary hospitals. 

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PHC health sector

activities Prevention of disease, and the

promotion of health, some examples

include:• Immunisation

• Hygiene education

• Safe sex education

• Better lifting• Care-seeking counselling

• Childe development counselling

• Regulation for food hygiene, medical waste,

seatbelts, etc

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PHC health sector

activities Traditional health systems. Traditional

health services already operate in many

communities. These should be utilised andincluded in overall attempts to improve thehealth of the community. Cooperation withtraditional health workers should be

encouraged• Maximise available resources

• Maximise access to the community

• Can enable a conceptual bridge for health

care

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PHC health sector

activities Information for health and

development

Example:

-Community mapping and participatoryplanning

- Strengthening formal healthmonitoring data through basicimunisation and vital events recording

- Survey

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Pulling diverse activitiestogether-integration

(horizontal approach) Real example: effective PHC attribute success to

the provision of a “array” of services that addressmany different health issues at one time (example

of “co-morbidity” in children)  Crucial to accessible services

Essential fact of life for health staff and managersat the local level “officer in charge” simply becausethere might nobody else

 At the national level it is also critical:

• National planners must support the peripherallevel,

• National planners should balance all health

priorities in making efficient and cost-effective

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Integration balanced bysingle-issue (vertical

approach) They were criticised that they

 – Created pararel systems of staff andinfrastructure inefficiently focused on a narrow

scope of work – Created replacement mortality rather thanimproving overal health

 – Were more expensive and difficult to sustain

But vertical approaches are benefit to many

health priorities : – Focused advocacy (eg immunisation in late 90s,

HIV) can increase resources and political will – Some diseases need strong centralised support

in terms of equipment, supplies and commonstandars (eg to prevent drug resistance)

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