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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)