phc concept & principles

Dip. Oral Health Programme

PRIMARY HEALTH CARE:

CONCEPT & PRINCIPLES

By

Abiodun Bamigboye, FRSH

Community Health Department Obafemi Awolowo University, Ile-Ife. paobamiboye@yahoo.com.

Primary Health Care !!!

THE POLITICAL DEVELOPMENT OF 1978

Critical Appraisal of Health Services in Nigeria – Pre 1988

Majorly curative MOH oriented No community participation Disease oriented

Global Health situation Before PHC Some improvement? BUT Life Expectancy was low 50-50 chance

of survival Only a fifth of the world has access to

any permanent form of health care

World Health Situation

One third of the people in developing countries had access to safe water

less have access to safe means of excreta disposal

Continued disparity in access to health between poor and the ‘rich’ and btw rural and urban

World Health Situation

No community involvement and participation (people who need to be healthy are not involved)

Public health services of the 67 poorest developing countries excluding China spend less in total than the rich countries spend on tranquillisers.

PHC Definition

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 the that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination .

The Declaration

The world Health Assembly in 1978 after an in-depth consideration of the situation of the health status of the world rose and declared PHC the cornerstone of global health attainment.

Nigeria was (an important) signatory to the declaration

The Declaration (Contd)

Unprecedented political event Formed basis for a World Health Policy Served as basis for formulation of

health policies in most countries

The Meaning of PHC

PHC involves the directing of the national health services to community health needs.

Democratically we can define PHC as ‘the Health of the PEOPLE by the PEOPLE and for the PEOPLE’.

The Alma- Ata conference envisaged PHC as a radical reinterpretation of health services.

The Meaning of PHC (Contd.)

For the conference, HFA represented a commitment to greater justice and equity in health resources allocation.

This implies a denunciation of existing inequalities and at least implicitly, the resolve to redress such imbalances.

PHC

Health within reach of everyone By Health we mean a personal state of

wellbeing Not just availability of services the ultimate is to ENABLE each one lead

a socially economic productive life HFA= removal of ALL obstacles to health

PHC

HFA= seeing health as the main goal of economic development and not as one of the means of attaining it.

HFA= literally demands ultimately literacy for all

HFA depends on continued progress in medical and Public health

PHC

The technical definition of PHC clearly indicate the goals and the ways to which it was intended to be directed. It is clear from the declaration that it was intended to be people oriented .

PHC

HFA/2000 thus became a popular slogan and a lucrative programme at all levels of governments in the country

It has also become more or less a propaganda

Obstacles to health

Ignorance Malnutrition Contaminated drinking water Unhygienic housing

Solutions to these Obstacles?

Health interventions? HFA is a holistic concept calling for

efforts in agric, industry, education, housing, communications, medicine and public health.

Solutions

Medical care cannot bring health to a hungry people living in slums. Health for such people requires a whole new way of life and fresh opportunities to provide themselves with a higher standard of living

Components of PHC (1st 8)

Education concerning prevailing health problems and methods of preventing and controlling them

Promotion of food supply and proper nutrition

Adequate supply of safe water and basic sanitation

Maternal and child health including family planning (MCH)

1st 8 Components

Immunization against the major infectious diseases

Prevention and control of locally endemic diseases

Appropriate treatment of common diseases and injuries

Provision of essential drugs

Components

What else was missing?

WHO was persuaded to add some other components

Additional Components ***

Oral health Mental health

Pillars

        APPROPRIATE TECHNOLOGY the use of the most appropriate and cost effective methods and equipment for each level of care

        HEALTH PROMOTION AND PREVENTION – adopting a comprehensive approach which combines facility-based health services with multi-sectoral public health interventions.

5 PILLARS OF PHC

EQUITY  COMMUNITY INVOLVEMENT/ PARTICIPATION INTERSECTORAL

COLLABORATION : acceptance of the health professions to collaborate with other sectors that have direct and indirect impact on attainment of health

Principles of PHC

PHC shaped around life pattern should meet the needs of the communities

PHC should be integral part of the national health system

PHC should be integrated with activities of other community development-oriented sectors

Principles of PHC (Contd.)

The local population/beneficiaries should be involved at every stage of its planning, implementation

Reliance on community resources PHC should use integrated approach of

preventive, promotive, curative and rehabilitative services for the individual, family and community

Decentralisation of health intervention to the most peripheral level possible

Critical Question

What impact did these have in the countries at :

National (government) level Health services level Community, family and individual level

8 BIG Questions of Halfdan Mahler (DG, 1978)

Directed to the delegates: Are you ready to-

Address the health care gap Promote health as part of overall socio-

economic development Allocate health resources to the social

periphery as a priority Mobilize communities to ensure their

participation

Halfdan Mahler

Make available the required manpower and technology

Introduce the necessary changes in the existing health delivery system

Fight the political and technical battles required to overcome obstacles and resistance

Make political commitment to adopt PHC to attain the objectives of HFA

Implications of Mahler’s poser

Affirmative answers are preconditions for success of HFA through PHC

Countries where answers are not in the affirmative (at any stage of PHC implementation) cannot be said to be implementing PHC

Was the original Concept Understood? Macdonald observed that it was unlikely that

the countries which signed the document in 1978 realize the full significance of what they were endorsing

It could also be asserted that health workers perhaps did not fully understand the nature of PHC neither did they realise the implications of the terms of the declaration.

PHC and health Professions

* PHC is a direct challenge of the power, influence and monopoly of conventional medical/health practice and medical/health practitioners.

* Resistance from professionals- rather too late

* Acceptance of reality is required

PMC/PHC

PMC: addition of simple curative services to some limited population-focused preventive programmes such as immunization of children, routine antenatal care for mothers who care to come to the clinics, inadequately delivered water and sanitation programme, etc.

PHC: It is a re-orien-tation of all health services towards the health needs of the communities and a rejection of the old model of health care that is disease oriented.

Health Status of Nigerians

Since 1987 Nigeria ranked 136th

out of 162 countries recently assessed by the United Nations using universally accepted Human Development Index (Nigeria Tribune, 31st August 2001).

Health status of Nigerians

the need to improve the situation made the country to expressly formulate the 1986 National Health Policy which state inter alia that: ‘The goal of the national health policy shall be a level of health that will enable all Nigerians achieve socially and economically productive lives’. It went further to state that the national health policy shall be based on Primary Health care

National Health System: Features

1. A three tier system of health services with shared responsibilities among each level of government in a decentralized health system.

2. The full participation of the PEOPLE in the planning and implementation of health care services as a matter of duty and right

3.  That health care shall be accorded higher priority in the allocation of nation’s resources

National Health System: Features

1.A three tier system of health services with shared responsibilities among each level of government in a decentralized health system.

2. The full participation of the PEOPLE in the planning and implementation of health care services as a matter of duty and right

3.  That health care shall be accorded higher priority in the allocation of nation’s resources

National Health System: Features

  4. Equitable distribution of health resources as regards the at risk and the undeserved

5. Emphasis on preventive and promotive measures in an integrated manner

6. Involvement of all relevant sectors of the society to contribute to health

7. Provision of affordable services with the aim of increasing accessibility to health care

PHC in Nigeria

Started in 1987 Introduced focused LGAs (Nigeria

approach) Later willing LGAs Then others joined EPI was used as an entry point in most

parts of the country.

PHC in Nigeria

Country divided into 4 health zones Several workshops held 3 documents produced at LGA levels Most states decentralised around 1986 Strengthening of SHT in Nigeria Introduction of Community Health

workers scheme

National Health System: Features

A look at these general and specific policy issues would convince one of the level of seriousness with which PHC was contemplated in the country.

BUT what is the situation today?.

PHC in Nigeria: Features

Health workers are still reluctant Community participation almost non

existent = (SH) Decentralised responsibility not decision

making process Disparity btw social & economic classes Governments paying lip service

Health of Nigerians 1985-2003

Selected Health Indices Of Nigerians (1985-2003) INDICATOR 1985 3,6 1995 7 19988 20009 200310 Crude death rate

16/000 14.4/000 13/000 14/000 13

Maternal mortality Rate

N.A 1000+ /100,000

750/ 100,000 N.A 704-1500

Childhood mortality

144/000 114/000 N.A N.A 198/1000

Infant mortality Rate

85 N.A 79 75 75

% of birth attended by trained personnel

30 N.A 31 N.A 41.6

Gross National Income/capita

N.A N.A US$ 300 (USA29,240) Brazil 4, 630

US$ 260, USA 32,000 Brazil 4,350

US$590 Tunisia US$6090

Life expectancy at birth

50 52 52 52 50

% access to safe water

45(U 65) (R 36)

49.5, (U79.5) (R 39.1)

57 (R 39) 62 54.1 (U70.6, R48

% access to safe sanitation

N.A 57.3 (U 82.1) (R48.2)

63 (R 45) 63, (U 85) (R 45)

52.8 U75.3, R44.4

Characteristics of Health Care

Continuity of care: Integration of care Comprehensiveness of care (holistic

care)

Characteristics of service

Decentralization of the service Permanence of the service Polyvalence of the service

Major Problem

weak management Gap btw policy and actions Exist at all levels but more at LGA

Current Challenges of PHC implementation in Nigeria Poor and inconsistent political and administrative

will and commitment Low health budget – <10% is allocated for health Lack of competent and committed programmers

and programme implementers. Lack of appropriate information regarding progress

made (Output, Outcome, process rather than Input).

– **. Indicators of effectiveness – ** efficiency, and – ** acceptability

What types of indicators ?

Process- Activities (sometimes may be input) Productivity Use Utilization Quality

Still on indicators!

Output Coverage Efficiency Efficacy

Outcome- Effectiveness

Problems of PHC in Nigeria

Continuing injustice in health care delivery system especially in disfavour of the rural areas.

Continuing gap between what is said and what is done.

Weak and ineffective DHC System

Factors Precipitating the problems

Political commitment to the goals of health to ensure consistency and continuity of programmes is usually very weak and unpredictable,

Policy of the ruling party on health in terms of commitment and strategies to be adopted has been generally non-specific, unclear and unrealistic,

Factors Precipitating the problems

Improvement in people’s welfare means different things to the policy makers and staff . In many cases achievements are measured in terms of number of projects commissioned and not in terms of improvement in socio-economic status of the people . Therefore notable achievements which only means physical structures predominates during planning and resource allocation,

Factors Precipitating the problems

Low financial viability of LGAs. Most LGA depend mainly on the funds accruing from the federation account. When this is not forthcoming development projects comes to a standstill no matter how urgent the need to execute them,

Politics in the mobilization, allocation and use of facilities/resources and services

An Attempt to subvert PHC: The Selective PHC

Soon after Alma Ata, Politicians & ‘experts’ from DC wee not

comfortable with PHC principles of focusing on people

Advocated for a ‘new concept’ SPHC Disease oriented, using U5

Their arguments

CPHC was Idealistic Expensive and Unachievable- U5s are the real target

people

Their Identified Strategies!

Infant mortality reduction based on: focusing on growth monitoring, oral rehydration solutions, breastfeeding and immunisation,

SPHC’ achievements

took the decision-making power and control central to PHC away from the communities

delivered it to foreign consultants with technical expertise in these specific areas.

These ‘technical experts’ often employed by the funding agencies, were subject to the policies of their agencies, not the communities.

SPHC reintroduced vertical programs at the cost of comprehensive PHC

Approach to Improving Health Situation- 7th REPORT ON World Health

1987, WHO reaffirmed that: Political commitment to equity will remain a

fundamental pre-requisite to achieving the goal of HFA

Leadership to ensure that national policies decisions are aimed at correcting socio-economic disparities.

Not only the health sector but other sectors relevant to health have to contribute to the attainment of the goal

Way Forward

The capacity of health sector to cooperate effectively with economic and other social factors in policy decision must be increased

Mobilization of support and commitment from professional groups and individuals and counteracting public apathy and professional ignorance/ resistance

Way Forward

Vigorous management of the health systems and

Building a TEAM spirit for Health Effective decentralization

‘REFORM’ is central.

The missing link: MANAGEMENT!!

Organizational structures and management systems

This require the understand and cooperation of every part of the system

Management

The primary concern of management is to establish, strengthen and sustain the infrastructure required for effective implementation of strategies based on PHC.

Functions of Organizational structure in PHC 1.   Support the promotion of equitable distribution of health care resources 2. Encourage the participation of other sectors 3. Promote the scrutiny of all development initiatives for their impact in and in

relationship with health status, and

Functions of Organizational structure in PHC

4.  Strengthen or establish suitable institutions with recognised

channels of influence, in which dialogue and negotiation between health care

providers and beneficiaries can take place.

Assignment (Term Paper 1) PUH 603. Due 27th January 2007

Examine PHC implementation in Nigeria within the concept of health management.

If you have an opportunity to lead the health system in an LGA, explain how you would use PHC to bring about the desired improvement in people’s welfare

Reading Assignments

Read materials on Selective PHC. The originators and the political implications of the move

Relevance of Health Sector Reforms to PHC implementation

Guidelines on Implementing PHC in the LGA

Roles of each level of Govt in PHC

Reference materials

The Meaning of HFA by the year 2000 . Halfdan Mahler. World Health Forum 1981.

Primary Health Care: Medicine in its Place. Macdonald John. Earthscan Pub. Ltd. London, 1993.

Other relevant materials

Thank you