Principles of primary health

care

Presenter : Dr Vaishnavi C

Guide : Dr Priyadarshini C

23/2/2015

1

CONTENTS

• Introduction to health care

• Evolution of primary health care

-The Alma-Ata Declaration

• Attributes of primary health care

• Components of primary health care

• Principles of primary health care

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CONTENTS Contd...

• Evolution of primary health care in India

• Primary health care scenario in India

• 30 years after Alma-Ata

• Conclusion

• References

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INTRODUCTION TO HEALTH CARE

• Health - fundamental human right

• Integrated care comprising preventive, promotive, curative &

rehabilitation services

• Extending from “womb to tomb”

• Key to socio economic development and progress of the country

• Organized in three levels

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TERTIARY

LEVEL

SECONDARY

LEVEL

PRIMARY

LEVEL

HEALTH CARE PYRAMID

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EVOLUTION OF PRIMARY HEALTH

CARE

The Alma-Ata Conference

• International conference on primary health care

• Conducted from 6-12th September 1978 at Alma Ata

• Mile stone in the history of public health

• Key to the attainment of the goal of the Health for All

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OBJECTIVES OF ALMA-ATA

• To promote the concept of primary health care

• To evaluate the present health care situation

• To define the principles of primary health care

• To define the roles of governmental, national and international

organisations

• To formulate recommendations for the development

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DECLARATION OF ALMA-ATA

• Existing gross inequality in the health status of the people is

unacceptable

• People have a right and duty in participating individually and

collectively

• Primary health care is essential health care

• An acceptable level of health for all the people by 200023/2/2015

8

DEFINITION

• Primary health care -“an essential health care made

universally accessible to individuals and acceptable to them,

through their full participation and at a cost the community

and country can afford to maintain at every stage of their

development in the spirit of self reliance and self

determination”

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ATTRIBUTES OF PRIMARY HEALTH

CARE

• Essential health care

• Universally accessible

• Acceptable

• Community based

• First point of contact

• Affordability

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ATTRIBUTES Contd...

• Adaptability

• Appropriateness

• Community participation

• Continuity

• Comprehensiveness

• Coordination

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ATTRIBUTES contd...

Accessible

Affordable

Primary health care

Acceptable

Appropriate

Adaptable

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COMPONENTS OF PRIMARY HEALTH

CARE

• Education concerning the prevailing health problems and the

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 care including family planning

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COMPONENTS Contd...

• Immunization against major infectious diseases

• Prevention and control of locally endemic diseases

• Appropriate treatment of common diseases and injuries

• Provision of essential drugs

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PRINCIPLES OF PRIMARY HEALTH

CARE

Equitable distribution

Community participation

Intersectoral coordination

Appropriate technology

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EQUITABLE DISTRIBUTION

• Inequity in the availability of health

services - major concern

• Supply of health care resources- more towards affluent areas

• Julian Tudor Hart - “Inverse Care Law”

Availability of good medical care tends to vary inversely with

the need for it in the population served

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EQUITABLE DISTRIBUTION

• First key principle in the primary health care

• Ensures that individuals with more compromised health

conditions will receive more health services

• Commitment to health equity focuses not only on ensuring

program inputs but also reducing differences in health

outcomes

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EQUITABLE DISTRIBUTION

• Access to health care - horizontal equity & vertical equity

• Horizontal equity - “equal access for equal needs”

equal resources

equal access to health care

equal utilization of health services

equal health

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EQUITABLE DISTRIBUTION

• Vertical equity - unequal should be treated in proportion of

their inequality

• Individuals with more need should have more treatment

• The central theme of “need” therefore determines equity

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Aspects of equity in health and health care:

Equity in access to health care

Equity in health

Effective coverage

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Examples of equitable distribution in access to health care in

India:

Tripura- helicopter service to reach the remote set of tribal

hamlets

Andhra Pradesh- free bus passes to pregnant women for the

antenatal visits

Assam - Akha-ship to provide primary care services in riverine

Island through boat clinics

Tamil Nadu – concept of birth resorts is introduced in remote

and hilly areas for institutional deliveries23/2/2015

21

Socio economic inequalities are widening than narrowing

• Failure of publicly financed health care to reach the poor

people

• Too little knowledge about the relative importance of

inequalities in the determinants of health and health service

utilization

• Too little is known about the impact of programmes and

policies on health sector inequalities

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To overcome inequality

Concern of attaining health equity is no longer the domain of

health professionals only

Multi disciplinary action involving diverse resources

Adoption of Millennium Development goals ,2000 - latest

international initiative to attempt at equity

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MDG - 2015

1.Eradicate extreme poverty & hunger

2: Achieve universal primary education

3: Promote gender equality and empower women

4: Reduce child mortality

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MDG -2015

5: Improve maternal health

6: Combat HIV/AIDS, malaria & other diseases

7: Ensure environmental sustainability

8: Develop a global partnership for development

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COMMUNITY PARTICIPATION

• Involvement of the individuals,

families and community

• Determines both collective needs and priorities

• Important role in formulating a health problem, make informed

choices ,objectives with community priorities

• Universal coverage cannot be achieved without the involvement

of the local community

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• Bare foot doctors:

In China, lack of availability of rural

health services was addressed from 1965 to

80 by development of bare foot doctors.

Rural farm workers were given basic

heath training to provide combination of

traditional and western medicine.

Regarded as model for development of

community health workers

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COMMUNITY PARTICIPATION contd...

• 2 Types: active & passive

• Active – co-operation + resources

• Passive – Co-operation only

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Advantages of community participation:

• Increases program acceptance and

leadership

• Ensures that the program meets the local needs

• Cost of implementing the program may be reduced by using

the local resources

• Uses local/ familiar organizations and hence problem solving

is efficient

• Commitments to the decision is facilitated

• Key to the sustainability

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Planning steps in community participation:

Identification and prioritization of the problems

Planning together

Implementation by community members

Evaluation by community members

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Examples of community participation in India:

• Village health guides, trained dais, ASHA

• Selected by the local community and trained locally

• Essential feature of health care in India

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NAME OF THE

COMMUNITY

BASED WORKER

STATE OF

IMPLEMENTATION

SERVICES

PROVIDED

Village health guide Whole country Health education,

MCH and family

welfare, first aid

Mahila Swasthya

Sangh

Whole country Assisting ANM in

educating and

motivating the

community

Community based

worker

Uttar Pradesh Assisting ANM,

community

mobilization for

MCH services

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NAME OF THE

COMMUNITY

BASED WORKER

STATE OF

IMPLEMENTATION

SERVICES

PROVIDED

Bharat vaidya Andhra Pradesh Health surveys,

registration of births

and deaths, daily

home visits

Jan Mangal Couple Rajasthan Promoting small

family norm

Traditional birth

attendants

180 districts Conduct safe

deliveries, postnatal

care

NAME OF THE

COMMUNITY BASED

WORKER

STATE OF

IMPLEMENTATION

SERVICES

PROVIDED

Jan Swasthya

Rakshak

Madhya Pradesh Public health services

and curative services

Mitanin Chhattisgarh Immunization,

malaria vector

control, opposition of

domestic violence

Sanjeevani Haryana Formation of Jagriti

Mandalis (awareness

groups)

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• Village Health and Sanitation Committee: Play multiple

roles including IEC, household surveys, preparation of health

registers, organisation of meetings at the village level,

promoting household toilet, sanitation programme.

• Rogi Kalyan Samitis/ patient welfare society

• Jan Swasthya Abhiyan Initiative- People Rural Health watch

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INTERSECTORAL CO-ORDINATION

• “Primary care involves in addition to the health sector, all related

sectors and aspects of national and community development”

• Includes sustainable participation that combine inter-

organizational cooperative working alliances

• Possibly, but not necessarily,

in collaboration with

the health sector

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Pre-requisites for Intersectoral Coordination:

• Proper orientation of policies and programme

• Formation of joint coordination committee at each level

• Defining role and responsibilities of participatory agencies

• Participatory decision making

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Intersectoral Co-ordination Contd...

• Developing formal system of interaction, discussion and

debate

• Sharing of the problems faced in implementation

• Spelling out strategies and procedure

• Joint evaluation and monitoring

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Mechanism of co-ordination:

• List out names of different sectors

• Identify the NGOs and voluntary organisation

• Constitute the district level co-ordination committee

• Formulate specific task forces

• Jointly decide the objectives and areas

• Decide the role and responsibility

• Development a plan

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Difficulties facing intersectoral co-ordination:

• Create conflicts of interest and disequilibrium

• Power struggles

• Agencies must be able to compromise and impose change on

the normal working patterns

• Cultural changes may occur within organisations

• Co-ordination may turn out to be more expensive in terms of

time, money and manpower23/2/2015

40

• Irrespective of the disadvantages, intersectoral coordination is

the key principle outlined by WHO if Health for All has to be

achieved

• An outstanding example of the intersectoral coordination at the

grass root level - Anganwadi as a part of ICDS programme

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Examples of intersectoral co-ordination-India:

• Convergence with Indian system of medicine (AYUSH)

• Co-ordination with rural health practitioners

• In Bihar, Janani - “Titli” & “Surya” clinics

• Co-ordination with non-governmental and civil organisation-

mother NGO schemes (MNGO), service NGO (SNGO)

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APPROPRIATE TECHNOLOGY

• “Technology that is scientifically sound, adaptable to local

needs and acceptable to those who apply it and those for

whom it is used and is maintained by the people themselves in

keeping with the principle of self reliance with the resources

the country and the community can afford”

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Appropriate Technology contd...

• Designed to meet specific health needs

• Criteria for choosing which needs should be addressed -

include magnitude of the population affected, the degree of

morbidity or mortality caused by the health condition

• Lack of solutions that are effective, safe, acceptable,

affordable, accessible, and sustainable

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An appropriate technology should be: (WHO-1989)

• Scientifically valid

• Adapted to local needs

• Acceptable to users and recipients

• Maintainable with local resources

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Technology only effective if accompanied by...

• Knowledgeable and skilled users

• Clear practice guidelines and policies

• Effective financing and distribution to make them available

• Community efforts to bring clients into contact with health

services in timely way

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• Only have impact if incorporated into a comprehensive health

delivery system

• Defining the attributes and characteristics of appropriate health

technologies needs to take place early

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Examples for the appropriate technology

• Use of coloured tapes for measuring mid upper arm

circumference

• Use of ORS

• Tender coconut for oral hydration

• Growth chart maintenance for under five children

• ITN

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Jan Swasthya Sahyog:

• CMC Vellore and AIIMS

• Low cost techniques

• Detection of UTI costs less than Rs.2/test, anaemia less than

Re 1, diabetes and pregnancy at Rs.3

• Low cost mosquito repellent creams

• Simple water purification

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• Informational technological advancements that have been

proven to ultimately enhancing the service delivery-

Health Management Information System

Telemedicine

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EVOLUTION OF PRIMARY HEALTH CARE IN

INDIA

• One of the first countries to recognize the merits

• Conceptualized in 1946 - Health Survey and Development

Committee Report

• Sir Joseph Bhore’s recommendations formed the basis for

organization of health services in India

• 1952: primary health centres to provide integrated promotive,

preventive, curative and rehabilitative services to entire rural

population

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Evolution Contd...

• Second five year plan (1956-61) - “Health survey and

planning committee” by Dr.A.L.Mudaliar

• Basic Health services- 1965

• Jungalwalla committee in 1967

• The Kartar Singh Committee on multipurpose workers -1973

• The Shrivatsav Committee -“A referral service complex”

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Evolution Contd...

• Rural Health Scheme was launched in 1977

• National Health policy in 1983 - to achieve the goal of ‘Health

for All’ by 2000 AD

• II National Health policy – 2002

• NRHM- 2005 : Strengthening the delivery of primary health

care

• 12th Five year plan- Universal Health Coverage

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PRIMARY HEALTH CARE SCENARIO IN

INDIA

• Progress in the health of the population served by the PHC

• Encouraging signs at all levels of a shift toward embracing a

more comprehensive menu of health intervention content and a

more comprehensive health system building

• 80% of health needs can be met by primary health care

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Scenario Contd...

• Universality, equity, quality, efficiency and sustainability

• Created a conducive environment

• main achievement - improved coverage

• Eradication (e.g. poliomyelitis) and elimination (e.g. measles)

campaigns - wide network of primary health care facilities and

workers

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Indicators 1951 2014

CBR 41.7# 21.4*

CDR 25# 7.0*

IMR 146# 40*

MMR 437# 109*

Life expectancy 41.38# 66.21*

*- SRS BULLETIN September 2014

#- Development towards achieving health, medind.nic.in

30 YEARS AFTER ALMA-ATA

• WHO - “PHC Now More Than Ever”

• Structured the PHC reforms in four groups

• Reflected on values of equity, solidarity and social justice

• Growing expectations of the population in modernizing

societies.

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PHC- NOW MORE THAN EVER

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CONCLUSION

• Fundamental changes have occurred affecting health service

delivery

• Changes have further increased the critical importance of

primary health care and its central role in sustainable

development

• It should aim to remain as the leader and the means to

achieving health for all

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REFERENCES

1.Park K. Park’s Textbook of preventive and social medicine. 22

ed. Jabalpur (India): BanarasidasBhanot Publishers; 2013.

P.831-56

2.Detels R, Beaglehole R, Lansang MA, Gulliford M. Oxford

Textbook of Public Health. 5th ed. United Kingdom: Oxford

University press; 2009.p.831-7

3.Balwar R, Vaidya R, Tilak R, Guptha RK, Kunte R. Textbook

of Public Health and Community Medicine. 1st ed. Department

of community medicine, AFMC, Pune in collaboration with

WHO India office.New Delhi (India); 2009. p.380-1

23/2/201561

REFERENCES

4.Lal S, Adarsh, Pankaj. Textbook of Community Medicine.

3rded. CBS Publishers & Distributions Pvt Ltd, New Delhi;

2013.

5.Suryakantha AH. Community Medicine with recent advances.

1st ed. New Delhi (India): Jaypee Brothers medical publishers;

2009.

6.Primary health care as a strategy for achieving equitable care.

[online] 2007 [cited on 2015 Feb 14]; Available

from:URL:http://www.who.int/social_determinants/resources/

csdh_media/primary_health_care_2007_en.pdf23/2/201562

REFERENCES

7.Vlassof C, tanner M, Weiss M, Rao S. Putting People first: A

Primary Health Care Success In Rural India. Indian J

community Med 2010 Apr;35(2):326-30.

8.PHC- Now More Than Ever. World health report 2008 [Online]

2008 [cited on 2015 Feb 12]; Available from:URL:

www.who.int/whr/2008/whr08_en.pdf

9.Report of International Conference on Primary Health Care.

WHO [Online] 1978 [cited on 2015 Jan 10]; Available

from:URL:

http://www.searo.who.int/entity/primary_health_care/documen

ts/hfa_s_1.pdf

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REFERENCES

10.Breiger WR. Community participation. Johns Hopkins

Bloomberg school of Public Health [Online] 2006 [cited on

2015 Jan 10]; Available from:URL:

http://ocw.jhsph.edu/courses/socialbehavioralfoundations/PDFs/

Lecture15.pdf

11.Haq C, Hall T, Thompson D, Bryant J. Primary Health Care-

Past, Present and Future. Global health education consortium

[Online] 2009 Feb [cited on 2015 Jan 31]; Available

from:URL:http://cugh.org//27_Primary_Health_Care_PHC_Pas

t_Present_Future_FINAL.pdf

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REFERENCES

12.Programme Management. National Institute of Health and

Family Welfare. New Delhi (India): 2013.p.45-58

13.Primary Health care- Indian scenario. World Health

organization [online] 2008 Aug [cited on 2015 Jan 31];

Available from:URL:http://who.int/health_care_documents/phc

-Indian scenario.pdf

14.Rahim A. Principles and Practice of Community Medicine. 1st

ed. New Delhi(India): Jaypee Brothers medical publishers(P)

Ltd; 2008.p.23-33

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“When we talk about capacity, we absolutely must talk about the importance of primary health care. It

is the cornerstone of building the capacity of health systems”

- Dr. Margaret chan

director, Director general

who

THANK YOU

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