Dip. Oral Health Programme PRIMARY HEALTH CARE: CONCEPT & PRINCIPLES By Abiodun Bamigboye, FRSH Community Health Department Obafemi Awolowo University, Ile-Ife. paobamiboye @yahoo.com .
Dip. Oral Health Programme
PRIMARY HEALTH CARE:
CONCEPT & PRINCIPLES
By
Abiodun Bamigboye, FRSH
Community Health Department Obafemi Awolowo University, Ile-Ife. [email protected].
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