Primary Health Care

Principles, terms and concepts

Preamble

• “Primary Care”- 1920 in England.LordDawson reported on “First ContactMedical Care and the Promotion ofPrimary Health Centre”.

• In 1962, the term was used in Britain todenote General Practice

• Prior to Alma Ata, nations had one systemor the other of health care delivery

• Nigeria had BHSS in the 70’s

2

Alma-Ata Declaration

• This was adopted at the International

Conference on Primary Health Care

(PHC), Almaty (formerly Alma-Ata),

Kazakhstan (formerly Kazakh Soviet

Socialist Republic), 6–12 September 1978

• It expressed the need for urgent action by

all governments, all health workers, and

the world community to protect and

promote the health of all people3

Alma-Ata Declaration

• It was the first international declaration

underlining the importance of primary

health care

• The primary health care approach has

since then been accepted by member

countries of the World Health Organization

(WHO) as the key to achieving the goal of

"Health For All"

4

Alma Ata USSR 1978 (12/9/78), defined

PHC as

• 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 that the community and the country

can afford to maintain at every stage of their

development

• in the spirit of self reliance and self determination”5

REASONS FOR A NEW APPROACH

• Gross inequalities exists b/w developed and developing countries and also within countries – leading to inequity

• High cost of technology

• Access problems

• Sustainability of many health interventions in doubt

• Univalent programmes which never translated into a healthy population

6

BHSS in Nigeria

• Objectives:

- Increase access to appropriate health

services by the end of 1975-1980

- Provision of essential services, correction

of imbalance between rural and urban

areas/regions, utilizing lower cadre of staff

capable of accomplishing task

- Prevention and health promotion services

to be integrated with curative services

- Basic Health Units to achieve integration7

BHSS in Nigeria

• Implementation:

- 1 BHU with Four categories of HF

1 comprehensive HF at apex – 50,000 pop.

4 PHC centers – 10,000 pop. each

20 health clinics – 2,000 pop. each

5 mobile clinics – 40,000 pop. each

- States refused to comply because it meant constructing 25 HF in 1LGA

- After about N200 million at the end of 1983, most of the facilities remained uncompleted all over the country 8

Reasons for failure of BHSS• Reliance on unsustainable structures and

equipments

• Poor inter-sectoral collaboration

• Selection based on political expediency

• The training of health personnel were also

institutional based

• Concentrated on provision of health facilities

and training of health workers

• Little attention to community participation & use

of appropriate technology

• Workers integration problems /same reason for

preference of urban posting persists

9

Evolution of PHC in Nigeria

• The global target of Health for All was

declared in 1978 at Alma ata

• Primary health care (PHC) has been

adopted and accepted universally to be

the approach to achieving this lofty goal.

10

History and Conceptualization

of PHC in Nigeria• In Nigeria, primary healthcare was

adopted in the National Health Policy of

1988 (FMOH, 2004) as the cornerstone of

the Nigerian health system as part of efforts

to improve equity in access and utilization

of basic health services.

• Since then, primary health care in

Nigeria has evolved through various

stages of development. 11

History and Conceptualization

of PHC Cont’d• Historically, there were three major attempts at

evolving and sustaining a community and

people oriented health system in Nigeria.

• The first attempt occurred between 1975 and

1980. The fulcrum of this period was the

introduction of the Basic Health Services

Scheme (BHSS).The Basic Health Services

Scheme came into being in 1975 as an integral

part of Nigeria’s Third National Development

Plan (1975 – 79) 12

Second Historical Attempt on

PHC• A second attempt which was led by

• late Professor Olukoye Ransome-Kuti occurred

between 1986 and 1992

• This period was characterized by the

development of model primary health care in

fifty two (52) pilot local government areas all of

which were implementing all eight

components of primary health care.

• A key result of this dispensation was the

attainment of 80% immunization coverage for

fully 13

Third Historical Attempt at PHC

• The National Primary Healthcare

Development Agency (NPHCDA) was

established in 1992 and heralded the third

attempt to make basic healthcare accessible

to the grassroots

• During this period, which spanned through

2001, the Ward Health System (WHS) which

utilizes the electoral ward (with a

representative councilor) as the basic

operational unit for primary health care

delivery was instituted. 14

Definition contd• First level of contact of individuals, the family

and the community with the National Health

System,

• Bringing health-care as close as possible to

where people live and work

15

A model PHC in Nigeria

16

5 universal principles of Primary

Health Care

• Equitable distribution

• Community participation

• Preventive and promotive approach

• Appropriate technology

• A multi-sectoral approach

17

Community Participation

• It is the hallmark of PHC

• It is a process by which individuals and

families assume responsibility for their

own health and those of the community

• It involve identification of needs,

development of strategy to meet identified

needs & strategy for

• implementation, monitoring and evaluation

18

Inter-sectoral Collaboration

• ‘Production’ of health is not something

that the health sector alone can do; it

involves

• efforts/inputs from other sectors including

education, agriculture, livestock, finance,

information, etc

19

Equity

• All primary health care resources and

services should be made accessible and

affordable to all

• Health services must be shared equally

among the people irrespective of their

ability to pay

• At present health services are mainly

concentrated in the major towns & cities

20

Integration of health

programmes

• Various components of primary health

care need to be provided in a coordinated

way and made

• available, to the community, including

referrals.

21

Appropriate Technology

• The technology ( methods of care,

service delivery, procedures and

equipment) should be simple

• and scientifically sound. It should also be

within reach of the individual/community

• This also applies to use of costly

equipment, procedures and techniques

when cheaper, scientifically valid &

acceptable ones are available e.g. ORS22

Components of Primary Health Care

• Immunization against major infectious

diseases

• Prevention and control of locally endemic

and epidemic diseases

• Adequate supply of safe water and basic

sanitation

• Promotion of food supply and proper

nutrition

• Health Education and promotion23

Components of PHC contd

• Maternal and child health care including family

planning

• Appropriate treatment of common diseases and

injuries

• Provision of essential drugs and revolving

system.

• *Dental health care

• *Mental health care

• *Primary eye care

• * Geriatric care 24

Immunization against Major

Infectious diseases• Immunization is the most powerful and

cost-effective means of preventing some

of the deadly diseases of childhood

• The prevention of diseases by

immunization, a conventional public health

measure is today the best known practical,

low-cost community-base way of

protecting children against the major killer

childhood diseases25

Immunization against major

infectious diseases

• Expanded Programme(EPI) now National Program

on Immunization (NPI) has some challenges;

(i) Mobilizing the community so that everyone spreads

the word about immunization.

(ii) Getting the health authorities to ensure constant

availability of vaccines.

(iii) Educating and convincing parents to demand

immunization for their children.

(iv) Motivating mothers to act, to go back repeatedly

until full dose26

Prevention and control of locally

endemic and epidemic diseases

• The prevention and control of locally

endemic and epidemic diseases is an

important aspect of Primary Health Care

• Health for all cannot be achieved unless

positive efforts are made to control the

major communicable and non-

communicable diseases that plague many

developing countries, using appropriate and

affordable ways.27

Prevention and control of locally

Endemic Diseases Cont’d• Major endemic diseases include malaria

infection, viral diseases (yellow fever and lassa

fever), bacterial diseases (cholera, cerebro-

spinal meningitis, typhoid fever. leprosy and

tuberculosis), helminthic infestations

guineaworm,schistosomiasis,onchocercia-sis,

filariasis and loaisis), and sexually transmitted

diseases (HIV/AIDS)

• Some of the diseases often occur as serious

epidemics killing many people, e.g, yellow

fever, lassa fever. cholera and,cerebrospinal

28

Maternal and child health care

including family planning• The aim of maternal and child health

(MCH) services is to reduce to a minimum

the risks of pregnancy and childbirth, as

well as reduce the maternal mortality rate

and childhood mortality rate

• A well-articulated MCH program will as a

matter of necessity include family planning

29

Maternal and Child Heath

including family planning• Family planning has a great potential for

1) reducing maternal mortality by reducing

births that would have occurred among

women in high risk group (old age, high

parity, previously bad obstetric history),

2) reducing unwanted pregnancies that

would have resulted in illegal/unsafe

abortion.

30

Health Education and

Promotion• The process of educating the community on

prevailing health problems and methods of

controlling them is considered by many as the

most important component of primary health

care.

• Information, education and communication

(IEC) activities must lead to a situation where

people not only value good health but know

how to achieve it and what to do individually

and collectively towards achieving good health

Health Education and

Promotion• Health education is central to primary health

care and success in the implementation of the

other components of primary health care

depends mainly on individual and communities

that are:

• (i) adequately informed to recognize their health

problem and to utilize the available health

services and facilities in solving them

• (ii) adequately motivated to feel the need for

additional justified services and to assume

active interest, participation and leadership in

the provision of such services

32

Promotion of Food Supply and

proper nutrition• Nutrition problems constitute the greatest threat

to public health in the world.

• The problem of malnutrition is universal but

most common in Asia, Africa and South

America.

• Food may also be the vehicle of transmission

for many other infectious diseases. These

include typhoid and paratyphoid fever,

shigellosis, streptococcal phyryngitis,

brucellosis, infective hepatitis,amoebiasis,

cholera33

Promotion of Food Supply and

proper nutrition Cont’d• Nutritional rehabilitation is an important aspect

of malnutrition intervention aimed at

rehabilitating malnourished children as quickly

as possible at PHC

• The objective of nutritional rehabilitation has

been expanded beyond mere cheap

convalescence and treatment measures to

include exposure of mothers and the whole

community to farming, household food security,

nutrition and income generation. 34

Provision of essential drugs and

revolving system• The provision of drugs forms an integral part of

overall health delivery primary health care.

• Essential drugs are those drugs that satisfy the

health care needs of the great majority of the

people and which should be available at all

times in adequate amount and appropriate

forms

• They are those basic drugs that must be

available for the treatment of the common

diseases in an area 35

Criteria for selection of essential

drugs1.The drug must be of proven efficiency and

safety.

2. Side effects must be minimal.

3 The quality and availability of dosage form

should be assured

4. The dosage form should have reasonably long

stability under the expected conditions of storage.

5 . Tablets should be preferred to syrups and

solutions because the can keep better.

6.Drugs formulated in single compounds are 36

Basic Requirements for a sound

PHC ( the 8A’s and 4 C’s)

• Appropriateness

– Services provided are essential to meeting

the population’s needs

• Adequacy

– Services provided are proportionate to what is

required by the community

• Affordability

– The cost of the services provided should be

within the means and resources of the

individual and the country 37

Basic Requirements for a sound

PHC ( the 8A’s and 4 C’s)

• Accessibility

– Services provided must be ‘reachable’ (

geographically, economically and culturally)

• Acceptability

– Services provided must elicit adequate

communication between health care providers

and patients and must be trusted by patients

• Availability

– People must be able to obtain the services

they need as at when they need them 38

Basic Requirements for a sound

PHC ( the 8A’s and 4 C’s)

• Assessibility

– People must be able to evaluate the services

that are provided

• Accountability

– It should be possible to review how the

resources have been used to provide services

• Completeness

– Adequate attention should be paid to all

aspects of a medical problem – prevention,

early detection, diagnosis, treatment, follow-

up measures, and necessary rehabilitation39

Basic Requirements for a sound

PHC ( the 8A’s and 4 C’s)

• Comprehensiveness

– Care is provided for all types of health

problems

• Continuity

– The management of patient’s care over time

must be coordinated among providers

• Community full participation

– Beneficiaries of services should be included in

the identification of their health needs and

how to meet such needs. 40

Implementation of PHC in

Nigeria• 1975: Establishment of the National Basic

Health Services Scheme (BHSS)

• 1978: Alma Ata Declaration

• 1985: African Health Ministers’ re-

affirmation to the Alma Ata Declaration

• 1986: Adoption of PHC in Nigeria in 52

LGAs as models ( funded and managed

by FGN)

41

Implementation of PHC in

Nigeria• 1987: Adoption of the Bamako Initiative

by African Health Ministers

• 1988: Launch of Nigeria’s first

comprehensive National Health Policy

based on Primary Health Care

• 1986-90: Establishment of Schools of

Health Technology

• Expansion of PHC to all LGAs

• Achievement of Universal Child

Immunization Target of over 80%42

Implementation of PHC in

Nigeria• 1992: Establishment of the National

Primary Healthcare Development Agency

(NPHCDA)

• 1993: Beginning of the collapse of PHC in

Nigeria

• 1997: Establishment of the National

Programme on Immunization (NPI)

• 2001: Report on Needs Assessment

Survey to Determine the Status of PHC

in Nigeria43

Levels of Health Care

• Primary health care

• Secondary health care

• Tertiary health care

44

Primary Health Care

• The “first” level of contact between the

individual and the health system

• Essential health care (PHC) is provided

• A majority of prevailing health problems

can be satisfactorily managed

• The closest to the people

• Provided by the primary health centers

45

Misconceptions about PHC

• PHC is only of relevance to poor developing countries which

cannot afford modern medical care

• PHC is second best medicine acceptable only to the rural poor

and urban slum dwellers

• PHC is a stopgap solution to be replaced by something better at

a later stage and

• PHC is a separate stand-alone service isolated from the main

health care system.

Secondary Health Care

• More complex problems are dealt with.

• Comprises curative services

• Provided by the district/general hospitals

• The 1st referral level

47

Tertiary Health Care

• Offers specialist care

• Provided by regional/central level

institution

• Provide training programs

48

Referral system

• A process by which a healthcare provider

transfers the responsibility of the patients

management temporarily/permanently to

another health care provider or

professional

• Two-way referral is the desired

– allows for cross-fertilization of ideas, better

interaction and enhances transfer of

knowledge between providers

49

Current status of PHC in Nigeria• Ward Health System: represents the current national

strategy for the delivery of PHC services.

• Utilises the electoral ward from which a representative councillor is elected as the basic operational unit

• Aims of WHS:

- To promote full & active community participation at the grass root level

- To improve access to quality health care and ensure equity

- To promote local initiatives and encourage poverty alleviation activities in the ward

- To reinforce political commitment at grass root level

- To reduce morbidity and mortality especially amongst women and children under five years

50

PHC Under one roof (PHCUOR)

• The PHC under one roof (PHCUOR)

policy was formulated in 2011 to address

the problem of fragmentation in PHC and

ensure the integration of PHC services

under one authority.

• Its impact is yet to be felt on health status

and utilization of PHC in Nigeria since

PHC under one roof became a national

policy only few years ago. 51

PHCUOR Cont’d

• The inability of PHC centers to provide

basic medical services to the Nigerian

population have made both secondary and

tertiary health-care facilities experience an

influx of patients.

• This has had its toll on the secondary and

tertiary levels of care

52

Committees at PHC level

• LG PHC Management Committee

• PHC Technical Committee

• Ward Development Committee

• Village Development Committee

53

PHC Organogram

LGA Chairman

Secretary

Medical Officer of Health/PHCC

APHCC APHCC APHCC APHCC APHCC APHCC

Ward level Coordinators/Station heads

Station heads

Village level coordinators

LGPHC Management committee

PHC Technical Committee

Ward Development Committee

Village Development Committee

DPM Supervisory

councilor for

health

54

Health Manpower at the PHC

• Medical Officer of Health

• Community Health Officer ± midwifery skills

• Public Health Nurse

• CHEW

• JCHEW

• Environmental health Officer/Technician/assistant (EHO/EHA/EHT)

• Pharmacy technicians

• Others: lab technician, record staff, administrative officer &

• Support staff - Health assistants/Health attendant

55

Medical Officer of Health

• 1856: the Association of Metropolitan

Medical Officers of Health.

• Ladipo Oluwole

• 2007: Association of Medical Officers of

Health in Nigeria

Managerial functions

Technical functions

Clinical functions

56

Monitoring and evaluation of

PHC activities• Instrument of evaluation

– Routine reporting systems

– Sentinel reporting system

– Coverage survey

– Outbreak investigation

– Program review

– Cost analysis

– Cold chain & logistic evaluation

57

Indicators for monitoring PHC• Proportion of population with access to

media outlets

• Measurement of adult literacy activities in

the community

• Immunization coverage

• % of deliveries attended by a trained

health worker

• Disease incidence and prevalence,

mortality rate

• Provision & availability of essential drugs58

Indicators for monitoring PHC

• Proportion of pregnant women receiving

ante natal and post natal care

• Proportion of eligible women (15-45 years)

receiving family planning advice or actually

using modern method of family planning

• Percentage of children U5 years below

reference value of weight –for-age

• Number of children U5 year treated with

home made rehydration salt59

Indicators for monitoring PHC

• Percentage of population with safe water

in home or within 200m of portable water

source200 meters of potable

• Percentage of population with adequate

facilities for excreta disposal or living

within 50m of a pit latrine or toilet

• Percentage of population living within 5km

or ½ to 1 hr travel time of a HF

60

Challenges of PHC implementation

• Poor political will

• Funding gaps

• Structural problems of the three –tiered

• Allocative & managerial inefficiencies

• Lack of human resource planning

• Gaps in recruitment of skilled manpower

• Developmental inequalities

• Dearth of human resources especially in rural areas

61

Challenges of PHC implementation

• Poor coordination

• Fragmentation of programmes due to

multiplicity of implementing partners and

development partners

• Lack of clear definition of roles and

responsibilities of the various levels of

government with respect to health in

general

• Corruption/fraud/mismanagement of

resources and lack of accountability &

tranparency 62

Challenges of PHC implementation

• Little attention paid to inter-sectoral

collaboration which is supposed to be one

of the pillars of PHC

• No clearly defined policy on the financing

of PHC services

• Inadequate equipment and poor condition

of infrastructure

• Lack of essential drug supply

63

Infrastructural decay at a PHC

64

Infrastructural Decay at a PHC

65

Recommendations

• Government should;

1. Increase political will and provide technical support for PHC implementation

2. Address funding gaps and inequalities

3. Human resource for health development through; recruitment of skilled manpower

4. Ensure transparency and accountability in disbursement of PHC funds

5. Address infrastructure and equipment deficits bedeviling PHCs. 66

References

• Aigbiremolen, A.O., Alenoghena, I., Eboreime,

E., Abejegah, C; Primary Health Care in

Nigeria: From conceptualization to

Implementation; Journal of Medical and Applied

biosciences Vol 6(2)35-43

• Bolaji Samson Aregbeshola and Samina

Mohsin Khan;Primary Health Care in Nigeria:

24 Years after Olikoye Ransome-Kuti’s

Leadership;Front Public Health 2017(5):48

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC

5346888/67

Thank you for your attention

68