Primary health care (phc) and health policy

Primary Health Care (PHC)

Definition

Historical development

Principles

The PHC philosophy

Strategy

The level of care

The components/elements of PHC

PHC in Ethiopia

Primary Health Care

(PHC)

Definition

PHC is essential health care based on practical, scientifically sound,

and socially accepted methods and technology made universally

accessible to individual and families in the community through their

full participation and at a cost that 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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Main terms in the definition

1. Essential – basic and indispensable

2. Scientifically sound – scientifically explainable and acceptable

3. Socially acceptable methods and technology – acceptable by the

community and consider the local value, culture and belief

4. Universally accessible – to bring health care as close as possible to

where people live and work

5. Community involvement – individual and families assume greater

responsibility for their own health.

6. Self reliance and self determination- Being independent understanding

your own needs and trying to minimize problems.

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Historical development

• WHO was established in 1948.

Major objective was the attainment by all people of the highest

possible level of health

• Health care approaches implemented in different countries between

1948 and 1978 did not enable WHO to meet its objective

• In the 1950s

– Vertical health service strategy was implemented (control of

malaria, TB and venereal diseases) -Was expensive and

unsuccessful.

– Strategy of health service – construction of health centers and

health stations.

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• In the early 1970s

– Integration of the vertical control programs

– Disease oriented based on high cost, requiring advanced

technology to solve health problems

– Health status of hundreds of millions of people in the world is

unacceptable

– Tremendous strides in medicine and technology didn’t solve health

problems of most people

– The organized limited health institutions failed to meet the demand

of most people

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PHC…cont’d

– The health services often created in isolation neglecting other

sectors, which are relevant to health.

– Health institutions stressed curative services.

– The community has rarely been participated.

• In the late 1970s

– 1977 - “Health for all by the year 2000.”

– 1978 – Strategy to meet the above goal was defined

• PHC in Alma-Ata USSR.

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PHC Principles

1. Inter-sectoral collaboration

2. Community participation

3. Appropriate technology

4. Equity

5. Focus on prevention of disease and health promotion

6. Decentralization

1. Inter-sectoral collaboration

– Joint concern and responsibility of sectors in identifying problems,

programs and undertaking tasks.

– Health has several dimensions that can be affected by other sectors.

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2. Community involvement

The communities should be actively involved:

– In the assessment of the situation

– Problem identification

– Priority setting and making decisions

– Sharing responsibility in the planning, implementing, monitoring

and evaluation.

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Advantages of community participation

– Extend service/better coverage

– Programs are affordable and acceptable

– Promote self reliance and confidence

– Create sense of responsibility

– Consider real needs and demands

– Promote local community initiatives and technology

– Reduce dependency on technical personnel

– Build the community’s capacity to deal with problems

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Skills for enhancing community participation

– Belief in community’s potential

– Skills in participatory approach (look, listen and learn)

– Ability to motivate

– Awareness creation among leaders

– Understanding community culture

– Identify or create a mechanism for community participation.

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3. Appropriate technology

Criteria for appropriateness:

• Effective

• Culturally acceptable and valuable

• Affordable, i.e., cost effective

• Locally sustainable

• Environmentally accountable

• Measurable

• Politically responsible

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4. Equity

Universal coverage of the population with care provided according

to need.

Possible definition of equity includes:

Equal health

Equal access to health care

Equal utilization of health care

.

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5. Focus on prevention and promotive health services

Balanced allocation of resources to preventive and curative care

6. Decentralization

Taking decision making closer to the communities served and to

the field providers of services.

Enhance the ability to tap new sources for financing health care.

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The PHC Philosophy

A. Equity and justice

– Equitable distribution of services, resources and health care.

– Health service should be accessible and affordable.

B. Individual and community self-reliance

– Personal responsibility for their own and their family’s health.

C. Inter-relationship of health and development

– Health makes a fundamental contribution to a country’s economy.

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The PHC Strategy

1. Changes in the health care system

– Total coverage with essential health care

– Integrated systems

– Involvement of communities

– Use and control of resources

– Redistribution of existing resources

– Reorientation of health human resources

– Legislative changes

– Design, planning and management of health system

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2. Individual and collective responsibility for health

– Political issue – decentralization of decision-making.

– Self realization – personal responsibility for their own and their

family’s health.

– For both aspects it is important to have informed and motivated

public.

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PHC – The level of care

Primary level

– Primary care provided by PHCU and district hospital

– Levels of prevention – primary, secondary and tertiary.

Intermediate level

– Secondary care provided by zonal and regional hospitals.

– Levels of prevention - primary, secondary and tertiary.

Central level

– Tertiary care provided by central referral and teaching hospital.

– Levels of prevention – Tertiary prevention.

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The components/elements of PHC

1. Health education

2. Provision of essential drugs

3. Immunization

4. MCH/FP

5. Treatment of common diseases and injuries

6. Adequate supply of safe water and basic sanitation

7. Communicable disease control

8. Food supply and proper nutrition

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Additional elements incorporated after Alma-Ata

1. Oral health

2. Mental health

3. The use of traditional medicine

4. Occupational health

5. HIV/AIDS

6. ARI

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PHC in Ethiopia

Formally began in 1980s and includes the following:

1. Education on the prevailing health problems and methods of preventing

and controlling them

2. Locally endemic diseases prevention and control

3. EPI

4. MCH/FP

5. Essential drugs provision

6. Nutrition promotion of food supply

7. Treatment of common diseases and injuries

8. Sanitation and safe water supply

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Major problems in the implementation of PHC in Ethiopia

– Absence of infrastructure at the district level

– Difficulty in achieving inter sectoral collaboration

– Inadequate health service coverage and mal-distribution for

available health services

– Inadequate resource allocation

– Absence of clear guidelines or directives on implementation

– Presence of culturally dictated HTP or unscientific beliefs

– Absence of sound legal rules to support env’t health activities

– Weak community involvement in health

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Health Delivery System and

Health Policy in Ethiopia

• Policies are expressed in whole series of practices, statements,

regulations and even laws which are the result of decisions about

how we will do things.

• Health care policy may be seen as the networks of inter-related

decisions which together form an approach or strategy in relation

to practical issues concerning health care delivery.

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Historical development of health service policies in Ethiopia

– Modern medicine was introduced to Ethiopia in the 16th century

– 1908 an office dealing with health created in ministry of interior

– World war II- Italian occupation (1935-41) no marked event has

taken place during this period

– 1947 the 1st health legislation established

– 1948 Ministry of Health established

– 1960 begun to develop basic health services

– 1962 Gondar college of PH established.

– 1949-1951 three nursing schools were established

– 1966 the 1st medical school was opened in Addis

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Health plans (The 5-year development plan)

The 1st 5 year (1958-1962)

– Did not include public health

– Priority was development of infrastructure

The 2nd 5 year (1963-1967)

– Contained major policies and strategies regarding health sector

– Emphasis on preventive measures

– Expansion of basic health services

– Set long term objectives for health centers (HC) and health stations (HS)

It envisioned:

• 1 HC to serve 50,000 population and supervise 10 HS

• 1 HS to serve 5,000 people on average

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• Limitation of the 2nd five year plan

– Man power shortage

– Inadequate supervision mechanism

– Inadequate supply of drugs, medical equipment and supplies

– Insufficient recurrent budget

– Inadequate communication system to develop referral service

– Plan implementation problem

– Under utilization of capital budget

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The 3rd 5 year (1968-1973)

Major goals focused on:

1. Malaria eradication program

2. Establishing the provincial health departments

To ensure closer supervision of health activities

To enhance preventive function

3. Emphasis to be given to training of all professionals and auxiliary

personnel

Limitation was again plan implementation gap

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The 4th 5 years (1974-1979)

– Re-emphasized the importance of PH services

– Targeted to increase health service coverage from 15 to 30%

– This plan was not materialized due to government change.

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Structure and development of health care system since the

revolution of Derg era (1974GC)

• Health service distribution was concentrated in a few urban centers

– AA, Asmera, Harar

• 43% of health budget allocated for 3 big cities

• By 1974 there were

– 6,474 health personnel

– 650 HSs

– 93 HCs

– 84 hospitals with 8,624 beds

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Structure and development of health since the derg era…cont’d

Change in health policy

Focus was:

– Primary Health Care (PHC) and rural health service

– Prevention and control of communicable diseases

– Self-reliance and community participation in health activities

through its declaration of NDRP in 1976

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Specific aspects of policy emphasis are on:

– Community involvement

– Coordinate efforts of development sectors

– Gradual integration of special program and specialized health

institutions

– Delivery of essential health care at the cost affordable by the

community

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Development of a 6 tired health service system

Which include:

1. Community health services (health post), 1:1000,

2. HSs (clinics), 1:10,000

3. HCs, 1:50-100,000

4. Rural hospitals, 1:50-100,000

5. Regional hospitals, 1:1.6-3 million population

6. Central referral and teaching hospitals

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On assessment it indicated that:

– The management is very centralized

– Minimum participation of community and the private sector

– Has undesirable impact on efficiency and resource allocation

– Overlapping or redundant service around a minor segment of the

population.

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Six annual campaign plans (1978-1984/85)

– The Gov’t through the NDRP, under took annual campaign

(Development through cooperation campaigns).

– Result was encouraging

– Construction of thousands of wells and latrines.

– Community health services introduced in more than 5000

localities.

– HSs tripled from 650-1950.

– HCs increased from 93-145.

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The ten year health sector plan (1985-1994)

– A main objective of the plan focuses on

• Full and active community involvement

• Multi-sectoral collaboration and coordination

• Extend health services to 80% of the population

• Put under control all major communicable disease

• Expand EPI services

• Comprehensive health services to special population

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The target of 10 years plan

– Reduction of IMR from 155/1000 to 95/1000.

– Reduction of CMR from 247/1000 to 95/1000.

– Improvement of LE at birth from 42 years to 55 years.

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Number of professionals to increase as follows:

– All medical doctors from 721-2000

– Specialists from 349-819

– Nurses from 1960-5498

– Sanitarians from 298-1962

– Lab. Tech from 425-1,209

– Health assistants from 6,991-13,500.

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• Problems that hampered the health development

– Economic and political problems,

– Poverty, shortage of resources,

– Under utilization of PHC services.

• Events that took place between 1974 and 1984

– Change of Gondar P.H college to medical school.

– Establishment of a third medical school in Jimma.

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• Major short comings were:

– Inequitable distribution

– Recommended organizational and structural arrangements

remained unsolved.

– Unrealistic goals,

– Attention shifted towards the political conflict and war.

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The Health Policy of

Transitional Government of Ethiopia

General policy

1. Democratization and decentralization of the health service system

2. Prevention and promotive components of health care

3. Equitable and acceptable standard of health service system

4. Promoting and strengthening of inter-sectoral activities

5. Strengthening of national self-reliance in health development

mobilizing and maximally utilizing internal and external resources

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Health policy…cont’d

6. Assurance of accessibility of health care

7. Cross boundary health issues

8. Appropriate capacity building

9. Provision of health care (payment according to ability)

10. Involvement of private sector and NGOs

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Priorities of the policy

1. Information, Education and Communication (IEC).

2. Emphasis shall be given to:

– The control of CDs, epidemics, diseases related to nutrition and

poor living conditions,

– The promotion of occupational health and safety,

– The development of environmental health,

– The rehabilitation of infrastructure and

– Appropriate health service management system

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Priorities of the policy…cont’d

3. Curative and rehabilitative components including mental

health.

4. Traditional medicine including related research and gradual

integration into modern medicine

5. Applied health research

6. Provision of essential drugs and supplies shall be

strengthened

7. Development of human resources

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Priorities of the policy…cont’d

8. Special attention shall be given to the health needs of:

– Family particularly women and children.

– Those in the forefront of productivity

– Those most neglected regions and segments of the population

– Victims of man-made and natural disasters

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Strategies

1. Democratization

2. Decentralization

3. Inter-sectoral collaboration in addressing health problems

4. Health education

5. Promotive and preventive activities

– Control of CDs and nutritional diseases

– Prevention of related affluence and aging from emerging as major

health problems.

– Prevention of environmental pollution

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6. Human resource development

– Team approach health care

– Community based, task oriented front line and middle level health

workers

– Continuing education

– Attractive career structure, remuneration and incentive for all

health cadres.

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Strategies …cont’d

7. Assuring availability of drugs and supplies

– Develop quality control capacity

– Maintenance and repair facilities for equipment

8. Encouraging the use of traditional medicine

– Coordinating and encouraging research

– Identifying and encouraging utilization

– Developing regulation and registration for its use

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Strategies…cont’d

9. Health systems research, Identifying priority areas, Expanding applied

research

10. Referral system to be developed

11. Diagnostic and supportive services – prompt diagnosis and treatment.

12. Health management information system, Making the system

appropriate and relevant for decision making.

13. Financing the health service

14. Health legislation shall be revised

15. Strengthening of administration and management of health system

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Strategies…cont’d

Twenty year health sector development plan (1996-2015)

HSDP – I, II, III, IV

• Give acceptable standards of comprehensive and integrated PHC

through equitably distributed institutions based at the grass root level.

• Focusing on preventive and promotive aspects of care:

– Health education

– Reproductive health care

– Immunization

– Environmental health and sanitation

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Health sector development plan…cont’d

• Change of the six tire system into four tire system,

• Decentralized, democratized and participatory administration.

• Designed for a period of 20 years with a rolling 5 year program

periods.

The main goals are:

– Building basic infrastructure

– Provision of standard facilities and supplies

– Development and deployment of an appropriate health human

power

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Levels of care

Level Population Staff category Function

PHCU 25,000 H.Os + others Prev, prom + curative

District H 250,000 G.Ps + others Prev, prom + curative

Regional H

1,000,000 Specialists, G.Ps + Others

Most specialities

Spec/teaching H

5,000,000 High qualified Teaching + spec. ser

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Currently the health system in Ethiopia is organized in 3 level (3 tiered system)?

Primary health care (phc) and health policy

Health & Medicine

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