principles of primary health care

1. Principles of primary health
care
Presenter : Dr Vaishnavi C
Guide : Dr Priyadarshini C
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2. 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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3. 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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4. 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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5. TERTIARY
LEVEL
SECONDARY
LEVEL
PRIMARY
LEVEL
HEALTH CARE PYRAMID
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6. 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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7. 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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8. 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 2000
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9. 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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10. ATTRIBUTES OF PRIMARY HEALTH
CARE
• Essential health care
• Universally accessible
• Acceptable
• Community based
• First point of contact
• Affordability
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11. ATTRIBUTES Contd...
• Adaptability
• Appropriateness
• Community participation
• Continuity
• Comprehensiveness
• Coordination
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12. ATTRIBUTES contd...
Accessible
Affordable
Primary health care
Acceptable
Appropriate
Adaptable
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13. 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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14. 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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15. PRINCIPLES OF PRIMARY HEALTH
CARE
 Equitable distribution
 Community participation
 Intersectoral coordination
 Appropriate technology
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16. 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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17. 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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18. 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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19. 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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20. Aspects of equity in health and health care:
 Equity in access to health care
 Equity in health
 Effective coverage
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21. 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 deliveries
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22. 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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23. 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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24. 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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25. 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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26. 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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27. • 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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28. COMMUNITY PARTICIPATION contd...
• 2 Types: active & passive
• Active – co-operation + resources
• Passive – Co-operation only
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29. 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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30. 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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31. 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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32. 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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33. 23/2/2015
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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

34. 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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35. • 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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36. 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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37. 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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38. 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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39. 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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40. 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 manpower
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41. • 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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42. 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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43. 23/2/2015
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44. 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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45. 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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46. 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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47. 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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48. • 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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49. 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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50. 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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51. • Informational technological advancements that have been
proven to ultimately enhancing the service delivery-
 Health Management Information System
 Telemedicine
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52. 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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53. 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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54. 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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55. 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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56. 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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57. 23/2/2015
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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

58. 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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59. PHC- NOW MORE THAN EVER
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60. 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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61. 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
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62. REFERENCES
4.Lal S, Adarsh, Pankaj. Textbook of Community Medicine.
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2013.
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from:URL:http://www.who.int/social_determinants/resources/
csdh_media/primary_health_care_2007_en.pdf23/2/2015
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63. REFERENCES
7.Vlassof C, tanner M, Weiss M, Rao S. Putting People first: A
Primary Health Care Success In Rural India. Indian J
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8.PHC- Now More Than Ever. World health report 2008 [Online]
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http://www.searo.who.int/entity/primary_health_care/documen
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64. REFERENCES
10.Breiger WR. Community participation. Johns Hopkins
Bloomberg school of Public Health [Online] 2006 [cited on
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11.Haq C, Hall T, Thompson D, Bryant J. Primary Health Care-
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65. REFERENCES
12.Programme Management. National Institute of Health and
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13.Primary Health care- Indian scenario. World Health
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Ltd; 2008.p.23-33
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66. “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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