Community Health study notes

1. CHAPTER THREE
PRIMARY HEALTH CARE (PHC)
Objectives:
At the end of this unit, the student should be able to:
1.Define primary health care.
2.Define the elements of primary health care.
3.Define the principle/pillars of primary health care.
4.Discuss the different ways of health care financing.
5.Describe the millennium development goals.
6. Describe the sustainable development goals.
3.0 Introduction
For a long time, many countries have been trying to put greater emphasis on the
prevention of disease and on extending health services to underserved communities, but
these efforts have been met with limited success. In 1978, the Alma Ata International
conference on PHC provided a great stimulus to these efforts. The conference set as it
targets ”Health for all by the year 2000”.The Alma Ata declaration states: Primary Health
Care is essential health care made accessible to the community at an affordable cost by
using methods that are practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals 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.
The Alma Ata declaration also listed the following 8 key elements of PHC.
1.Education concerning primary prevailing health problems and the methods of preventing
and controlling them.
2.Promotion of food supply and proper nutrition.
3.An adequate supply of safe water and basic sanitation.
4.Maternal and child healthcare including family planning.
5 Immunization against major infectious diseases.
6.Prevention and control of locally endemic diseases.
8.Provision of essential drugs.
3.1 Principles /Pillars of Primary Health Care (PHC)
Equity:
The declaration highlighted the inequity between the developed and the developing
countries and termed it politically, socially and economically unacceptable.
Promoting equity is one of the greatest challenges facing many countries. Great progress
has been achieved in many countries in recent years. In the health sector, the fastest and
most effective way to reduce the social gaps that affect many countries is to apply the

2. primary care strategy, because decentralizing care and reaching out to people generate
enormous benefits for individuals, families, and society as a whole.
Community participation:
Only when a community fully understands and is committed to a programme will that
program stand a chance of success and sustainability. A community participation approach
is a cost-effective way to extend a health care system to the geographical and social
periphery of a country; communities that begin to understand their health status
objectively rather than fatalistically may be moved to take a series of preventive
measures. Communities that invest labor, time, money, and materials in health promoting
activities are more committed to the use and maintenance of the things they produce,
such as water supplies. Promoting community participation is a skill which must be taught
to community health workers, and backed up with support services.
Decentralization:
This refers to the transfer of authority from planning, decision making and management
(including social and financial management) from a higher to a lower level such as the
central government headquarters (ministries) to the districts or some local organization.
Decentralization is an important element in the policy formulation and implementation of
Primary Health Care (PHC) in developing countries. While this may well be the case,
certain forms of “decentralization” policies can have negative implications for the
development of PHC. It can be associated with a reduced role of the public sector, weaken
the central Ministry of Health, be instrumental in producing inequity and facilitate political
domination. It is necessary to examine decentralization with a view to securing its effective
formulation and implementation.
Accessibility
Accessibility can be defined as the opportunity or ease with which consumers or
communities are able to use appropriate services in proportion to their need.
Access to primary health care is a key policy issue in many countries, and is of particular
importance in those countries committed to equitable access to primary health care as a
strategy for addressing health inequity. Making sure primary health care systems are
equitable and accessible to those who need them most is more complex than equal use
by all people or population groups.
Health promotion and disease prevention:
Health Promotion is the provision of information and/or education to individuals, families,
and communities that-encourage family unity, community commitment, and traditional
spirituality that make positive contributions to theirhealth status. Health Promotion is also
the promotion of healthy ideas and concepts to motivate individuals to adopt healthy
behaviors. According to the World Health Organization, Health promotion is the process
of enabling people to increase control over, and to improve their health. Health promotion
is a broad concept that includes behavior change in relation to many activities such as
nutrition, environment and recreation, rather than the prevention of a specific disease.

3. Prevention implies identification of a risk group and implementing appropriate preventive
measures.
Effectiveness
Implies that the technologies and the strategies used in health care do work, that is, they
reduce risk and prevent or cure diseases.
Integration of health programs
Primary health care in many low and middle-income countries is organized through a
series of vertical programmes for specific health problems such as tuberculosis control or
immunizations of children. Vertical programmes can help deliver particular technologies,
but may lead to service duplication, inefficiency and service fragmentation. The World
Health Organization and other organizations promote integration, where inputs, delivery,
management and organization of particular service functions are brought together, as a
solution to such problems.
Efficiency
Means that the methods used to achieve a given result use the minimum resources
facilities, manpower, money and time required to do the job.
3.2 Health care financing.
Over the past decades many kinds of treatments have been developed for several
illnesses. These treatments are frequently expensive. Different methods of financing of
financing health services have been developed. Sometimes, sick people have to pay for
treatment when sick; sometimes services are paid out of taxes (often mistakenly called
“free” medical care because it is free at the time you need it).Other methods of payment
have included cost sharing insurance schemes or by making employers pay. It is essential
when formulating priorities and making choices to realize that there is no such thing as
free medical care. Politicians may like to talk about it and about the right to the free
medical care. All the things that make up the costs of health and medical care. There are
various ways in which costs can be spread throughout the community and over time, but
in the end, someone may pay or the service will cease.
1. Fee for service.
This is the oldest and most widespread method of payment. If you are sick, you go to the
hospital and pay the required fee. This is the market approach. It tends to make healthcare
providers concentrate on what the community wants, but has the disadvantage that those
who cannot pay will not get the service when they need it.
2. Payment from taxes.
For many years, all government services have been paid out of money collected as taxes
or donated. Some of the government health services provided are free to the patient at
the time they need the services.

4. 2. Insurance:
The principle of insurance is sharing risks. Those who belong to an insurance scheme pay
a fixed amount every month or year whether they are ill or not. When an insured person
needs service, it is paid for out of the funds which have been collected from members of
the insurance scheme on a regular basis. The amount paid, as premiums match the type
of service provided. There are very expensive insurance plans that will for almost all
medical expenses and there are less expensive ones that will pay for limited services
3. Employment related payment:
Some employers provide some health services to their employees, and sometimes to the
employees’ families. Such services may be considered part of the workers wage or salary.
They may be provided by the company running an occupational health service itself or by
contracting out to others to other health care providers. This type of payment for
healthcare is only available to those who are employment.
3.4 The Millennium Development Goals (MDGs)
The Millennium Development Goals (MDGs) are the most broadly supported,
comprehensive and specific development goals the world has ever agreed upon. These
eight time-bound goals provide concrete, numerical benchmarks for tackling extreme
poverty in its many dimensions. Adopted by world leaders in the year 2000 and set to be
achieved by 2015, the MDGs are both global and local, tailored by each country to suit
specific development needs. The Millennium Development Goals (MDGs) were developed
out of the eight chapters of the United Nations Millennium Declaration signed in September
2000. There are eight goals with 21 targets, and a series of measurable indicators for each
target.
There are eight Millennium Development Goals namely:
Goal 1: Eradicate extreme poverty and hunger:
 Halve, between 1990 and 2015, the proportion of people whose income is less than
$1 a day.
 Halve, between 1990 and 2015, the proportion of people who suffer from hunger.
Goal 2: Achieve Universal Primary Education:
 Ensure that, by 2015, children everywhere, boys and girls alike, will be able to
complete a full course of primary schooling
Goal 3: Promote Gender Equality and Empower Women:
 Eliminate gender disparity in primary and secondary education, preferably by 2005,
and in all levels of education no later than 2015.
Goal 4: Reduce Child Mortality:

5.  Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.
Goal 5: Improve Maternal Health:
 Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio.
Goal 6: Combat HIV/AIDS, Malaria and other diseases:
 Have halted by 2015 and begun to reverse the spread of HIV/AIDS.
Goal 7: Ensure Environmental Sustainability:
 Integrate the principles of sustainable development into country policies and
programs and reverse the loss of environmental resources.
Goal 8: Develop a Global Partnership for Development:
 Develop further an open, rule-based, predictable, nondiscriminatory trading and
financial system (includes a commitment to good governance, development, and
poverty reduction, both nationally and internationally)
3.4.1 Millennium development goals and the progress of public health
While some countries have made impressive gains in achieving health-related targets,
others are falling behind. Often the countries making the least progress are those affected
by high levels of HIV/AIDS, economic hardship or conflict. Children's nutrition has
improved. The percentage of underweight children is estimated to have declined from
25% in 1990 to 16% in 2010. But 104 million children are still undernourished. Stunting
in children under five years old has decreased globally from 40% to 27% over the same
period. However, in the UN Africa Region, the number of stunted children is projected to
increase from 45 million in 1990 to 60 million in 2010. Annual deaths of children under
five years of age in 2008 fell to 8.8 million, down by 30% from 1990. The pace of decline
has accelerated since 2000. In the WHO African Region, the rate of decline in child deaths
doubled from 2000–2008, compared to the previous decade. The deaths of nearly 3 million
children under five each year worldwide can be attributed to diarrhoea and pneumonia.
An estimated 40% of deaths in children under five occur in the first month of life, so
improving newborn care is essential for further progress. The number of infants
immunized against measles increased from 94 million to 107 million from 1990 to 2008,
a rise in coverage of 73% to 83%. Maternal health remains the MDG target for which
progress has been most disappointing. Recent academic estimates1 suggest that maternal
mortality has fallen since 1990 though at a pace well short of the annual 5.5% reduction
needed to achieve the MDG targets. The study reports a global annual average rate of
decline over the period 1990-2008 of 1.3% compared with the 0.4% decline reported by
the UN between 1990-2005. The UN estimates are currently being updated and this will

6. involve a process of country consultation so that the final results will not be available until
later in the year. Preliminary evidence indicates modest reductions in maternal mortality
and improvements in use of skilled attendant at birth in several countries. It is critical to
note that all such estimates are uncertain due to different statistical assumptions and
modeling approaches. There is an urgent need for bettercountry level data and for support
to building information systems able to identify and monitor all births and deaths.
From 2000 to 2008 fewer than half of all pregnant women made the WHO-recommended
minimum of four antenatal visits. While the global proportion of births attended by a skilled
health worker has increased, in the WHO regions of Africa and South-East Asia fewer than
half of all births had skilled assistance.
Women in developing countries are increasingly able to plan their families due to
contraceptive use. The proportion of women in developing countries who report using
contraceptives increased from 50% in 1990 to 62% in 2005. From 2000 to 2007 there
were 47 births per 1000 adolescent girls aged 15–19 globally. From 2001 to 2008 new
HIV infections worldwide declined by 16%. In 2008, 2.7 million people contracted the virus
and there were 2 million HIV/AIDS-related deaths. In 2008, around 45% of the 1.4 million
HIV-positive, pregnant women in low- and middle-income countries received antiretroviral
therapy (ART) to prevent the transmission of HIV to their babies. More than 4 million
people in low- and middle-income countries were receiving ART by the end of 2008 but
that left more than 5 million untreated HIV-positive people in these countries. Despite a
rise in the number of new tuberculosis (TB) cases worldwide – due to an increase in
population – more people are being successfully treated. TB mortality among HIV-negative
people has dropped from 30 deaths per 100 000 people in 1990 to 21 deaths per 100 000
in 2008. However, HIV-associated TB and multidrug-resistant TB are harder to diagnose
and cure. Indications are that 38 countries are on course to meet the MDG target for
reducing malaria; in 2008 an estimated 243 million cases of malaria caused 863 000
deaths, mostly of children under five. The supply of insecticide-treated nets increased but
need outweighed availability almost everywhere. Access to ant malarial medicines
(especially artemisinin-based combination therapy) increased but it was inadequate in all
countries surveyed in 2007 and 2008. Globally, the percentage of the world’s population
with access to safe drinking-water increased from 77% to 87%, which is sufficient to reach
the MDG target if the rate of improvement is maintained. In low-income countries,
however, the annual rate of increase needs to double in order to reach the target and a
gap persists between urban and rural areas in many countries.
In 2008, 2.6 billion people had no access to a hygienic toilet or latrine and 1.1 billion were
defecating in the open. The slowest improvement has been in the WHO African Region,
where the percentage of the population using toilets or latrines increased from 30% in
1990 to 34% in 2008. Inadequate sewerage spreads infections such as schistosomiasis,
trachoma, viral hepatitis and cholera.

7. Revision Questions
1 Define primary health care.
2.Define the elements of primary health care.
3.Define the principle/pillars of primary health care.
4.Discuss the different ways of health care financing.
5.Describe the millennium development goals.
Activity 3
a). Describe whether the millennium and sustainable development goals have been
achieved within your community.
b). What are the different ways that are being used to finance health care within your
community?