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1. PRIMARY HEALTH CARE ( phc )
BACKGROUND/ CONCEPT
• Universal concept.
• Infinite adaptability to any region, culture and stage of development.
• Speak a common language, represents values long held by nurse and is immensely
practical.
• Proceeds by involving all sectors of community dealing with health, environment, social
welfare, labor, housing, transportation , agriculture, media to create partnership among
family, health profession and governmental agencies
• Together these sectors focuses upon major health problem with appropriate technology
and personnel for the solution in each setting
• The drives toward PHC are determination of priorities.
• Clean water is needed before antibiotics; food is needed before Vitamin pills, basic
literacy and education before computers, home before prestigious projects in towns and
cities.
• The priorities thus should create healthy individual, family, communities that are free of
social, economic, cultural and political illness.
• PHC before Alma Ata declaration was considered as the care given by lower level health
professionals.
DEFINITATION
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
HISTORY OF PHC IN NEPAL
➢ In 1978, Alma Ata declaration made at USSR by WHO, UNICEF and government of 134
countries and many voluntary agencies.
➢ The conference detailed the principles which must be considered to establish PHC in
order to provide “Health for all’ by 2000 according to WHO.
• Then the concept of PHC became the strategy to achieve the goal of Health for all by
2000 A.D.
➢ PHC is new approach to health care.
➢ Integrates at the community level all the factors required for improving the health status
of the population.
➢ Integrates promotive, preventive and curative health services.
➢ Based on principles of equity, wider coverage, individual and community involvement
and intersectoral co-ordination.
➢ An integral part of the country’s plan for socio economic development.
➢ In Nepal, PHC system has implemented since 1980 and it has given more stress after the
democracy.
➢ The National Health Policy (NHP) was adopted in 1991 (2048) to improve the health
condition of the people.
➢ The primary objective of the NHP is to extend PHC system to rural population so that
they can benefit from modern facilities and trained health care providers.

2. PRINCIPLES OF PHC
There are 5 basic principles of PHC:
1. Equitable distribution (Accessibility of health services to all population)
2. Community participation towards achievement of PHC
3. Emphasis on services that are preventive and promotive rather than curative
4. Use of appropriate technology
5. Multisectorial approach/ intersectrol coordination
Equitable distribution (Accessibility of health services to all population)
➢ The first key principal in the PHC strategy is equity or equitable disturbation of health.
➢ Health services must be shared equally irrespective of their ability to pay, rich or poor,
rural or urban must have access to health services.
➢ The primary health care must be given to all individual in equal amount in community
irrespective of their gender, age, caste, and colour, urban rural and social class
➢ Health service must be located within short distance beneficiaries residence, that health
post must be located in place where people can reach easily.
Community participation towards achievement of PHC
➢ Community participation is the process by which individuals families assume
responsibilities for their own health and welfare of the community and develop the
capacity to contribute to their and community's development
➢ Community should be involved in problem identification, planning for man money and
materials, planning for health action by using local resources, implementation and
evaluation.
Advantages of community participation:
➢ Acceptance of health services.
➢ Mobilization of the local resources
➢ Increase self confidence and self respect.
Emphasis on services that is preventive and promotive rather than curative
➢ Preventive and promotive service includes providing clean water to communities
sanitation facilities such as latrines and sewages, adequate housing and the isolation of ill
people from other family members.
➢ Availability of adequate amount of nutritious food and vaccination programs.
➢ Curative services should be provided together with preventive and promotive services.
➢ Provisions of care as well as health education should be given to sick or disable people.
Use of appropriate technology
➢ Technology should be provided that is accessible, affordable, feasible and culturally
acceptable to the community for the promotion of primary Health Care. E.g. use of
refrigerator for vaccine, use of tractor for the agriculture etc.
➢ Technology that is scientifically sounds, adaptable to local needs and acceptable to those
who apply it and those for whom it is used and that can be maintained by the people
themselves in keeping with the principle of self reliance with the resources the
community and country can afford.
➢ Eg built of toilet by using locally available materials like wood stone and bamboo,
homemade dehydration solution.
Multisectorial approach/ intersectrol coordination
➢ Health and family welfare program cannot stand on its own in an isolated manner.
➢ Other sectors are equally important in improving community’s health and self reliance.

3. ➢ Thus, these sectors need to work together to coordinate their goals, plans and activities to
ensure that they contribute the health of the community and to avoid conflicting or
duplicating efforts.
➢ The sectors are equally important in promoting the community's health and self reliance ,
these sectors are :
• Agriculture
• Irrigation
• Education
• Animal husbandry
• Public works
• Communication
• Rural development
• Industries
• Voluntary organization units
Elements of phc
➢ E= Education for health
➢ L= Locally endemic disease control
➢ E= Expanded program for immunization
➢ M=Maternal and Child Health including responsible parenthood
➢ E= Essential drugs
➢ N= Nutrition
➢ T= Treatment of communicable and non-communicable diseases
➢ S= safe water and sanitation
➢ M= Mental health
➢ D = Dental health
Education
➢ Health education is an integral part of the health care thus all health personnel are
responsible for educating people as to how they can improve their own health.
➢ Health education should be focused on actual health problems because felt need is first
need of man.
➢ Health education should focus on preventive and controlling measures of health
problems.
➢ The CHN should play important role in organizing appropriate health education program
according to the need of the community collaborating with multi-sectoral teams.
Prevention and Control of locally endemic disease
➢ Endemic diseases are the diseases that commonly occur in certain geographical area or
country or among certain group of people.
➢ The endemic diseases in Nepal are malaria, goiter and Kalaazar.
➢ The community health nurse must provide health education, care to the ill, visit and
follow up the ill patient.
Expanded program against Immunization
➢ Immunization is important for prevention and control of communicable disease.
➢ Immunization against major killer disease.
➢ Vaccine preventable disease (measles, diptheria, pertusis, hepatitis, tuberculosis,
poliomyelitis and tetanus) has made a great stride worldwide.
➢ Gradually added vaccine against Hemophilus Influenza B virus (Hib) and hepatitis B in
DPT and named as pentavalent vaccine.

4. ➢ Added vaccine against Japanese Encephalitis (J.E.), Pneumococcal conjugate vaccine
(PCV), Inactivated Polio Vaccine (IPV), Rota vaccine.
➢ The National Immunization Programme (NIP) is a priority 1 (P1) programme of the
Government of Nepal and launched as the Expanded Programme on Immunization in
2034 BS (1977/78)
Maternal and child health care including family planning
➢ Maternal and child health are the important indicators of development.
➢ The main cause of high MMR are PPH, infection, obstructed labor, abortion and related
complication which can be prevented
➢ Provide antenatal, intranatal, perinatal and postnatal care, newborn care and infant care.
➢ Provision of family planning
➢ Legalizing abortion to prevent abortion related complications leading to death.
Essential drugs
• To provide and to participate in PHC, all the health workers has to procure and keep and
also utilize the essential drug treatment whenever needed.
• Adopting the WHO list of essential drugs, Department of Drug Administration (DDA),
Nepal has compiled a list of 200+ drugs and has been working towards supply and
management of essential drugs from periphery to tertiary level health institutions.
• Usually the number of drugs available at PHCC is 60.
Promotion of food supply and proper nutrition
➢ There is a close relationship between nutrition and health as it is essential for proper
growth and development and for prevention of infection.
➢ Educate the community about food and nutrition and its relation to health.
➢ Provision of iodine supplementary.
➢ Educate about safe birth spacing, breast feeding, safe weaning practice, basic sanitary
skills.
➢ Motivate and counsel to grow inter-seasonal food, preparation of supplementary food,
balance diet and selection of food in quantity and quality.
➢ Weighing infant and under five children, monitoring growth chart.
Appropriate treatment of common diseases and injuries
➢ Common diseases and minor injuries should be treated at health post level, PHC, district
hospital, central hospital according to the need.
➢ Common ailments and first aid management is available at the first level of health i.e.,
health post. For this adequate supplies required for care should always be available.
➢ Health workers should be trained up-to- date tackle the common disease condition and in
emergency situations. This reduces the complications, restore health early and timely
refer the case.
➢ Department of health (DOH) Nepal has provision of care from health post to tertiary care
facilities for referral management.
Adequate Supply of Safe water and Basic Sanitation
➢ Adequate Supply of Safe water and Basic Sanitation are essential for the health and well
being of the community.
➢ Educate community about ways of purifying drinking water, environmental sanitation,
construct household and community latrines make provision for composting facility and
safety tanks.
➢ Nurse should coordinate other sector for providing safe water and maintenance of good
sanitation for the community.

5. Mental health
➢ It is the important aspect of health, number of mental illness is increasing day by day, and
modern life can be extremely stressful and may provoke mental illness. So, PHC should
concentrate on the mental problem which prevails in the community.
➢ Nurse should teach community people about stress management, prevention of mental
illness and proper management of mentally disturbed people.
Dental health
➢ Nepalese people are suffering from various dental problems, the objective of dental
health services is the prevention of dental diseases of all kinds, as well as the treatment of
dental disorders.
➢ Nurse should conduct school health program and provide health education on oral care,
treatment about oral and tooth disorders.
➢ DOHS implemented dental health care at district and community providing training on
dental health care to service provider of DHO, PHCC and PHs to enable them to provide
basic dental health care.
Alma -Ata declaration
➢ International conference on primary health care, Alma- Ata, USSR, 6-12 September
1978.Expressing the need for urgent action by all governments, all health and
development workers, and the world community to protect and promote the health of all
the people of the world, hereby makes the following Declaration:-
1. The Conference strongly reaffirms that health, which is a state of complete physical,
mental and social wellbeing, and not merely the absence of disease or infirmity, is a
fundamental human right and that the attainment of the highest possible level of health is
a most important world-wide social goal whose realization requires the action of many
other social and economic sectors in addition to the health sector
2. The existing gross inequality in the health status of the people particularly between
developed and developing countries as well as within countries is politically, socially and
economically unacceptable and is, therefore, of common concern to all countries.
3. Economic and social development, based on a New International Economic Order, is of
basic importance to the fullest attainment of health for all and to the reduction of the gap
between the health status of the developing and developed countries. The promotion and
protection of the health of the people is essential to sustained economic and social
development and contributes to a better quality of life and to world peace.
4. The people have the right and duty to participate individually and collectively in the
planning and implementation of their health care.
5. Governments have a responsibility for the health of their people which can be fulfilled
only by the provision of adequate health and social measures. A main social target of
governments, international organizations and the whole world community in the coming
decades should be the attainment by all peoples of the world by the year 2000 of a level
of health that will permit them to lead a socially and economically productive life.
Prima~ health care is the key to attaining this target as part of development in the spirit of
social justice.
6. Primary health care is essential health care based on practical, scientifically sound and
socially acceptable 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 semi-reliance and self-determination. It forms an integral part both of the
country’s health system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the first level of contact

6. of individuals, the family and community with the national health system bringing health
care as close as possible to where people live and work, and constitutes the first element
of a continuing health care process.
7. Primary health care
➢ Reflects and evolves from the economic conditions and socio cultural and political
characteristics of the country and its communities and is based on the application of the
relevant results of social, biomedical and health services research and public health
experience;
➢ Addresses the main health problems in the community, providing promotive, preventive,
curative and rehabilitative services accordingly.
➢ Includes at least: education concerning prevailing health problems and the methods of
preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,
including family planning; immunization against the major infectious diseases;
prevention and control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs
➢ Involves, in addition to the health sector, related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other sectors; and demands the
coordinated efforts of all those sectors;
➢ Requires and promotes maximum community and individual self-reliance and
participation in the planning, organization operation and control of primary health care,
making fullest use of local, national and other available resources; and to this end
develops through appropriate education the ability of communities to participate
➢ Should be sustained by integrated, functional and mutually supportive referral systems,
leading to the progressive improvement of comprehensive health care for all an and
giving priority to those most in need
➢ Relies, at local and referral levels, on health workers, including physicians, nurses,
midwives, auxiliaries and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and technically to work as a health team
and to respond to the expressed health needs of the community
8. All governments should formulate national policies, strategies and plans of action to
launch and sustain primary health care as part of a comprehensive national health system
and in co-ordination with other sectors. To this end, it will be necessary to exercise
political will, to mobilize the country's resources and to use available external resources
rationally.
9. All countries should cooperate in a spirit of partnership and service to ensure primary
healthcare for all people since the attainment of health by people in any one country
directly concerns and benefits every other country. In this context the joint
WHO/UNICEF report on primary health care constitutes a solid basis for the further
development and operation of primary health care throughout the world.
10. An acceptable level of health for all the people of the world by the year 2000 can be
attained through a fuller and better use of the world's resources, a considerable part of
which is now spent on armaments and military conflicts. A genuine policy of
independence, peace, détente and disarmament could and should release additional
resources that could well be devoted to peaceful aims and in particular to the acceleration
of social and economic development of which primary health care, as an essential part,
should be allotted its proper share. The International Conference on Primary Health Care
calls for urgent and effective national and international action to develop and implement
primary health care throughout the world and particularly in developing countries in a
spirit of technical cooperation and in Keeping with a New International Economic Order.
It urges governments, WHO and UNICEF, and other international organizations, as well

7. as multilateral and bilateral agencies , nongovernmental organizations, funding agencies,
all health workers and We whole World community to support national and international
commitment to primary health care and to channel increased technical and financial
support to it, particularly in developing countries.
GOAL
➢ The global goal as stated in the Alma Ata Declaration is Health for all by the year 2000
through self-reliance.
➢ Health begins at home, in schools and in the workplace because it is there where people
live and work that health is made or broken.
➢ It also means that people will use better approaches than they do now for preventing
diseases and alleviating unavoidable disease and disability and have better ways of
growing up, growing old and dying gracefully.
➢ It also means that here will be even distribution among the population of whatever
resources for health are available.
➢ It means that essential health services will be accessible to all individuals and families in
an acceptable and affordable way.
Strategies
1. Accessibility , availability , affordability and acceptability of health services:
➢ Health services delivered where the people are.
➢ Use of indigenous/resident volunteer health worker as a health care provider with a ratio
of one community health worker per 10-20 households.
➢ Use of traditional (herbal medicine ) with essential drugs
2. Provision of quality, basic and essential health services:
➢ Training design and curriculum based on community needs and priorities.
➢ Attitudes, knowledge and skills developed are on promotive, preventive, curative and
rehabilitative health care.
➢ Regular monitoring and periodic evaluation of community health workers performance
by the community and health staff
3. Community participation:
➢ Awareness, building and consciousness rising on health and health-related issues.
➢ Planning, implementation, monitoring and evaluation done through small group meetings
(10-20 households cluster)
➢ Selection of community health workers by the community
➢ Formation of health committees
➢ Establishment of a community health organization at the parish or municipal level
➢ Mass health campaigns and mobilization to combat health problems
4. Self reliance :
➢ Community generates support (cash, labor) for health programs
➢ Use of local resources (human, financial, material)
➢ Training of community in leadership and management skills
➢ Incorporation of income generating projects, cooperatives and small scale industries
5. Recognition of interrelationship of health and development :
➢ Convergence of health, food, nutrition, water, sanitation and population services
➢ Integration of PHC into national, regional, provincial, municipal and education,
agriculture, industry, housing, public works, communication and social services.
➢ Establishment of an effective health referral system
6. Social mobilization
➢ Establishment of an effective health care referral system.
➢ Multi- sectoral and interdisciplinary linkage
➢ Information, education, communication support using multi-media

8. ➢ Collaboration between government and nongovernmental organizations
7. Decentralization
➢ Reallocation of budgetary resources
➢ Reorientation of health professional and PHC
➢ Advocacy for political and support from the national leadership down to the barangay
level.
Role of the nurse in primary health care
Primary health care means to provide basic and essential health services to people by using
limited resources. Nurses are not restricted only inside the four boundaries of hospital their
roles are spread from clinical areas to community at door to door. In community, the horizon
of nursing is wide and the nurse has several roles to achieve the goal “Health for all" Some of
the important roles are as follows:
❑ Health educator
❑ Health care provider
❑ Motivator
❑ Counselor
❑ Supervisor
❑ Manager
❑ Coordinator
❑ Evaluator
❑ Facilitator
❑ Change agent
❑ Researcher
References
1. Ghimire Binda, A text book of community health nursing, 4th
edition, heritage
publication and distributors P .ltd bhotahity , Kathmandu 2015
2. Basavanthappa BT, community health nursing, 2nd
edition, jaypee.
3. ..Alma Atta declerationa E93944.pdf