1) Primary health care aims to provide universal access to essential health services based on principles of equity, community participation, and intersectoral coordination. It was established as a key concept at the Alma-Ata Conference in 1978. 2) India has evolved its primary health care system over time based on recommendations from committees. The National Rural Health Mission in 2005 aimed to strengthen primary health care delivery. 3) While primary health care coverage and health indicators in India have improved in the past decades, challenges remain in achieving universal access and health equity goals according to primary health care principles.

1. PRESENTED BY,
MR. KAILASH NAGAR
ASSIST. PROF.
DEPT. OF COMMUNITY HEALTH NSG.
DINSHA PATEL COLLEGE OF NURSING, NADIAD

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

3. CONTENTS
Contd...
• Evolution of primary health care in India
• Primary health care scenario in India
• 30 years afterAlma-Ata
• Conclusion
• References

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

5. TERTIARY
LEVEL
SECONDARY
LEVEL
PRIMARY
LEVEL
HEALTH CARE PYRAMID

6. EVOLUTION OF PRIMARYHEALTH
CARE
The Alma-Ata Conference
• International conference on primary health care
• Conducted from 6-12th September 1978 at AlmaAta
• Mile stone in the history of public health
• Key to the attainment of the goal of the Health forAll

7. OBJECTIVES OFALMA-
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

8. DECLARATION OFALMA-
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

9. DEFINITIO
N
• 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”

10. ATTRIBUTES OF PRIMARY HEALTH
CARE
• Essential health care
• Universally accessible
• Acceptable
• Community based
• First point of contact
• Affordability

11. ATTRIBUTES
Contd
...• Adaptability
• Appropriateness
• Community participation
• Continuity
• Comprehensiveness
• Coordination

12. ATTRIBUTES contd...
Accessible
Affordable
Primary health care
Acceptable
Appropriate
Adaptable

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

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

15. PRINCIPLES OF PRIMARY
HEALTH CARE
 Equitable distribution
 Community participation
 Intersectoral coordination
 Appropriate technology

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

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

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

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

20. Aspects of equity in health and health care:
 Equity in access to health care
 Equity in health
 Effective coverage

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

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

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

24. MDG - 2015
1.Eradicate extreme poverty & hunger
2: Achieve universal primaryeducation
3: Promote gender equality and empower women
4: Reduce child mortality

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

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

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

28. COMMUNITY PARTICIPATION
contd...
• 2 Types: active & passive
• Active – co-operation + resources
• Passive – Co-operation only

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

30. Planning steps in community participation:
Identification and prioritization of the problems
Planning together
Implementation by community members
Evaluation by community members

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
31

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 AssistingANM,
community
mobilization for
MCH services
32

33. 33
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
COMMUNITYBASED
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)
34

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
35

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
36

37. 37
23/2/2015
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

38. 38
23/2/2015
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

39. 39
23/2/2015
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

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
40
23/2/2015

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
41
23/2/2015

42. 42
23/2/2015
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)

43. 43
23/2/2015

44. 44
23/2/2015
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”

45. 45
23/2/2015
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

46. 46
23/2/2015
An appropriate technology should be: (WHO-1989)
• Scientifically valid
• Adapted to local needs
• Acceptable to users and recipients
• Maintainable with local resources

47. 47
23/2/2015
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

48. 48
23/2/2015
• 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

49. 49
23/2/2015
mid upper arm
Examples for the appropriate technology
• Use of coloured tapes for measuring
circumference
• Use of ORS
• Tender coconut for oral hydration
• Growth chart maintenance for under five children
• ITN

50. 50
23/2/2015
Jan Swasthya Sahyog:
• CMC Vellore andAIIMS
• 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

51. 51
23/2/2015
been• Informational technological advancements that have
proven to ultimately enhancing the service delivery-
 Health Management Information System
 Telemedicine

52. 52
23/2/2015
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

53. 53
23/2/2015
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”

54. 54
23/2/2015
Evolution Contd...
• Rural Health Scheme was launched in 1977
• National Health policy in 1983 - to achieve the goal of ‘Health
for All’ by 2000AD
• II National Health policy – 2002
• NRHM- 2005 : Strengthening the delivery of primary health
care
• 12th Five year plan- Universal HealthCoverage

55. 55
23/2/2015
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

56. 56
23/2/2015
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

57. 57
23/2/2015
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 AFTERALMA-
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.
58
23/2/2015

59. PHC- NOW MORE THAN
EVER
59
23/2/2015

60. 60
23/2/2015
CONCLUSIO
N
• 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

61. 61
23/2/2015
REFERENCE
S1.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

62. csdh_media/primary_health_care_2007_en.pdf 62
REFERENCE
S4.Lal S, Adarsh, Pankaj. Textbook of CommunityMedicine.
3rded. CBS Publishers & Distributions Pvt Ltd, New Delhi;
2013.
5.Suryakantha AH. Community Medicine with recentadvances.
1st ed. New Delhi (India): Jaypee Brothers medical publishers;
2009.
6.Primary health care as a strategy for achieving equitable care.
[online] 2007 [cited on 2015 Feb 14]; Available
from:URL:http://www.who.int/social_determinants/resources/

63. ts/hfa_s_1.pdf
23/2/2015
63
REFERENCE
S7.Vlassof C, tanner M, Weiss M, Rao S. Putting People first:A
Primary Health Care Success In Rural India. Indian J
community Med 2010Apr;35(2):326-30.
8.PHC- Now More Than Ever. World health report 2008 [Online]
2008 [cited on 2015 Feb 12]; Available from:URL:
www.who.int/whr/2008/whr08_en.pdf
9.Report of International Conference on Primary Health Care.
WHO [Online] 1978 [cited on 2015 Jan 10]; Available
from:URL:
http://www.searo.who.int/entity/primary_health_care/documen

64. 64
REFERENCE
S10.Breiger WR. Community participation. Johns Hopkins
Bloomberg school of Public Health [Online] 2006 [cited on
2015 Jan 10]; Available from:URL:
http://ocw.jhsph.edu/courses/socialbehavioralfoundations/PDFs/
Lecture15.pdf
11.Haq C, Hall T, Thompson D, Bryant J. Primary Health Care-
Past, Present and Future. Global health education consortium
[Online] 2009 Feb [cited on 2015 Jan 31]; Available
from:URL:http://cugh.org//27_Primary_Health_Care_PHC_Pas
t_Present_Future_FINAL.pdf

65. 65
REFERENCE
S
12.Programme Management. National Institute of Health and
Family Welfare. New Delhi (India): 2013.p.45-58
13.Primary Health care- Indian scenario.
organization [online] 2008 Aug [cited on
World Health
2015 Jan 31];
Available from:URL:http://who.int/health_care_documents/phc
-Indian scenario.pdf
14.Rahim A. Principles and Practice of Community Medicine. 1st
ed. New Delhi(India): Jaypee Brothers medical publishers(P)
Ltd; 2008.p.23-33

66. “When we talk about capacity, we absolutely must talk about the importanceof primaryhealth care. It
is the cornerstoneof buildingthe capacity of health systems”• director, Director ge
• who
• THA
- Dr. Margaretchan
neral
NK YOU
66