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Principles of primary health care

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principles of primary health care

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Principles of primary health care

  1. 1. Principles of primary health care Presenter : Dr Vaishnavi C Guide : Dr Priyadarshini C 23/2/2015 1
  2. 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 23/2/2015 2
  3. 3. CONTENTS Contd... • Evolution of primary health care in India • Primary health care scenario in India • 30 years after Alma-Ata • Conclusion • References 23/2/2015 3
  4. 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 23/2/2015 4
  5. 5. TERTIARY LEVEL SECONDARY LEVEL PRIMARY LEVEL HEALTH CARE PYRAMID 23/2/2015 5
  6. 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 23/2/2015 6
  7. 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 23/2/2015 7
  8. 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 23/2/2015 8
  9. 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” 23/2/2015 9
  10. 10. ATTRIBUTES OF PRIMARY HEALTH CARE • Essential health care • Universally accessible • Acceptable • Community based • First point of contact • Affordability 23/2/2015 10
  11. 11. ATTRIBUTES Contd... • Adaptability • Appropriateness • Community participation • Continuity • Comprehensiveness • Coordination 23/2/2015 11
  12. 12. ATTRIBUTES contd... Accessible Affordable Primary health care Acceptable Appropriate Adaptable 23/2/2015 12
  13. 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 23/2/2015 13
  14. 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 23/2/2015 14
  15. 15. PRINCIPLES OF PRIMARY HEALTH CARE  Equitable distribution  Community participation  Intersectoral coordination  Appropriate technology 23/2/2015 15
  16. 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 23/2/2015 16
  17. 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 23/2/2015 17
  18. 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 23/2/2015 18
  19. 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 23/2/2015 19
  20. 20. Aspects of equity in health and health care:  Equity in access to health care  Equity in health  Effective coverage 23/2/2015 20
  21. 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 23/2/2015 21
  22. 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 23/2/2015 22
  23. 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 23/2/2015 23
  24. 24. MDG - 2015 1.Eradicate extreme poverty & hunger 2: Achieve universal primary education 3: Promote gender equality and empower women 4: Reduce child mortality 23/2/2015 24
  25. 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 23/2/2015 25
  26. 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 23/2/2015 26
  27. 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 23/2/2015 27
  28. 28. COMMUNITY PARTICIPATION contd... • 2 Types: active & passive • Active – co-operation + resources • Passive – Co-operation only 23/2/2015 28
  29. 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 23/2/2015 29
  30. 30. Planning steps in community participation: Identification and prioritization of the problems Planning together Implementation by community members Evaluation by community members 23/2/2015 30
  31. 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 23/2/2015 31
  32. 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 23/2/2015 32
  33. 33. 23/2/2015 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. 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) 23/2/2015 34
  35. 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 23/2/2015 35
  36. 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 23/2/2015 36
  37. 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 23/2/2015 37
  38. 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 23/2/2015 38
  39. 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 23/2/2015 39
  40. 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 23/2/2015 40
  41. 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 23/2/2015 41
  42. 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) 23/2/2015 42
  43. 43. 23/2/2015 43
  44. 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” 23/2/2015 44
  45. 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 23/2/2015 45
  46. 46. An appropriate technology should be: (WHO-1989) • Scientifically valid • Adapted to local needs • Acceptable to users and recipients • Maintainable with local resources 23/2/2015 46
  47. 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 23/2/2015 47
  48. 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 23/2/2015 48
  49. 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 23/2/2015 49
  50. 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 23/2/2015 50
  51. 51. • Informational technological advancements that have been proven to ultimately enhancing the service delivery-  Health Management Information System  Telemedicine 23/2/2015 51
  52. 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 23/2/2015 52
  53. 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” 23/2/2015 53
  54. 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 23/2/2015 54
  55. 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 23/2/2015 55
  56. 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 23/2/2015 56
  57. 57. 23/2/2015 57 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. 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. 23/2/2015 58
  59. 59. PHC- NOW MORE THAN EVER 23/2/2015 59
  60. 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 23/2/2015 60
  61. 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 23/2/2015 61
  62. 62. REFERENCES 4.Lal S, Adarsh, Pankaj. Textbook of Community Medicine. 3rded. CBS Publishers & Distributions Pvt Ltd, New Delhi; 2013. 5.Suryakantha AH. Community Medicine with recent advances. 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/ csdh_media/primary_health_care_2007_en.pdf23/2/2015 62
  63. 63. REFERENCES 7.Vlassof C, tanner M, Weiss M, Rao S. Putting People first: A Primary Health Care Success In Rural India. Indian J community Med 2010 Apr;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 ts/hfa_s_1.pdf 23/2/2015 63
  64. 64. REFERENCES 10.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 23/2/2015 64
  65. 65. REFERENCES 12.Programme Management. National Institute of Health and Family Welfare. New Delhi (India): 2013.p.45-58 13.Primary Health care- Indian scenario. World Health organization [online] 2008 Aug [cited on 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 23/2/2015 65
  66. 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 23/2/2015 66

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