Concept of disability The intervention in disability will often be social or environmental as well as medical. While impairment which is the easiest stage has a large medical component, disability and handicap which are later stages have large social and environmental components in terms of dependence and social. Disability prevention: Another concept is “disability prevention’. It relates to all the levels of prevention: (a) reducing the gecurrence of impairment, immunization against polio (primary prevention); disability limitation by appropriate treatment (secondary prevention); and (c) preventing the transition of disability into handicap (tertiary prevention). The major causes of disabling impairments in the developing countries are communicable diseases, * malnutrition, low quality prenatal care and accidents. ‘These are responsible for about 2per cent of cases of disability in developing countries. Secondary prevention is the most effective way of dealing with the disability problem in developing countries, Rehabilitation Rehabilitation has been defined as ‘the combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest responsible level of fimetional ability’. It includes all measures aimed at reducing the impact of disabling and handicapping conditions and at enabling the disabled and handicapped to achieve social integration, Social integration has been defined as the active participation of disabled and handicapped people in the mainstream of immunity life. Rehabilitation medicine has emerged in recent years as a medical specialty. It involves disciplines such as physical medicine or physiotherapy. occupational therapy. speech therapy. audiology. psychology, education, social work, educational guidance and placement services. ‘The following concerns in rehabilitation have been identified a. Medical rehabilitation - restoration of function b. Vocational rebiabilitation ~ restoration of the capacity to eam a livelihood € Social rehabilitation - restoration of family and social relationships . d. Psychological rehabilitation - restoration of personal dignity confidence, Rehabilitation is no longer looked upon as an extracurricular activity of the physician, ‘The current view is that the responsibility of the doctor does not end when the “temperature normal and stitehes are removed’. The patient must be monitored and retrained ‘to live and work within the limits of his capability but the hilt of his capacity’. As such medical rehabilitation should start very early in the process of medical treatment. Examples of rehabilitation are: establishing schools for the provision of aids for the crippled. reconstructive surgery in leprosy. musgle re-education and graded exercises in neurological disorders like polio, change of profession for a more suitable one and modification of life in general in the case of tuberculosis. curiae patients and others. The purpose of rehabilitation is to make productive people out of non-productive people. Health for All by 2000 AD aims at providing ‘rehabilitation for all” It is now recognized that rehabilitation is a difficult and demanding task that seldom gives totally satisfactory results; but needs enthusiastic cooperation form different segments of society as well as expertise, equipment and funds not readily available for this purpose even in affluent societies, It is further recognized that interventions at earlier stages are mote feasible, will yield results and are less 17demanding of HEALTH CARE OF THE COMMUNITY Health has been declared a fundamental human right. ‘This implies that the State has a responsibility for the health of its people. National governments all over the world are striving to expand and improve their health care services, The current criticism against health care services is that they are (a) predominantly urban-oriented (b) mostly curative in nature, and (c) accessible mainly to a small part of the population, The present concern in both developed and developing countries is not only to reach the whole population with adequate health care services, but also to secure an acceptable level of health through the application of prima health care programmes. Concept of health care Since health is influenced by a number of factors such as adequate food, housing, basic sanitation, healthy lifestyles. protection against environmental hazards and communicable diseases, the frontiers of health extend beyond the narrow limits of medical care. It is thus clear that “health care” implies more than “medical care”. It embraces a multitude of “services provided to individuals or communities by agents of the health services or professions, for the purpose of promoting, maintaining. monitoring, or restoring health”, ‘The term “medical care” is not synonymous with “health care”, It refers chiefly to those personal services that are provided directly by physicians or rendered as the result of physician's instructions. It ranges from domiciliary care to resident hospital care. Medical care is a subset of health care system Health care is a public right, and it is the responsibility of governments to provide this care to all people in equal measure. These principles have been recognized by nearly all governments of the world and enshrined in their respective constitutions. In Nigeria, health care is largely a governmental function. Health system Health services are designed to meet the health needs of the community through the use of available knowledge and resources. It is not possible to define a fixed role for health services when the socioeconomic pattern of one country differs so much from another. The health services are delivered by the “health system”, which constitutes the management sector and involves organizational matters. Two major themes have emerged in recent years in the delivery of health services: (a) First, that health services should be organized to meet the needs of entire populations and not merely selected groups. Health services should cover the full range of preventive, curative and rehabilitation services. Health services are now seen as part of the basic social services of a country (2): (b)Secondly. it is now fully realized that the best way to provide health care to the vast majority of underserved rural people and urban poor is to develop effective “primary health care services supported by an appropriate referral system. The social policy throughout thie world was to build up health systems based on primary health care Community participation is now recognized a major component in the approach to the whole system of health care-treatment, promotion and prevention. The stress is on the provision of 18these services to the people representing a shift from medical care to health care and from urban population to rural population. Levels of health eare It is customary to describe health care service at 3 levels, viz, primary, secondary and tertiary care levels. These levels represent different types of care involving varying degrees of complexity. 1. Primary care level Itis the first level of contact of individuals, the family and community with the national health ystem, where “primary health care”. Le. essential health care is provided. As a level of care, it is close to the people. where most of their health problems can be dealt with and resolved. It is at this level that health care will be most effective within the context of the area’s needs and limitations. In the Nigeria context, primary health care is provided by the complex of primary health centres and their subcentres through the agency of multipurpose health workers, village health workers and traditional bitth attendants, Besides providing primary health care, the village “health teams” bridge the cultural and communication gap between the rural people and organized health sector. Since Nigeria opted for “Health for All” by 2000 AD, the primary health care system has been reorganized and strengthened to make the primary health care delivery system more effective. 2. Secondary care level The next higher level of care is the secondary (intermediate) health care level. At this level more complex problems are dealt with. In Nigeria, this kind of care is generally provided in General hospitals and State hospital, which also serve as the first refe! 3. Tertiary care level The tertiary level is a more specialized level than secondary care level and requires specific facilities and attention of highly specialized health workers. This care is provided by the Federal Government e.g. Federal Med i Centre. Idi Aba, Neuropsychiatric Hospital, Aro, University College Hospital. Ibadan e A fundamental and necessary tinction of health care system is to provide a sound referral system. It must be a two-way exchange of information and returning patients to those who ferred them for follow-up care. It will ensure continuity of care and inspire confidence of the consumer in the system. For a large majority of developing countries, this aspect of the health system remains very weak Primary Health Care Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and acceptable to them, through their full participation and at @ cost that the community and country can afford to maintain at all levels of their development in the spirit of self reliance and self determination 19The primary health care is equally valid for all countries from the most to the least developed, although it takes varying forms in each of them. ‘The concept of primary health care bas been accepted by all countries as the key to the attainment of Health for All. It has also been accepted as an integral part of the country’s health system. Elements of Primary Health Care: Although specific ser provided will vary in different countries and communities, the Alma-Ata Declaration has outlined 11 essential components of primary health care. 1. 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 major infectious diseases; 6. Prevention and control of locally endemic diseases: Appropriate treatment of common diseases and injuries: 8. Provision of essential drugs. 9. Oral Health 10. Mental Health I. Care of the aged. wRYD ~ Principles of Pri ary Health Care 1. Equitable distribution ‘The first key principle in the primary health care strategy is equity or equitable distribution of health services. i.e, health services must be sisared equally by all people irrespective of their ability to pay. and all (rich or poor, urban or rural) rust have access to health services. At present. health services are mainly concentrated in the major towns and cities resulting in inequality of care to the people in rural areas. The worst hits are the needy and vulnerable groups of the population in rural areas and urban slums. This has been termed aS social injustice, The failure to reach the majority of the people is usually due to inaccessibility Primary health care aims to redress this imbalance by shifting the centre of gravity of the health care system from cities (where three-quarters of the health budget is spent) to the rural areas (where three-quarters of the people live), and bring these services as near people's homes as possible. ; Be Community participation Notwithstanding the overall responsibility of the Federal and State Governments, the involvement of individuals, families, and communities in promotion of their own health and welfare, is an essential ingredient of primary health care. Countries are now conscious of the fact that universal coverage by primary health care cannot be achieved without the involvement of the local community. “There must be a continuing effort to secure meaningful involvement of the community in the planning. implementation and maintenance of heaith services, besides maximum reliance on local resources such as manpower. moncy andmaterials, In short, primary health care must be built on the principle of community participation, community involvement and community ownership: One approach that has been tried successfilly in Nigeria is the use of village health workers. ‘They are selected by the local community and (rained locally in the delivery of primary health care to the community they belong, free of charge. By overcoming cultural and communication barriers. they provide primary health care in ways that are acceptable to the community. It is now considered that “village health workers and traditional birth attendants are an essential feature of primary health care in Nigeria. These concepts are revolutionary ‘They have been greatly influenced by experience in China where community participation in the form of bare-foot doctors took place on an unprecedented scale. 3. Intersectoral coordination There is an increasing realization of the fact that the components of primary health care cannot be provided by the health sector alone. The Declaration of Alma-Ata states that “primary health care involves in addition to the health sector, all related sectors and aspects of national and community development. in particular agriculture. animal husbandry, food, industry education, housing, public works, communication and other sectors. ‘To achieve such cooperation, countries may have to review their administrative system. reallocate their resources and introduce suitable legislation to ensure that coordination can take place. ‘This requires strong political will to translate values into action. An important element of intersectoral approach is planning ~ planning with other sectors to avoid unnecessary duplication of activities. 4. Appropriate technology Appropriate technology has been defined as “technology that is scientifically sound. 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.’ The term “appropriate” is emphasized because in Some countries, large, luxurious hospitals that are totally inappropriate to the local needs, are built, which absorb a major part of the national health budget. effectively blocking any improvement in general health services. ‘This also applies to using costly equipment, procedures and techniques when cheaper, scientifically valid and acceptable ones are available, e.g. oral rehydration (uid, standpipes which are socially acceptable, and financially more feasible than house-to-house connections, etc. twill be seen from the above discussion that primary care is qualitatively a different approach to deal with the health problems of a community. Unlike the previous approaches (e.g. basic health services, integrated health care, vertical health services) which depended upon taking health services to the doors of the people, primary health care approach starts with the people themselves. This approach signifies a new dynamism in health care and has been described as Health by the people, placing people’s heaith in people's hand, i.e, community ownership. ‘The ends of the primary health care approach are the same as those oF earlier approaches (i.e: atiainment of an acceptable level of health by every individual), bul the means adopted are different , that is, more equitable distribution and nation-wide coverage, more intersectoral coordination and more community involvement in health related matters. In short, primary health care goes beyond the conventional health services. It forms part of the larger concept of Human Resources and Development. 21HEALTH FOR ALL In'1977, it was decided in the World Health Assembly to launch a movement known as “Health for All by the year 2000", The fundamental principle of HFA strategy is equity, that is, an equal health status for people and countries, ensured by an equitable distribution of health resources. The Member countries of WHO at the 30" World Healthy Assembly defined Health for All as: “Attainment of a level of health that will enable every individual 10 lead a socially and economically productive life.” On 12" September, 1978. the Alma-Ata Intemational conference on Primary Health Care reaffirmed Health for All as the major sogial goal of governments, and stated that the best approach to achieve the goal of HPA is by providing primary health care, especially to the vast majority of underserved rural people and urban poor. It was envisaged that by the year 2000, at least essential health care should be accessible to all individuals and families in an acceptable and affordable way. with thefr full participation The Alma-Ata Conference called on all governments to formulate national policies. strategies and plans of action to launch and sustain primary health care as part of a national health system. It is left to each country to develop its norms and indicators for providing primary health care according to its own circumstances. In 1981, a global strategy for HFA was evolved by WHO. The global strategy provides a global framework that is broad enough to apply to “all member States and flexible enough to be adapted to national and regional variations of conditions and requirements. This was followed by individual countries ‘developing their own strategies for achieving HFA, and synthesis of national strategies for developing regional ‘strategies. The WHO has established 12 global indicators as the basic point of reference for assessing the progress towards HPA, as for example, a minimum fife expectancy of 60 years and maximum infant mortality rate of 50 per 1000 live births. ‘The National Health Policy echoes the WHO cali for HFA and the Alma-Ata Declaration. It had laid down specific goals in respect of the various health indicators by different dates such 1990 and 2000 AD. Foremost among the goal to be achieved by 2000 AD were (1) Reduction of infant mortality from the level of 125 to below 60. (2) To raise the expectation of life at birth from the level of 52 years to 64. (3) To reduce the crude death rate from the level of 14 per 1000 population to 9 per 1000. (4) To reduce the crude birth rate from the level of 33 per 1000 population to 21. (5) To achieve a Net Reproduction Rate of one (6) To provide potablé water to the entire rural population. ‘Through the framework of the Five Year Plans and the 20 points programme, steps are already under way to implement the strategies outlined in the national health policy HEALTH STATUS AND HEALTH PROBLEMS An assessment of the health status and health problems is the first requisite for any planned effort to develop health care serv This is also known as Community Diagnosis. ‘The data required for analyzing the health situation and for the defining the health problems comprise the following: 2