Chapter 7.

Continuation of PHC

Learning Objectives:

1. Explain the pillars/cornerstones of Primary Health Care

2. Compare and contrast primary care and Primary Health Care

3. Elucidate how appropriate health technology will benefit the health of population groups and
communities

Determinants of success for PHC

Criteria for appropriate technology

Essential Drug/medicine

Traditional and alternative care

Health Development

It operates employing year 2000 to 2015 that seeks to improve health the core functions of assessment,
policy, and of mothers and children. Part of this policy assurance. Generating and utilizing evidence
issued by the national government is enjoining from research and epidemiology serves as local
government units and private healthcare basis for developing health programs and organizations to
align their activities under services. This in turn will be used to inform this administrative order. Hence, it
offers decision makers to formulate policies across integrated approach that guarantees the health all
levels of governance to promote and protect service consuming public of same standards peoples'
health. Thus a functional system made and same outcomes. Inherent to the concept of accessible to the
people is crucial to achieving multi-sectoral approach (MSA) is fostering inter improved health
outcomes. Birthing centers and intra-sectoral linkages. Inter-sectoral pertains or lying-in clinics are
integrated as part of two coordinated actions between two or more rural health units in provinces of the
county. agencies from a different sector. Example of this This is mandated thru Department of Health's
is the fight against zoonosis—diseases that are (DOH) administrative order 2008-0029 that transmitted
from animals to humans. Rabies focuses on safe motherhood. Birthing clinics are having been a problem
affecting communities

public health is a multidisciplinary science that revolves around preventing disease. prolonging life, and
promoting health and efficiency of populations thru collective efforts considered as an essential health
service located at the very heart of the community. Its presence in the neighborhood provides mothers
access to professional care especially during labor and delivery. This will help avoid incidents of women
delivering at home that may result to complications like hemorrhage and uterine atony. With this in
mind, maternal deaths are reduced and will improve health outcomes for women across all regions.
Multi-sectoral policy entails a functional coordination between public and private agencies in making
health for all possible. Salunke (2017) states that "Multi-sectoral approach (MSA) refers to deliberate
collaboration among various stakeholder groups (e.g., government, civil society, and private sector) and
sectors (e.g., health, environment, and economy) to jointly achieve a policy outcome. By engaging
multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from
their combined and varied strengths as they work toward the shared goal of producing better health
outcomes." To illustrate we look again at the Department of Health's AO 2008-0029. It aims to rapidly
reduce maternal mortality across the country. This policy stems from the commitment of the country to
the millennium development goals that covered the period for several decades already. The solution to
this is not limited to one sector like health professionals and agencies. It involves local government
units, department of agriculture and department of environment and natural resources. This is clearly
evident in the rabies prevention and control program of the DOH that seeks to eradicate rabies in the
country by the year 2022. Intra-sectoral refers to activities within the same sector like referrals among
health professionals from primary to secondary care. The purpose of this is to ensure not only continuity
of care but provision of competent care Such is the purpose of the two-way referral system in the
country. In the end, it will benefit the people by ensuring safe and quality care deserved by all.

Empowered people and communities are pivotal to the success of PI-IC since it envisions health in the
hands of the people.

Determinants of success for PHC

The Astana Declaration (WHO, 2018a) outlined four critical factors for achieving health for all by all.

1. Knowledge and Capacity Building— Information is an essential element of self-sufficiency.

Communities should actively participate in every stage of planning and developing health programs
and services. Shared leadership and participatory governance are critical in fostering a people
centered healthcare system. Thus, health education activities and training sessions for people in the
community should be conducted regularly so that they acquire knowledge and skills to manage their
own health. Community organizing is also done to identify potential leaders that can help augment
the limited number of health workers in rural areas. Over time and given proper training they
produce their own community health workers or barangay health workers that can attend to the
health needs of their neighborhood. Thus they become active partners of health agencies and
professionals in promoting health and preventing disease.

2. Human Resources for Health—Community health needs are varied and require not only holistic
care but multidisciplinary approach. Hence. the need for skill mix to address health needs of the
people is crucial to the efficient implementation of primary health care. Manpower is the most
important resource in healthcare delivery. Systems, technology, and facilities cannot run without
personnel (Box 9.5). PHC relies heavily on human resources that include nurses, midwives, physicians
and other health professionals. However, the need to distribute health workers equitably for all
people to enjoy access remains a major concern. According to services in their own private clinics as
the first point of contact in a service delivery care network offers a solution to the challenge of
shifting away from hospital-focused services. Expanding the nurse practitioner program also offers a
solution." To address this problem of health human resource distribution, the DOH is continuously
deploying health professionals to underserved local government units. They will provide the much
needed assistance in delivering essential healthcare packages especially to the marginalized.
Examples of program under this banner include the doctors to the barrios and nurse deployment
program.

3. Financing—PHC aims to strengthen the healthcare delivery system by providing people access to
essential health services that will ultimately advance the well-being of individuals, families, and the
population in general. However, operation of healthcare systems including personnel, technology,
and services entail cost and thus requires funding. The Philippines has a mixed healthcare system
composed of public and private organizations. "Ibe DOH (2018) reported that "More than half of
health expenditures remained to be funded by out of-pocket (OOP) payments despite increased to
Dayrit (2018), majority of health professionals are in hospitals and in terms of distribution they are
mostly concentrated in urbanized areas. This distribution results to disparities in health service and
health outcomes. For nurses in particular, 74% are working in hospitals and only 26% are working in
primary care facilities as stated in the 2018 Philippines Health Systems Review. Further, Dayrit (2018)
mentioned that "the hospital-centric distribution of doctors and nurses in health institutions is
reflective of a model of care that diverges from the ideal set-up of a first point of contact at the
primary care level. Mobilizing doctors who are providing resources for health in recent years. While
the huge budgetary infusion translated to higher PhilHeaIth coverage and led to the design of pro-
poor schemes such as the No Balance Billing (NBB) policy, social health insurance remained
inadequate in protecting Filipn8 from the financial burden of healthcare This number deprives the
marginalized the opportunity to seek medical care and in turn brings about unfavorable health
outcomes

Thus, reforms in the health system are crucial to cover all Filipinos and this begins with legislation. To
generate more funding for health, the national government thru congress formulated sin taxes last
2013 which include Republic Act 10351. This law increased the excise taxes for both tobacco and
alcohols to generate revenue for health financing. Another milestone in Philippines.

Health legislation is the implementation of Republic Act 10963 also known as TRAIN law or the tax
reform for inclusion and acceleration of 2018. This further increased the excise taxes for tobacco and
alcohol and introduced a sugar beverage tax for the first time in history. It added 6 to 12 pesos per
liter tax for soda and concentrated beverages resulting to higher prices of products like powdered
juice and soft drinks. The purpose of these measures is not simply to generate funding for healthcare
but aims to discourage people to purchase these products. It also hopes to reduce the populations'
risks for non-communicable diseases like diabetes and cardiovascular problems. Finally, to genuinely
achieve the goals of PHC the World Health Organization calls on all countries to spend adequately for
the health needs of their constituents. Savedoff (2003) states that "it is commonplace to find
references to a WHO recommendation that countries should spend 5% of GDP/GNP (Gross Domestic
Product or Gross National Product) on health" but how much should government spend on
healthcare is not a simple question that can be answered with outright figures. It entails
consideration of several factors like epidemiological situation and demographic considerations.
Above all, budget for public health should always take into account the principle of achieving the
greatest good for the greatest number.

4. Technology - To ensure that people from all walks of life enjoy the highest possible level of
wellness, access to available service and technology must be provided. This means that science and
its fruits be translated to practical use thru interventions and innovations. Technology is defined in a
general context as application of science for the benefit of communities. In the context of primary
health care it must be viewed as a means to help the public maintain, restore, and promote their
optimum level of functioning. WHO (2018) defines it as application of organized knowledge and skills
in the form of devices, medicines, vaccines. procedures and systems developed to solve a health
problem and improve quality of lives." Health professionals therefore employ and equip their
practice with technologies to contribute to the goals of PHC. In the Alma-ata declaration of 1978,
appropriate technology was cited as part of essential healthcare that should be accessible to all and
scientifically sound as well. As such, both conventional and traditional approaches can used to
achieve the goals of PHC.

Criteria for appropriate health technology

The World Health Organization as cited by Goodyear (2009) defines appropriate health technology as
methods, procedures, techniques and equipment that are: scientifically valid, adapted to local needs,
acceptable to users and recipients, and maintainable with local resources. Examples of this can range
from simple items like Oresol to delicate testing kits for rapid detection of specific conditions like the
INSI Dengue kit. Moreover, Goodyear (2009) states that health technology should be characterized
by the following:

Effective—it delivers the intended benefit or purpose of the technology as proven through scientific
processes.

Safe—it assures users that no harm will result from the use of the technology or to the least, it
minimizes risk of harm.

Affordable—the cost of technology will not be a burden for both individual consumers and
organizations like the government to guarantee its accessibility.

Sustainable—the technology is of utility to the population and can be maintained, supplied to all, and
repaired as needed by users.

Acceptable—use of technology is in harmony with community norms and culture. It should also
spring from an expressed need of the people employing bottom up approach.

Essential drugs/medicines

An important element in the effective delivery of health service is the provision of medicines to treat
endemic conditions affecting people in the community. This will contribute to the reduction of
unnecessary deaths and improve health outcomes. Drugs that are considered essential are not only
regarded as lifesaving but can be used for all population groups. Examples include the provision of
paracetamol and amoxicillin in primary' care facilities to address common problems like fever,
headache, and infections.

Government efforts to increase people's access to this vital resource include legislative measures like
the Generics Act of 1998 (RA 6675), the Price Act (RA 7581) and the Cheaper Medicine Act of 2008
(RA 9502). These laws seek to offer consumers more competitive prices in the purchase of medicines.
According to the DOH (2018) the Generics Act of 1998, "sought to ensure adequate supply,
distribution, use and acceptance of drugs and medicines identified by their generic names. It was
supported by Executive Order (EO) 49, s. 1 993, which directed the mandatory use of the Philippine
National Drug Formulary (PNDF) as the basis for the procurement of drug products by the
government." Another initiative from the public sector is the implementation of the Medicines
Access Program (MAP) and the Cheaper Medicine Program (CMP). Under these programs, the
Department of Health launched COMPack and Botika ng Barangay (BnB). Compack or complete
treatment pack aims to provide marginalized groups monthly supply of essential medicines to treat
conditions like diabetes and hyper-tension in barangay health stations across the country. It will also
ensure compliance of patients enduring the leading causes of mortality of the country Medicines
currently offered under COMPack are Amlodipine, Losartan, Metforrnin, and Simvastatin. For
communities, the government also encourages the establishment of Botika ng Barangay (BnB) to
offer essential medicines are cheaper price.

Traditional and alternative health care

There are two general schools of thought in medicine, eastern and western. Both are anchored on a
well-established body of knowledge; the former scientific while the latter traditional. Examples of
healthcare under western school of thought are surgical procedures and pharmacotherapy on one
hand while on the other, acupuncture, herbal medicines, and massage. Primary Health Care
advocates for the provision of health service for all. To achieve this requires that both modern and
traditional knowledge go hand in hand in improving people's health (WHO, 2013). Specifically, in the
context of developing countries where financial resources may be limited, it is imperative that people
are aware of indigenous resources available to them. Thus, the WHO recognizes the significance of
incorporating traditional and complementary interventions in achieving better health outcomes for
all.

In the Philippines, traditional and complementary medicine has been institutionalized through
Republic Act 8423. This law created the Philippine Institute of Traditional Alternative Health Care or
PITAHC which has the broad mandate of initiating activities to advocate develop, and promote use of
indigenous healthcare practices in the country agency works under the DOH and closely coordinates
with the Department of Science and Technology for undertaking researches to widen the evidence
base for this application by establishing its safety and efficacy.

World Health Organization (2019) defines traditional medicine as "the sum total of the knowledge,
skill and practices based on the theories, beliefs and experiences indigenous to different cultures,
whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis,
improvement or treatment of physical and mental illness." The term complementary medicine is
used to denote the combination of both traditional and conventional methods.

Herbal medicines

This refers to the use of plants or derivatives from plants for the treatment of specific

conditions. In the Philippines, herbal medicines are considered as one of the most popular modalities
of complementary medicine. They are commonly sold in the local market as food supplements and
are regulated by the Food and Drug Administration (FDA). Over the last decade, various researches
were undertaken to discover, investigate, and develop more herbal formulations to address the
spiraling cost of conventional medicines and the growing number of people burdened by disease The
 Department of Health declared a national dengue epidemic during the second quarter of 2019.
Children from different regions of the country were rushed to hospitals due to hemorrhage. Locals
claim that Tawa- tawa (Euphorbia hirta) a hairy herb that grows on roadsides and grass lands offer a
cure for dengue. However, a large scale study is still warranted to further establish its clinical efficacy
Scenarios like this only proves that herbal medicine offers a promising solution to current health
problems as part of appropriate technology. Widely used herbs in the country include Banaba
(Lagerstroemia speciosa), Oregano (Origanum vulgare), and Guyabano (Annona muricata) to name a
few. Listed in Tables 9.2 and 9.3 are DOH recommended and approved herbal medicines with the
corresponding uses and preparation. The DOH hopes to expand this list with continuing research

Accupressure A method of healing and health promotion that uses the application of pressure on acupuncture points
without puncturing the skin.
Acupuncture A method of healing using special needles to puncture and stimulate specific anatomical points on the
body.
aromatherapy The art and science of the sense of smell whereby essential aromatic oils are combined and then applied
to the body in some form of treatment.
Chiropractic A discipline of the healing arts concerned with the pathogenesis, diagnosis, therapy. and prophylaxis of
functional disturbances, pathomechanical states, pain syndromes, and neurophysiological effects related
to the static and dynamics Of the locomotor system, especially of the spine and pelvis.
Herbal medicine Finished, labeled. medicinal products that contain as active ingredients aerial or underground parts of the
plant or other materials or combination thereof, either in the crude state or as plant preparations.
Massage A method wherein the superficial soft parts of the body are rubbed, stroked, kneaded. or tapped for
remedial. aesthetic, hygienic, or limited therapeutic purposes.
Nutritional therapy The use of food as medicine and to improve health by enhancing the nutritional value of food
components that reduces the risk of a disease. It is synonymous with nutritional healing.
Pranic healing A holistic approach of healing that follows the principle of balancing energy.
Reflexology The application of therapeutic pressure on the body reflex points to enhance the body natural healing
mechanisms and balance body functions. It IS based on the principle that internal glands and organs
can be influenced by properly applying pressure to the corresponding reflex area on the body.
Methods of Herbal Preparation

Preparation Procedure
Decoction . the recommended part of the plant material in water.
Recommended boiling time is 20 minutes
Infusion Plant material is soaked in hot water. much like making a
tea. Recommended period of soaking is 10-15 minutes.
Poultice . Directly apply recommended plant matenal on the part
affected. usually used on bruises. wounds. or rashes
Tincture Mix the plant matenal in alcohol.

Table 9.2 DOH Recommended Herbal Medicines

Medicinal
Plants Usenndication Preparation
Lagundi Asthma. cough and colds, Decoction fever, dysentery. pain
Wash affected Skin diseases (scabies. Site With ulcer.
eczema). wounds decoction

Yerba Headache, stomachache Decoction buena Cough and colds

Infusion
Rheumatism. arthritis Massage sap
Sambong Antiederna/ Decoction antiurolithlasis

Tsaang Diarrhea Stomachache Decoction gubat

Myog- Antihelrntnthic Seeds are used nryogan

Bayabas Washing wounds Decoction

Diarrhea, gargle. toothache

Akapulko Antifungal Poultice

Ulasimang bato/Pansit-pansitan- Lowers blood uric acid Decoct •on
(rheumatjsm and gout) Eaten raw

Bawang Eaten raw/ blood cholesterol Apply on Toothache part

Hypertension. lowers

Ampalaya Diabetes mellitus (mild Decoction non-insulin- dependent)

Steamed

DOH Recommendations for HRH and Primary Health Facilities Ratio to Population
 RHU/HC Physician 20.000 Population ratio

Public Health Nurse: 10.000 Population ratio

Public Health Midwife: 5,000 Population ratio

Public Health Dentist: 50,000 Population ratio

RHU: 20.000 Population Ratio

1 BHS: 5.000 Population Ratio

DOH HRH Programs

Medical Pool Placement and Utilization Program (MD and/or medical specialists are in DOH hospitals
and/or provincial hospitals based needs and program criteria;

Doctors to the Barrios (DTTB) Program—Physicians are assigned, for two years primarily in 4th to 6th
class municipalities that had not had a doctor for at least 2 years;

Nurse Deployment Program (NDP) nurses are assigned for months in the community (Rural Health
Units) and other were augment manpower of hospital service:

Rural Health Midwives Program—Midwives are assigned in Barangay Health Stations and Rural Health
Units for Improved maternal and child care. These facilities then provide Basic Emergency Obstetrics and
Newborn care (BEmONC);

Rural Health Team Placement Program, dentist, medical technologists, and nutritionist dietitians are
assigned in field health facilities to complement existing RHU personnel: and

DOH Pre-Service Scholarship Program—Medical and midwifery students are granted full scholarships.
and return. Will render return service for two years for every year of DOH scholarship.

Majority of health professionals are in hospitals and in terms of distribution they are mostly
concentrated in urbanized areas. This distribution results to disparities in health service and health
outcomes. For nurses in particular, 74% are working in hospitals and only 26% are working in primary
care facilities as stated in the 2018 Philippines Health Systems Review. Further, Dayrit (2018) mentioned
that "the hospital-centric distribution of doctors and nurses in health institutions is reflective of a model
of care that diverges from the ideal set-up of a first point of contact at the primary care level.

Goodyear (2009) states that health technology should be characterized by the following:

Effective—it delivers the intended benefit or purpose of the technology as proven through scientific
processes.
Safe—it assures users that no harm will result from the use of the technology or to the least, it
minimizes risk of harm.

Affordable—the cost of technology will not be a burden for both individual consumers and organizations
like the government to guarantee its accessibility.

Sustainable—the technology is of utility to the population and can be maintained, supplied to all, and
repaired as needed by users.

Acceptable—use of technology is in harmony with community norms and culture. It should also spring
from an expressed need of the people employing bottom up approach.