Chapter 6: Primary Health Care

Learning Objectives:
1. Define Primary Health Care
2. Discuss what are the values enshrined in both Alma-ata and Astana Declaration documents on Primary
Health Care
3. Describe Primary Health Care as a strategy in helping populations achieve health in their hands.
4. Enumerate the different services of Primary Health Care
Concept of primary health care
From Alma-ata to Astana: Leaving no one behind in the quest for health
Elements of primary health care

Primary care vs. Primary health care

The clamor for equitable health care stems from our understanding that health is a human right and as
such is everybody's responsibility. This paved the way for the concept of health in the hands of the
people Bringing healthcare closer to people is a key feature of Primary Health Care (PHC). This is a total
approach in ensuring peoples' health by fostering active community participation and establishing
partnerships among all sectors of society in working for better health.

In the medical model of care, provision of interventions to cure specific conditions of individuals at the
level of the community is termed as primary care Awofeso (2004) states that this approach is usually
termed as preventive medicine. However, the term primary care is often confused with the term
primary health care. Primary care is first level of healthcare delivery in which a generalist like a physician
or a nurse renders medical and nursing services for individuals and population groups. It can be a
government owned clinic but more often than not are privately owned.

Some of the services offered in these facilities include medical consultation, first-aid, urgent care,
immunization, wound care, simple laboratory tests, counseling and normal deliveries for mothers in
labor. In many settings, primary care, which is the first contact of people with health services that are
continuous, comprehensive and coordinated, has, too often, been focused on treating illness as and
when it arises rather than preventing disease in the first place (Beard, 2014).

Most of the time. primary care offers outpatient management while hospitalization and in-patient
service are expected for both secondary and tertiary levels of care. This means that the cost of
healthcare and the complexity of cases are expected to increase as the level of healthcare moves up the
pyramid. Moreover, the figure also illustrates that these facilities are widely distributed in all areas of
the country and accounts for the biggest share in the healthcare delivery system. However, the cost of
private primary care remains high, preventing lower income groups from gaining access. This results to
disparities in health outcomes among different regions of the country. Thus, the challenge of providing
healthcare for all remains an urgent concern today. Hence, it is in this context that Primary Health Care
was conceived.

It has been four decades since the 1978 Alma Ata Declaration that Primary Health Care (PHC) was the
way to achieve health for all by the year 2000. PHC as a concept, philosophy and an approach received
much criticism as it was misunderstood. In the mid-1990's, the global health scenario characterized by
the HIV/ AIDS epidemic, resurgence of TB and malaria prompted the WHO to review its approaches to
address these emergencies. The start of the 21st century saw the MDGs being put forward as
framework for development cooperation. In 2010, the WHO commissioned a report on universal health
coverage which became central to the SDGs. (WHO, 2017b)

Reiterating the earlier definition, PHC is an approach to health and well-being centered on the needs
and circumstances of individuals, families and communities and addresses comprehensive and
interrelated physical, mental and social health and well-being. (WHO, 2019). PHC looks at the person's
health in a holistic manner and not just addressing disease or illness conditions. It also emphasizes the
services being delivered in places where the people live or as close to where they live.

WHO's definition of PHC is based on three components:

• Ensuring people's health problems are addressed through comprehensive, promotive, protective,
preventive, curative, rehabilitative and palliative care throughout the life course, strategically prioritizing
key system functions aimed at individuals and families and the population as the central elements of
integrated service delivery across all levels of care

• Systematically addressing the broader determinants of health (including social, economic,

environmental as well as people's characteristics and behaviors) through evidence-informed public
policies and actions across all sectors; and

• Empowering individuals, families and communities to optimize their health, advocates for policies that
promote and protect health and well-being, as co-developers of health and social services through their
participation, and as self-carers and caregivers to others.

Understanding primary health care (PHO

Primary Health Care is an over-all approach to providing people access to basic healthcare and
ultimately improve health of communities. It calls for collective efforts among all stakeholders in society
and gives premium to people empowerment in health; that is allowing them to improve health thru
their own efforts. This approach has three dimensions; first it is a goal, second it is a strategy, and third it
is a philosophy.

As a goal, primary health care seeks to ensure that all people regardless of age, sex. creed, religion,
ideology, and race are provided access to basic health services. This is anchored on the declaration of
health as a human right and therefore, provides the impetus for universal health coverage.

As a strategy, it promotes collaboration among all sectors in society and values partnership between
public and private organizations. This strategy highlights the fact that health is a shared reality and
concerns everyone in the community.

It is a philosophy that guides public health practitioners to rally communities to assume responsibility for
their health and to involve themselves in issues affecting their health.

Historical background and nature of PHC

It was in 1977 when the United Nations (UN) thru the World Health Organization launched "Health for
All by the Year 2000" as a global agenda to be pursued to fully realize the dream of attaining the full
potential of peoples around the world in both social and economic terms. The adoption of PHC as key
strategy to achieve the global agenda ensued as stated in the Almaata Declaration. This declaration
adopted by member states of the UN in September 1978 aims to implement worldwide system reform
focusing on accessibility of healthcare for all population groups. In our country, PHC was implemented
thru Letter of Instruction 949 (1979) from then President Marcos who underscored the need to promote
health development in rural areas and to integrate health in all government activities.

Primary Health Care is defined as "essential

Health care based on practical, scientifically sound and socially acceptable methods and technology
made universally accessible to individuals 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 (WHO, 2008). 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 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" (WHO,
1981).

From this definition we hear again the spirit of community/public health nursing that speaks of
collaboration and collective efforts to achieve better health through capacity building initiatives.
Likewise, we recognize that the mission of PHC is to strengthen healthcare systems by providing and
supporting conditions where people manage their own health and ultimately realize the goal of health in
their own hands). It advocates for a healthcare system characterized by 5 A's namely: accessible,
available, affordable, acceptable, and appropriate.

Accessible healthcare is the first step in making PHC a reality. Facilities for health and services delivered
by health professionals are situated closer to where people are. This entails that it can be reached within
30 minutes from households or within 5 kilometer distance. Evidence supports that when resources are
accessible, peoples' health seeking behavior improves which in turn results to better health outcomes. A
classic example of this is the provision of prenatal check-up for pregnant women in Rural Health units or
Barangay Health Stations. Since these facilities are located in the neighborhood, women are observed to
regularly visit to seek consultation and receive other services to promote safe motherhood and
pregnancy.

Essential Services in PHC

 Health Education
 Immunization
 Essential medicine/drugs
 Mother and Child Health services
 Endemic diseases control and management
 Nutrition
 Treatment of simple condition
 Sanitation and access to safe water supply

Available healthcare refers to ensuring that essential services are provided to people in communities
across all strata of society. Inherent in this concept is the delivery of medical, dental and nursing services
that will promote, maintain, and even contribute to the restoration of well-being. Further, the effective
and efficient utilization of resources by organizations and governments is a critical element of sustaining
healthcare available to the people. Box 9.3 lists the essential services of PHC that should be made
available to communities.

Affordable healthcare flows from the Alma Ata's declaration specifically highlighting that reform for
healthcare systems across the globe should be within the context of financial realities of governments.
This necessitates that the expenses for healthcare should be within the budgetary capacity of each
country. Efforts to reduce out-of-pocket expense for healthcare by consumers should be prioritized by
adopting policies that will improve costs of medicines and medical procedures. Moreover, the concept
of affordable healthcare requires that both private and public healthcare systems avail of technology for
a reasonable price so that budget for health services can be maximized to benefit more people.

Acceptable healthcare speaks of the need to contextualized health service in the lens of culture.
Collective beliefs, values, and practices of people shape their concept of health and illness (IRininger,
1991). This in turn predicts their health seeking behavior. Thus, health care service and technology must
fit the culture of the community, otherwise utility may be futile. This same concept is cited by [Rininger
(1991) who developed the sunrise model of transcultural nursing. She states that it is imperative that
nurses deliver culturally congruent care to genuinely promote participation of clientele in managing
their own health.

Appropriate healthcare connotes the use of technology based on expressed needs of the people that are
not only scientifically proven effective but at the same time safe. This guarantees that communities are
provided service designed to specifically address their needs employing local/indigenous resources that
can be sustained over time.

From Alma-ata to Astana: Leaving no one behind in the quest for health

Wellness is everybody’s business. It is the common ground that connects all people. Health more than a
physical reality, is a social phenomenon shaped by politics, culture. education, and employment. These
factors form part of the so called social determinants of health. Extant literature has established fully
how health disparities and inequalities result from these. Unfortunately, evidence shows that life
expectancy varies from one place to another and this can be attributed to the social determinants of
health.

According to the World Health Organization, the social determinants of health are the conditions in
which people are born. grow, live, work and age. These circumstances are shaped by the distribution of
money, power and resources at global, national and local levels. To address the perennial problem Of
injustice in health outcomes, member states of the United Nations introduced Primary Health Care in
1978 during the international conference held in Alma-ata, Kazakhstan. It offers a holistic approach for
achieving inclusive development by prioritizing healthcare that puts people first on the agenda. This
strategy strongly emphasizes participatory technique and values partnership with community.

Make health for all a reality. It likewise, outlines initiatives/programs grounded on social illStice that will
touch on the social determinants of health. Forty years from the inception of PHC in 1978, world health
leaders converged once again last October 2018 this time at Astana, Kazakhstan to affirm the
declaration of Alma-ata that health is a tondamental right of all people and that all should be afforded
equitable healthcare access. Leaders present during this global conference specified that "strengthening
primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people's
phvsical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable
health system for universal health coverage (UIHC) and health-related Sustainable Development Goals"
(WHO, 2018).

The following are the key points of the Astana Declaration:

The success of primary health care will be driven by:

Knowledge and capacity-building

We will apply knowledge, including scientific as well as traditional knowledge, to strengthen PHC,
improve health outcomes and ensure access for all people to the right care at the right time and
at the most appropriate level of care, respecting their rights, needs, dignity and autonomy. We
will continue to research and share knowledge and experience, build capacity and improve the
delivery of health services and care. Human resources for health. We will create decent work and
appropriate compensation for health professionals and other health personnel working at the
primary health care level to respond effectively to people’s health needs in a multidisciplinary
context. We will continue to invest in the education, training, recruitment, development,
motivation and retention of the PHC workforce, with an appropriate skill mix. We will strive for
the retention and availability of the PHC workforce in rural, remote and less developed areas. We
assert that the international migration of health personnel should not undermine countries’,
particularly developing countries’, ability to meet the health needs of their populations.

Technology

We support broadening and extending access to a range of health care services through the use
of high quality, safe, effective and affordable medicines, including, as appropriate, traditional
medicines, vaccines, diagnostics and other technologies. We will promote their accessibility and
their rational and safe use and the protection of personal data. Through advances in information
systems, we will be better able to collect appropriately disaggregated, high-quality data and to
improve information continuity, disease surveillance, transparency, accountability and monitoring
of health system performance. We will use a variety of technologies to improve access to health
care, enrich health service delivery, improve the quality of service and patient safety, and increase
the efficiency and coordination of care. Through digital and other technologies, we will enable
individuals and communities to identify their health needs, participate in the planning and
delivery of services and play an active role in maintaining their own health and well-being.

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.

Financing

We call on all countries to continue to invest in PHC to improve health outcomes. We will address
the inefficiencies and inequities that expose people to financial hardship resulting from their use
of health services by ensuring better allocation of resources for health, adequate financing of
primary health care and appropriate reimbursement systems in order to improve access and
achieve better health outcomes. We will work towards the financial sustainability, efficiency and
resilience of national health systems, appropriately allocating resources to PHC based on national
context. We will leave no one behind, including those in fragile situations and conflict affected
areas, by providing access to quality PHC services across the continuum of care.

Empower individuals and communities

We support the involvement of individuals, families, communities and civil society through their
participation in the development and implementation of policies and plans that have an impact
on health. We will promote health literacy and work to satisfy the expectations of individuals and
communities for reliable information about health. We will support people in acquiring the
knowledge, skills and resources needed to maintain their health or the health of those for whom
they care, guided by health professionals. We will protect and promote solidarity, ethics and
human rights. We will increase community ownership and contribute to the accountability of the
public and private sectors for more people to live healthier lives in enabling and health-conducive
environments.

Align stakeholder support to national policies, strategies and plans

We call on all stakeholders – health professionals, academia, patients, civil society, local and
international partners, agencies and funds, the private sector, faith-based organizations and
others – to align with national policies, strategies and plans across all sectors, including through
people-centered, gender-sensitive approaches, and to take joint actions to build stronger and
sustainable PHC towards achieving UHC. Stakeholder support can assist countries to direct
sufficient human, technological, financial and information resources to PHC. In implementing this
Declaration, countries and stakeholders will work together in a spirit of partnership and effective
development cooperation, sharing knowledge and good practices while fully respecting national
sovereignty and human rights.

Essential Public Health Services

1. Monitor health status to identify and solve community health problems

2. Diagnose and Investigate health problems and health hazards in the community
3. Inform. educate. and empower people about heart issues
4. Mobilize community partnerships and action to identify and solve health problems
5. Develop policies and plans that support individual and community health efforts
6. Enforce laws and regulations that protect health and ensure safety
7. Link people to needed personal health services and assure the provision of health care when
otherwise unavailable
 8. Assure competent public and personal health care workforce
9. Evaluate effectiveness. accessibility. and quality of personal and population-based health
services
10. Research for new insights and innovative solutions to health problems

Elements of primary health care

According to the WHO Technical Series on PHC (2018), three main elements define PHC:

l) primary care and essential public health functions as the core of integrated services

2) multi-sectoral policy and action,

3) empowered people and communities.