PRIMARY HEALTH CARE -

INTRODUCTION, PRINCIPLES AND

ELEMENTS

Dr. Beesan Maraqa, MD, PBFM

Assistant Professor
Consultant family Medicine
beesanm@hebron.edu
INTRODUCTION

Health is a state of complete physical, mental and

social well being and not merely absence of disease
or infirmity (WHO Definition of Health 1948).
Health is a fundamental human right.

PHC became a core policy for the WHO with the Alma-Ata
Declaration in 1978 and the ‘Health-for-All by the Year 2000’
Program.

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THE RIVER STORY

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LEVELS OF HEALTH CARE

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ALMA ATA DECLARATION
“HEALTH FOR ALL”

In 1978, 134 health ministries signed the Alma Ata

Declaration.
 Declaring that “The existing gross inequality in the health status of
people particularly between developed and developing countries as
well as within countries is politically, socially and economically
unacceptable”
 It set a deadline of the year 2000 for achieving a level of health that would
enable all of the world's people to lead a socially and economically productive
life
The strategy to achieve this goal was focused on PHC with the
emphasis on
 Community participation
 Intersectoral policy and action
 Tackling the underlying causes of disease (poverty, illiteracy and poor sanitation,…etc)

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ALMA ATA DECLARATION
“HEALTH FOR ALL”

"'Health for All' does not mean an end to disease and disability, or that
doctors and nurses will care for everyone.
 It means that health is to be brought within the reach of every one in a given community.
 It means that

 Resources for health are evenly distributed and that

essential health care is accessible to everyone.
 Health begins at home, in schools, and at the workplace,
 People shape their own lives and the lives of their families,
free from the avoidable burden of disease."

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ALMA ATA DECLARATION
“HEALTH FOR ALL”

The emphasized the following themes, which became widely quoted as

“Health for All Principles”
 Reducing inequalities in health
 Positive health through Health Promotion and disease
prevention
 Community Participation
 Cooperation between health authorities, local
authorities, and others with impact on health
 A focus on PHC as a basis of the HC system

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MDGS

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SDGS

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UNIVERSAL HEALTH COVERAGE

The right care

For all who need it
Without risk of financial burden

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UNIVERSAL HEALTH COVERAGE

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PRIMARY HEALTH CARE

PHC is essential health care that is socially appropriate, universally

accessible, scientifically sound first level care provided by a suitably
trained workforce supported by integrated referral systems and in a
way that gives priority to those most in need, maximises community
and individual participation and involves collaboration with other
sectors

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 PRIMARY HEALTH CARE

Primary Care:
Is the provision of first contact, person-focused,
ongoing care over time.
That meets the health related needs of people.
Coordinates care when people receive services
services at other levels of care

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 PRIMARY HEALTH CARE

Primary Care:
Provide acceptable health services to the community and
there must be active involvement of the community.
Provide effective, preventive, promotive and curative
health services .
Services are an integral part of the country’s health
system.
The program must be efficient, multi-sectorial because
health does not exit in isolation

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PRINCIPLES OF PRIMARY HEALTH
CARE
Equity

Community Participation

Inter-sectoral Coordination

Appropriate Technology

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PRINCIPLES OF PRIMARY HEALTH
CARE
Equity/Equitable Distribution
 The first key principle is equity or equitable distribution of health
services.
 Health services must be shared equally by all people irrespective of
their ability to pay and all ( rich or poor, urban or rural) must have
access to health services.
Community Participation
 Overall responsibility is of the national authority.
 The involvement of individuals, families, and communities in
promotion of their own health and welfare is an essential ingredient
of primary health care.
 PHC coverage cannot be achieved without the involvement of community in planning, implementation and maintenance of
health services.

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PRINCIPLES OF PRIMARY HEALTH
CARE
Inter-sectoral Coordination
 Declaration of Alma –Ata states that PHC involves in addition
to the health sector all related sectors, in particular education,
agriculture, animal husbandry, food, industry, education,
housing, public works and communication.
 To achieve cooperation, planning at country level is required
to involve all sectors.
Appropriate Technology
 Technology that is scientifically sound, adaptable to the local
needs, and acceptable to those who apply it and those for
whom it is used and can be maintained by the people
themselves with the resources of the community and country
can afford.
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THE BASIC REQUIREMENTS FOR SOUND PHC (THE 8
A’S AND THE 4 C’S)
Appropriateness Assessability
Availability Accountability
Adequacy Completeness
Accessibility Comprehensiveness
Acceptability Continuity
Affordability Patient- Centered

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ESSENTIAL COMPONENT (ELEMENTS) OF
PHC
1. Education concerning prevailing health problems and the methods
of identifying, preventing and controlling them
2. Promotion of food supply and proper nutrition, an adequate
supply of safe water and basic sanitation
3. Maternal and child health care including family planning
4. Immunization against major infectious diseases
5. Prevention and control of locally endemic diseases
6. Treatment of common diseases and injuries
7. Promotion of mental health
8. Provision of essential drugs

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ESSENTIAL COMPONENT (ELEMENTS) OF
PHC
Public Education
Public education is the first, and one of the most essential,
component of primary health care. By educating the public on the
prevention and control of health problems, and encouraging
participation, the WHO works to keep disease from spreading on a
personal level.

Proper Nutrition
Nutrition is another essential component of health care. WHO works
to prevent malnutrition and starvation and to prevent many diseases
and afflictions.

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ESSENTIAL COMPONENT (ELEMENTS) OF
PHC
Maternal & Child Health Care
Ensuring comprehensive and adequate health care to children and
to mothers, both expecting and otherwise, is another essential
element of PHC. By caring for those who are at the greatest risk of
health problems, WHO helps future generations have a chance to
thrive and contribute to globally. Sometimes, care for these
individuals involves adequate counseling on family planning and
safe sex.

Immunization
By administering global immunizations, WHO works to wipe out major
infectious diseases, greatly improving overall health globally.

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ESSENTIAL COMPONENT (ELEMENTS) OF
PHC
Child Health Clean water & Sanitation
A supply of clean, safe drinking water, and basic sanitation measures
regarding trash, sewage and water cleanliness can significantly improve
the health of a population, reducing and even eliminating many
preventable diseases.

Local Disease Control

Prevention and control of local diseases is critical to promoting primary
health care in a population. Many diseases vary based on location. Taking
these diseases into account and initiating measures to prevent them are key
factors in efforts to reduce infection rates.

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ESSENTIAL COMPONENT (ELEMENTS) OF
PHC
Accessible Treatment
Another important component of primary health care is access to
appropriate medical care for the treatment of diseases and injuries. By
treating disease and injury right away, caregivers can help avoid
complications and the expense of later, more extensive, medical treatment.

Provision of Drugs
By providing essential drugs to those who need them, such as antibiotics to
those with infections, caregivers can help prevent disease from escalating.
This makes the community safer, as there is less chance for diseases to be
passed along.

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IMPACT OF PRIMARY CARE
o Lower cost
oImprove outcome
oImprove equity
oImprove problem recognition
oImprove diagnostic accuracy
oDecrease hospitalization
oIncrease prevention

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PRIMARY HEALTH CARE VS FAMILY
MEDICINE

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MATERNAL HEALTH CARE PROGRAM

Importance of the MHC Program

Mothers and children are both vulnerable groups of
the community.
Women in the childbearing period (15-49 years)
constitute about 25% of the population.
Children on the other hand constitute about 40% to
45% of the population in developing countries.
Characterized by relative high mortality and
morbidity rates.

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THE LIFETIME RISK OF MATERNAL DEATH
RANGES FROM 1 IN 5,300 IN HIGH INCOME
COUNTRIES TO 1 IN 49 IN LOW INCOME
COUNTRIES

Source: WHO, UNICEF, UNFPA and The World Bank, Trends in

Maternal Mortality: 2000 to 2020, WHO, Geneva, 2023.
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MATERNAL HEALTH CARE PROGRAM

Source: World Health Organization, UNICEF, United Nations Population Fund and The World
Bank, Trends in Maternal Mortality: 2000 to 2020 WHO, Geneva, 2023.
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MATERNAL HEALTH CARE PROGRAM

Objectives of the MHC Program

The primary aim is to achieve at the end of the pregnancy a healthy
mother and a healthy baby
Promote, protect and maintain the health of the mother during
pregnancy
Detect high risk pregnancy and give them special attention.
Reduce maternal and infant mortality and morbidity
Promotion of reproductive health

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MATERNAL HEALTH CARE PROGRAM
Strategies of the MHC Program
Registration and record keeping
Periodic visits and clinical examination
Health education
Nutrition Assessment, Nutrition Education and Supplementation
Immunization
Risk detection and management
Referral services (if needed)
Home visiting and Social care

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MATERNAL HEALTH CARE SERVICES
Comprehensive medical examination

Laboratory examination

Periodic visits and examination

Immunization: TT

Nutrient supplementations

Medical services when needed

Screening

Health education: nutrition, family planning, self care, delivery,

parenthood, breastfeeding, etc.
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 MATERNAL HEALTH CARE
PROGRAM

MHC

Pre-conceptional Antenatal Intra-natal Postnatal

Care care Care care

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Expanded program of immunization (EPI)

Objectives of the EPI program

Routine Immunization
Supplementary Immunization Activities
Polio Eradication Initiative
Elimination of Measles , Rubella, CRS, NT
Control of Pediatric Bacterial Meningitis,
Viral Hepatitis. T.B
Injection Safety

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Expanded program of immunization (EPI)

Activities of the EPI program

Routine Immunization
Supplementary Immunization
Polio Eradication
Disease Elimination
Injection Safety
Cold Chain

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NATIONAL IMMUNIZATION PROGRAM

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SCHOOL HEALTH PROGRAM

Importance of the School Health Program

Biological vulnerability
Accessibility
Effectiveness
Positive impact on the community
Cost-efective
Continuity of care
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SCHOOL HEALTH PROGRAM

Based on the FRESH approach:

 School health policies
WASH (Waste, sanitation and School Health Environment)
Skills-based health Education
School-based health services

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SCHOOL HEALTH PROGRAM

Objectives of the School Health Program

is to prepare school children physically, psychologically, socially and

intellectually to become healthy productive adults, through, providing

preventive and curative health care services

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SCHOOL HEALTH PROGRAM

Strategies of the School Health

Program

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SCHOOL HEALTH PROGRAM

School Health Services

Preventive Health Services
 Comprehensive medical examination
 Vaccinations
 Periodic general examination
 Monitoring of school environment
 Medical examination of children sharing in sports teams
 Increasing health awareness among students
 Supervising the students’ nutrition
 Screening

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THE INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS (IMCI)

•A broad strategy to improve child health outcomes

developed by WHO and UNICEF.

•Includes interventions at home, in the community and

in the health system.

•The aims are

•to reduce childhood deaths, illnesses, and disability
•to improve children's growth and development.
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THE INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS (IMCI)

Assess and classify

Finding Classification Treatment
Danger signs Severe disease Urgent referral
Cough or difficulty in Severe disease Urgent referral
breathing
Diarrhoea Disease with specific Specific medical treatment
Fever therapy

Ear problem Disease without specific Symptomatic treatment

therapy
Nutritional status/
anaemia
Vaccination status Complete/incomplete Vaccinate

Department of Child and Adolescent Health

and Development

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THE INTEGRATED MANAGEMENT OF
CHILDHOOD ILLNESS (IMCI)

•IMCI has three main components:

–Improve family and community practices related
to child health and nutrition;
–Improve the health system for effective
management of childhood illness;
–Improve health care workers' skills.

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES
Objectives of the CDC department
Control and prevent the incidence and prevalence of communicable
diseases

Decreases the overall morbidity and mortality

Early detection and control of communicable diseases outbreaks

Optimal Management of cases

Prevent and control the contacts

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NOTIFIABLE DISEASES
Diseases to be notified immediately
AFP Bacterial Meningitis
Poliomyelitis Plague
HIV/AIDs Hemorrhagic Fever
Cholera Rabies
Diphtheria Tetanus
Food Poisoning Yellow Fever
Measles West Nile Fever
H1N1 Any Emerging Disease

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NOTIFIABLE DISEASES
Diseases to be notified weekly
Leshmaniasis Viral Meningitis
Brucellosis Encephalitis
Viral Hepatitis Mumps
Leprosy STDs
Tuberculosis Pertosis
Typhoid & Paratyphoid fever Rubella
Malaria Chemical Poisoning

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES
Prevention and Control of TB
Promptly identify, diagnose and treat potentially
infectious patients with TB disease
Health Education: mode of spread, importance of early diagnosis
and continued adherence to treatment
Reduce or eliminate those social conditions that increase
the risk of infection
Preventive chemotherapy with INH (6–12 months)
Screening for LTB
BCG immunization
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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES

Prevention and Control of Hepatitis B

Routine universal newborn or infant immunization.
Immunize adults in defined risk groups.
Hepatitis B Immunoglobulin
Prevent peri-natal HBV transmission by:
 Screening all pregnant women
 At birth, providing HBIG and HB vaccine to infants of HBsAg positive mothers

In blood banks:
 Screening of blood donors
 Avoid donors from risky group.

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES

Rabies Post-exposure Prophylaxis

A) First aid
B) Specific treatment (serum and vaccine):
 Passive immunization: HRIG or ERIG in a single dose.
 Active immunization recommendation :
 Old : Five IM doses: 1st,3rd, 7th, 14th, and 28th days
 New: Four IM doses: 1st,3rd, 7th, 14th

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Type of contact, exposure and recommended post - exposure prophylaxis

Type of contact with a suspect or

Category of confirmed rabid domestic or wilda Recommended treatment
exposure animal or animal unavailable for
observation

Touching or feeding of animal

I Licks on intact skin
None, if reliable case history available

-Administer
vaccine immediately
Nibbling of uncovered skin
-Stop treatment if animal remains healthy
Minor scratches or abrasion without
II bleeding
throughout observation (10 days) or is
killed and found to be negative for rabies
Licks on broken skin
by appropriate laboratory technique

-Immunoglobulin and vaccine immediately

Singleor multiple transdermal bites or
-Stop treatment if animal remains healthy
scratches
III Contamination of mucous membrane
throughout observation (10 days) or is
killed and found to be negative for rabies
with saliva (licks)
by appropriate laboratory techniques
aExposure to rodents, and rabbits seldom if ever requires specific anti-rabies treatment
bThe placing of an apparently healthy dog or cat in or from a low-risk area under careful supervision may warrant delaying treatment
cApplicable only to dogs and cats. Except for threatened or endangered species, other animals suspected of rabies must be killed and their tissues examined using
appropriate laboratory techniques

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES
Eradicating Polio
Strong routine immunization program
National Immunization days
AFP surveillance
Mooping-up immunization
Screening of sewage

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES

Eliminating Measles
Strong routine immunization program
Supplementary Immunization activities
Strengthening surveillance system
Management of cases

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PREVENTION AND CONTROL OF LOCALLY
ENDEMIC DISEASES

Eliminating N. Tetanus
Immunize pregnant women with TT
Immunize women who are in child bearing age who
in area of high risk for NT transmission
Provide clean delivery and cord care practice
Management of cases
Conduct effective NT surveillance
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 TETANUS WOUND MANAGEMENT

Clean, minor All other

wounds wounds
Vaccination history Td TIG Td TIG
Unknown or <3
Yes No Yes Yes
doses
3+ doses No* No No** No
*Yes, if >10 years since last dose
**Yes, if >5 years since last dose
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 PRIMARY HEALTH CARE

It includes the following:

 Health promotion
 Illness prevention
 Care of the sick
 Advocacy
 Community development

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HEALTH PROMOTION

 It is the process of enabling people to improve their health and

quality of life.
 Depends on effective educational, social, economic and political
efforts.

The components of health promotion are:

 Prevention of diseases
 Health Education
 Health Protection

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MAIN CHALLENGES FACED BY THE PRIMARY HEALTH
SYSTEMS IN DEVASTATED LOCATIONS IN EMR
• Poverty & lack of access to basic services.
• Programs sustainability.
• Weak linkages between PHC and mobilized community.
• Inadequate distribution of resources (human and non-human).
• Deteriorated physical infrastructure- water-sewage systems &
environmental degradation.
• Limited institutional and human resources capacity building, and lack
of an electronic health information system.
• Moving obstacles from hospital oriented health system to primary
health care (health professionals, community, etc.).
• Inadequate care continuity - personnel, pathway, appointment.
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HEALTH PROMOTION STRATEGIES:
EXAMPLES:

This Photo by Unknown Author is licensed under CC BY-SA

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