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Oral Health Programme

PRIMARY HEALTH CARE: CONCEPT & PRINCIPLES
By

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Abiodun Bamigboye, FRSH Community Health Department Obafemi Awolowo University, Ile-Ife. paobamiboye@yahoo.com.

Primary Health Care !!!

THE POLITICAL DEVELOPMENT OF 1978

Critical Appraisal of Health Services in Nigeria – Pre 1988

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Majorly curative MOH oriented No community participation Disease oriented

Global Health situation Before PHC     Some improvement? BUT Life Expectancy was low 50-50 chance of survival Only a fifth of the world has access to any permanent form of health care .

World Health Situation    One third of the people in developing countries had access to safe water less have access to safe means of excreta disposal Continued disparity in access to health between poor and the ‘rich’ and btw rural and urban .

.World Health Situation   No community involvement and participation (people who need to be healthy are not involved) Public health services of the 67 poorest developing countries excluding China spend less in total than the rich countries spend on tranquillisers.

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 the that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination .PHC Definition  Essential health care based on practical. .

The Declaration   The world Health Assembly in 1978 after an in-depth consideration of the situation of the health status of the world rose and declared PHC the cornerstone of global health attainment. Nigeria was (an important) signatory to the declaration .

The Declaration (Contd)    Unprecedented political event Formed basis for a World Health Policy Served as basis for formulation of health policies in most countries .

Democratically we can define PHC as ‘the Health of the PEOPLE by the PEOPLE and for the PEOPLE’. .Ata conference envisaged PHC as a radical reinterpretation of health services. The Alma.The Meaning of PHC    PHC involves the directing of the national health services to community health needs.

This implies a denunciation of existing inequalities and at least implicitly. HFA represented a commitment to greater justice and equity in health resources allocation. the resolve to redress such imbalances.)   For the conference.The Meaning of PHC (Contd. .

PHC      Health within reach of everyone By Health we mean a personal state of wellbeing Not just availability of services the ultimate is to ENABLE each one lead a socially economic productive life HFA= removal of ALL obstacles to health .

PHC    HFA= seeing health as the main goal of economic development and not as one of the means of attaining it. HFA= literally demands ultimately literacy for all HFA depends on continued progress in medical and Public health .

. It is clear from the declaration that it was intended to be people oriented .PHC  The technical definition of PHC clearly indicate the goals and the ways to which it was intended to be directed.

PHC   HFA/2000 thus became a popular slogan and a lucrative programme at all levels of governments in the country It has also become more or less a propaganda .

Obstacles to health     Ignorance Malnutrition Contaminated drinking water Unhygienic housing .

communications. housing. education. industry. . medicine and public health.Solutions to these Obstacles?   Health interventions? HFA is a holistic concept calling for efforts in agric.

Health for such people requires a whole new way of life and fresh opportunities to provide themselves with a higher standard of living .Solutions  Medical care cannot bring health to a hungry people living in slums.

Components of PHC (1st 8)     Education concerning prevailing health problems and 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 including family planning (MCH) .

st 1  8 Components    Immunization against the major infectious diseases Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs .

Components  What else was missing?  WHO was persuaded to add some other components .

Additional Components ***   Oral health Mental health .

.Pillars    APPROPRIATE TECHNOLOGY the use of the most appropriate and cost effective methods and equipment for each level of care  HEALTH PROMOTION AND PREVENTION – adopting a comprehensive approach which combines facility-based health services with multi-sectoral public health interventions.

5 PILLARS OF PHC    EQUITY  COMMUNITY INVOLVEMENT/ PARTICIPATION INTERSECTORAL COLLABORATION : acceptance of the health professions to collaborate with other sectors that have direct and indirect impact on attainment of health .

Principles of PHC    PHC shaped around life pattern should meet the needs of the communities PHC should be integral part of the national health system PHC should be integrated with activities of other community developmentoriented sectors .

family and community Decentralisation of health intervention to the most peripheral level possible . implementation Reliance on community resources PHC should use integrated approach of preventive. promotive.)     The local population/beneficiaries should be involved at every stage of its planning. curative and rehabilitative services for the individual.Principles of PHC (Contd.

Critical Question     What impact did these have in the countries at : National (government) level Health services level Community. family and individual level .

1978)      Directed to the delegates: Are you ready toAddress the health care gap Promote health as part of overall socioeconomic development Allocate health resources to the social periphery as a priority Mobilize communities to ensure their participation .8 BIG Questions of Halfdan Mahler (DG.

Halfdan Mahler     Make available the required manpower and technology Introduce the necessary changes in the existing health delivery system Fight the political and technical battles required to overcome obstacles and resistance Make political commitment to adopt PHC to attain the objectives of HFA .

Implications of Mahler’s poser   Affirmative answers are preconditions for success of HFA through PHC Countries where answers are not in the affirmative (at any stage of PHC implementation) cannot be said to be implementing PHC .

.Was the original Concept Understood?   Macdonald observed that it was unlikely that the countries which signed the document in 1978 realize the full significance of what they were endorsing It could also be asserted that health workers perhaps did not fully understand the nature of PHC neither did they realise the implications of the terms of the declaration.

influence and monopoly of conventional medical/health practice and medical/health practitioners.rather too late * Acceptance of reality is required . * Resistance from professionals.PHC and health Professions * PHC is a direct challenge of the power.

PMC/PHC  PMC: addition of simple curative services to some limited population-focused preventive programmes such as immunization of children. etc.  PHC: It is a re-orientation of all health services towards the health needs of the communities and a rejection of the old model of health care that is disease oriented. inadequately delivered water and sanitation programme. . routine antenatal care for mothers who care to come to the clinics.

Health Status of Nigerians   Since 1987 Nigeria ranked 136th out of 162 countries recently assessed by the United Nations using universally accepted Human Development Index (Nigeria Tribune. . 31st August 2001).

Health status of Nigerians  the need to improve the situation made the country to expressly formulate the 1986 National Health Policy which state inter alia that: ‘The goal of the national health policy shall be a level of health that will enable all Nigerians achieve socially and economically productive lives’. It went further to state that the national health policy shall be based on Primary Health care .

A three tier system of health services with shared responsibilities among each level of government in a decentralized health system. That health care shall be accorded higher priority in the allocation of nation’s resources . 2. The full participation of the PEOPLE in the planning and implementation of health care services as a matter of duty and right 3.National Health System: Features    1.

A three tier system of health services with shared responsibilities among each level of government in a decentralized health system. 2.National Health System: Features    1. That health care shall be accorded higher priority in the allocation of nation’s resources . The full participation of the PEOPLE in the planning and implementation of health care services as a matter of duty and right 3.

Emphasis on preventive and promotive measures in an integrated manner 6. Provision of affordable services with the aim of increasing accessibility to    .National Health System: Features 4. Involvement of all relevant sectors of the society to contribute to health 7. Equitable distribution of health resources as regards the at risk and the undeserved 5.

.PHC in Nigeria      Started in 1987 Introduced focused LGAs (Nigeria approach) Later willing LGAs Then others joined EPI was used as an entry point in most parts of the country.

PHC in Nigeria       Country divided into 4 health zones Several workshops held 3 documents produced at LGA levels Most states decentralised around 1986 Strengthening of SHT in Nigeria Introduction of Community Health workers scheme .

National Health System: Features   A look at these general and specific policy issues would convince one of the level of seriousness with which PHC was contemplated in the country. BUT what is the situation today?. .

PHC in Nigeria: Features      Health workers are still reluctant Community participation almost non existent = (SH) Decentralised responsibility not decision making process Disparity btw social & economic classes Governments paying lip service .

6.000 Brazil 4. (U 85) (R 45) 54.A N.A 75 N.4/000 1000+ /100.A 19988 13/000 750/ 100.A 49.Health of Nigerians 1985-2003 Selected Health Indices Of Nigerians (1985-2003) INDICATOR Crude death rate Maternal mortality Rate Childhood mortality Infant mortality Rate % of birth attended by trained personnel Gross National Income/capita 1985 3.6 16/000 N.4 .5. 630 Life expectancy at birth % access to safe water % access to safe sanitation 50 52 52 US$ 260. R48 52. USA 32.6 N.1) 57.A 200310 13 704-1500 198/1000 75 41.8 U75.A 79 31 20009 14/000 N.A US$ 300 (USA29.3 (U 82.5) (R 39.000 N.000 114/000 N.3.350 52 US$590 Tunisia US$6090 50 45(U 65) (R 36) N.1) (R48. R44.1 (U70.A N.2) 57 (R 39) 62 63 (R 45) 63.240) Brazil 4.A 144/000 85 30 1995 7 14.A N. (U79.

Characteristics of Health Care    Continuity of care: Integration of care Comprehensiveness of care (holistic care) .

Characteristics of service    Decentralization of the service Permanence of the service Polyvalence of the service .

Major Problem    weak management Gap btw policy and actions Exist at all levels but more at LGA .

process rather than Input). Outcome. – – – **. and ** acceptability . Lack of appropriate information regarding progress made (Output. Indicators of effectiveness ** efficiency.Current Challenges of PHC implementation in Nigeria     Poor and inconsistent political and administrative will and commitment Low health budget – <10% is allocated for health Lack of competent and committed programmers and programme implementers.

What types of indicators ? Process Activities (sometimes may be input)  Productivity  Use  Utilization  Quality .

Still on indicators! Output  Coverage  Efficiency  Efficacy Outcome Effectiveness .

Weak and ineffective DHC System .Problems of PHC in Nigeria    Continuing injustice in health care delivery system especially in disfavour of the rural areas. Continuing gap between what is said and what is done.

. Policy of the ruling party on health in terms of commitment and strategies to be adopted has been generally nonspecific. unclear and unrealistic.Factors Precipitating the problems   Political commitment to the goals of health to ensure consistency and continuity of programmes is usually very weak and unpredictable.

Factors Precipitating the problems  Improvement in people’s welfare means different things to the policy makers and staff . In many cases achievements are measured in terms of number of projects commissioned and not in terms of improvement in socioeconomic status of the people . Therefore notable achievements which only means physical structures predominates during planning and resource allocation. .

Politics in the mobilization. allocation and use of facilities/resources and services .Factors Precipitating the problems   Low financial viability of LGAs. Most LGA depend mainly on the funds accruing from the federation account. When this is not forthcoming development projects comes to a standstill no matter how urgent the need to execute them.

An Attempt to subvert PHC: The Selective PHC

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Soon after Alma Ata, Politicians & ‘experts’ from DC wee not comfortable with PHC principles of focusing on people Advocated for a ‘new concept’ SPHC Disease oriented, using U5

Their arguments
CPHC was  Idealistic  Expensive and  Unachievable- U5s are the real target people

Their Identified Strategies!
Infant mortality reduction based on:  focusing on growth monitoring,  oral rehydration solutions,  breastfeeding and  immunisation,

not the communities.SPHC’ achievements     took the decision-making power and control central to PHC away from the communities delivered it to foreign consultants with technical expertise in these specific areas. were subject to the policies of their agencies. These ‘technical experts’ often employed by the funding agencies. SPHC reintroduced vertical programs at the cost of comprehensive PHC .

Not only the health sector but other sectors relevant to health have to contribute to the attainment of the goal .7th REPORT ON World Health 1987.Approach to Improving Health Situation. WHO reaffirmed that:    Political commitment to equity will remain a fundamental pre-requisite to achieving the goal of HFA Leadership to ensure that national policies decisions are aimed at correcting socioeconomic disparities.

Way Forward   The capacity of health sector to cooperate effectively with economic and other social factors in policy decision must be increased Mobilization of support and commitment from professional groups and individuals and counteracting public apathy and professional ignorance/ resistance .

Way Forward    Vigorous management of the health systems and Building a TEAM spirit for Health Effective decentralization ‘REFORM’ is central.  .

The missing link: MANAGEMENT!!   Organizational structures and management systems This require the understand and cooperation of every part of the system .

. strengthen and sustain the infrastructure required for effective implementation of strategies based on PHC.Management  The primary concern of management is to establish.

and . Encourage the participation of other sectors 3. Promote the scrutiny of all development initiatives for their impact in and in relationship with health status. Support the promotion of equitable distribution of health care resources 2.Functions of Organizational structure in PHC 1.

in which dialogue and negotiation between health care providers and beneficiaries can take place. .Functions of Organizational structure in PHC 4. Strengthen or establish suitable institutions with recognised channels of influence.

Assignment (Term Paper 1) PUH 603. If you have an opportunity to lead the health system in an LGA. Due 27th January 2007   Examine PHC implementation in Nigeria within the concept of health management. explain how you would use PHC to bring about the desired improvement in people’s welfare .

Reading Assignments     Read materials on Selective PHC. The originators and the political implications of the move Relevance of Health Sector Reforms to PHC implementation Guidelines on Implementing PHC in the LGA Roles of each level of Govt in PHC .

Primary Health Care: Medicine in its Place. Other relevant materials . Macdonald John. 1993. World Health Forum 1981. Ltd. Halfdan Mahler. London.Reference materials    The Meaning of HFA by the year 2000 . Earthscan Pub.

 Thank you .

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