Unit 2

Primary Health Care (PHC)

HSMMRB-2011
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 Unit objectives
At the end of this chapter, the student is able to:
 Describe the historical development of PHC.
 Identify the philosophy, principles, components and
strategies of PHC.
 Analyze the situation in the Ethiopian context.
 Adopt PHC for the year 2000 and beyond.
 Identify the Global indicators for monitoring and
evaluation of the Health for All strategy.
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 Primary Health Care

Definition
It is an 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 the country can afford

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Primary Health Care

Main focus is on the overall social and economic

development of the community.
It brings health care as close as possible to where people live.
It is essentially a call for partnership.
PHC is not:
More medicine for the poor; but it is essential health services
valued for all countries

A medical reform but a transfer of responsibility, i.e. a social

reform.
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 Historical development of PHC

 Establishment of WHO in 1948

 Its major goal of the highest possible level of health to

all people
 Failure of the WHO to meet the above stated goal
 The expensive and unsuccessful vertical approach of
control programmes as malaria, TBc and STI.
 Low health status of majority of people in disadvantaged
areas globally
 The rise of Basic health Service concept in mid 1950s. 5
 Historical development . . . . . . . .
 Then, attention given to construction of HCs and HSs and
provision of both preventive and curative care.
 Integration of disease control programs with the basic health
services
 But, less impact on the health status of the population

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 Historical development of PHC . . . . ..

 Neglected other sectors

 Practical focus to curative service than preventive,
promotive and rehabilitative
 Thus -the magnitude of health problems and inadequate
distribution of health resources called for a new
approach and the concept of PHC was born.

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Historical development of PHC . . . . .

 In 1977 the WHO set a goal of providing "Health for

All by the year 2000”
 The strategy to meet this goal was later defined in the
1978 WHO/UNICEF joint meeting at Alma-Ata
USSR. = The Primary Health Care (PHC) strategy

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Principles of PHC

The following principles underline the concept of PHC

1. Intersectoral collaboration
2. Community participation
3. Appropriate technology
4. Equity
5. Focus on prevention and health promotion
6. Decentralisation

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1. Inter sectoral collaboration

 It means a joint concern and responsibility of other

sectors for identifying problems, programmes and
undertaking tasks
 Why is intersectoral collaboration important?

• To save resources (effective use of resources)

• To identify community needs together

B/c the causes of ill health are not limited only to factors
related to the health sector.
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 Which sectors must collaborate?
 Education for literacy,
 Income supplementation,
 Clean water, sanitation, and improved housing,
 Ecological sustainability,
 More effective marketing of products,
 Construction of roads and water ways,
 Enhanced roles of women, are changes that may have
substantial impact on health
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 2. Community Participation
• Is the process of assuming responsibility by individuals
and families for developing capacity to contribute to their
health and the community's development

The communities should be actively involved in:

• Problem identification

• Priority setting and making decisions (Planning)

• Implementing,

• Monitoring and evaluating programs

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 3. Appropriate technology for Health 
Purpose:
• To avoid dependence on foreign resources
• To create sustainability and self -reliance
Appropriate technology criteria?
• Effective . Culturally acceptable
• Affordable---cost (efficiency) . Locally sustainable
• Evolutionary capacity . Measurable
• Evaluated . Politically responsible
• Environmental accountable (harmless)

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 4.Equity (Equitable distribution)
Possible definition of equity include:-
• Equal health
• Equal access to health care according to need
• Equal utilization of health care according to need

Planning for equity in PHC requires the identification of

disadvantaged groups in terms of health status, access to
or utilization of services.

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5. Focus on prevention and promotion of health

• Health promotion relates to the importance of adopting, a

promotive or preventive approach to health problems.
Such an approach sees health as a positive attribute,
rather than simply" the absence of disease“.

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6.Decentralization

The Purpose is to :
• Bring decision making to the communities served and to
field level providers of services, making it more
appropriate.
• Enhance multisectoral collaboration at the lower service-
delivery level.
• Enhance the ability to tap new sources for financing
health care.
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 The PHC philosophy
1. Equity and justice = Effective PHC
• Ensures equitable distribution of resources and health care
for all the citizens to lead productive life.
• Makes an important contribution to greater social justice and
equity by Narrowing the gap B/n the "have's and the "have
not's".
• If all cannot be served those most in need should have priority.
2. Individual and community self reliance =

• Personal responsibility for their own and their families

health. 17
 The PHC philosophy
3.:Inter relation ship of health and development
Development: Is multidimensional process involving
• Changes in structure, attitude and institutions
• Acceleration of economic growth,
• Reduction of in equality.
• Eradication of absolute poverty

Health: Makes a fundamental contribution to:

 Improved health
 Create bigger and better work force
 Increased productivity
 Growth in a country's economy 18
 The PHC strategy
1. Change in the health care system:
• Design, Planning & management of health system
• Integrated systems
• Involvement of communities
• Redistribution, use and control of existing resources
• Reorientation of health human resources
• Legislative changes
• Total coverage with essential health care
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The PHC strategy . . . . ..

2. Individual and Collective Responsibility for Health:

• First aspect- is a political and Decentralization issues
• Second aspect:- self-realization
• For both aspects it is important to have Informed and
motivated public
• Personal responsibility for their own and their families’
health.

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The PHC strategy . . . . ..

3 Intersectoral Action for Health , Practical Action for

this is:-
• Attention of over all economic development.
• More consciously and directly towards the maximization
of health
• Sharpening awareness at the community, District,
Regional level

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 PHC - The level of care

PHC level means most peripheral level of organized

health care- the point of contact between community &
the health services.
• It provides intact two ways referral system addressing all
health care programme elements
• It requires the involvement of communities and other
sectors within the functional infrastructure.
• See the following table
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Table 6.1: Primary Health Care as a level of health care

Level Administrati Health Types of Levels of

ve area Facilities Care Prevention

Local Kebele PHCU 10 Care 10 + 20 + 30

+ (HC+ 5CHP) Preventions
Woreda

Intermed Zonal/ Zonal 20 Care 10 + 20 + 30

iate Regional Preventions

Central referral
Central National & teaching H/L 30 care 30 Prevention

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The Eight elements of PHC (WHO/UNICEF 1978)
1. Health education
2. Provision of food supply and nutrition
3. Water supply and basic sanitation
4. Expanded program on immunization
5. Maternal and child health including family planning
6. Prevention and control of locally endemic disease
7. Appropriate treatment of common disease and injuries
8. Provision of essential drugs

Additional elements incorporated include:

• Oral Health . Mental Health
• Occupational Health . HIV/AIDS
• The use of traditional Medicine . ARI 24
Challenges faced in the implementation of PHC (Global)

1. Political constrains
• Problem in political commitment to reallocate and
decentralize resources,
2. Professional constrains
• Less emphasis given to prevention
• Less commitment from professionals

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Challenges faced in the implementation of (Global)

3. Experience constraints
• Experiences of project success only in some countries,

4. management problems
• Decreased budget for public sector
• Low success in achieving intersectoral and programs
collaboration

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PHC in Ethiopia included

 Increased health awareness of the population.

 Increasing number of medical and paramedical personnel.
 Expansion of health services to the broad masses
 Locally endemic diseases prevention and control.
 EPI against six major CDs, MCH (FP)
 Provision of essential drugs
 Nutrition & promotion of food supply
 Treatment of common diseases and injuries
 Sanitation and safe water supply 27
Major problems in implementation of PHC in Ethiopia

A. Absence of infrastructure
B. Failure to achieve intersectoral collaboration
C. Inadequate health service coverage
D. Inadequate resource allocation
E. Absence of clear guidelines on how to implement PHC
F. Absence of sound legal rules to support environmental
health activities = Lack of enforcement

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Major problems in implementation of . . . . . . . .

G. Weak community involvement

H. Poor leader ship and insufficient political commitment

I. Failure to address demands and needs of the population
J. Unrealistic expectation of PHC
K. Presence of culturally dictated harmful traditional
practices and beliefs

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Approaches in PHC

• Marked variations in perception and approaches among

countries and individual.
Two approaches in PHC implementation (1979/80):
1. Selective PHC (sPHC)
2. Comprehensive PHC (cPHC)

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Approaches in PHC

Selective PHC approach

• Was aimed at:

 directing most effective health services toward

controlling diseases producing the largest number of
deaths and disability with the limited human and
financial resources available.
 Making health care accessible to the greater number,
using criteria of morbidity, prevalence, mortality/severity
and disability, and feasibility of control 31
Selective PHC approach . . . . . . .
• Views health as the absence of disease.
• It measures achievements in terms of reducing those
diseases most feasible to control.
The low cost strategy of sPHC
G = Growth monitoring
O = Oral rehydration
B = Breast feeding
I = Immunization
F = Female education
F = Family planning
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Approaches in PHC . . . . . . .
Advantage of sPHC approach
• Easier decision-making
• Faster and more satisfactory results
Disadvantage of sPHC approach
• Limited scope of activities
• Is disease oriented. (treats individuals who are sick)
• Failure to address general community health problems

• Failure to address priorities of the community

• It is Doctor dependent

• Failure to involved other sectors 33

Approaches in PHC . . . . . . .
Comprehensive PHC

Focus on a positive (holistic ) state of well being

Advantage of the cPHC approach
• It looks at health holistically
• Sees health as part of the development
• It involves and empowers people

• It promotes equity and deals with priorities of the community

• It advocates multisectoral collaborations

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Approaches in PHC . . . . . . .

Disadvantages of the cPHC approach

• It is expensive initially to set up an infrastructure
• It requires conscious planning
• Results are gradual
• It is a long and complex process

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Equity in the provision of health care
What is equity ? Is the faire distribution of the costs of health
services and benefits obtained from their use among different
groups in the population
Possible definition of equity include:-
• Equal health

• Equal access to health care according to need

• Equal utilization of health care according to need

• Equity in PHC requires the identification of groups which are

currently disadvantaged in terms of health status, access to or
utilization of services. 36
Two major types of equity

1. Horizontal equity = means that individuals with the

same health condition should have equal access to
health services
i.e. the charge levied by all providers for a particular service
should be the same for house holds with equal ability to
pay ( regardless of gender, marital status , and so on ).

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Two major types of equity . . . . . .

2. Vertical equity = is based on the principle that

individuals who are un equal in the society should be
treated differently .
i.e. consumers should be charged for the same service
according to their ability to pay

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Equity in the provision of health care

Note
• Good health is widely perceived as a basic human right
• Provision of cost-effective health service to the poor is
an effective and socially acceptable approach to poverty
reduction
• This in turn closes the gap between ‘’the haves and
don’t haves’’

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