Basics of PRIMARY HEALTH

CARE: Highlight

Yayeh Kassa
MPH Epidemiology
FMOH PHC and HEP Expert
February 2021 , Jigjiga

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 Session 1: Basics of PHC

PHC
HFA 2000
MDG 2015
SDG 2030
UHC 2030

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 Session Objective

•The objective is this session is to help the

participants reflect on and conceptualize the
essence of PHC

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 Health

Well being
Menta Economical
Physical Social
l

Care
Primary Secondary Tertiary

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 Key Definitions
Health: A state of complete physical, mental and
social wellbeing not merely the absence of disease
and infirmity (WHO, 1947)

Health Care: It is what happens when someone who

is ill (or who thinks he or she is ill or who wants to avoid
getting ill) consults a health professional in a health care
facility or community setting for advice, tests,
treatment or referral to specialist care. (Trisha Greenhalgh.
Department of Primary Care and Population Sciences University College London
UK, 2007.)

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 Health care: Historical Milstones
• Ancient society 1500 to 500 BC

– Evidence of bath rooms and sewers in

northern India
– Evidence of water drainage in middle
kingdom of Egypt

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 Cont’d
– More than 700 drugs were known to the
Egyptians
– The code of Hammurabi, laws related to
physicians and health practices(Babylon evidence)
– Books of Leviticus provide guidelines for personal
cleanliness, sanitary, disinfection of wells,
isolation of patients, disposal of refuse and
hygiene of maternity

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 cont’d
• Classical cultures: 500 BC to 500 AD (golden
age of Greece)
– Games of strength and skill for men community
sanitation
– Water supplies for local cities
– Based on Greece engineering, Romans built aqua
ducts and sewer systems
– Romans also built public hospitals

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 cont’d
• Middle age 500-1500 AD
– Spiritual era of public health
– Great epidemic of plaque

• 1500-1700 AD( renaissance and exploration)

– Use of epidemiology to explain who was getting
sick( saints and sinners both)
– Belief that diseases were caused by
environmental not by spiritual factors
– Diagnosing the sick, understanding of sign and
symptoms of disease

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 Cont’d
18th century
– Industrial growth and medical advances
– In 1796- Dr. Edward Jenner discovered small pox
vaccination saving the lives of millions

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 Cont’d
• 19th and 20th century
– Advancement in public health
– Miasmas theory of contagious disease
– Dr. John Snow and cholera epidemic in London
– Isolation of microbial disease causing agent
– Invention of antibiotics(penicillin) and vaccines
– Advancement of diagnosis and treatment
– Advancement in disease prevention (primary,
secondary, tertiary) and control
– Advancement in genetical medicine
–

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 Cont’d
21th century ???

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 Philosophy of Public Health Care
• Health Care is consumable goods
• Health care is fundamental human right
• Health care is an investment

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 Levels of Care

• Primary health care ( our concern)

• Secondary health care
• Tertiary health care

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 CONTD.
PHC
• The “first” level of contact between the
individual and the health system.
• Essential health care is provided.
• Mostly preventive and promotive
• A majority of prevailing health problems can be
satisfactorily managed.
• The closest to the people.
• Provided by the primary health centers.

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 CONTD.
Secondary health care
• More complex problems are dealt with.
• Comprises curative services
• Provided by the district hospitals
• The 1st referral level
Tertiary health care
• Offers super-specialist care
• Provided by regional/central level institution.
• Provide training programs
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 Primary health care (PHC) became a core policy for
the World Health Organization with the Alma-Ata
Declaration in 1978 and the ‘Health-for-All by the
Year 2000’ Program.

The commitment to global improvements in health,

especially for the most disadvantaged populations,
was renewed in 1998 by the World Health
Assembly. This led to the ‘Health-for-All for the
twenty-first Century’ policy and program, within
which the commitment to PHC development is
restated.

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 What is PHC?
“PHC health care is 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 : Alma Ata Declaration, 1978

HEALTH FOR ALL (HFA- 2000)

ATTAINMENT OF A LEVEL OF HEALTH THAT WILL ENABLE
EVERY INDIVIDUAL LEAD A SOCIALLY AND ECONOMICALLY
PRODUCTIVE LIFE

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 Key Principles
Comprehensive care (a combination of promotive,
preventive, curative and rehabilitative services);
Intersect oral collaboration and action;
action
Community involvement
Appropriate care and use of technology; and
Equity

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 Contd.

• Primary Health Care is different in each

community depending upon:
– Needs of the residents;
– Availability of health care providers;
– The communities geographic location; &
– Proximity to other health care services in the
area.

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 ELEMENTS OF PRIMARY HEATH CARE (Alma Ata)
• Education concerning prevailing health problems and
the methods of preventing an controlling them
• Promotion of food supply and proper nutrition
• An adequate supply of safe water and basic sanitation
• Maternal and child health care including FP
• Immunization against major infections diseases
• Prevention and control local endemic diseases
• Appropriate treatment of common diseases
• Provision of essential drugs

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 EXTENDED ELEMENTS OF PHC
• Expanded options of immunization
• Reproductive health needs
• Provision of essential technologies for health
• Prevention and control of non communicable
diseases
• Food safety and provision of selected food
supplements.

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The Basic Requirements for Sound PHC (the 8 A’s
and the 3 C’s)

• Appropriateness • Assessability
• Availability • Accountability
• Adequacy • Completeness
• Accessibility • Comprehensiveness
• Acceptability • Continuity
• Affordability

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 Strategies of PHC
1.Reducing excess mortality of poor marginalized populations:
PHC must ensure access to health services for the most
disadvantaged populations, and focus on interventions which
will directly impact on the major causes of mortality,
morbidity and disability for those populations.

2. Reducing the leading risk factors to human health:

PHC, through its preventative and health promotion roles,
must address those known risk factors, which are the major
determinants of health outcomes for local populations.

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 Strategies contd.
3. Developing Sustainable Health Systems:
PHC as a component of health systems must develop in
ways, which are financially sustainable, supported by
political leaders, and supported by the populations
served.

4. Developing an enabling policy and institutional

environment:
PHC policy must be integrated with other policy domains,
and play its part in the pursuit of wider social, economic,
environmental and development
policy.
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 Evaluation of HFA : 1979-2006
• Reasons for slow progress:
– Insufficient political commitment
– Failure to achieve equity in acess to all PHC
components
– The continuing low status of women
– Slow socio- economic development
– Difficulty in achieving inter sectoral action for
Health
– Unbalanced distribution of resources
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 Reasons for slow progress (contd.)
• Widespread inequity of health promotion efforts
• Weak health information systems and lack of baseline
data
• Pollution, poor food safety, and lack of water supply
and sanitation
• Rapid demographic and epidemiological changes
• Inappropriate use and allocation of resources for high
cost technology
• Natural and man made disasters
• Misinterpretation of the PHC concept
• Centralized planning and management

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 Brief History of health care in Ethiopia
• Modern medicine was introduced to Ethiopia in the 16th century
during Emperor Libne Dingel (1508–1540)

• promoted during the reigns of Emperor Menelik II (1889–1913) and

Emperor Haile Selassie (1930–1974). Menelik invited travelers,
missionaries and members of diplomatic missions to introduce
medicines and provide medical services, mostly in Addis Ababa,

• Emperor Haile Selassie established the Ministry of Public Health,

and the first National Health Service, in 1947.
• The Alma-Ata Declaration on PHC was welcomed by the Ethiopian
Gov. However, PHC implementation was largely unsuccessful for the
following reasons:
• The PHC were not clearly defined at national level.
• Regions and health facilities had limited awareness of those
elements as defined at the central level.
• There was lack of clarity on health policies in most regions as a result
of poor and inadequate dissemination of information on the
policies.
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 PHC achievements
• Over the last 20 years, the five-year– the
HSDP– has been used to guide the planning
and implementation of health-related policies
and programmes in Ethiopia.
• The country has successfully completed four
consecutive phases of the HSDP (I, II, III, IV)
since its inception in 1997/1998. and showed
encouraging successes in both health service
coverage and the utilization of services at all
levels of the health care system in Ethiopia.

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 Cont
• Ethiopia Service Provision Assessment Plus (ESPA+) survey
and other sources, reveal that Ethiopia has performed
impressively in meeting most of the MDG targets.
– The achievement of MDG 4, with a 67% drop in U5MR from the 1990
estimate, contributed to an increase in life expectancy at birth from 45 to
64 years by 2014.
– Maternal mortality was reduced by 69% from the estimate of 1400 per 100
000 live births.
– HIV new infection and mortality among adults have dropped by 90% and
50%, respectively.
– The mother-to-child transmission of HIV declined by 50% between 2009
and 2012.
– Similarly, mortality due to and prevalence of tuberculosis has declined by
more than 50%.
– The national implementation of PHC strategies and expansion of
infrastructure have also been carried out successfully; over the past 20
years, 18 440 HPs, 3747 HCs and 311 hospitals constructed.
– In parallel with the construction of health facilities, investment in human
resource development and management has been scaled up.
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 Cont
• Despite the impressive progress made,
Ethiopia still has high rates of morbidity and
mortality from preventable causes.

• Source: Primary health care systems (PRIMASYS): case study from Ethiopia,
abridged version. Geneva: WHO; 2017.

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 FOUR SETS OF PHC REFORMS
• UNIVERSAL COVERAGE REFORMS: reforms that ensure
that health systems con- tribute to health equity, social
justice and the end of exclusion, primarily by moving
towards universal access and social health protection

• SERVICE DELIVERY REFORMS: reforms that

reorganize health services as primary care, i.e. around
people’s needs and expectations, so as to make them
more socially relevant and more responsive to the
changing world while producing better outcomes

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 Cont
• PUBLIC POLICY REFORMS ; reforms that
secure healthier communities, by integrating public
health actions with primary care and by pursuing
healthy public policies across sectors

• LEADERSHIP REFORMS: reforms that replace

disproportionate reliance on command and control on
one hand, and laissez-faire disengagement of the state
on the other, by the inclusive, participatory,
negotiation-based leadership required by the
complexity of contemporary health systems

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 Why PHC redefining / reform
• Urbanization
– Fast expansion, Substandard houses ; Lack of
infrastructure; Life style change
• Triple burden
– CDs: HIV/AIDS, TB, Pneumonia, DD continue to be a
problem
– NCDs: DM, CVD, Ca, COPD, Mental health (52% of deaths in
major urban areas is due to NCDs)
– Injuries: accident and Violence
• Lesson learned
– from other countries with remarkable achievement: cuba,
Brazil, [family health team, community clinic ]

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 cont
• Demand of the Community +
– need of having equitable & Quality comprehensive care with
affordable costs for all age groups across all geographic areas
• Wish of moving towards UHC by 2030
– Service Availability
– Service Coverage
– Financial Risk protection
– Health Safety
– Service responsiveness

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 Progress of PHC reform (major)
• Eth Health Policy under revision
• PHC envisioning document finalized
• UPHCU reform underway (both rural and Urban)
• CBHIS started
• EHSP finalized
• HEP optimization launched: HEPO roadmap
under development
• HEP national assessment finalized

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 Ethiopia`s PHC: Existing major challenges
 Poor functional integration between UHEps and HC staffs as
one Unit
 Did not provide all spectrums of health care services particularly for
community based health care services : mostly Health Education
 One size fit for all principle
 The same type of health services not based on family need
 There was no risk assessment and Prioritization /Categorization
 Plan of intervention for every HH is universally similar

 In most cases; community health care were not Multidisciplinary

 Lacks genuine community participation/ Dictated by Expertise view
 Equity ?? - Street dwellers, elders with no family support, mentally ill,
hard to reach areas …
 Appropriate technology utilization ??

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