Primary Health Care (2)Primary Health Care (2)

Dr Rasha SalamaDr Rasha Salama

PhD Community MedicinePhD Community Medicine

Suez Canal UniversitySuez Canal University

Definition Definition

PHC is an essential health care that is a PHC is an essential health care that is a socially appropriate, universally accessible, socially appropriate, universally accessible, scientifically sound first level care provided by scientifically sound first level care provided by a suitably trained workforce supported by a suitably trained workforce supported by integrated referral systems and in a way that integrated referral systems and in a way that gives priority to those most in need, maximises gives priority to those most in need, maximises community and individual self-reliance and community and individual self-reliance and participation and involves collaboration with participation and involves collaboration with other sectors.other sectors.

Elements of PHCElements of PHC

Education concerning prevailing health problems Education concerning prevailing health problems and the methods of preventing and controlling themand the methods of preventing and controlling them

Promotion of food supply and proper nutritionPromotion of food supply and proper nutrition Monitoring an adequate supply of safe water and Monitoring an adequate supply of safe water and

basic sanitationbasic sanitation Maternal and child health care, including family Maternal and child health care, including family

planningplanning Immunization against the major infectious diseasesImmunization against the major infectious diseases

Elements of PHC (cont.)Elements of PHC (cont.)

Prevention and control of locally endemic diseasesPrevention and control of locally endemic diseases Appropriate treatment of common diseases and Appropriate treatment of common diseases and

injuriesinjuries Basic laboratory services and provision of essential Basic laboratory services and provision of essential

drugs.drugs. Training of health guides, health workers and health Training of health guides, health workers and health

assistants. assistants. Referral servicesReferral services

Elements of PHC (cont.)Elements of PHC (cont.)

Mental healthMental health Physical handicapsPhysical handicaps Health and social care of the elderlyHealth and social care of the elderly

Primary Health Care

Preventive services Curative services

General services Care of vulnerable groups

Outpatient clinic (referral)

Laboratory services

Dispensary

First aid and emergency services

Health educationMonitoring of environmentPrev.&control of endemic diseasesHealth office services

Maternal &child health s.

School health servicesGeriatric health services

Occupational health services

Maternal and Child HealthMaternal and Child Health

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

Maternal HealthMaternal Health According to 2000 WHO estimations it was According to 2000 WHO estimations it was

concluded that:concluded that: From every 210 pregnant women who annually get From every 210 pregnant women who annually get

pregnant, 8 suffer from life threatening complications. pregnant, 8 suffer from life threatening complications. More than half a million (529,000) women died during More than half a million (529,000) women died during

pregnancypregnancy MMR globally was500/100,000 LB, ranging from2.4 MMR globally was500/100,000 LB, ranging from2.4

in Scandinavia and Switzerland to 1200 in Yemenin Scandinavia and Switzerland to 1200 in Yemen 50,000,000 women are left with chronic debilitating 50,000,000 women are left with chronic debilitating

diseases annually. diseases annually.

Maternal MortalityMaternal Mortality The other 1/3rd of maternal The other 1/3rd of maternal

deaths worldwide results deaths worldwide results from indirect causes or an from indirect causes or an existing medical condition existing medical condition made worse by pregnancy or made worse by pregnancy or delivery:delivery: MalariaMalaria AnemiaAnemia HepatitisHepatitis AIDS AIDS TuberculosisTuberculosis Malnutrition Malnutrition

Nearly 2/3rds of maternal Nearly 2/3rds of maternal deaths worldwide results deaths worldwide results from five causes:from five causes: Hemorrhage (24%)Hemorrhage (24%) Obstructed labor (8%)Obstructed labor (8%) Eclampsia (pregnancy Eclampsia (pregnancy

induced hypertension) induced hypertension) (12%)(12%)

Sepsis (15%)Sepsis (15%) Unsafe abortion (13%) Unsafe abortion (13%)

Some Factors that Contribute to Some Factors that Contribute to Maternal Mortality and MorbidityMaternal Mortality and Morbidity

The 4 “too”s of pregnancy:The 4 “too”s of pregnancy: Too youngToo young Too oldToo old Too manyToo many Too soonToo soon

In other words: young or old age of pregnancy, In other words: young or old age of pregnancy, short intervals between pregnancies, and high short intervals between pregnancies, and high parity. Other factors include low socio-parity. Other factors include low socio-economic status and inadequate maternal care.economic status and inadequate maternal care.

MDGsMDGs

In the 8 Millennium Development Goals, 3 of In the 8 Millennium Development Goals, 3 of them are directed to MCH:them are directed to MCH: Improve maternal healthImprove maternal health Reduce infant and child mortalityReduce infant and child mortality Combat HIV, malaria, TB and other conditions.Combat HIV, malaria, TB and other conditions.

Objective of MCHObjective of MCH

To improve the health status of the largest To improve the health status of the largest and most vulnerable sector of the and most vulnerable sector of the population by providing the best health population by providing the best health care available.care available.

Maternal Health CareMaternal Health Care

MHCMHC

PreconceptionalCare

Postnatal Care

Intra-natal Care

AntenatalCare

Including Premarital Care

Preconceptional Care

It is a care of female before conception.It is a care of female before conception. It is continued care from birth, through stages It is continued care from birth, through stages

of growth and development, and until the time of growth and development, and until the time of conception and pregnancy, so as to prepare of conception and pregnancy, so as to prepare the female for normal child bearing and the female for normal child bearing and delivery in the future.delivery in the future.

Components of Preconceptional Components of Preconceptional Care:Care: Health promotion and prevention of health hazards Health promotion and prevention of health hazards

specially those of particular risk to pregnancy.specially those of particular risk to pregnancy. Regular health appraisal for early case detection and Regular health appraisal for early case detection and

management, and prevention of sequelae or management, and prevention of sequelae or complications.complications.

Health education of young girls e.g. determinants and Health education of young girls e.g. determinants and requirement of health, family health, family requirement of health, family health, family planning…..planning…..

Premarital care (for both partners).Premarital care (for both partners).

Premarital CarePremarital Care

It includes:It includes: Premarital counselingPremarital counseling Premarital immunizationPremarital immunization Premarital examination:Premarital examination:

History takingHistory taking Genetic counselingGenetic counseling Systemic medical examinationSystemic medical examination Investigations Investigations

Antenatal (Prenatal) CareAntenatal (Prenatal) Care

General objective:General objective:

“ “ The general objective of antenatal (prenatal) The general objective of antenatal (prenatal) care is to prepare the mother both physically care is to prepare the mother both physically and psychologically to give birth to a healthy and psychologically to give birth to a healthy newborn (favorable outcome of pregnancy) newborn (favorable outcome of pregnancy) and to be able to care for it.”and to be able to care for it.”

Components Antenatal (Prenatal) Components Antenatal (Prenatal) CareCare Registration: During the booking visit, and record Registration: During the booking visit, and record

keepingkeeping Medical examination and investigations; for both the Medical examination and investigations; for both the

booking visit and continuing visits.booking visit and continuing visits. Health educationHealth education ImmunizationImmunization Supplementations Supplementations Clinical servicesClinical services Social services (outreach services).Social services (outreach services).

Intra-natal Care Intra-natal Care

“ “Normal delivery is defined as a process of delivery Normal delivery is defined as a process of delivery of a single fetus and other products of conception of a single fetus and other products of conception within 24 hours, through the normal birth canal and within 24 hours, through the normal birth canal and without complications.”without complications.”

Objectives of intra-natal care: safety of mother and Objectives of intra-natal care: safety of mother and fetus, by helping the pregnant to have a normal fetus, by helping the pregnant to have a normal delivery, and providing emergency services when delivery, and providing emergency services when needed.needed.

Determination of place of birth, with a well-organized Determination of place of birth, with a well-organized back up system. back up system.

High Risk DeliveriesHigh Risk DeliveriesMother Mother Delivery Delivery Fetus Fetus

Toxemia of Toxemia of pregnancypregnancy

Prolonged laborProlonged labor Prematurity Prematurity

Diabetes mellitusDiabetes mellitus Breech Breech presentationpresentation

LBWLBW

Age < 20 yrsAge < 20 yrs Cord prolapseCord prolapse Fetal distressFetal distress

Age > 35 yrsAge > 35 yrs Multiple Multiple pregnancypregnancy

Meconium Meconium stained liquor stained liquor amnii amnii Parity 5 +Parity 5 + Premature rupture Premature rupture

of membranesof membranes

Postnatal Care Postnatal Care

Care of mother after delivery.Care of mother after delivery. Its components are:Its components are:

Postpartum examinationPostpartum examination Medical careMedical care Follow upFollow up Health educationHealth education Family planning servicesFamily planning services Psychological and social support Psychological and social support

CHILD HEALTHCHILD HEALTHWhy tackle child health?Why tackle child health? The global equity gap in health is largest among The global equity gap in health is largest among

children, and is concentrated in communicable diseases. children, and is concentrated in communicable diseases. Children under five yearsChildren under five years of age account for more than of age account for more than

50% of the global gap in mortality between the poorest 50% of the global gap in mortality between the poorest and richest quintiles of the world's population. and richest quintiles of the world's population.

Children under five bear 30% of the total burden of Children under five bear 30% of the total burden of disease in poor countries. disease in poor countries.

Almost all (99%)Almost all (99%) of the 10.9 million children under of the 10.9 million children under five who died in 2000 were from developing countries. five who died in 2000 were from developing countries. Of these children, 36% died in Asia, 33% in Africa. Of these children, 36% died in Asia, 33% in Africa.

Perinatal mortality accounted for more than 20% of deaths in children under five years of age, in 2000 and includes birth asphyxia, trauma, and low birth weight.

Infant and child priorities (UNICEF)Infant and child priorities (UNICEF)

1.1. Reduction of infant and under 5 mortality Reduction of infant and under 5 mortality raterate

2.2. Reduction of moderate and severe Reduction of moderate and severe malnutritionmalnutrition

3.3. Universal access to safe drinking waterUniversal access to safe drinking water4.4. Access to all couples to information and Access to all couples to information and

services to prevent pregnancies that are too services to prevent pregnancies that are too early, too closely spaced, too late or too early, too closely spaced, too late or too many.many.

Infant and child priorities (UNICEF) Infant and child priorities (UNICEF) cont.cont.

6. Reduction of low birth weight babies6. Reduction of low birth weight babies7. Elimination of iodine deficiency7. Elimination of iodine deficiency8. Elimination of vitamin A deficiency8. Elimination of vitamin A deficiency9. Encouragement of women to breast feed their 9. Encouragement of women to breast feed their

children exclusivelychildren exclusively10. Growth promotion and monitoring10. Growth promotion and monitoring11. Eradication of poliomyelitis11. Eradication of poliomyelitis12. Elimination of neonatal tetanus12. Elimination of neonatal tetanus13. Reduction of measles death13. Reduction of measles death

Infant and child priorities (UNICEF) Infant and child priorities (UNICEF) cont.cont.

14. Maintenance of a high level of immunization 14. Maintenance of a high level of immunization coverage.coverage.

15. Reduction of deathes due to diarrheal diseases15. Reduction of deathes due to diarrheal diseases

16. Reduction of deaths due to ARIs16. Reduction of deaths due to ARIs

17. Increased acquisition of knowledge, skills and 17. Increased acquisition of knowledge, skills and values required for better living by all families.values required for better living by all families.

What can be done to What can be done to improve child healthimprove child health??

Child Health Service (Program)Child Health Service (Program) The MCH center provides child care that starts The MCH center provides child care that starts

before birth and continues through out childhood.before birth and continues through out childhood.

Functions of MCH centers for child care:Functions of MCH centers for child care: Maternal care (prenatal and natal)Maternal care (prenatal and natal) Neonatal careNeonatal care Adequate nutrition of infants and childrenAdequate nutrition of infants and children Health appraisal (assessment)Health appraisal (assessment) Prevention and control of communicable diseases including Prevention and control of communicable diseases including

immunization.immunization. Clinical (curative services)Clinical (curative services) Social services.Social services.

The Integrated Management of The Integrated Management of Childhood Illness (IMCI)Childhood Illness (IMCI)

IMCI is a broad strategy to improve child health outcomes IMCI is a broad strategy to improve child health outcomes developed by WHO and UNICEF. IMCI encompasses developed by WHO and UNICEF. IMCI encompasses interventions at home, in the community and in the health interventions at home, in the community and in the health system. The aims are to reduce childhood deaths, illnesses, system. The aims are to reduce childhood deaths, illnesses, and disability and to improve children's growth and and disability and to improve children's growth and development, with a particular focus on the poorest and development, with a particular focus on the poorest and most disadvantaged children. IMCI has three main most disadvantaged children. IMCI has three main components: components: Improve family and community practices related to child Improve family and community practices related to child

health and nutrition; health and nutrition; Improve the health system for effective management of Improve the health system for effective management of

childhood illness;childhood illness; Improve health workers' skillsImprove health workers' skills. .

Improve family and community practices Improve family and community practices related to child health and nutrition; related to child health and nutrition;

Counseling on child feedingCounseling on child feeding including including exclusive breast feedingexclusive breast feeding Adequate amount of micronutrient or supplementationAdequate amount of micronutrient or supplementation

Complete full course of immunization for childrenComplete full course of immunization for children Promote safe disposal of waste and hand washing before Promote safe disposal of waste and hand washing before

preparing meals and feeding children preparing meals and feeding children Provide adequate care to sick childrenProvide adequate care to sick children Promote mental and social development by responding to Promote mental and social development by responding to

children's needs for care, children's needs for care, Provide adequate prenatal care to every pregnant woman Provide adequate prenatal care to every pregnant woman

Improve the health system for effective Improve the health system for effective management of childhood illness;management of childhood illness;

EnsureEnsure drugs and supplies drugs and supplies for treating major for treating major childhood illnesses are available in health childhood illnesses are available in health facilities facilities

Improve quality of careImprove quality of care provided at health provided at health facilities and organization of work facilities and organization of work

Improve referral pathways Improve referral pathways Identify and develop methods for sustainable Identify and develop methods for sustainable

financing and equity of access financing and equity of access

Improve health workers' skillsImprove health workers' skills..

Develop and adapt case management Develop and adapt case management guidelines guidelines and standards for major childhood and standards for major childhood illnesses in the country illnesses in the country

Train health providersTrain health providers at first level health at first level health facilities and referral level in standard case facilities and referral level in standard case management management

Improve and maintain health workers' Improve and maintain health workers' performance through performance through follow-up after training follow-up after training and periodic supervisionand periodic supervision

A combination of integrated A combination of integrated curative and curative and preventivepreventive interventions is required to address interventions is required to address the immediate and underlying determinants of the immediate and underlying determinants of child health. Maternal determinants and risk child health. Maternal determinants and risk factors associated with pregnancy and factors associated with pregnancy and childbirth are especially important. childbirth are especially important.

Simple, cost-effective interventions delivered Simple, cost-effective interventions delivered at the community level can save most newborn at the community level can save most newborn and children lives in developing countries. and children lives in developing countries.

To summarize To summarize

Optimum child health is achieved through:Optimum child health is achieved through: Adequate maternal careAdequate maternal care Periodic follow up of the “healthy child”Periodic follow up of the “healthy child” Breast feeding and proper child nutritionBreast feeding and proper child nutrition ImmunizationImmunization Early detection and proper managementEarly detection and proper management A sanitary and safe environmentA sanitary and safe environment Health education of parents.Health education of parents.

THANK YOU THANK YOU

Thank You