PRIMARY HEALTH CARE• The primary health care movement officially began in

1977 when the 30th world assembly adopted resolution accepting the goal of attaining a level of health that permitted all citizens of the world to live socially and economically productive lives. At the International Conference in 1978 in Alma Ata, USSR sponsored by WHO and the UNICEF which was attended by 150 member states of the WHO, where Philippines is one of the signatories, it was determined that this goal was to be met through “Primary Health Care”. This resolution became known by the slogan “ Health for All by the year 2000”(HFA/2000) and captured the official health target for all of the member-nations of the WHO.

Health for all (HFA)

– Means that health is brought within reach of everyone in a given country.

– Implies the removal of the obstacles to health – Meant that health should be regarded as an

objective of economic development and not merely as one of the means attaining it.

• Ultimately demands literacy for all until this becomes reality it demands, at least , the beginning of our understanding of what health means for every individual

• Health for all is defined as “the attainment of a level of health that will enable every individual to lead a socially and economically productive life”

• The commitment of the Philippine government to attain the goal of health for all in the year 2000 is embodied in the Letter of Instruction No. 949 issued by the President of the Republic of the Philippines. It mandated the Ministry of health to adopt primary health care as an approach towards the design, development and implementation of programs, which focus health development at the community level.

• HISTORY OF PRIMARY HEALTH CARE IN THE PHILIPPINES

( Adopted from IBON Foundation Inc.)

PHC as an approach in health programs has a long history in the Philippines. In the early 1970’s, Community Based Health Programs emerged after several groups began to question the government’s existing health care approaches and started exploring new ways of answering the health needs of the people.

• In the urban areas, allied health students worked with concerned health professionals to serve the poor in Manila. A group of Catholic sisters from different congregations decided to work with health care professionals and formed a mobile health team to service the most depressed rural areas. The health team trained paramedics at the grassroots level. Soon the Sisters of the Rural Missionaries of the Philippines along with their health and community volunteers initiated programs in Luzon (Isabela) Visayas (Leyte) and Mindanao (Lanao del Norte), launching their pilot CBHPs in 1975.

• The CBHPs attempted to bring health education and services to the barrios that had long been neglected by clinic and hospital-oriented; city and town center based government health care system. Exposure to the realities in the barrios quickly deepened their views of a structural approach to the solution of the health problems of the people. The relationship of poverty to malnutrition and disease became painful explicit, Later, the experiences of the CBHPs were adopted by other religious organizations, like the National Council of Churches in the Philippines (NCCP) and AKAP, both establishing their nationwide network.

• Those involved in CBHPs found out that the political, economic and cultural structure were related to the prevailing health situation then. This rule awakening catalyzed an understanding that health problems would need to be solved through people’s organizations. Such Organizations would become for a for addressing the people’s needs and problems as well as the venues for discussions, planning, answering the needs and drawing up solutions. Thus, community organizing was seen as a key factor in CBHPs and in uplifting the situation of the people.

• DURING THE TIME OF MARCOS. Unfortunately, the development of CBHPs happened during the time of Martial Law. Advocates of CBHPs were tagged as subversives and were harassed by local authorities. Several programs failed and dropped their organizing efforts while others held on to organizing and/or coordinating with people’s organizations, unmindful of the risks involved. But when the Philippines became a signatory to the Alma Ata Conference in 1978, the government committees itself to the objectives and principles of primary health care. Sudd3enly, CBHPs became acceptable and respectable. The government then initiated research and development in PHC. However, it was only in 1981 when the nationwide implementation of PHC started. The government organized Primary Health Care Committees at all levels. “Botika sa Barangays” and barangay health programs bearing the slogan “Health for all” was seen all over the country. A lot of health programs were launched to promote the principles of PHC.

• DURING THE TIME OF AQUINO. The “Health for All” slogan slowly vanished and PHC as a core strategy was never adopted due to the Marcosian label alluded to it. It was only in 1991, barely a year before the end of President Aquino’s term, that a program using PHC was created. In a Post-Research/action Workshop on PCHD in June 1991, then Health Undersecretary Mario Taguiwalo expresses the need to refocus PHC, as it was associated with a dictatorial regime. Refocusing would mean a conceptualization of a new term to prevent confusion. The new term adopted was Partnership for Community Health Development (PHCD).

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• DURING THE TIME OF RAMOS. Secretary Juan Flavier continued PCHD with 149 M financial package from the World Bank. The health program saw the revival of catchy slogans that used to be a practice during the Marcos dictatorship. And with the implementation of the Local Government Code of 1991, the status of the PHC was aggravated even more. This spelled major revamp in the management of PHC from the national government to the local government units. The government sees this process called devolution as a way to “bring government closer to the people” since the powers and responsibilities in the management of basic services were transferred into the hands of the LGUs. The DOH formally declared “Health in the hands of the people” as the core strategy in the programs thrust of the government at all levels.

RATIONALE

• More than half the population of the world do not have the benefits of proper health care yet health is recognized as a fundamental human rights. The following discussion explains the rationale of primary health care.

•  • Magnitude of Health Problem• The health statistics remain high in infant and child deaths caused

by diseases long considered preventable.• The incidence of communicable diseases is on the increase if not

unchanged.• Millions of people still suffer and die from diseases whose

prevention, treatment and cure already exist or they survive with physical and mental sequelae that developed from lack of basic health care.

• Environmental sanitation is still a problem.• Health conditions are made worse by rapid population growth,

ignorance, and poverty.•  

• Inadequate and Unequal Distribution of Health Resources

• Hundreds of millions of people have little or no access to proper health care particularly those in the rural areas.

• Health facilities are inadequate and where they exist, they maybe under utilized.

• Hospitals and other health facilities remain concentrated in urban areas.

• Uneven distribution of qualified health personnel between urban and rural areas continues to characterize the health manpower situation.

• The urban facilities serving only small portion of the population absorbs the majority of financial material and human resources.

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• Increasing cost of medical care• Cost of medical care continues to rise beyond the reach of those

who need it most.• The allocation of the budget for health expenditure on which the

poor depend is spent most on the treatment of the sick. 70 to 80 percent of the entire public health budget to cure and care of individuals as opposed to public health services therefore is directed only to few.

•  • Isolation of Health Care Activities from other Health Activities.• Health care is relatively isolated from other development sectors.

The DOH assumed all the responsibilities for health services alone.• In the past, the attitude of the health sector was not to get involved

in activities undertaken by other sectors maybe because of convenience, political weakness, and helplessness against traditional rigid institutional practices or sense of inadequacy in relation to the magnitude of the task.

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DEFINITION OF PRIMARY HEALTH CARE

• The Alma-Ata Conference defines primary health care as essential health care based on practical, scientifically sound and socially acceptable method and technology made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

• Universally accessible – refers to continuing and organized supply of care that is geographically, financially, culturally within easy reach of the whole community.

• Socially acceptable – implies that care has to be appropriate and adequate in quality to satisfy the health needs of the people and has to be provided by methods acceptable to them within their social-cultural norms.

• Affordable – implies that whatever the methods of payment used, the services should be affordable by community and country.

• Participation implies that the process by which individuals, families and communities assume the responsibility in promoting their own health and welfare.

GOAL OF PHC

• An improved state of health and quality of life for all people attained through self-reliance is the overall goal of primary health care.

• Two-pronged goal• Social – it is directed to the improvement of the quality of

life and the extension of maximum health benefits to all, particularly to the unserved and underserved segments of the population.

• Developmental – it views the community as moving progressively towards socio-economic prosperity with the ultimate goal of self-reliance.

• Primary Health in a given country or community will vary according to :

• Political commitments• Economic realities• Social values

TRADITIONAL VERSUS PHC PHC is a change from disease-oriented, individual-centered, and hospital-based health care to a health-oriented, people-centered and community-based service.

TABLE 1. The traditional versus the Primary Health Care Approaches to the Delivery of Health Care

DIMENSION TRADITIONAL PRIMARY HEALTH CARE

GOAL ABSENCE OF DISEASE

DEVELOPMENT AND PREVENTIVE HEALTH CARE

FOCUS OF CARE THE SICK THE WELL AND EARLY SICK

SETTING OF SEDRVICES

URBAN-BASED HOSPITLAS,CLINICS AND HOMESACCESIBILITY ONLY TO FEW

RURAL BASED ON SATELITE CLINICS\

COMMUNITY HEALTH CENTERS, HEALTH POSTS ARE ACCESSIBLE TO ALL

PEOPLE PASSIVE RECEPIENTS OF HEALTH CARE

ACTIVE DEVELOPMENT OF HEALTH DEVELOPMENT

PRIMARY HEATH CAREPRINCIPLES AND STRATEGIES

1.ACCESSIBILITY, AVAILABILITY, AFFORDABILITY AND ACCEPTABILITY OF HEALTH SERVICES

STRATEGIES:

a)Health services delivered where the people are

b)Use of indigenous/resident volunteer worker as a health care provider with a ratio of one community health worker per 10-20 households

c)Use of traditional(herbal) medicine with essential drugs

PRINCIPLES AND STRATEGIES2. Provision of quality, basic and essential

health servicesSTRATEGIES:

a)Training design and curriculum based on community needs and priorities

b)Attitudes, knowledge and skills developed are on promotive, preventive, curative and rehabilitative healthcare

c)Regular monitoring and periodic evaluation of community health worker performance by the community and health staff

PRINCIPLES AND STRATEGIES3. COMMUNITY PARTICIPATIONSTRATEGIES:a)Awareness-building and consciousness raising

on health and health-related issues.b)Planning, implementation, monitoring and

evaluation done through small group meetings(10-20 household cluster).

c)Selection of community health workers by the community

d)Formation of health committees.e)Establishment of community health organization

at the parish or municipal levelf)Mass health campaigns and mobilization to

combat health problems.

PRINCIPLES AND STRATEGIES4. self-relianceStrategies:

Community generates support(cash,labor) for health program

a.Use of local resources(human, financial and material)

b.Training of community in leadership and management skills

c.Incorporation of income generating projects, cooperatives and small scale industries

PRINCIPLES AND STRATEGIES5. Recognition of the interrelationship of

health and developmentStrategies:a.Convergence of health, food, nutrition , water,

sanitation and population servicesb.Integration of PHC into national, regional,

provincial, municipal and barangay development plans

c.Coordination of activities with economic planning, education, agriculture, industry, housing, public works, communication and social services

d.Establishment of an effective health referral system

PRINCIPLES AND STRATEGIES6. Social mobilizationStrategies:a.Establishment of an effective health

referral systemb.Multi-sectoral and interdisciplinary

linkagec.Information, education, communication

support using multi-mediad.Collaboration between government and

non-government organizations

PRINCIPLES AND STRATEGIES7. DecentralizationStrategies:a.Reallocation of budgetary resourcesb.Reorientation of health professionals on

PHCc.Advocacy for political will support from

the national leadership down to barangay level

ESSENTIAL HEALTH SERVICES IN PHCThe Alma Ata report on PHC outlined eight(8)

essential elements to be emphasized in PHC. These shall comprise the initial and continuing care at the point of entry into the health system. The list of essential elements is a modification of the basic health services of eralier times. To facilitate easy recall of these, the acronym ELEMENTS is used to these.

ESSENTIAL HEALTH SERVICES IN PHCEducation for healthLocally endemic diseases controlExpanded program for immunizationMaternal and Child Health including

responsible parenthoodEssential DrugsNutritionTreatment of communicable and non-

communicable diseasesSafe water and sanitation

Health Education

What is Health Education?a process that informs, motivates and helps

people to adopt and maintain healthy practices and life-styles, advocates environmental changes as needed to facilitate this goal and conducts professional training and research to the same end.

Directives:Inform people or disseminate scientific knowledge

about prevention of disease and promotion of health.MotivationShould be conducted by a variety of health,

education and communication personnel in a variety of settings.

Aims of Health Education:To help people to understand that health is the most

valuable community asset; & to help them to achieve by their own activities and efforts.

To develop a sense of responsibility for improvement of their health as individual members of families and community.

To develop scientific knowledge, attitude, and skills on health matters to enable people to develop correct habits.

To educate people for proper use of health services for whatever form it is made available to them by the government.

To alter behavior which may have directly or indirectly influenced occurrence or spread of diseases in a given cultural setting.

To help people achieve health by their own actions and efforts.

At promoting the greater possible fulfillment of inherited powers of the mind and body and happy adjustment of individual to society.

To provide a person with appropriate knowledge to enjoy decent health and also the knowledge about the occurrence and spread of the disease thus enabling him to adopt relevant preventive measures.

To create in him an interest in his own health and well-being.

To create in him an interest for the health of other members of his family as well as those living in his surroundings.

To create in him a desire to support HE program in this area

Objectives of Health EducationTo inform people or disseminate scientific

knowledge about prevention of disease and promotion of health.

To motivate people to change their habits and life-styles, which are harmful to their health and also motivate people to adopt habits and ways of living conducive to health.

To guide the people who need the help to adopt and maintain practices and life-styles by showing proper community resources.

Principles of Health Education:Education should be based on the principle of interest.Education should be based on the principle of active

learning.Start the educational program from the point, where

people are already are, and move from known to unknown.

Know the level of understanding, education and literacy of the people to whom the teaching is directed.

Reinforce the message by repeating them using different methods and media.

Help to motivate people to desire a change in their attitudes and behaviors.

Provide opportunities for people to learn by doing.

The people are the soil, the health facts the seed, and the transmitting media the sower.

The nurse should maintain good human relations through the educational approaches.

Community leaders should be taken into consideration for the success of any health program including health education.

HE considers the health status of the people.HE should be recognized as the basic function of all

health workers.HE takes place in home, in the school and the

community.HE utilizes community resources.HE is a creative process.HE makes a careful evaluation of the planning,

organization and implementation of all health education programs and

activities.

Learning is a:permanent change in behavior,

practice, habit,

and attitude caused byexperience or practice.

Goal:

enable individuals, groups and communities

functioning, effective & productive

Conditions and Principles in Adult Learning:Learning is an experience.Learning is the discovery of the

personal meaning and the relevance of ideas.

Behavioral change is a sequence of experience.

Learning is a cooperative and collaborative process.

Learning is an evolutionary process.Learning is a painful process.

Learning is facilitated in an atmosphere which:

Encourages people to be active.Promotes and facilitates the individual

discovery of the personal meaning of ideas.

Emphasizes the uniquely personal and subjective nature of learning.

Differentiates the good and desirable.Consistently recognizes people’s tight to

make mistakes.Tolerates ambiguity.

Fosters evaluation as a cooperative process which emphasize on self-evaluation.

Encourages openness of self rather than concealment of self.

Encourage trust in themselves as well as internal sources.

Respects people’s feelings, accepts people and finally permits confrontation.

Health Education involves:

Motivation,

Communication,

Decision-making

Motivation

A combination of forces which initiates, directs and sustains behavior towards a particular goal.

A process of creating an interest and desire in a person to do something.

People’s behavior is governed by five important principles:

Behavior depends on both the person and his environment.

Each individual behaves in ways which make sense to him.

An individual’s perception of situation influences his behavior in that situation.

An individual’s view of himself influences what he does.

An individual’s behavior is influenced by his needs, which vary from person to person and

from time to time.

For successful motivation, the community health nurse has to keep the following points in HE:

Give accurate and complete information.Holding the attention and stimulating

interest of the individual.Use of “satisfied adopters” and leaders in

the community.Providing encouragement to the individual.Making necessary facilities available.Ensuring that services are of high quality.Follow-up the individual, continuing the services and involving the individual

as “satisfied adopter.”

When adoption of new ideas in a person, the people appear to pass through certain phases:

A - AwarenessN - Felt needs of the people/ind’l.I - InterestT - TrialA - Adoption

Phases:Person – new idea or practice – determines

whether he needs or not – weighs the pros & cons when he felt the need of the idea – puts more interest – decide to put into practice – make trial and error in the practice – get some information to overcome the problems in implementing the new ideas into practice –

decides that the new practice is good and adopts it.

CommunicationRefers to the giving and receiving of

verbal and non-verbal messages or information.

To transmit information from one person or group of persons with a view to bring about behavioral change.

Allows nurses to better understand the patient’s needs and develops ralationships that will help patients to attain healthy

behavior.

Barriers of Communication:

Physiological barriersPsychological barriersEnvironmental barriersCultural barriers

Some rules for reducing the barrier of communicaiton:

Do not try to give too much information at one time.

Choose a topic that is closely relevant to the needs of the people.

Choose a time and place which is convenient for the community.

Check if the audience is seated comfortably so that they can see and hear well.

Use simple language.Use a combination of talk, demonstration and

return demonstration.Try out different ways of presenting

information to keep the learner’s interest.Use suitable aids which are in keeping with

the local traditions and culture.Make your teaching lively.Involve the learners as much as possible by

asking them questions.Avoid any sharp criticisms or making fun of

any one of their traditional beliefs and customs.

Avoid losing temper if provoked.Do not make presentation too long.

After 45 minutes to an hour, people tend to become restless.

Watch your audience for their response: are they attentive?interested?participating? Restless?

Conclude the teaching by covering main point.

Decision MakingRefers to deciding in advance, planning for

HE.Measures to follow when planning HE:

know the problems and felt need of the community by observing, interviewing, seeing records and reports and by conducting surveys.

Know the people and place.Find out available resources, fund staff and

equipment.Select methods and materials, and build on

what they have.Launch the program.Study the results.

Methods of Health Education:Didactic Methods:

“one way” methodBased on direct instructions to the

individual or group.

= Lecture= Mass Media

Socratic Method:Interchange of knowledge among people themselves.

“two way method”1. Group discussion2. Panel discussion3. Seminar4. Symposium5. Demostration

6. Role-playing7. Interview8. Task force9. Brainstorming10. Buzz sessions11. Case study12. Open forum13. Skits14. Field Trips

Steps in planning HE program:Identify health problems and health needs

of the community through baseline surveys.

Discuss these findings with members of the health team.

Identify the leaders in the community.Meet with leaders and discuss findings of

the survey.

Select with the help of the leaders the health problems and needs to be tackled through health education.

Keeping view such factors on priorities of the community, available facilities, feasibility of solving problems.

Involve leaders and other members of the community in deciding a plan of action.

Prepare talking points and select, collect or prepare necessary audio-visual materials and equipment of the program.

Implement the HE program with the active participation of the leaders and the other members of the community.

Follow-up HE program.Evaluate the program.

Qualities of a good health educator Knowledgeable/mastery of subject matterCredibleGood listenerCan emphasized topicsPossess teaching skillsFlexiblePatienceCreative and innovativeEffective motivatorAble to rephrase and summarizeEncourages group participationGood sense of humorWorks for joy of it

2. LOCALLY ENDEMIC DISEASE CONTROL

The nature of the public health program is to prevent the transmission of endemic diseases through vector control and detection and early treatment to reduce case and prevent deaths.

1.Malaria A systemic protozoan infection with

fever, chills, sweats, headachesThe sporozoans: Plasmodium vivax, P.

Malariae, P. Falciparum and P. Ovale

Malaria cont….Transmitted through bite of infective

female anopheles mosquitoCommon in forested, mountainous areasProtective and Preventive Measures:Chemically treated mosquito netsLarva-eating fishEnvironmental clean up for stagnant water,

cutting of vegetation overhanging along stream banks

Anti-mosquito soap/Fidel soapNeem tree or other herbal plants zooprohylaxisOthers: fumigation or housing spraying, avoid

outdoor night activities

MALARIA CONT…EARLY DIAGNOSIS THROUGH

IDENTIFICATION OF CASES THROUGH SIGNS AND SYMPTOMS AND MICROSCOPIC METHOD DONE BY A MEDICAL TECHNOLOGIST OR MICROSCOPIST AT THE MAIN HEALTH CENTER OR CITY HEALTH OFFICE.

2. LEPROSYIS A CHRONIC DISEASE OF THE SKIN AND

PERIPHERAL NERVES CAUSED BY MYCOBACTERIUM LIPRAE OR HANSEN’S BACILLUS.

LEPROSY CONT…EARLY SIGNS AND SYMPTOMS:CHANGE IN SKIN COLORLOSS OF SKIN SENSATION ON THE SKIN

LESIONDECREASE OR LOSS OF SWEATING AND HAIT

GROWTH OVER THE WOUNDTHICKENED OR PAINFUL NERVESMUSCLE WEAKNESS OR PARALYSISPAIN AND REDNESS OF THE EYESNASAL OBSTRUCTION OR BLEEDINGULCERS(WOUND)THAT DO NOT HEAL

LEPROSY CONT…LATE SIGNS AND SYMPTOMS:LOSS OF EYEBROWINABILITY TO CLOSE EYELIDCLAWING OF FINGERS AND TOESSINKING OF THE NOSEBRIDGEENLARGEMENT OF THE BREAST IN MALES

LEPROSY CONT…METHOD OF TRANSMISSION:1. PROLONGED SKIN TO SKIN CONTACT2. DROPLET INFECTION

LEPROSY CONT…PREVENTION:1.AVOIDANCE OF PROLONGED SKIN-TO-

SKIN CONTACT ESPECIALLY WITH A LEPROMATOUS CASE

2. CHILDREN SHOULD AVOID CONTACT WITH ACTIVE, UNTREATED LEPROSY CASE

3. BCG VACCINATION4. ADEQUATE NUTRITION5. HEALTH EDUCATION

LEPTOSPIROSISDISEASE CAUSED BY BACTERIAL

LEPTOSPIRES, LEPTOPIRA INTERROGANSOCCUR IN ALL SEASONS AND DEVELOPS

DURING HOT WEATHERRAT IS THE MAIN HOSTTRANSMITTED THROUGH CONTACT OF THE

SKIN ESPECIALLY OPEN WOUNDS, MOIST SOIL OR VEGETATION CONTAMINATED WITH URINE OR INFECTIVE HOST

AFFECTS FARMERS, VETERINARIANS, MINERS, SEWER WORKERS, ABBATOIR WORKERS.

LEPTO…..SIGNS AND SYMPTOMS:1. PRESENCE OF LEPTOSPIRES IN THE

BLOOD CSF2. FEVER3. HEADACHE4. NAUSEA5. VOMITING6. COUGH7. CHEST PAIN8. PAINFUL MUSCLES

LEPTO…PREVENTION:1. IMPROVED EDUCATION OF PEOPLE WHO

ARE AT RISK ..EX. FARMERS, MINERS, CHILDREN PLAYING AT MUDDY WATER

2. USE OF PROTECTIVE CLOTHING, BOOTS AND GLOVES

3.COMMUNITY-WIDE ERADICATION PROGRAM THROUGH PROPER DISPOSAL OF WASTE

4. SEGREGATE DOMESTIC ANIMALS POTENTIALLY INFECTED FROM MAN’S WORKING AND RECREATION AREAS

4.ISOLATION OF PATIENTS AND DISINFECTION OF SOILED ARTICLES