Section 3

Health Care Delivery

12 Primary Health Care

Rafique Soomro, Muhammad Irfanullah Siddiqui
Muhammad Illyas
225

13 Hospital Administration and

Management
235

Muhammad Irfanullah Siddiqui

14 Accidents and Their Control

Kashif Shafique, Mubashir Zafar
Ghulam Qadir Malik, Mohamed Iliyas
247

15 Disaster Management and Control

Ghulam Qadir Malik
255

16 Military Hygiene
Maj. General (Retd.) Prof. Dr. Akhtar Ali Qureshi
Brig. (Retd.) Dr. M. Riazul Haque Mohyuddin
261
12
Primary Health Care

Muhammad Illyas
Rafique Soomro
Muhammad Irfanullah Siddiqui

Objectives
By the end of the chapter, medical students will be able to:
1. Define Primary Health Cae (PHC)
2. Describe the fundamental principle of PHC.
3. Enumerate the essential components (elements) of PHC.
4. Understand the key concepts of PHC.
5. Use planning cycle to prioritise the community problem and solve them.
6. Describe the Primary Health Care in Pakistan and understand the concept
of Integrated Rural Health Complex.
7. Discuss and compare comprehensive and selective health care.
226
Introduction
In accordance with decision of the WHO Assembly and the
Executive Board of the UNICEF, an International Conference
on Primary Health Care (PHC) was held from 6-12 Sept. 1978
in Alma-Ata, capital of the Kazakhistan.
Attended by 134 governments and by representatives of 67
UN organisations, spe­cialized agencies and non-governmen-
tal organisations in official relation with WHO and UNICEF
declared as follows:
The fundamental principle of primary health care is the
participation of the commu­nity at all stages. For communities
to be in­volved, they need to have easy access to the right
kind of information concerning their health situation and how
they themselves can help improve it. The conference defined
PHC as follows:
The health status of millions of people in the world today is
unacceptable, particularly in developing countries. More than
half the population of the world does not have the benefit of
proper health care. The conference therefore affirmed that the
PHC approach is essential to achieving an acceptable level of
health throughout the world as an integral part of social devel-
opment in the spirit of social justice. Thus the goal of health
for all by the year 2000 would be attained. This will close the
existing gap between the “haves” and “have nots”.
The Conference emphasized the multi-sectoral nature of
health development and recognized that the improvement of
health substantially contributes to increased productivity and
well being of the individual and the community.
Definition
PHC is essential health care made universally accessible to
individuals and families in the community by means accept­
able to them, through their full participation and at a cost that
the community and country can afford. It forms an integral
part, both of the country’s health system of which it is the
nucleus, and of the overall social and eco­nomic development
of the community.
Concept of Primary Health Care
The following are the concepts that emerge from the defini-
tion of PHC.
 PHC is for all specia­lly for the needy. This means regard-
Primary Health Care
less of social and eco­nomic status every individual in the
nation must have access to good health care.
 The services should be acceptable to the community and
there must be active involvement of the community.
 The health services must be effective, preventive, promo-
tive and curative.
 The services should form an integral part of the country’s
health system.
 The programme must be efficient, multi-sectoral because
health does not exist in isolation. Economic produc­tivity is
based on other factors which include the cooperation of
Depart­ment of Agriculture for crop improve­ment, coordina-
tion of sanitary engi­neers for the provision of safe water,
coordination of Department of Ani­mal Husbandry for cattle
health and cottage industry for economic im­provement to
enable the inhabitants for a healthy life style.
Essential components or elements of a PHC
programme
The essential components or elements of a PHC programme
are.
 Education concerning prevailing health problems and the
methods of identifying, preventing, and control­ling them.
 Promotion of food supply and proper nutrition, an ad-
equate sup­ply of safe water and basic sanitation.
 Maternal and child health care, including family planning.
 Immunization against the major infectious diseases.
 Prevention and control of locally en­demic diseases.
 Appropriate treatment of common dis­eases and injuries.
 Promotion of mental health.
 Provision of essential drugs.
In addition to the health sector, involve all related sec-
tors and aspects of national and community development,
in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other
sector making full use of locally available resources securing
maximum cooperation of the community.
Key Concepts in Primary Health Care
Planning
Aside from the obvious importance of community involve-
Primary Health Care
ment, three key concepts are of fundamental importance
in the planning and development of Primary Health Care.
These are (1) Equity (2) Effectiveness and (3) Efficiency.
These concepts should be care­fully inter-linked (Bryant J.H).
If each one of these were to operate alone the results will
be ineffective:
Equity. It has two connotations. One is that everyone should
be entitled for health care and secondly his/her needs should
be taken into account. This does not imply that every­one
should receive equal care, because everyone’s needs are
not equal, thus the call for care according to need.
Equity without effectiveness and effi­ciency will not fulfil the
objective of equity because the services available should be
effec­tive and at a reasonable cost.
Effectiveness. Each primary health care programme activ-
ity such as EPI, ORT and Growth Monitoring should have a
favourable effect that is measurable through indicators.
Effectiveness without equity and effi­ciency would mean loss
of desired force of effectiveness, to have full or a large part of
it at reasonable costs. Actually, much of the mod­ern medical
care is ineffective in dealing with fundamental problems of
the people and is expensive.
Efficiency. Whenever primary health care programmes are
undertaken, they should be low cost and consistent with
favourable effect.
To have efficiency without equity and effectiveness means
inaccessibility to large sections of the population to obtain
desired results. In fact low cost ineffective services and in-
equitability are not unusual in the developing world.
227
Guidelines in PHC Planning
The first step in the planning is Community Assessment
which include exploration of:
 Social, Cultural and Political Factors (Figure 12-2).
 Health Services Assessment.
 Demographic Profile of Community.
 Identification of Felt Needs of Community.
A subsequent step is Prioritization of Health Problems. The
ensuing five dia­grams illustrate the essentials of planning
cycles. These should be carefully studied for a clear under-
standing of the planning process. Assessment of community
involves:
 Survey of the health and demographic features.
 Assessing the existing health services (Figure 12-3).
 Identification of social, cultural and political parameters.
These steps of assessment lead to identification of the
problems. From the health and demo­graphic survey the fol-
lowing information are made available (Figure 12-4).
 The population of concern
 Characteristics of the population
Health and Identify Social,
Assess Existing
Health Services
Demographic Cultural, Political
Survey Parameters

Planning Primary Health Care System Community

Assessment
Having learnt the elements and con­cepts of the PHC sys-
tem, the student is intro­duced to the planning process. The
component is obtained from the reference material pre­sented Identify
by John H. Bryant at McMaster Univer­sity during a Confer- Monitor Problems
Evaluate
ence of Community orien­tation network in 1993 as well as
from the ex­perience of Aga Khan University (Figure 12-1).
Planning is not a one time exercise, but is dynamic and
goes on repeatedly through a cycle. While the planning cycle Set
Community Participation Priorities
calls for pro­gression through a sequence of steps, in actuality Implement
many of the steps will be carried out simul­taneously, services
may commence while data are being gathered.
Plan Solution
Preparatory Stages
Plan for for Individual
Implementation Problem

Laying out the steps of the planning process is a prerequi-

site to sound planning for which policy and broad goals must Combine Individual
Solution into
be laid down. The goals are those of WHO in relation to the Integrated PHC
System
global strategy for HEALTH FOR ALL by the year 2000 and
include in it the elements and concepts of PHC, as teaching
and research in relation to the service delivery. Figure 12-1
Health Planning Cycle
Source: Bryant JH. Lecture on Planning for PHC. Aga Khan University (1993)
228 Primary Health Care

 Environmental conditions
On the basis of identified problems establish overall
goals.

Assessment of Felt Needs of the Community

As a corollary to the assessment of community it becomes
necessary to identify the felt needs of the community.
Baqai University’s experience is presented in the subse-
quent paragraphs.
Prior to undertaking suitable steps of planning PHC pro-
gramme a team of health providers established contacts
with leaders of rural community around the medical college
campus. The felt needs were:
 Water supply
 Improvement in agriculture
 Income generation, and
 Women’s education
The community faced scarcity of wa­ter with the resulting de-

STRUCTURE PROCESS OUTCOME

PROGRAM CONFIGURATION
HEALTH SERVICES INPUTS

Figure 12-2 Health Facilities

Health Manpower
Social, cultural and political factors used in the planning PHC Logistics/Supplies

systems.
HEALTH ACTIVITIES
HEALTH SERVICES OUTPUTS

Nature of Activities
 Age and sex distributions. Cout of Activities
Location of Activities
 Occupation and type of living Outreach
Periodicity
 The boundaries of the area
 The felt needs of the community HEALTH SERVICES UTILIZATION
 The prevailing health problems Community Acceptance
Community Participation
 The morbidity pattern and mortality Community Use of Services
Distance to Services
From the health services assessment following information Mode of Transport to Services
Cost of Services
are obtained.
 Available health services. MANAGEMENT
 The extent of utilization of health services. Quality Control
Surveillance
 The finances of the services. Monitoring PROGRAM
Information System OUTCOMES/IMPACTS
From the identification of social, cultural and political pa- Financing
Manpower Indicators Beliefs
rameters, following problems are noted. Supervision Mortality Understanding
Continuing Education Morbidity Participation
 Religious beliefs Utilization

 Customs and traditions

 Political organizations Figure 12-3
 Access of women to work Health services assessment
Source: Bryant JH. Lecture on Planning for PHC. Aga Khan University (1993)
Primary Health Care 229
tory infections of chil­dren including immunizable disease
SOURCES OF DATA control.
Hospital/Health Center Records Prioritization: Figure 12-5 illustrates with examples a system
Governmental Reports
RHS Health Information System of prioritization by assigning scores in relation to the prob-
Other Surveys
Knowledgeable Persons lems. Priority in this ex­ample is towards neonatal tetanus and
Extrapolation from Similar Settings
Reliability (+ to ++++)
diar­rhoea, followed by common illnesses

Parameters for Planning

DEMOGRAPHY HEALTH INDICATORS From the health and demographic sur­vey (Figure 12-1). We
Population ... defined area Crude Birth Rate ascertain the population of concern, its characteristic, age
Age Distribution Crude Death Rate
Family Size and Structure Infant Mortality Rate and sex distribution, problems of communications, environ­
Fertility ... Parity, Spacing
Language, Ethnicity, Religion
Neonatal Mortality rate
Post Neonatal Mortality rate
mental and housing conditions. The health problems faced,
Migration 1-4 Mortality Rate and the causes of morbidity and mortality.
Income Maternal Mortality Rate
Literacy Death <5 as Proportion
Working, non-working of all deaths
Occupations Causes of Death
Age Specific Cause of Death
From the Health Service Assessment
Morbidity
% ill for more than one week We ascertain the number and type of health services, avail-
% major cause of illness able utilization, pattern and costs.
Average expenses incurred per
treatment or per illness

From the Identification of Social, Cultural

ENVIRONMENTAL CONDITIONS
Type of House Construction
Rooms per Housing Unit
Persons per Housing Unit
Persons per Room
% Housing Units with Private Water Connection
% Housing Units with Modern Toilet (Soak Pit/Flush)
% Housing Units with Electricity
Figure 12-4
Planning PHC systems using health and demographic information
cline in agriculture crops and shortage of water for drinking and
domestic purposes. The low income groups were many and
therefore less chances of im­proved nutrition. Lastly women felt
a need for basic education for their school going children.
In proceeding with assessment of identifica­tions of the
needs the planning steps that followed were:
Fulfilling the community needs through:
 Provision of loan for boring of wells.
 Establishment of revolving fund for returnable loans to
small shopkeep­ers.
 Provision of sewing machines to women through com-
munity leader.
 Constituting Women’s interest group and appointing
teachers who were educated.
Setting Goals for Health Improvement by:
 Reduction of maternal deaths
 Reduction of infant mortality
 Reducing morbidity due to diarrhoea and acute respira-
and Political Parameters
Relevant information can be obtained regarding cultural fac-
tors, religious beliefs, customs and traditions, political organiza-
tions, private or public, occupation, women’s status, conditions
of housing, water and waste dis­posal arrangements.
In proceeding with the assessment steps of identifying the
problems, it is necessary to set up goals. A few examples
are given in the following.
 Improve Maternal Health: Reduce maternal mortality by
30% in 5 years.
 Improve Infant Health Reduce (IMR) infant mortality by
50%.
 Improve Child Health: Reduce death rates of under 5
years by 50% in 3 years.
To achieve the goals identify priority problems (Figure 12-5)
before implementation.
Implementation of PHC Plans and General
Principles
 Programmes should be cost-effective, that is to obtain
maximum benefits with investment of scarce resources,
for example, establish priority for ORS use for treatment
of diarrhoea.
 Establish partnership with commu­nity. Involve improve
the community in all stages of planning and imple­
mentation.
 Motivate the community to constitute a Health Committee
for Implemen­tation and periodical evaluation.
 Involve women for implementation and promotion as in
the Prime Minister’s programme.
230 Primary Health Care

Prevalence Seriousness Susceptibility to Community Score

Control Concern
Malnutrition ++ +++ +++ ++ 36
Neonatal Tetanus ++ ++++ ++++ ++++ 128
Large Poorly Spaced Families +++ +++ ++ ++ 36
Cancer + ++++ 0 (hidden) 0
+++
Diarrhea +++ +++ +++ +++ 81
Common Illness (Curative services) +++ ++ +++ +++ 54

Effectiveness of Compatibility with Organisational and Health Care system

technology socio-cultural norms political feasibility feasibility
Malnutrition +++ ++ +++ ++
Neonatal Tetanus ++++ ++++ ++++ ++++
Large Families +++ + + +++
Cancer 0 +++ ++++ 0
Diarrhea +++ +++ +++ +++
Common Illness ++ ++++ ++++ ++

Figure 12-2
Setting priorities in planning PHC systems.
Source: Bryant JH. Lecture on Planning for PHC. Aga Khan University (1993)

Quality Issues in PHC tion. This calls for a basic change in the culture of a hospital.
It may. however, be emphasized that such a change does
This vital principle of quality of PHC is the cost of the doc-
not im­ply that hospital will cease to offer high tech­nology. A
tor patient relationship and the extent of achievement of set
basic change implies essentially a change in the relation-
goals de­termined by an evaluation process, as for ex­ample
ship of technology and community. From an inwards look-
immunization coverage. During the pre­vious decade Zaire
ing market technology oriented institution, a hospital opens
met the challenge of com­prehensive PHC at a cost of one
itself to a community to respond to its requirements bringing
dollar per head. Baqai Medical College has similar expe­rience
about the necessary reorientation in its technology and in its
in its PHC network. This cost has how­ever doubled to a level
organization and management.
of two dollars per head during the current decade.
Hospitals thus become closely inte­grated with the entire
As for the doctor/patient relationship, the consumer has
health service system. Even beyond this, the approach of
acceptance of advice through continued persuasion and
Primary Health Care envisages that the entire pyramid of
communication skills of the doctor. Another factor influencing
the health service system is specially subor­dinated to the
this relationship is the continued availability of the doctor and
interests and requirements of the community as a whole.
his/her readiness to serve individual cases in times of need.
Other consider­ations governing the quality issues relate to the With these considerations in view the Aga Khan Founda-
extent of community participation and equity. The equity factor tion organised an international conference in collaboration
seems hard to attain in the developing world where there is with WHO during November 1981. It brought out valuable
socio-eco­nomic disparity between its 30% urban and 70% recommendations focusing on:
rural population. Even in the urban popu­lation such disparity is
 The role of hospitals in promot­ing and using community
more than evident be­tween the higher socio-economic group
par­ticipation in the development of PHC.
and amongst those living in urban slums (kacchi abadis).
Nevertheless equity should be the aim for comprehensive  The role of hospitals in providing direct support to PHC
primary health care and the hospital activities (continuous education, supervi­sion, referral,
supplies etc.).
The approach of Primary Health Care envisages that the
 The role of hospitals in orienting physicians, nurses and
hospital becomes responsive to community within which it is
other health professions toward PHC.
located. A hospital is required to become a community institu-
Primary Health Care
 The role of hospitals in conduct­ing and supporting health
ser­vices research.
During the previous decade an article in World Health Fo-
rum (1987 Vol.8, No.1 p.80) forcefully expressed the need
for hospitals to be involved in Primary Health Care and gave
interesting examples of ways in which this has been done.
Great scope exists for innovation, trial and error, and the
sharing of experiences. In this connection J.G. Dickson de-
scribes the approaches explored at Patal Hospital in Nepal,
and states that giving Primary Medical Care in the hospital
sets the scene for other primary health care activities.
According to this approach, the role of hospitals in PHC
consists of conducting in­ternal activities and providing support
for ex­ternal ones for technical advice and referral sys­tem.
Not only were the technical support and activities carried
out by the hospital au­thorities, but participated in community
devel­opment relating to: Informal Education, Animal Health,
Hu­man Health, Pregnancy, Literacy, Smoke­less Stoves, Ru-
ral Industries, Milling Agri­culture, Seed Distribution, Fodder,
Composting, Solar Drying of Food, Nutri­tion Counselling,
Tree Planting, Potable Water and Sanitation.
Primary Health Care in Pakistan
Government of Pakistan embarked on primary health care
service prior to the 1978 ALMA ATA Declaration of Health
for All by the year 2000. A total of 492 Rural Health Centres
and 3496 Basic Health Units (primary health care units)
were built during the Fifth and Sixth Five-year Plan, out of
a total of 625 RHCs and 4596 planned during 1978-83. The
achievement would have been better if budget­ary allocation
were adequate.
At present primary health care facilities are being offered
through several basic health units, and rural health centres
and facilities such as dispensaries, maternity and child health
centres and sub-centres.
Nationwide health care, for which primary health care (PHC)
has been provided, ensures a systematic link between the
village community and the whole health system. Depending
upon the density and scatter of the population, a Basic Health
Unit serves 5,000 to 10,000 population. Services provided at
this Unit include MCH services, child care, immu­nization, diar-
rheal disease control, malaria control, child spacing, mental
health and school health services within its area. Outreach
services will be provided primarily for MCH through training
birth attendants, 5-10 Basic Health Units will be linked to a
Rural Health Centre. Each Rural Health Centre has about 25
beds, a Laboratory, X-ray, and provision for minor surgery.
The RHC is linked through Tehsil/Taluka Hospital which in
turn, is linked to District Headquarters Hospital, which will
have all medical facilities, other existing facili­ties such as
dispensaries and MCH centre etc., will be upgraded to Ba-
sic Health Units (BHU). The whole system of BHUs, RHCs,
Tehsil Hospital and finally District Headquarters Hos­pital, is
231
designated as “Integrated Rural Health Complex”.
All the BHUs, are staffed by Medical Officer, a male and
female Health Technician, and support personnel. RHC will
play a pivotal role and act as a focal point in the health sys­
tem and it will also be provided with dentist, a microscopist,
and a sanitary inspector. This type of approach will remove
disparity in ur­ban and rural areas in times to come.
The present Expanded Programme of Immunization, diar-
rhoea disease control and the training of Traditional Birth
Attendants, malaria and Tuberculosis control programmes will
become an integral part of the health system. The posting of
a Medical officer in each BHU will not only improve the quality
of care but will also improve the over all working of the BHUs
and minimize referrals and hard­ship to the community.
Selective Primary Health Care
Comprehensive Primary Health Care is said to be beyond
the reach of most developing countries and a selective ap-
proach targeted on a small number of diseases has therefore
been advocated. In practice however, the results of selected
intervention do not live up to the expectations.
The Selective Approach was put for­ward on the ground that
Health for all by the year 2000 is a noble goal, but one that
does not seem attainable through a comprehensive primary
health care approach. Such is the thesis of those who advo-
cate selective health care a policy of selective interventions
to deal with the most serious public health problems, rather
than the comprehensive primary health care, which is con-
sidered too costly requiring a large number of trained staff
to meet the broad scope of its eight elements.
The Selective Approach
The Selective Approach put forward by Walsh and War-
ren, gives priority to certain diseases according to (a) their
prevalence, (b) the morbidity or disability they cause, (c)
their mortality rate and (d) the feasibility and effectiveness
of control measures and the cost of interventions.
According to them the selective approach should be aimed
at children less than 3 years and women of child bearing
age. This would result in significant decline in the mortality
rate in any area in which it is appropriately applied. Its five
components are:
 Measles and DPT vaccination for chil­d ren over 6
months old
 Tetanus toxoid for pregnant women to prevent neonatal
tetanus
 Encouragement of long-term breast feeding
 Chloroquine treatment during febrile episodes for children
under 3 year in malarious regions and
 Provision of oral rehydration salts and instructions for
their use in the treat­ment of diarrhoea.
232
These five components could be provided either by fixed
or mobile teams visiting the area once every 4-6 months.
These units/teams should restrict their activity to a minimum
number of health problems affecting large number of people
and for which low cost methods of interventions of proven
efficiency are available.
Walsh quotes the example of the Haiti Project, which was
based on a selective approach, the target diseases included
diarrhoea, tetanus, measles, diphtheria, pertussis, polio­
myelitis; mortality rate declined by more than 40%. Such
positive results are clear evidence that selective primary
health care is the right approach.
Boelen and Young, who also support the selective ap-
proach, took the issue with the claim that comprehensive
health care can be achieved with an annual expenditure of
as little as US$ 6 per capita. This, however, does not include
the cost of supervision, logistics, depreciation, travel, training,
safe water supply, and proper sanitation. When all these costs
are taken into account, comprehensive primary health care is
generally five times more expensive, in fact, too expensive for
most developing countries. It seems therefore a more selec-
tive approach would be realistic for these countries.
Boelen & Young also examine the politi­cal factors involved
in adopting the different types of primary health care. In China,
Cuba and the United Republic of Tanzania, gov­ernments
exercise strong political strength in bringing about radical
changes in the health system resulting in success of primary
health care to their population. In Afghanistan, India, Nigeria
and other developing countries, in con­trast, where primary
health care has encoun­tered great difficulties, governments
are not ready to pay the political price of drastically changing
their health system, not only because of the political climate
but also due to the strength of the highly clinically oriented
man­power. The authors therefore, claim, for poor countries
to “trade some measures of individual freedom for improved
individual health”. Free­dom and health, they seem to think,
do not mix. Boelen & Young conclude that, because of the
high cost of comprehensive primary health care, and because
of the unlikely projection of change of political structures in
foreseeable future, a more selective approach must be en-
couraged. The selective PHC should encompass nutrition,
EPI, control of endemic diseases and health education.
Some writers in India advocate Health Education as an
alternative to comprehensive care. Merely educating the
population, they say, improves the life style of individuals pre­
venting many ailments. Non-formal education of women, for
example, has shown an evidence of decline in maternal and
infant deaths. In the Baqai network of primary health care in
Paki­stan such an approach has led to improved domiciliary
midwifery showing a substantial decline in maternal and infant
mortality over a period of six years.
Eans and his colleagues also favour a selective approach.
The ability to plan and implement strategies and programmes
that makes the best use of scarce resources is seriously
deficient in most developing countries. PHC could be deliv-
Primary Health Care
ered to people at low cost if the programmes were carefully
selected and adopted to the prevailing needs. The greatest
improvement in life expectancy would, they believe, result from
maternal and child health services, including control of major
infections and parasitic diseases in children under five.
Selective Versus Comprehensive Primary
Health Care
The whole concept of primary health care is based on the phi-
losophy of health service development quite different from the
selective approach. Primary Health Care is based on people,
for the people. It emphasises social control over health ser-
vices, involving the community at all stages of health services
devel­opment, including problem identification, programme
formulation and implementation as well as evaluation.
Selective PHC thus be­comes a piece from the whole and
reflects an adoption of an authoritarian approach in se­lecting
a number of limited health programmes.
The argument that selective approach is most effective
raises fundamental questions in health system research. It
would need convincing evidence to prove that package of a
few selected programmes provides an approach that is epi-
demiologically and socially more effective than a programme
of comprehensive health services.
There is no doubt that there have been shortcomings in the
implementation of primary health care in most developing coun-
tries. But the advocates of selective approach have yet to prove
its cost effectiveness. The promotion of selective approach by
some agencies may prove to be counterproductive.
UNICEF proposed a selective ap­proach with emphasis
on mother and child health according to GOBI-FFF which
indicates:
G = Growth Monitoring
O = ORS
B = Breast Feeding
I = Immunization
F = Family Planning
F = Female Education
F = Female Nutrition
In the African region, implementation of these elements
showed a decline in Infant Mortality by 40% within less than a
decade. Similar results were obtained in some other regions.
As for women’s education Christine van Wijk - Sibesma
states (WHO Forum 1987, Vol.8 No.1, p.28) that mere provi-
sion of health information is unlikely to change the behaviour
pattern based on what is often a com­plex of socio-economic
and cultural factors.
More can be expected from the adap­tation of local designs
to the needs and prac­tice of women, together with the involve-
ment of women as planners and educators.
Primary Health Care
Three decades ago, the Government of Pakistan initiated
an Accelerated Health Programme (AHP) with focus on ORS
Immunization and Traditional Birth Atten­dants Training with
a similar objective as of UNICEF. However in some WHO
quarters it has been argued not to slice off comprehensive
PHC. As a matter of fact, implementation of se­lective PHC
programme virtually poses a threat of neglect of other vital
components of compre­hensive PHC.
Constraints in Primary Health Care
Although substantial progress has been made in the devel-
oping world, there have been inhibitive influences in several
countries. These are as follows.
Political climate: In several countries, the allocation of not
less than 40% of the financial resources go toward defense
25-30% towards debt servicing and 5-20% are reserved for
non development ex­penditure. Therefore, very little is left
for devel­opment. Health thus assumes a low priority. Unfa-
vourable climate particularly due to nuclear arms race had
been a serious constraint in achieving the health for all goal
by the year 2000, inspite of noteworthy progress by many
developing countries.
Disregard of human rights: Ethnic violence and social evils
seem to be raging during the current decade. This necessitates
diversion of large amount for maintenance of law and order.
Political commitment: Those holding the authority of re-
source allocations are influenced by high level professionals
towards large spending on sophisticated technology in utter
disregard of PHC requirements.
Lack of appreciation of multifaceted approach: Invest-
ments merely in the health sec­tor are not conducive toward
a healthy life style. Environmental degradation arising as a
result of scanty rainfall, agriculture crop fail­ure, deforestation,
soil erosion as well as pov­erty and illiteracy are to be consid-
ered as health related components. There is now a growing
realization toward this in developing countries. It is on such
considerations that the Government of Pakistan introduced
during the previous decade, Junejo Plan, Benazir’s Five Point
Plan and the Social Action Plan (SAP) for improvement in
agriculture, education, income generation, basic sanitation
and all such factors that have bearing on health. The govern-
ment is also training a large number of village health workers,
especially women.
Although the goal of Health for All had not been achieved
by the year 2000, but im­pressive gains have been made in
several countries to achieve this target.
Building Community Partnership with Health Professions
Education Initiative
The community partnership with the health professions
education initiative is linked with health professions educa-
tional institution -the university, to help direct the education
of professionals by creating community based non-hospital
teaching centres that stress primary health care education
233
and research from a multidisciplinary approach. This initiative
led some medical colleges in the Public and Pri­vate sector of
Pakistan to establish Primary Health Care teaching models.
Assuming responsibility for a defined population, Baqai
University established in the private sector a Primary Health
Care network for a 20,000 rural population and an urban
based centre for 10,000 population of middle and low income
groups.
Students are taught by faculty teams comprising of physi-
cians, behavioural scientists and environmentalists, a multi-
disciplinary team in a non-hospital environment.
The service delivery initiative began by a demographic
survey of the population and identification of community
needs. The rural population with an income of Rs.1000 per
capita per annum (US $20), unbridled population growth,
limited access to health services. identified priority needs for
water-supply, agri­cultural improvement, women’s education,
human health, animal health and income genera­tion. This
led the university to establish a multifaceted project to meet
the identified needs.
University, Government and Community
Alliance
For fulfilment of the identified needs an alliance was es-
tablished, with the government, non-government agencies
Orangi Pilot Project (OPP) and Adventist Rehabilitation
Agency (ADRA) and the community. The responsibili­ties
were shared by each one of them, OPP for assistance in
agriculture and water supply, District Council for supply of
vaccines and training of community workers, ADRA for im-
munization, the community for provision of physical facilities
and the University for provi­sion of multidisciplinary teaching
and resource manpower. The sharing of responsibility is
carried out through a coordination committee headed by the
Dean of The Faculty of Health Science who is the chairman
of community medicine department.
A great advantage of a multifaceted approach is a positive
step in not only bringing about a change in the role of future
physician but in the production of Charles Boelen’s five star
doctors.
These are equally applicable to a Dentist and Nurse. The
technical component of PHC net­work include inter alia,
primary eye care, dental care, community psychiatry, social
obstetrics and a referral for secondary and tertiary care.
Bibliography
1. The Alma Ata Conference 1978
2. World Health Forum 1984, vol.5, No.4
3. Role of Hospitals in Primary Health Care, Aga Khan Foundation & WHO
conference November 26, 1987