1

PRIMARY HEALTH
CARE

DR AGUNWA CHUKA C,
DEPARTMENT OF COMMUNITY MEDICINE,
MUTH.
 COURSE OUTLINE
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 The basic health services Scheme (BHSS)

 The Alma Ata Declaration
 Principles & Components of PHC, Old and New
 PHC Implementation & Organizational Structure in Nigeria
 PHC Planning and Management
 Community diagnosis and Mobilization for Action
 PHC related Global Health Programmes
 Bamako initiative
 Monitoring and Evaluation of PHC activities
 Developing PHC programmes
 The Medical Officer of Health and other PHC health workers.
 INTRODUCTION
3

 DEFINITION: Essential health care, based

on practical, scientifically sound and
socially acceptable methods and
technology, made universally accesible to
individuals and families in the community
through their full participation and at a
cost they can afford to maintain at every
stage of their development in the spirit of
self reliance and self determination.
4

Constitutionally, services belong to either

 Exclusive list: Only rendered by Federal

Govt eg. Security, finance, drugs, prisons

 Concurrent list: rendered by all levels of

Govt. eg. Health, education, agriculture,

 BRIEF HISTORY
5

 Declaration of Health for All (HFA) by the

U.N. in 1977
 September 12, 1978; Alma-ata,
Russia(former USSR/Soviet Union);
WHO/UNICEF joint conference on primary
health care.
 PHC was recognised as the key strategy to
achieving Health for all people of the
world. The conference report was called
the Alma-Ata declaration.
6

 PHC is practiced in both urban and rural

areas
 It forms the central focus of the health
system of most countries
 It is the first point of contact between an
individual and the health system
 It brings health care as close as possible to
where the people work and live
 It is the primary responsibility of the Local
Government, with support from higher
levels of Government
 MISCONCEPTIONS ABOUT
7
PHC
 It is health care for the poor only
 It is a stopgap measure, to be replaced
with something else in the future
 It is a separate stand alone service
isolated from the main health care
system
 REPONSIBILITIES OF
DIFFERENT TIERS OF
8
GOVERNMENT
FG
 Policy issues

 Definition of standards

 Promotion of research

 Monitoring and evaluation

 National health plan implementation

 Technical support
9

State government
 Establishment of managerial processes

 Appropriate implementation of health

plans
 Coordination of disease control activities

 Supervision, monitoring & evaluation

 Managerial functions ( State Hospital mgt

board)
 Technical support
10

Local government
 PHC implementation

 Establishment of village health system

 Community mobilization

NB: In Nigeria PHC is based on the ward

health system except 5 states which are
using the district health system( Kaduna,
Kano, Lagos, Enugu, Taraba)
 PRINCIPLES OF PHC
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 Essential health care: addressing the major

health problems of the community(essential
health care)
 Intersectoral collaboration: There should be
involvement of other sectors of the society eg.
Agriculture, water, industry, education, housing
etc.
 Use of appropriate technology: This is technology
that is acceptable to users and can be
maintained at the prevalent level of technology
eg. ORS, solar powered refrigerators, etc. It
discourages “blind borrowing of methods and
ideas.
12

 Equity: There should be equitable

distribution of resources in order to
ensure equal coverage of the population.
Q: what is the difference between equity
and equality?
 Self reliance: the use of what is available

in that environment in terms of financial,

human and material resources.
13

 Community participation: The most

important; this empowers the
community to take responsibility for
their health. They are involved in stages
of planning, implementation and
evaluation of health service programs.
The best way to achieve this is by
institution of HEALTH COMMITTEES
 HEALTH COMMITTEES
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 This is formed at village, ward, district and LGA

levels.
 Its membership is made up influential ( not
necessary wealthy) members of society at each
level, who command respect and followership
and can protect the interests of the community.
Eg. Priests, headmasters, Town union officials
etc.
 Leaders of the committees at a level form the
membership of higher level committees. At the
LGA level, the Chairman should be the committee
chairman and the HOD Health the secretary.
 COMPONENTS OF PHC
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 There are at least 8 but countries may add

more if need be
 1. Immunization against major
communicable diseases (vaccine
preventable diseases)
 2. Prevention and control of locally
endemic and epidemic diseases
 3. Maternal and Child Health, including
Family planning
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 4. Environmental sanitation: adequate

water supply, basic sanitation
 >30% of health problems are water related
 5. Health Education: on prevailing
problems and how to control them
 6.Adequate nutrition: promotion of food
supply and adequate nutrition
 7. Provision of essential drugs: Essential
drugs are those required to address the
common ailments encountered in a
community
 ESSENTIAL DRUG CRITERIA
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 Cost effective, affordable

 Generic brands are preferred

 Compound drugs are avoided

 Efficacy of drugs must be well documented

 Used to treat prevalent disease conditions

 DRUG REVOLVING FUND is the strategy

used to make this possible.

Read Bamako Initiative
18

 8. Appropriate treatment of common

diseases and injuries
 This is achieved using STANDING ORDERS;
documents designed for different levels of
health workers to aid in evaluation of
symptoms, diagnosis and proper treatment.
However it is not to be used by doctors but
by lower level HCWs.
 Recently 3 more have been added; primary
eye care, mental health and dental health.
 THE BASIC HEALTH SERVICES
SCHEME(1975-80)
19  First serious attempt at PHC implementation
in Nigeria
 Emphasis was on building health facilities,
correction of geographical infrastructural
imbalances, provision of essential services &
training of health workers
 Schools of Health technology established in
each state to train Community health workers
 No emphasis on appropriate technology &
community participation
 Eventually failed , became financially
impracticable.
20

 A second attempt btw 1980-85 focused

on vertical programming with resulting
fragmentation of health services. This
also failed.
 NPHCDA (NATIONAL
PRIMARY HEALTH CARE
21
DEVT. AGENCY)
 As part of efforts to strengthen PHC in Nigeria
The FG under decree 29 0f 1992 set up the
NPHCDA. It is a parastatal under the FMOH
which provides technical support and training
for health workers as well as monitoring of PHC
implementation.
 Its head is the Executive Director, who reports
DIRECTLY to the Minister of Health
 State Primary Health Care Development Agency
 The country has been divided into 6 zones to
ensure effective coordination. These are as
follows:
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ZONE HQ STATES COVERED

NORTH BAUCHI BAUCHI, BORNO, ADAMAWA, TARABA, YOBE,

EAST GOMBE
NORTH KADUN KADUNA, KANO, KATSINA, ZAMFARA, KEBBI,
WEST A JIGAWA
SOUTH ENUGU ENUGU, IMO, ABIA, ANAMBRA, EBONYI
EAST
NORTH JOS FCT, BENUE, KOGI, KWARA, PLATEAU,
CENTRAL NASARAWA, NIGER,
SOUTH IBADAN OYO, OSUN, EKITI, OGUN, ONDO, LAGOS
WEST
SOUTH BENIN EDO, DELTA, CROSS RIVER, RIVER, AKWA
SOUTH IBOM, BAYELSA
 NIGERIAN HEALTH SYSTEM
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 A health system is an organisation

comprising people, equipment, materials
and funding mechanisms whose major aim
is delivery of health services
 In Nigeria it is divided into PRIMARY,
SECONDARY and TERTIARY health facilities.
 The primary level is the first level of health
care. It provides general health services of
PROMOTIVE, PREVENTIVE, CURATIVE AND
REHABILITATIVE nature.
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 Health centers are the health facilities used

at the PHC level. There are 4 types:
 Comprehensive HC (Type 3): the largest,

has 30 beds; 10 each for maternity,

pediatric and adult(male & female)
sections.
It is usually manned by a doctor and offers
diagnostic, disease control, training services
as well as mgt of complicated pregnancies
It has been erroneously called “cottage
hospital” in the past
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 Primary Health center(Type 2): They are the

most common facilities, with 10 maternity
beds and 1-2 more for acute cases. They
are usually run by CHOs and nurse/midwives
and offer the same services as CHCs.
 Basic HC (Type 1): small with limited staff
and resources They usually don’t offer
inpatient services and refer serious cases to
higher facilities. Their services include
immunization, normal deliveries, home
visits, education, referral services, etc.
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 Health post: Rare, usually a room

donated by the community and run by
a volunteer health worker(VHW). Their
services are limited.
 NB: referrals within the PHC system are
expected to terminate at the CHCs
(when available) before further referral
to other levels of care. However this
must not always be the case.
 PHC REFERRAL SYSTEM
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 Referral is the process by which a health care
provider transfers responsibility for a patient
(temporarily or permanently) to another health
care provider
 Referral usually follows a hierarchical order(from

the lowest to the highest facility) except in cases of

emergencies.
REFERRAL IS NECESSARY WHEN A PATIENT:
.requires expert advice . Requires a technical exam
. requires a specialised procedure .requests a
referral
. Requires protracted in patient care
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 The ideal practice is “2 way referral” where

the referral facility gives relevant feedback
to the referring facility with transfer of the
patient back to the lower level facility after
a higher level of care has been given.
ADVANTAGES OF 2 WAY REFERRAL
 Exchange of ideas regarding patient

management
 Better quality of care

 Increased client satisfaction

 Decreased morbidity, mortality rates

 PRIMARY HEALTH CARE
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WORKERS
Medical Officer of health (MOH): The most
senior PHC worker. A medical doctor who
has PG training in community medicine.
The MOH is the LGA PHC coordinator with
diverse functions comprising advisory,
management, clinical, supervisory,
epidemic control, training, disease
notification activities etc.
Where there is no PG trained doctor, a
physician can be appointed for this role.
Dr Ladipo Oluwole- first Nigerian MOH
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A. General Administration
 Adviser on Health and Environmental matters

to the Local Government

 General administration of staff in Public Health

Dept (postings, leaves, transfers, promotions)

 In charge of planning to extend health facilities

 Recruitment, training of health personnel

 Health financing, budgeting for PHC

 Collaboration with other agencies

 Inspection of hospitals, nursing houses, other

facilities
 B. Environmental Health
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Services
House to House inspection


 Food Hygiene and Sanitation

 Waste collection and Disposal (solid
waste, sewage)
 Public Toilet construction, inspection
 Transfer of corpses
 Control of water and air pollution
 International vaccination
 Vector control
 Market inspection, market sanitation
 C. Health Information
System (Vital Health
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Statistics)
 Collection, analysis of health information
 Collection, analysis of morbidity, mortality
data
 Monthly disease notification (22) to the SMOH
 Record keeping
 Case finding, monitoring, follow up
 Monitoring and Evaluation
 Maintenance of records of individuals with
impairments
 D. Family Health Services
33  Maternal and Child Health Services
 Family Planning services
 National Program on Immunization/ORT
 School Health Services
 Nutritional Clinic (with food demonstration)
 TBA (Traditional birth attendants)
coordination
 Health education within PHCs, clinics
 Breastfeeding promotion, support
 Home visits, outreaches
 E. Health Education
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 Stimulate public to recognise existing

health problems
 Design and implement HE programs to
solve them
 Individual instruction (PHN)
 Public health lectures, short courses,
seminars for community members
 Production of health education materials
 F. Drug Revolving Fund/
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Pharmacy
 Purchase of drugs for the PHCs (LGA
central store)
 Drug distribution, monitoring from LGA
to PHCs
 COMMUNITY HEALTH
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OFFICER
 The highest cadre of core PHC workers
 Public health nurses, midwives, health
superintendents, & SCHEWs at a teaching
hospital. The CHO has medical (in the
absence of a medical officer) &
administrative functions at the PHC.
 Supervises training of CHEWs and VHWs
 COMMUNITY HEALTH EXTENSION
WORKERS(CHEWs)
37

 Senior and Junior CHEWs are trained in

Schools of Health Technology
 SCHEW trained for 4 years. Entry
requirements; 4 credits WASC. Spends 60%
of time in the health center.
 JCHEWs trained for 2 years. Entry
requirements; WASC OR WASC attempted.
Spends 10% of time in health center.
 Training revolves around components of
PHC. It also involves management, planning,
M&E
 VHW(VILLAGE/VOLUNTEER HEALTH
WORKER)
38

 Some authors use it to refer to TBAs.

 These are nominated members of the
community who are trained for 4-6 weeks
 Basic function is *community mobilization
for health actions as well as *carrying out
promotive, preventive and curative
care(dispensing drugs & FP commodities,
record keeping, conducting normal
deliveries, health education etc)
39

 Environmental Health Officer(EHO):

trained for 5 yrs in a school of health
technology; handles environmental health
matters eg. Insecticide spraying, drainage
etc.
 Public health nurse: A nurse/midwife who
receives additional 1 yr training in a school
of public health nursing.
 Pharmacy technicians
 Lab technicians
 Village Health Workers (VHWs)
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 THE NATIONAL PROGRAMME ON
IMMUNIZATION(NPI)
41

 The prevention of diseases by immunization

is the most practical, low-cost , community
based intervention against childhood
illnesses known today
 Immunization is the process whereby a
person is made immune or resistant to an
infectious disease, typically by the
administration of a vaccine. Vaccines
stimulate the body's own immune system to
protect the person against subsequent
infection or disease - WHO
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45
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 The EPI was launched in 1974 by WHO. Its aim

is to immunize children aged 0-2 yrs against 6
Vaccine Preventable Diseases (VPDs); TB,
POLIOMYELITIS, WHOOPING COUGH,
DIPHTERIA, MEASLES and YELLOW FEVER.
 It also immunises women of child bearing age
against tetanus; a measure that protects both
mother and child
 Achieved its initial target of 80% coverage by
1990 then a decline.
 Renamed NPI in 1996
 Goal: The overarching goal is to reduce morbidity and mortality
from diseases scheduled for protection by vaccination in Nigeria
specifically measles, polio, diphtheria, tetanus, pertussis,
pneumococcal disease, Hib disease, hepatitis B, yellow fever.
47

 Strategic Objectives
 1 To accelerate the achievement of 87% sustained
national coverage of infants with all scheduled routine
antigens by 2015
 a. To guarantee safe bundled vaccines for all
immunizations in which the wastes are safely disposed
off.
 b. To reduce successively the numbers of unimmunized
infants between 35% and 50% annually compared to
the previous year.
 c. To create demand for routine immunizfation beyond
behavioural change communication to social
transformations and change to 80% by 2015
48

2 To improve the quality of reported data and all other

components of the routine immunization monitoring
system in the context of an effective HMIS
3 To entrench an accountability framework for routine
immunization that is implemented by all stake
holders
4 To support the roll out of penta-valent vaccines to
all states in 2013 and complete the phased
introduction of pneumococcal vaccine (PCV)by 2015.
5 To link with Polio eradication initiative and other
interventions in an integrated manner that
strengthens the overall PHC system
 NPI Schedule
AGE VACCINE DOSE ROUTE
49
BIRTH BCG 0.05mls ID, ULA
OPVo 2-3 DROPS ORAL
HBV1 0.5 mls IM
6 WEEKS PENTA1, PCV 0.5mls IM
1
OPV1 2-3 DROPS ORAL
10 WEEKS PENTA 2, PCV 0.5mls IM
2
OPV2 2-3 DROPS ORAL
14 WEEKS PENTA 3, PCV 0.5mls IM
3
OPV3 2-3 DROPS ORAL
9 MEASLES 0.5 mls SC, ULA
MONTHS
YELLOW 0.5 mls SC, URA
FEVER
 COLD CHAIN

50 A system for storing, transporting and
distributing vaccines in potent form from the
manufacturer to the end user. It is a complex
system comprising equipment and people.
 Equipment include Ice lined freezers/
refrigerators, Cold boxes, Vaccine carriers,
thermometers etc.
 Cold chain
51
FALSE CONTRAINDICATIONS TO
IMMUNIZATION
52

 Minor illnesses eg. URTIs, diarrhea(polio

should be repeated), fever below 38ºC
 Allergy, asthma, hay fever or other atopy
 Family hx of convulsions
 Tx with antibiotics, low dose steroids
 Jaundice after birth
 Prematurity, small for date infants
 Malnutrition
 Breastfeeding child
 Previous hx of a VPD
 CONRAINDICATIONS TO IMMUNIZATION

53 Acute febrile illness with temp > 38ºC
 Immunodeficiency states eg. Agammaglobulinemia,
leukemia, high dose steroid Tx, Q: what about HIV?
 Hx of severe adverse effects (anaphylaxis, shock,
encephalopathy, non febrile convulsion) ffg
previous dose of vaccine
 Hx of severe adverse effects (anaphylaxis, shock,
encephalopathy, non febrile convulsion) ffg egg
ingestion – Don’t give YF, influenza
 Pregnancy – live vaccines
 Children with neurological disorders eg. Epilepsy,
infantile spasms, progressive encephalopathy -
pertussis
 COMMUNITY DIAGNOSIS
54

 A process by which the health needs of the

community are identified by the community (felt
needs) and/or health workers.
 It requires data collection wrt a number of issues

such as births, deaths, migration, health

manpower, environmental factors
 Information is obtained by

a. Observation

b. Review of records

c. Screening for specific problems

This is used for baseline evaluation and constraint

identification
 USES OF COMMUNITY
DIAGNOSIS
It facilitates health program planning
55
1.

2. It provides basis for resource determination

3. It provides a baseline for future M&E of
health problems
4. It shows occurrence & distribution of
diseases or health indicators (descriptive CD)
5. It identifies groups needing care, causal
factors for disease, risk factors, and
community syndromes(eg. MalN,
hypertension, obesity etc (analytic CD)
 METHODOLOGY FOR CD
56

 Community mapping
 Itemisation of all resources
 Locate infrastructure related to health eg. Wells,
toilets etc
 Investigate socio cultural practices
 Identify socio economic activities
 Interview the people (questionnaire, oral , FGDs)
 Discuss with community leaders, health workers
 Carry out survey using data collection, analysis
 Report writing
 Feedback to community, health authorities
 CURRENT STATUS OF PHC
57
IN NIGERIA
 Ward health system: current national strategy
ecept in 5 states; Enugu, Kano, Kaduna, Lagos &
Taraba
 Utilizes the electoral ward as the basic operational
unit
 The aims of this approach are
- To promote full community participation at the
grassroot level
- Improve access to quality care
- Promote equity
- Promote local initiative
- To reduce maternal and under 5 morbidity &
mortality
 CHALLENGES OF PHC IN
58
NIGERIA
 Poor political will
 Lack of sincerity
 3 tier responsibility
 Allocative inefficiencies
 Managerial inefficiencies
 Lack of human resource planning
 Mediocrity
 Gaps in recruitment of skilled manpower
 Developmental inequalities