PRIMARY HEALTH CARE

MAIGA AYUB HUSSEIN

M&E, ADSHM, BScN,Ms-Epid

ZZIWA SWAIBU
BEH,MPH(MUK)

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 Course objectives
By the end of this section learners will be introduced
to;-
• Healthy system in Uganda
• Levels of health care
• Definition of PHC
• Concepts of primary health care
• Components of PHC
• Pillars/ principles of PHC
• Challenges in PHC implementation
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 National health System in Uganda
 National health System in Uganda is made up of the public and the private
sectors.

 The public sector includes all Government health facilities under the Ministry
of Health (MOH), health services of the Ministries of Defence (Army),
Internal Affairs (police and prisons) and Ministry of Local Government.

 The private health delivery system consists of private health practitioners

(PHPs), private-not-for-profit (PNFPs) providers and the traditional and
complementary medicine practitioners (TCMPs).

 The MOH has four levels of administration: the national, regional, district,
and community levels

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 National health System Cont’d
 The central level includes the National Directorate of Public Health of the
Ministry of Health (which houses the NMCP), where national guidelines and
norms are promulgated

 The MOH provides leadership for the health sector and is responsible for
overseeing the delivery of curative, preventive, palliative,and rehabilitative
services to the people of Uganda

 The health services are structured into National Referral Hospitals (NRHs) and
Regional Referral Hospitals (RRHs), general hospitals, and health centres
(HC)IVs, IIIs and IIs.

 Uganda’s Health Management Information System (HMIS) remains the

primary source of malaria morbidity and mortality

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The organization of health services in Uganda

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 Levels of health care

• Primary health care

• Secondary health care
• Tertiary health care

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 Levels of health care cont’d
• Primary health care
• The “first” level of contact between the individual and the health
system.
• Essential health care (PHC) is provided.
• A majority of prevailing health problems can be satisfactorily
managed.
• Closest to the people.
• Provided by the primary health centres i.e II,III $ IV.
• It addresses many health problems in the community.
• It provides promotive, preventive, curative and rehabilitating services
accordingly.
• It’s services vary from country to country

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 Levels of health care cont’d

•Secondary health care

•More complex problems are dealt with.
•Comprises curative services
•Provided by the district hospitals
•It’s mainly concerned with health problem of individuals
•It requires trained health professionals
•It’s mainly concerned with health problem of individuals
•The 1st referral level

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 Levels of health care cont’d
• Tertiary health care
• Offers super-specialist care
• Provide training programs
• It’s hospital based health care
• It deals with individual
medicine
• It’s composed of bed side
nurses
• It requires trained health
professionals
• It’s mainly concerned with
health problem of individuals
• It provides mainly curative
services
• Drugs are costly and not
evenly distributed
• It’s mainly concerned with
health problem of individuals
• It provides mainly curative
services
• Provided by regional and
national hospitals
• Accessibility is too costly or
not for all, it’s for urban and
rich people
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 PRIMARY HEALTH CARE
• Primary health care was born in September in 1978 at
Alma-Ata in Russia former USSR. This was a world health
organization review of the progress and challenges of faced
by health care world wide.
• It was a time when the 2nd world war in 1945 had
depreciated health services.
• The conference took place on the 6th-12th September 1978
and 134 countries that attended the conference realized that
no country had enough health resources for its population.
• The ministry of health and other government Ministries had
to compete for the scarce resources with other sectors fore-
example; agriculture, transport and defence

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 PHC cont’d
• This called for the need to change from
curative medicine to preventive health care.
• More than 90% of the disease burden are
preventable, so the new approach was branded
or baptized primary health care. Therefore,
P.H.C became the declaration of the Alma-ata
conference.

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 What is P.H.C( Alma-Ata declaration)
• Primary health care is the essential health care based on
practical, scientifically sound, socially acceptable methods and
technology made universally accessible to individuals,
families and communities 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 (WHO, The Alma- Ata
Declaration, 1978)
• It is the first level of contact of the individual, the family and
community with the national health system bringing health
care as close as possible to where people live and work, and
constitutes the first element of a continuing health care
process.
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 Concepts of PHC
• Essential health care;- health care that meets local
needs of the community with their full participation
• Practical, scientifically sound methods and
technology;- able to solve health problems using
locally available resources and technology which exist in
the community
• Socially acceptance methods;- the health care
should not conflict with norms and culture of a community
that the recieves the health services

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 Goal of PHC
• The ultimate goal of primary healthcare is the
attainment of better health services for all

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 Concepts of PHC cont’d
• Accessibility;- the services to promote health in a
community should be within easy reach of
individuals/families in that community
• Full community participation and involvement;-
the community should be actively in the needs
assessment, monitoring, implementation and evaluation for
services to be socially acceptable and sustainable
• Affordability ;- the cost of a health care service and its
maitainance should be affordable both by the community
and the country

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 Concepts of PHC cont’d
• Self reliance;- strategies for PHC implementation
should aim at encouraging communities to be
independent, confident and trusting them selves from
being passive recipients of services.
• Self determination;- the community should be able to
decide on matters concerning their own health and
development
• Integration;- all sectors should be actively involved in
promotion of PHC

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Characteristics of PHC cont.

• Majority of prevailing health problems can be

satisfactorily managed.
• Closest to the people.
• Provided by the primary health centres i.e II,III $ IV.
• It addresses many health problems in the
community.
• It provides promotive, preventive, curative and
rehabilitating services accordingly.
• It’s services vary from country to country
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Characteristics of PHC include:
• Community participation
• Health workers collaborating in inter-
disciplinary teams
• Proactive Prevention Focus
• Accessibility
• Localized set of choices
• Sustainability
• Multi-sector alignment and involvement
• Self-reliance & determination
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 ELEMENTS / COMPONENTS OF PRIMARY
HEALTH CARE

1. Education [Health Education]

2. Locally Endemic diseases [Prevention of Locally endemic
diseases e.g. Malaria, Diarrhea, T.B ]
3. Expanded programme on immunization
4. Maternal and child Health care / family planning
5. Essential drug supply
6. Nutrition and adequate food supply
7. Treatment of common illness and prevention of minor
injuries
8. Sanitation and safe water supply
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 ELEMENTS cont’d

• While the above elements originated at the Alma-Ata

conference, the member state were made to add as more
as the situation would require in their countries.
Uganda added the following:-
1. Oral and dental health care
2. Mental health care
3. Eradication of Guinea Worms
4. Primary Eye Care
5. Community based rehabilitation services [CBR] and disability
prevention
6. HIV and STI prevention

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 Principles of PHC
• PHC rests upon three principles i.e. community
participation, intersectoral collaboration and equity.
• However , emerging from the prescription of the Alma
Ata conference there was liberty accorded to national
health systems to modify these principles according to
their own health needs. E.g. Uganda adopted
community participation, appropriate technology,
political commitment and intersectoral collaboration.
Since 1982 the country has been implementing PHC
activities along these four principles.

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Principles of PHC cont’d

Full community participation

Full community participation and involvement enhances a sense of
ownership and fosters sustainability.
Inter-sectoral collaboration.
There is need to co-ordinate and co-operate with others sectors for the
success of P.H.C e.g. politicians, religious leaders, educationists and
agriculturalists should combine effort.
Political commitment and support.
The politicians and civil leaders including traditional leaders should
not be left when implementing PHC activities.
Appropriate technology.
The methods and techniques used to deliver P.H.C must be
scientifically sound and socially acceptable. It should be evident based
(It has ever worked somewhere) and not to contradict the cultural issues
of a given community 22
 The Basic Requirements for Sound PHC
(the 8 A’s and the 3 C’s)/attributes of PHC
• Appropriateness • Assessability
• Availability • Accountability
• Adequacy • Completeness
• Accessibility • Comprehensiveness
• Acceptability • Continuity
• Affordability

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 Appropriateness
• Whether the service is needed at all in
relation to essential human needs, priorities
and policies.
• The service has to be properly selected and
carried out by trained personnel in the proper
way.

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 Adequacy
• The service proportionate to requirement.
• Sufficient volume of care to meet the need
and demand of a community

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 Affordability
• The cost should be within the means and
resources of the individual and the country.

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 Accessibility

• Reachable, convenient services

• Geographic, economic, cultural accessibility

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 Acceptability

• Acceptability of care depends on a variety of

factors, including satisfactory communication
between health care providers and the
patients, whether the patients trust this care,
and whether the patients believe in the
confidentiality and privacy of information
shared with the providers.

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 Availability

• Availability of medical care means that care

can be obtained whenever people need it.

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 Assessability

• Assessebility means that medical care can be

readily evaluated.

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 Accountability

• Accountability implies the feasibility of regular

review of financial records by certified public
accountants

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 Completeness

• Completeness of care requires adequate

attention to all aspects of a medical problem,
including prevention, early detection,
diagnosis, treatment, follow up measures, and
rehabilitation.

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 Comprehensiveness

• Comprehensiveness of care means that care is

provided for all types of health problems.

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 Continuity

• Continuity of care requires that the

management of a patient’s care over time be
coordinated among providers.

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 To Summarize
Primary care is an approach that:
• Focuses on the person not the disease,
considers all determinants of health
• Integrates care when there is more than one
problem
• Uses resources to narrow differences

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 To Summarize
• Forms the basis for other levels of health
systems
• Addresses most important problems in the
community by providing preventive, curative,
and rehabilitative services
• Organizes deployment of resources aiming at
promoting and maintaining health.

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 Strategies of PHC
• The following are the strategies of PHC
• Use of local resources
• Use of Appropriate Technology.
• Community Participation.
• Information dissemination
• Mobilization of Political Will
• Inter-Sectoral Collaboration
• Provision of accessible health services
• Reorientation of other health providers is needed
• Emphasize disease prevention and health promotion
• Ensure full community participation
• etc 37
 Stakeholders of PHC
• What is a stakeholder?
• A stakeholder is an entity who has an interest
in an organization and whose support is
required in order for an organization to be
successful
• Stakeholders are persons, groups or
organizations who have a vested interest or
concern in a given program or project

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 Different stakeholders at various levels in PHC implementation

• There are several key parties that play major roles in

the PHC. These include communities; local
governments; national governments, regional
institutions; NGOs, Corporations, Media and scientific
communities. They have been discussed below;-
• Communities
• Local governments
• National governments
• Regional institutions and organizations
• International agencies
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 IDENTIFICATION OF STAKE HOLDERS OF PHC
• PHC requires an institutional • Ministry of Information and
frame work through which Broad casting
implementation can be • Ministry of Internal affairs
carried out at all levels • Department of community
• National level development
• Ministry of health • NGOs at National level like
• Ministry of local government USAID, UKAID,ADD
• Ministry of Agriculture
• Ministry of planning and
economic development
• Ministry of Education and
ports
• Ministry of Gender youth and
culture 40
 Institutional structures of PHC
cont’d
• At District Level
• District Resistance
councils(DRC)
• District Development
Councils(DDC)
• District Health Committees
(DHC)
• District Health team (DHT)
• NGOs at district level
• At community level
• Local council I,II , III and ex-
officials from government
departments and NGOs
• Sub county Health committees
and ex- officials from
government departments and
NGO’s.
• Parish /village Health
committees
• Existing Health committees
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 Roles of stakeholders at different levels
National Level
• Establish a National Management Committee to monitor
and document PHC service delivery
• Develop a contingency plan for PHC as part of the overall
health sector strategic plan and this must be clearly spelt
out:
• the technical personnel required at all levels of management;
• nursing staff,
• Monitoring & Evaluation experts
• surveillance officers,
• Health Education experts and
• logisticians or supplies chain management specialists to
estimate the logistics required to provide PHC
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National level cont.
• Ensure regular monitoring and •
evaluation of district data
• Develop and produce
appropriate Information
Education and Communication •
materials to sensitize the
public about diseases.
• Provide technical assistance to
the district hospital and health
sub district on PHC.
• Ensure availability of medicine
stocks at national, district
levels and health sub district.
• Ensure coordination of donor
support and resource
mobilization.
Prepare facilities for regular
press conferences to update
the public and disseminate
health messages.
Integration of PHC into the
National health policies
• Formulation of National
Policies and guidelines on
PHC.
• Training of health care workers
of various cadres on disaster
management
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District level
• Ensure regular monitoring and
evaluation of district data on •
PHC
• Develop and produce
appropriate Information
Education and Communication
materials to sensitize about
disease prevention.
• Provide technical assistance to •
the district hospital and health
sub district on PHC
implementation.
• Ensure availability of medicine
stocks at national, district
levels and health sub district.
Ensure coordination of donor
support and resource
mobilization.
• Prepare facilities for regular
press conferences to update
the public and disseminate
health messages
Formulation of National
Policies and guidelines on
PHC.
• Training of health care workers
of various cadres about PHC
implementation
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• District level cont.
• Health education programs
aiming at bringing good
lifestyle to promote health
within the community
conducted by health workers
and religious leaders
• Improving communication
systems and transport within
the community by the
government agencies like
UNRA
• Construction of health facilities
for easy access to health
services by the community.
• Construction of schools to
reduce on level of illiteracy
which is a disease in the
community. by Ministry of
education, Church
organizations, and other NGOs
• Empowering community for
income generating activities
for self-reliance and
independency.
• Collaborating with the
community for community
mobilization and resource
identification for running the
services.
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 Health facility Level:(HSD)
• Re-orient the clinical staff to
update them on PHC
implementation
• Report any epidemic to higher
authorities
• Adopt national guidelines and •
policies on PHC
• Ensure that health education
materials are available and
displayed.
• Organize and conduct health •
education sessions about PHC
at the facility on a weekly basis
• Ensure that medicines and
supplies are adequate at the
health facility.
• Ensure that the community
health workers are well
informed about the PHC
Organize outreaches and
sensitization workshops with
community health workers
concerning PHC in the
community
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Health facility level (HSD)
• Improving communication
systems and transport within
the community by the
government agencies like
UNRA
• Construction of health facilities identification for running the
for easy access to health
services by the community.
• Construction of schools to
reduce on level of illiteracy
which is a disease in the
community. by Ministry of
education, Church
organizations, and other NGOs
• Empowering community for
income generating activities for
self-reliance and independency.
• Collaborating with the
community for community
mobilization and resource
services.
• Health education programs
aiming at bringing good
lifestyle to promote health
within the community
conducted by health workers
and religious leaders
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Community Level
• Orient the community health education sessions about PHC
workers on the possible in the community to promote
recommended actions to behavioral change
implement PHC • Distribution of IEC materials
• The Village Health on PHC and control in the
Teams(VHTs) should be community such as posters.
encouraged to sensitize the • Advocate for behavior change
community members about using media channels such as
disasters radios, televisions and social
• Organize regular screening media
exercises in the community • Enforcement of national
for early detection of guidelines and policies on
epidemic diseases disaster management
• Organize and conduct health
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 Community Level
• Health education programs
aiming at bringing good lifestyle
to promote health within the
community conducted by health
workers and religious leaders
• Improving communication
systems and transport within the
community by the government
agencies like UNRA
• Construction of health facilities
for easy access to health services •
by the community.
• Construction of schools to reduce
on level of illiteracy which is a
disease in the community. by
Ministry of education, Church
organizations, and other NGOs
• Empowering community for
income generating activities for
self-reliance and independency.
• Collaborating with the
community for community
mobilization and resource
identification for running the
services
•
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Roles of nurses/midwives, duties and responsibilities
in PHC implementation

• Health education on • Nutrition matters;-

matters concerning;- • The importance of good
• Environmental nutrition for all family
matters;- members, what food to
• The importance of the grow, how to prepare a
adequate and clean water balanced diet, how to
supply. store food and how to
• Good sanitation with the protect it from getting
use of pit latrines and contaminated and
proper refuse disposal. indicators of malnutrion
• Control of mosquitos,
keeping the home and
compound clean 50
 Roles of the nurses/midwives cont.;
• Promote behavioral
change;-
• Ensure personal hygiene to all
community members
• educate the community the
effects of smoking and
alchoholism
• Sexual behavior to control
and prevent STD’s and AIDs
• Community mobilization for
better health and
development through;-
• Home improvement
• Community cleaning and
removal of stagnant water.
• Protection of water sources
• Construction of pit latrines
and refuse dumps
• Promote income generating
activities such as poultry,
vegetable gardens, farming,
fisheries and life skills
education.
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 Roles of the nurses/midwives cont.;
• Promote maternal and
young child health care
through;-
• Encouraging pregnant
women to visit health
centres to receive
antenatal services e.g.
tetanus vaccine, iron and
folic acid
• Give nutritional advise
and education
• Assess the growth and
development of young
children
• Assess nutritional
indicators using basic
indices
• Routine immunization
• Give advice on family
planning
• Teach mothers how to
make ORS in order to
treat diarrhea
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Other roles of nurses/midwives
• Helps in promoting the the communities
PHC program in the • Helps to supervise and
community advise the TBAs on the
• Helps in identifying concepts of safe
problems and utilization motherhood
of resources to promote • Makes on spot
the elements of PHC diagnoses and screening
program in the and gives advice
community. accordingly
• Helps to promote •
reproductive health in
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 Other roles of nurses/midwives
• Plan, support and their own health and
implement activities living circumstances
and programs of PHC using PHC program.
in the community.
• Make advocacy for
communities and
empowering them to
take responsibility for

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 Challenges faced in implementation of PHC in
the community
• Lack of full community of
participation
• Lack of inter sectoral
collaboration
• Inappropriate technology
• Poor referral system
• poor relationship with
community members
• Failure to co-ordinate and
involve community health
workers
• Inadequate staffing e.g.
doctors, nurses and support
staff
• Lack of a clear national policy
for program development
• poor infrastructural
development
• Lack of motivation /incentives
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 Challenges cont’d
• Poor culture practices, community members
norms, customs, beliefs • Natural calamities like
and food taboos floods, drought,
• Poor attitude of local earthquake, heavy
leaders and community winds
members • Civil unrest
• Inadequate funding • Language barrier
• Some communities a • Corruption and
too embezzlement
rigid/conservativeness • Lack of political support
• Poverty among
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 References
• World Health Organization. Declaration of Alma-Ata. Adopted at the International
Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978
• Starfield, Barbara. "Politics, primary healthcare and health." J Epidemiol
Community Health 2011;65:653–655 doi:10.1136/jech.2009.102780
• Secretariat, WHO.
"International Conference on Primary Health Care, Alma-Ata: twenty-fifth anniver
sary"
(PDF). Report by the Secretariat. WHO. Retrieved 28 March 2011.
• "Health topics: Primary health care". World Health Organisation. Retrieved 28
March 2011.
• Braveman, Paula; E. Tarimo (1994).
Screening in Primary Health Care: Setting Priorities With Limited Resources.
World Health Organization. p. 14. ISBN 9241544732. Retrieved 4 November 2012.
• World Health Organization. World Health Report 2005, Chapter 5: Choosing
Interventions to Reduce Specific Risks. Geneva, WHO Press.

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Thanks

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