Primary Health Care Introduction

Definition of Primary Health Care

• Primary Health Care (PHC) is essential health care based on practical, scientifically sound, and socially acceptable methods and technology.
• It is made universally accessible to individuals and families in the community through their full participation and at a cost the community and country can afford.
• PHC is a philosophy of health care and an approach to providing health services that includes promotive, preventive, curative, rehabilitative, and supportive/palliative care.

Principles of Primary Health Care

• Equity: Health care should be related to the needs of the people, with more resources given to the disadvantaged to reduce the gap between the rich and poor.
• Community Participation: Involving people individually and collectively to manage their lives more effectively, respect diversity, and ensure effective and strategic planning.
• Intersectoral Coordination: Recognizing that health and well-being are linked to economic and social policy, and that providers from different disciplines should collaborate to meet the needs of health care consumers.
• Appropriate Technology: Using the fullest available resources and relevant technologies, considering alternatives to high-cost, high-tech services, and promoting healthy communities.

Key Goals and Strategies for PHC in Nigeria

• Enactment of the Nigerian Health Act: Ensuring effective access to equitable, affordable, and quality health care.
• Establishment of a minimum (essential) health package: In all Wards across the country.
• Reduction of financial barriers to health services: Through community-based social health insurance schemes.
• PHC infrastructural development: Promoting comprehensive and qualitative integrated health services delivery.

Primary Health Care Personnel

• Health workforce: All people engaged in actions whose primary intent is to enhance health, including health professionals, public health workforce, and those addressing social determinants of health.
• Categories of health professionals: Medical doctors, nurses, midwives, clinical officers, laboratory technicians, pharmacists, community health workers, and management and support staff.

Community Health Care Workers

• Community Health Officer (CHO): A senior cadre member of the primary health care team, responsible for community-based functions and supervision.
• Community Health Supervisor (CHS): A frontline public health worker with a close understanding of the community, serving as a liaison between health/social services and the community.
• Community Health Extension Worker (CHEW): A junior-level worker, responsible for community-based functions and supporting the CHO and CHS.

Community-Based Functions

• Community mobilization for health action: Explaining the PHC approach, carrying out community mobilization, and guiding and supporting Volunteer Village Health Workers (VVHWs) and Traditional Birth Attendants (TBAs).
• Supervision and monitoring: Supervising JCHEWs, VVHWs, and TBAs, and monitoring their activities.
• Health education and promotion: Teaching simple methods of data collection and analysis, and promoting health education campaigns.

Clinic-Based Functions

• Providing integrated PHC services: Organizing and running integrated PHC services, including health education, promotion of water supply and basic sanitation, maternal and child health, and immunization services.

Training Functions

• Identifying learning needs: Identifying learning needs of JCHEWs, VVHWs, and TBAs, and members of the Community Development Committee.
• Providing on-the-job training: Providing on-the-job training as necessary.

Financing of Primary Health Care

• Mechanisms for financing health care: Governments, donors, insurance, NGOs/CBOs, and out-of-pocket financing.
• Government budget allocation: Government budget allocations come from direct and indirect tax revenues, and should provide for public spending on primary healthcare.
• Health insurance: A social device for aggregating health risk and costs, with mandatory and voluntary schemes.### Primary Health Care (PHC) Financing
• Employment-based health insurance schemes are common, where employees and employers contribute to the scheme.
• Collaborating/Development Partners (donor agencies) are a major source of funds for PHC activities.
  • Multilateral organizations (e.g. UNDP, WHO, UNICEF, World Bank) and Bilateral Agencies (e.g. USAID, DFID) provide funding in the form of loans or grants.

Non-Governmental Organizations (NGOs) and Community-Based Organizations (CBOs)

• NGOs and CBOs are also a significant source of funding and provision of services in most communities in Nigeria.
• Examples of NGOs include Rotary International, Medicine San Frontiers, Lions, and Red Cross.

Out-of-Pocket Payments (OOPs)

• OOPs are direct payments made by patients to healthcare providers.
• Examples of OOPs include fees paid for consultations, traditional medicine, and other healthcare services.

Management of Primary Health Care

• Management involves making efficient use of resources (manpower, material, and money) to achieve predetermined objectives.
• Ten roles of a manager:
  1. Interpersonal figurehead
  2. Leader
  3. Liaison
  4. Information monitor
  5. Disseminator
  6. Spokesman
  7. Decisional entrepreneur
  8. Disturbance handler
  9. Resource allocator
  10. Negotiator

Principles of Management

• Division of work: reduces the span of attention or effort for any one person or group.
• Authority: the right to give orders.
• Discipline: outward marks of respect in accordance with formal or informal agreements.
• Unity of command: one person, one superior.
• Unity of direction: one head and one plan for a group of activities with the same objective.
• Subordination of individual interest to the general interest.
• Remuneration: fair pay for both employees and the organization.
• Centralization: always present to a greater or lesser extent.
• Scalar chain: the line of authority from top to bottom of the organization.
• Order: a place for everything and everything in its place.
• Equity: a combination of kindliness and justice towards employees.
• Stability of tenure of personnel: employees need time to settle into their jobs.
• Initiative: encourages staff to show initiative within their authority and discipline.
• Esprit de corps: harmony is a great strength to an organization.

Devolution and Decentralization of PHC Management

• Devolution of power: transferring power from the federal government to lower tiers of government.
• Decentralization: sharing decision-making power from the center with lower levels of management.

Management Committees and Community Participation

• A committee is a group of people appointed to deal with a particular matter.
• Community participation in PHC involves:
  • Identification of health needs
  • Design of required PHC activities
  • Monitoring quality of services
  • Participation in solving problems

Primary Health Care Facilities and Equipment

• Health facilities are categorized into four types:
  1. Type 1: health post, health clinics, and dispensaries
  2. Type 2: primary health care centers
  3. Type 3: comprehensive health centers, cottage hospitals, and general hospitals
  4. Type 4: specialist and teaching hospitals
• A primary health care facility is functional when it is well-staffed, equipped, and provides basic services.

Problems with PHC Facilities in Nigeria

• Mal-distribution
• Poor physical structures
• Inadequate staffing
• Poor access roads
• Poor referral networks

Utilization of Health Facilities

• Factors affecting utilization:
  • Proximity
  • Attitude of staff
  • Availability of essential services/drugs
  • Payment policy
  • Literacy level
  • Economic status of community members

Patient Satisfaction

• Factors affecting patient satisfaction:
  • Cleanliness of facilities
  • Patient-provider interaction
  • Waiting time
  • Availability of essential drugs at affordable prices

Provision of PHC Facilities

• Expected provision of facilities:
  • Federal government: one tertiary health facility or federal medical center per state
  • State government: one general hospital per LGA
  • Local government: one comprehensive/primary health center per political ward
  • Ward development committee: one health clinic per group of villages/communities
  • Village development committee: one health post per village

Types and Ownership of Health Facilities

• Type of health facility and ownership:
  • Teaching/tertiary hospital: federal government
  • General hospital: state government
  • Primary health center: local government
  • Health clinic/health post: ward development committee or village development committee

Equipment and Logistic Support for PHC

• Facility-based equipment: necessary for technical activities
• Programme-specific equipment: necessary for specific health programs
• Examples of equipment and logistic support:
  • Health education: overhead projectors, projector screens, public address systems
  • Nutrition: arm circumference tapes, cooking pots, store, poster on growth monitoring and promotion
  • Maternal and child health/family planning: delivery bed, foetal stethoscope, examination table, standing-weighting scale

National Health Management Information System (NHMIS)

• NHMIS: an organized way of collecting, collating, processing, and analyzing data and disseminating information to stakeholders.

Referral System

• Referral system: a predetermined arrangement for transferring patients from lower to higher levels of care.
• Factors affecting referral system:
  • Availability and accessibility of care facilities
  • Distance
  • Road condition
  • Affordability of cost of transportation
• Need for referral system:
  • Ensures quality of PHC services
  • Promotes credibility and quality of PHC services
  • Allows for supervision/support from higher levels
  • Promotes satisfaction of health care providers and consumers

Standard of Referral System

• In order to establish an effective referral system:
  • All cases that need referral services should be referred
  • All PHC staff should be trained on the system
  • An enabling environment should be provided
  • Referral should be a 2-way process

Steps in Developing Effective Referral System

• Identify services to be provided at each level
• Strengthen lower levels of care with material resources, manpower, and regular supervision
• Develop referral protocol cards and manuals
• Establish a functioning communication network
• Identify suitable transport mechanisms
• Establish a program in the community with agreed goals and objectives