PRIMARY HEALTH CARE 1.pdf

INTRODUCTION In Nigeria every health worker talks about Primary Health Care (PHC) , but if you ask them to define or explain the term , they often offer funny explanation such as rural health care or health care for the poor. This shows that as important as the program is, it is still not well under...

INTRODUCTION In Nigeria every health worker talks about Primary Health Care (PHC) , but if you ask them to define or explain the term , they often offer funny explanation such as rural health care or health care for the poor. This shows that as important as the program is, it is still not well understood. The Federal Ministry of Health in the pursuance of World Health Organization (Alma Ata ) declaration, adopted a new health system of health care delivery which can be extended to all citizens anywhere they live or work and at a cost they can afford. In other words, whether you live in a village or town, you have the right to be provided with essential health services Therefore PHC is a process of ensuring social justice. It is now a widely disseminated concept. We shall try to explain how the concept of PHC has evolved. HEALTH: This is a state of complete physical, mental and social well being, not merely in the absence of disease and infirmity. BRIEF HISTORY OF PRIMARY HEALTH CARE Historically, PHC concept has its root in the initial stages of our National health care approach which took place in MAY 1977 at the 30th World Health Assembly (WHA) which adopted a resolution that the main social target of government and WHO, in the coming decades should be ‘’Health for All’’(HFA) by the year 2000AD The basis of Health for All strategy gave birth to PHC. In 12th September, 1978 an International Conference of PHC was held in ALMA ALTA in Russia (USSR) jointly by WHO and UNICEF where 134 countries were in attendance including Nigeria during the conference. This led to the concept of PHC which was recommended by various health committees in 1946 HISTORICAL PERSPECTIVE OF PHC IN NIGERIA In Nigeria, there were three major attempts at evolving and sustaining a community and people oriented health system in Nigeria. The first attempt occurred between 1975 and 1980. This is the introduction of the Basic Health Services Scheme(BHSS). The BHSS came into being in 1975. The BHSS was structured using basic health units which consisted of 20 health clinics in each LGA, which were backed-up by 4 PHC Centres and supported by mobile clinics serving approximate population of 150,000 to make quality care accessible to the entire population. A second attempt which was led by late Professor Olukoye Rasome Kuti occurred between 1986 and 1992 to ensure development of model PHC in 52 LGA to implement 8 components of PHC and ensure 80% fully immunization coverage for underfive children. Before the third attempt of sustaining PHC, primary healthcare was adopted in the National Health Policy of 1988 as the cornerstone of the Nigerian health system as part of efforts to improve equity in access and utilization of Basic Health Services. The third attempt was the establishment of National Primary Health Care Development Agency(NPHCDA) in 1992. This is to make basic health care accessible to the grassroots in collaboration with Ward Minimum Health Care Package(WMHcp) which outlines a set of cost effective health interventions with reduction of morbidity and mortality over 500 health centers. It was established across the Nation by the Federal Government. In 2005, PHC facilities were found to make up over 85% of health care facilities in Nigeria. PHILOSOPHY OF PRIMARY HEALHT CARE All people, everywhere, deserve the right care, right in their community. This is the fundamental premise of primary health care. PHC addresses the majority of a person’s health needs throughout their life time. Primary health care was established essentially to bring health closer to the people, in the community, and through their full participation. It is meant to provide services to the majority of people based on need, without geographical, social, or financial barriers To achieve health for all by the National Health Policy which was based on the World Health Assembly in 1978, the following are the new philosophy: 1. Health is a fundamental human right 2. Health is an integral part of development 3. Health is an essence of productive life and not on the result of ever increasing expenditure or medical care 4. Health is central to the content of quality of life 5. Health involves individuals, State government and international responsibilties. CONCEPT OF PHC Primary health care addresses the majority of a person’s health needs throughout lifetime. This includes physical, mental, and social well being and it is peoplecentered rather than diseasecentered The concept is not intended to represent the second best medicine acceptable only to the rural poor or the dwellers of urban slums. Rather it is an essential care for all based on practically sound and socially acceptable methods and technology It is not a stopgap solution to be replaced by something better at a later stage. Rather, the primary health care approach is intended to be a permanent feature of all health services, the quality of care should steadily improve, and at all times it should be appropriate to the resources and the needs of the community. Primary health care is not intended to function in isolation but in collaboration with the referral and specialist services. These services should be mutually supportive. Without good Primary health care, the referral services would be overwhelmed by problems, which could have been dealt with at primary level Many of these would have be advanced cases with complications, which could have been prevented by early detection and prompt care at the primary unit. On the other hand primary health care requires the support of the referral services to cope with problems, which are beyond the scope of the peripheral units DEFINITION/OVERVIEW OF PRIMARY HEALTH CARE PHC can be defined according to WHO as in Alma Ata declaration (1978) ‘’ as an essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and 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’’ The first-level of health care that is focused on needs and priorities of individuals, families and communities such as health promotion, disease prevention, treatment, rehabilitation, palliative care. It is developed with the concept that the people of the country receive at least the basic minimum health services that are essential for their good health and care. From the above definition the following are the key words or characteristics of PHC: Accessibility: Which means to continuing an organized supply of care that is geographically, financially, culturally within easy reach to the whole community. Acceptability: Which implies that care has to be appropriate and adequate in quality and quantity to satisfy the health needs of people and has to be provided by methods which is okay by them within their socio-culturally norms Affordability: This entails that whatever the methods of payments used, the services should be affordable by the community and people. Appropriate Technology: This means using appropriate and relevant methods, techniques and locally available supplies and equipments which together with the people using them can contribute significantly to solving a health problem Primary Health Care is based on socially acceptable methods which the country can afford. Thus self-reliance and selfdetermination are emphasized. Thus we can say PHC is a practical approach to make essential health care universally accessible to individuals, families and community in an acceptable and affordable way and with their full participation. The significance of PHC is to have contact with members of the community for providing continuing health care in the light of national health system PHC focuses on promotion, preventive, curative, rehabilitation and emergency care to meet the main health problems in the community, giving special attention to the vulnerable groups such as mothers and children So combining all these ideas of PHC, we can briefly say that PHC is based on socially acceptable methods which the country can afford. Thus emphasizing on selfreliance and self-determination. AIMS AND OBJECTIVES OF PHC To make health services accessible and available to every one where ever they live or work. To tackle the health problems causing the highest mortality and morbidity at the cost the community can afford. To ensure that whatever technology is used it must be within the reach of the community to use effectively and maintain. To ensure that in implementing the health problems, the community must be fully involved in planning the delivery and evaluation of self-reliance COMPONENTS OF PHC Essential health care consisting of at least eight elements: 1. Health education on prevailing health problems 2. Promotion of food supply and proper nutrition 3. Adequate supply of safe water and basic sanitation 4. Maternal and Child health Services 5. Immunization against major communicable diseases 6. Prevention and control of locally endemic and epidemic diseases 7. Appropriate treatment of common diseases and injuries 8 Provisions of essential drugs and supplies Additional elements were incorporated after Alma-Ata 9. Promotion of mental health 10. Provision of oral health 11. Primary eye care 12. Leprosy control 13. Research and statistics. PRINCIPLES OF PRIMARY HEALTH CARE Equitable distribution Manpower development Community involvement or participation Appropriate technology Inter Sectoral collaboration EQUITABLE DISTRIBUTION This means that health services must be shared equally by all people irrespective of their ability to pay. Whether rich or poor, rural or urban must have access to health services without discrimination.. If we look at health statistics, you will find out that the health situation as indicated by health status indicators, e.g. infant mortality rate(IMR), Maternal mortality rate (MMR), birth rate (BR), death rate (DR), etc is lower in the urban areas than in rural areas. Why this difference? It is because, health services are mainly concentrated in the cities and towns, thus resulting inequality of care to the rural people.. This statistics reflect how the healthrelated resources are distributed with the countries including access to health services, education and income-earning opportunities. This is called social injustice. The inability to receive health care services by majority of rural people and those living in urban slums is inaccessibility. The aim of PHC, is to bridge this gap by shifting this concentrated health care system from cities or urban areas to the rural areas and bring the services as near as possible to the them. Another inequality to health is the disparity between genders which indicates that women suffer more from health problems than men MANPOWER DEVELOPMENT The manpower development in the context of health includes health professionals and auxiliary health personnel, members of community and supporting staff. PHC aims at mobilizing the human potential of the entire community by making use of all available resources. The requirements of health manpower will vary according to the varying needs of the groups of the population. PHC focuses on; Education and training of health workers to perform functions relevant to countries health problems. Reorientation of health personnel Planning health manpower according to the needs of health system, in terms of the right kind of manpower, the right number, at the right time and in the right place. These workers have to be trained and retrained so that they can play a progressive role in providing primary health care. The second categories of health personnel are traditional medical practitioners and birth attendants. They are often part of the local communities, culture, and traditions and exert influence on local practices. Therefore these indigenous practitioners need to be trained accordingly for improving the health of the community Lastly, we can say that family members are often main providers of health care, mainly women play an important role in promoting health thus they contribute significantly to primary health care, especially in ensuring the application of preventive measures. Women’s organization can be taught and encouraged to discuss on question as nutrition, child care, sanitation, and family planning. School teacher and adolescent girls can be trained on human sexuality and home nursing. Similarly young people can be educated on health matters. They can be effective in carrying these messages to their homes thus promoting primary health care. COMMUNITY PARTICIPATION This is the most essential and sensitive principle of PHC. Community participation is the process by which individuals, families and communities assume the responsibility in promoting their own health and welfare. By their own health decisions, they develop the capacity to contribute to their own and the community’s development, through their involvement in the planning, implementation and maintenance of health services The term community involvement in health describes the process in which partnership is established between government and local communities in planning and implementation of health activities. It aims at building local selfreliance and gaining social control over PHC infrastructures and technology. For example, in the training of village health workers and aids, they are selected by the local community and are trained locally in the delivery of primary health care This concept, is an essential feature of PHC. The individuals in the community, knows their own situations better and are motivated to solve their own common problems. Thus it can be stated that involvement of community in health matters will require attainment of capacity by individuals to appraise a situation, which the various possibilities and estimate what can be their own contributions. Your contribution in community participation, as a member of the health system, is to motivate the community to learn and solve their own health problems, explain, advise and provide clear information about favourable and adverse consequences of the health interventions proposed as well as their relative cost. The areas in which the individuals, families and communities can be involved/participate include; Involvement of the community in assessment of the situation Definition of the problem and setting of priorities. APPROPRIATE TECHNOLOGY Appropriate technology means the technology that is scientifically or technically sound, adaptable to local needs, culturally acceptable and financially feasible. This implies that technology should be in keeping with local culture. It must be capable of being adapted and further developed, if necessary. In addition, it should be easily understood and applicable by the community. The health for all target requires first and foremost scientifically sound health and technology that people can understand and accept. It also implies the use of cheaper, scientifically valid, acceptable and available equipments, procedures and techniques rather than those costlier and non affordable and non accessible to the community. For example, oral dehydration fluid, locally prepared weaning food. It is socially, economically and professionally acceptable o take the technology closer to the people, consumer, wherever possible. For example, making dehydration salts for babies. This is available to mothers in every home which is likely to be more useful than expecting the mothers to take their babies to the special centre The concept of appropriate technology can further be explained by taking the example of ORT (Oral rehydration therapy). The ORT packets is used for diarrhea, prescribed by WHO cannot be made available to each home. So the community is taught on how to prepare the sugar salt solution to combat dehydration in a child with diarrheas THE ROLES OF NURSES IN PHC Assessing, observing and speaking to patients Recording details and symptoms of patients medical history and current health. Preparing patients for investigations and treatment. Administering drugs and treatment through monitoring patients for side effects. Patient’s advocacy and education Effective communication. Empowering and supporting patients Securing health services relevant to community and population needs. Inter-professional communication Team work and Leadership People centered care and clinical practice Understanding individual needs. Continuous learning and research Maintaining professional expertise Reflective Research practice Team-based delivery are. PUBLIC HEALTH NURSING Public health is the sciences of protecting and improving the health of the people and their communities. This is achieved by promoting healthy lifestyle, researching the cause of diseases, injury prevention, detecting and responding to infectious diseases. It is also defined as organized efforts of society to keep people healthy and prevent injury , illness and premature death. Public health nursing is the practice of promoting and protecting the health of the populations using knowledge from nursing, social and public health sciences. It is also defined as a population focused community nursing practice with the goal of prevention of disease and disability by creating the condition where people can be healthy. It focuses on improving the health of the population by emphasising prevention and attending the multiple determinants of health(those factors that influences health status of an individuals such as education and literacy, income and social status, physical environment, health services, employment/working condition, healthy child development). A Public health nurse role are focused on health promotions, health protections and disease preventions. The health of the public health system in Nigeria is linked into Pre-colonial, Colonial and Post-colonial eras. PRE-COLONIAL ERA This is the period of the use of traditional medicine in different communities. In response to their health needs many communities make use of locally available materials/resources to treat the health problems of the people. The development of traditional medicine led to the categories of healers and healing strategies. The categories of traditional healers are: Herbalist: The Herbalist use mainly herbs such as plant to cure diseases. Traditional Birth Attendants(TBA): The TBAs are prominent in Nigeria till date, mostly found in rural areas who assist the mothers at childbirth based on their skills. Traditional Surgeons: They specialised in the cutting of tribal marks, male and female circumcision. Spiritual Healers: they are the fortune tellers, Priests who have supernatural forces. COLONIAL ERA The colonial era marks the period from the early 16th century up to the time Nigeria had independence from colonial rule in 1960. medical was managed by Missionary Agencies around the coast of West Africa. In the early 19th century the Missionary Agency opened health facilities in Lagos and Abeokuta(1895). During the same era government organized health care facilities established in Calabar(1898) and military health care in 1888. These health care facilities transformed into West African Medical services. Government/Colonial medical services became fully functional in the beginning of the 29th century. The first Medical Officer of health in Nigeia was Issac Ladipo Oluwole in 1925. He made contribution in public health services such as the first school of hygiene in Yaba, Lagos Nigeria, construction of new abbatoir to increase food security and promote malaria management. Between 1924 and 1930 bubonic plague struck Lagos mostly in unclean communities causing numerous deaths. Adequate sanitary inspection was carried out in order to combact the spread of bubonic plague. THE POST-COLONIAL ERA In 1967 to 1985, the State health Services located in different States between 1975 and 1980 had the Basic Health Services Scheme was a major attainment in the Public health sector in the country as it increases coverage, accessibility and utilization of health services especially to the rural areas this was as a result of the Alma-Ata declaration of 1978 on PHC as a strategy to provide Health Care for All. In 1987, Public Health was introduced in Nigeria, the national health policy was adopted in order to achieve a level of health that will enable all Nigerians to achieve socially and economically productive lives. The provision of access to primary, secondary and tertiary Health care through a funtional referral system. Historical perspectives of Public Health Nursing: the history of Public health nursing can be traced in the 1800s. In the 1800s the early home care began with religious and charitable group, lay women dedicated in serving the poor and the needy. Curative care as basically given to the sick individuals. In 1800 to 1990 they were district nurses who primarily care for the sick. They treat sick individuals under the directions of the physicians. The nurses instructed the people on personal hygiene, diets, healthy living habits, curative care and beginning of preventive care. Voluntary organization supports the activities of nurses. In 1990 to 1970, specialized programmes on infant and health teaching to the public. Nurses focused on sick people. They render both curative and preventive care, voluntary agencies and government supports the activities of nurses to improve the health of the society. In 1970 to present, more emphasis were based in the community on health promotion and illness prevention. Voluntary agencies, government, other independent practitioners gears to improve the health of the community. The public health nursing practice started in the early 1980s. The earliest Public Health Nurse were Dorcas Young, Late Miss Adebogun. The first Public Health nurse Tutor was Ann Adeguroye graduated in 1960and wrote a book in “Community Health Care” published in 1983. The Public Health Nurses were in-charge of all health centers in Nigeria. The first planned home visiting caring for the neglected children and visits to persons started with Sister Marie of the Assumption in 1986. In August 1989, the concept of essential drugs and expanded programme on Immunization in 300 hundred LGA were introduced. Most nurses were ready to be trained as a public health nurse. PURPOSE OF PUBLIC HEALTH NURSING a. To promote the health and efficiency b. To prevent and control disease and disabilities c. To prolong life by providing need based on individual and families. d. To provide comprehensive health care service to the population e. Educate community about managing chronic conditions and making a healthy choice. f. Conduct research to improve health care. ORGANIZATION AND SCOPE OF PHC SERVICES The healthcare service system of Nigeria is controlled by the three tiers of the government, federal, state and local government which in turn collectively control the levels of the health care system: primary, secondary and tertiary health care system. Each tier has very important roles to play in the organization of health services in Nigeria. Nevertheless, it is note worthy that today, unlike in the past local government have very important roles to play in the provision of health services at the grass root level. A good health system delivers quality services to all people when and where they need them. The federal government’s role is mostly limited to coordinating the affairs of the University Teaching hospitals, Federal Medical Centers (tertiary healthcare) while the State Government manages the various General hospitals (secondary healthcare) and the Local Government focus on dispensaries/Primary health Care Centres) which are regulated by the federal government through the National Primary Healthcare Development Agency (NPHCDA). FEDERAL GOVERNMENT: (FEDERAL MINISTRY OF HEALTH) The Federal Ministry of Health forms the apex of health care delivery system in Nigeria. The headquarters was formally in Lagos but later moved to Abuja. The political head of the ministry is the Minister of Health and Social Services, the federal permanent secretary in the ministry is the next to the minister in order of hierarchy. This is the highest level of healthcare. It provides referral to the Secondary level of Care. The Federal Government is primarily responsible for policy development, regulation, stewardship, leadership and providing for the tertiary care through the Federal Ministry of health. The institution of health care are the teaching hospital, federal medical centres and specialist hospitals. This level of health care has a large number of specialists and also embarked more on researches. They provide curative rehabilitative health care services. Following the civil service reforms of 1991 in which civil servants were organized into professional categories, the divisions within the federal ministry of health and state ministries were renamed directorate. Each directorate is headed by a director who is a career civil servant he is responsible for the day to day running of the directorates. Thus in the federal ministry of health there are directorates of Public health Hospital service and training Food and drug control Planning, research and statistics etc For each of the directorates there are professional staff or career officers who form a vertical structure. In the directorate of nursing structure such as: Director of Nursing service, Assistant Director of Nursing services, Chief nursing officer, Assistant chief nursing officer, principal nursing officer, senior nursing officer, nursing officer 1 and Nursing officer 11 respectively. The roles and functions of the federal ministry of health in the organization of health service in Nigeria are as follows: Formulation of national health policies Provision of funds for manpower training. Establishment of specialized training and research institutions such as colleges of Medicine, Teaching hospital and research unit Provision of funds for the ministry of health or health department at states and local government levels respectively either for capital projects, training or research. Monitoring supervision of projects and programmers at state and local government levels. Setting the standards for state and local government health department Promotes research activities and collaborates with the international bodies such as the World Health Organization (W.H.O) and UNICEF Organizing tertiary institutions etc Supervises the training of primary health care workers Monitoring and evaluation of measures for implementation of primary healthcare programmers at state and local government levels Provision and distribution of vaccines for states and local government National Programs on Immunizations. STATE GOVERNMENT LEVEL: (MINISTRY OF HEALTH) The organization of health services at State level follows the pattern of the federal Ministry of Health. In the State Ministry of Health, the Commissioner of health is the political head, followed by the permanent secretary of health, who is career civil servant. Like the federal ministry of health each directorate is headed by a director. The director is usually assisted by deputy and heads of unit This is the second level of healthcare services in Nigeria. Secondary health care provides specialized services to patients through outpatient and inpatient services of hospitals under the control of State government. Patients are referred from primary health care facilities to secondary hospitals. The state government is responsible for funding secondary healthcare level in the health institutions such as General Hospitals. The cares provided are mainly curative and rehabilitative services of specialized manner. They provide referral to the tertiary healthcare. They also give a bit of preventive and promotive care. Among their staff are general Medical Officer(Physicians), Surgeons paediatricians, gynaecologists, ophtalmologists, physiotherapies, nurses etc. The roles and function of State Ministry of Health: Establishment of Hospitals’ Management Board (HMB), one in each state which provides effective management and facilities for secondary care institutions, such as specialists and general hospitals. The board is headed by a permanent secretary Organization and management of health training institutions in the state such as the colleges of medicine, schools of nursing, midwifery and health technology Formation of state health policies Translation and execution of federal health policies Recruitment and discipline of staff Setting of standard for private and mission hospitals and clinics International liaison, ie liaising with International agencies, such as UNICEF, WHO, UNESCO etc Research activities etc THE LOCAL GOVERNMENT PRIMARY HEALTH CARE LEVEL The primary health care level is the lowest level. It is the entry point to health care services. According to the present arrangement, the local government is responsible for the provision of primary health care service at community level. Each local government is expected to organize primary health care facilities within the local government area. The level provides basic health services such as promotive, preventive, curative and rehabilitative services The political head of the primary health care unit in a local government is the Supervisory Councilor for health who is responsible to the Chairman of the Local government. The medical officer is the head of the health team. Other members of the team are, community health officers, midwives, nurses, community health extension workers e.t.c The team carries out the day to day organization of the various primary health care programmes, such as maternal and child health services, family planning, immunization, refuse disposal etc. Based on the national and state guidelines, each local government also formulates its policies on primary health care The most significant development in the reorganization of health services in Nigeria is the expanded role of local government as regards Primary health care services. They are now directly responsible for organization and rendering primary health services to the community people through the administration of primary health care centers within the local government areas. Each of the local government in Nigeria today, has a department of health. In any local government area where there is no Doctor the primary Health care department is usually headed by experienced Community Health Officers. The team manages all the health centers within the local government area. This primary health centers, such as health posts, primary health centers and comprehensive health centers within the local government area, provides various services such as, health education, pre and post-Natal cares, treatment of minor ailments, environmental sanitation, Reproductive Health care service. The roles and functions of local government as health care providers can be listed as follows: Recruitment, training, promotion and disciplines f staff Planning and organization of P.H.C service Liaising with state and federal government on primary health care matters. Enforcement of environmental health laws Referral services etc Compositions and functions of development Committee in PHC services VILLAGE DEVELOPMENT COMMITTEE All those who are very influential in the community like some rich men, philantropists, that resides in that community Those representing intersectoral agencies e.g Agricultural extension workers, Community development officers and educationists. Representatives of women organizations, religious organizations, men organizations, youth organizations, social clubs, etc Those representatives should be residing in that area, speak local language of that community, share their culture, attitude and beliefs. They should also be knowledgeable enough, command respect, be friendly. Approachable and must be willing to make sacrifices to the community. Functions of VDC Identifies health and social needs of the people in the community Identifies local, human and material resources to meet these essential needs Mobilizes and stimulates active participation of the members Involves everybody in the planning and implementation of the projects. HEALTH FACILITY DEVELOPMENT COMMITTEE This comprises of the residents in that area with knowledge and experience in finance and administration. Representative from the provincial administration In charge of the health facility District medical officer of health Area councillor or person in charge of the local authority health facilities All members should hold at least four level certificate of education Functions of HFDC Supervise and control the administration of the funds allocated to the facilities. Open and operate a bank account at an approved bank Prepare work plans based on the estimated expenditures. Oversees accounts of the income, expenditure, assets and liabilities of the facility. Prepare and submit certified periodic financial and performance reports as prescribed. Oversees the maintenance of a permanent record of all the deliberations. DISTRICT DEVELOPMENT COMMITTEE This comprises of: District head Representative of the village organizations Representative of health-related NGOs Representatives of health related sectors e.g Directorate of foods, roads,rural infrastructure and agriculture District health team FUNCTIONS OF DDC Organize fund raising activities. Liase with government and other voluntary agencies in the district to solve health and social problems Co-ordinate and supervise the activities of village health committee. LGA PHC DEVELOPMENT COMMITTEE COMPOSITION 1. 2. 3. 4. 5. 6. 7. Supervisory Council for Health. LGD/PHC Coordinator of health as secretary. Teaching Hospital PHC Co-ordinator School of Health Technology PHC Co-ordinator. Chief Community health officer for LGA Chief community development officer for LGA 3 representatives of the community must include a woman. 8. Representatives of the international NGO which has PHC program in the area. 9. Representative of the mass media. FUNCTIONS OF LGA PHC DCC Plan and manage PHC Services Identify training needs of health worker at LGA Mobilize communities for effective participation in health care programme.