Primary Health Care Jose $. Cruz Ill ake Introduction Brief History of Primary Health Care Definition of Primary Health Care Key Principles of Primary Health Care The 4 As of PHC: Accessibility, affordability, acceptability, and availability Support mechanisms Multisectoral approach Community participation Equitable distribution of health resources Appropriate technology Primary Health Care versus Primary Care Summary Pees Upon completion of this chapter, the reader should be able to: 1. Define primary health care (PHC). 2. Explain the definition of health by the World Health Organization 3. Outline the historical background of PHC. 4, Enumerate the key principles of PHC. 5. Relate the application of the PHC key principles in the implementation of public health programs 6. Describe traditional and alternative health care modalities that may be applied in communi Cite the differences between approach and primary care. [Sas acceptability accessibility affordability appropriate technology availability community participation equitable distribution of health resources health multisectoral approach (intersectoral, intrasectoral) primary health care support mechanisms PHC INTRODUCTION The improvement in health quality of the population is a continuing challenge for societies and governments. In spite of the many advances in medical practice and health sciences in past years, the vast majority of the population still barely meet 49= pinimum Standards for health care imaden uma development. Faced with the lequacies in health services, the emergence oF lifestyle diseases, new and uncontrolled {OmmMunicable diseases, maldistribution of health resources, and the worsening social and economic status of the marginalized, Some societies and governments are not able to cope adequately to meet the needs of the population. In the age of globalization, health and health problems too have become global. Cardiovascular diseases and cancer are no longer identified as diseases of just affluent countries; even developing countries like the Philippines are seeing a continuous upward tend of these diseases in the past decade. Note that health care is not just a problem of poor developing countries; even the wealthiest countries are facing health care concerns. These countries are now coping with the situation where they have an ageing population with chronic illnesses that need long-term care. Hence, an overall approach in the delivery of. health services is necessary—a strategy that engages both the health workers and the people themselves as partners, and a strategy that is affordable to the government yet still effective and acceptable to the communities, a strategy that ensures access to health care regardless of economic class, The World Health Organization (WHO) has long championed a strategy that it believes is the key to most of the health problems. And for more than 30 years now, the WHO has not wavered in its promotion for the global implementation of primary health care (PHC), ec ore BRIEF HISTORY OF ae ‘(HEALTH CARE ‘On September 6-12, 1978, health leaders from around 200 countries attended the International Conference for Primary Health Care held at Alma Ata, USSR initiated by 50 the WHO and United Nations chip Fund (International Conference on p, Health Care, Alma-Ata, 1978). Tope? they expressed the need for concene) efforts by all governments and health qe evelopment workers for the protection gn promotion of health of all the people. 7 ‘Alma Ata Declaration on Primary Health Cay: emerged from this conference. The Alma ays Conference made the following declarations «Health isa basic fundamental right, + There exists global burden of heal inequalities among populations + Economic and social development is of basic importance for the full attainment of health for all. + Governments have a responsibility for the health of their people. dren timar, The PHC strategy was later adopted in the Philippines by virtue of Letter of Instruction (LON) 949 of 1979, making the Philippines the first country in Asia to embark on meeting the challenge of PHC (Bautista, 2001). i must be noted that even prior to LOI 949, which provided impetus to the then Ministy of Health, there were several health workers, nongovernmental organizations (NGOs), and church organizations. offering community. based health programs in the rural areas of Visayas and Mindanao, applying the spirit of PHC even before it was formally adopted by the government. Basic to the PHC declaration is the common view that health “is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity’ (WHO, 1978). Viewing health from a holistic perspective, beyond just physical and mental ‘maladies, the WHO has put equal emphasis on the social dimensions of health, that wellness can be achieved by considering different factors that interdependently influence the health of the population, such as the environment, education, social services, and politics) leadership.In addition, health is seen as not just a product of social and economic development, but more so as a means of achieving development. Thus, government investment in the health of the population is ultimately linked to the country’s development. A healthy population has the capability to contribute more to its development, By emphasizing the people's right to health, the government is driven to increase investment on health care, The WHO recommends governments to allocate 5% of the gross national product (GNP) to health services. In the Philippines, the average allocation for health services from 2005 to 2007 was only 3.3% of the GNP (National Statistical Coordination Board 2011). According to the Alma Ata Declaration, PHC + CTC muacioa! scientificallysoumd and methods and technology made universally accessible to individuals and families in the community 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’, The universal goal of PHC as stated in the Alma Ata Declaration is by the year 2000. Health for all means an acceptable level of health for all the people of the world through community and_ individual self- reliance. This policy agenda of “health for all by the year 2000” technically was a global strategy employed for achieving three main objectives: (1) promotion of healthy lifestyles, (2) prevention of diseases, and (3) therapy for existing conditions. Although many states have adopted the plan and have made significant progress in achieving these objectives, the challenge rests among nations, developed or developing alike; and a considerable amount ITION OF PRIMARY HEALTH of work remains to be done to achieve the aims of the declaration. To put further emphasis on PHC in the Philippines, President Ferdinand Marcos signed the BON949 that has an underlying theme, hlealthyinsthe-Handsof the People by 2020", The WHO has identified to achieving the goal of “health for all”: 1. Reducing exclusion and social disparities in health (GiniversaWeoweragey 2. Organizing health services around people's needs and expectations (health 3. Integrating health into all sectors (public 4. rene collaborative models of policy dialogue (leadtershipterorts) 5. IRIGREASing StakeholdenpasticipATOnaS The AWW@"AtamPeclarationselistedmeight ‘Gsenitialhiealtheservices, using the acronym ELEMENTS as a memory aid: FE — Fducation forhealth== Rest ition noncommunicable diseases KEY PRINCIPLES OF The key principles that set PHC apart from the traditional mode of health care delivery are: + Accessibility, affordability, acceptability, and availability * Support mechanisms Multisectoral approach * Community participation ‘+ Equitable distribution of health resources + Appropriate technology 51The 4As of PHC: Accessibility, affordability, acceptal and availabil isually refers to the physical ‘This requires the existence of a facility. within reasonable distance from the catchment population or the people it is meant to serve. The WHO guideline states that for these health care facilities to be considered accessible, they must be oT om the communities. Barangay health stations (BHSs) are facilities intended to provide accessible health services at unity level. lability ismHOUSHly in ConsiderALION of ud yy for basic health services. Particularly for public u rd tHESEREWIRs, One of the factors the WHO. considers in determining affordability of health care is the for health care. This is the actual cost to the family for health services less any coverage of insurance. In the Philippines, the government health insurance is covered through PhilHealth. There are other health insurance policies offered by private companies or health management organizations. gist means that the eae ‘dis in @msomance with thelprevailin g wee is a question of whether the basic health services required the_peoplé@ire Oreo STEMTCRRSANTTC oe provided on a regular and organized manner. Consider the following health programs and analyze them according to the 4As as defined above. 1. Botika ng Bayan and the Botika ng Barangay. ‘These drugstores were established by the Philippine government to promote equity in health by ensuring the availability and accessibiliny Affordable, safe and effective, gy essential drugs tall, with prigg given to the marginalized, underser a critical, and hard-to-reach areas. They, government-run drugstores distribiy sell, or make available low-priced gene home remedies, over-the-counter drygs and selected, publicly known prescripren antibiotic drugs (DOH Administraiy Order 234, 1996). It must also be noteg that some Botika ng Barangay stores are operated by nongovernment institution, churches, and cooperatives. 2 one Childten aged 9 months to below 8 years old were vaccinated against measles and rubella In addition to a door-to-door campaign, the immunization is also offered in all health centers, BHSs, hospitals, and other temporary immunization sites such as basketball courts, town plazas, and other identified public places during the ‘campaign. The resources for eSS@iitialWHealiimservices come from three major entities: thelp@Oplel IeMBENEs, theagovernment, and the private S8GEMlike NGOs and socio-civie and faith groups. Health programs and projects provide better outputs when these three entities are involved. For efficient utilization of ‘resources from these three major sectors, a multisectoral approach is necessary. Multisectoral approach As health and disease are outcomes of multiple interrelated factors, PHGUFEquiTeS of exemplified through intrasectoral and intersectoral linkages,Intrasectoral linkages. Intrasectoral linkages refer to CORAWWHIE ‘i ‘oneeSOpeyiONaA ESM ATOTTOT Nn th r: among the members of the health team and among health agencies. his is exemplified by the team approach utilized by the personnel of a health center in dealing with health conditions and problems. The two-way referral system, another illustration of intrasectoral linkages, is necessary so that clients get the needed and desired care. For example, a pregnant woman who had prenatal checkups in the BHS or rural health unit (RHU) has been identified as high risk. She would be referred to the appropriate hospital for childbirth. In this case, competent care is ensured and available health resources are utilized properly. In the spirit of the two- way referral system, the same mother once discharged from the hospital is referred back to the RHU for follow-up home care, a service that most hospitals obviously do not provide. Hence, given the above scenario, the two- way referral system ensures competent care, maximum use of availability of resources, and continuity of care. Intersectoral linkages One of the major criticisms against the traditional perspective in development is that the tools for analysis and strategies used are primarily economic in orientation. The idea that the population is sick because they are poor implies that illness or health is a result of economic gains or the lack thereof. PHC seeks to reverse this paradigm, advocating a more comprehensive view of the synergy between health and economic development. Simply put, health is not merely the product of the ‘economic development. Health and economic development complement each other in the achievement of the societal goals of holistic human development. Health is a multisectoral concern, Therefore, primary health and public health programs should not and cannot be taken in isolation from the overall deve- lopment agenda of society. Intersectoral linkages encompass the com- munication, cooperation, and collaboration between the health sector and other sectors of society like education, public works, agriculture, and local government officials. A concrete example of intersectoral linkages is the Rabies Prevention and Control Program, It requires collaborative effort among the Department of Health (DOH), Department of Agriculture (DA), Department of Education (DepEd), and local government _ units (LGUs). The DOH provides immuniz. for victims of animal bites, the DA provides outreach rabies immunization for dogs, while the DepEd and the LGUs are in charge of information campaign in schools and communities. Community participation — A key to understanding the concept of PHC puts emphasis on how it is defined: that SSPGSCMINATON, and that viduals, families, and communities are not consi- Community participation is an educational and empowering process in which people, in partnership with those who are able to assist them, identify the problems and the needs and increasingly assume responsibilities themselves to plan, manage, control, and assess the collective actions that are proved necessary. Ideally, true or active participation means that people should be knowledgeable about their own health problems and should identify the needs for their solution or reduction and draw out plans of actions according to the priority and the resources available; organize and implement the programs and monitor and control their progress; and periodically evaluate for getting the feedback and do the reprogramming (Roy, 1986) 53detail the process Chapter 4 will includ " tici- and strategies to promote community Pa pation. The community must be involved in all stages of health care development. Equitable distribution of health resources PHC advocates for care that is community: based and preventive in orientation. It calls for an inventory and analysis of health resources, facilities, and manpower. According to the Development and Training Services. Philippines has an oversupply of graduates medicine and nursing, but they tend to flock to the urban rather than to the rural areas (EGD on the HMDTS, 2001). Among health professionals employed by the Philippine government, around 29% and 26% of doctors and nurses, respectively, practice in the National Capital Region and Calabarzon (National Statistical Coordination Board, 2011). There is also a general impression that graduates of health-related college programs prefer to work abroad rather than to stay in the Philippines. To reverse this trend, the DOH is spearheading two programs to ensure equitable distribution of manpower to the rural areas; these programs are: 1. Doctor to the Barrios (DTTB) Program. The DITB Program is the deployment of doctors to municipalities that are without doctors. DITB volunteers are fielded to manage the RHU or health centers in unserved, economically depressed fifth- or sixth-class municipalities for 2 years; they also have the option of being permanently absorbed by the ‘municipality. These volunteers are offered competitive compensation by the DOH and the LGU. 2. Registered Nurses Health Enhancement and Local Service (RN HEALS). The RN HEALS is a training and deployment program for unemployed nurses. RN Health Manpower the sof 54 junteers are deployed economically —depressey municipalities for 1 year to address the mejequate musing WorkForce in rya) communities and health facilities. I agg omyides the nurses valuable trainin Proenhance both their clinical apg preventive management competencie, Prmpensation for the volunteer ny araigo shared by the DOH and the 1¢u HEALS vol unserved: Appropriate technology the dictionary, technology jg applied science’, Health technology include tools, drugs, methods, procedures, ang techniques. Appropriate technology refers to the technology that is suitable to the re mmunity that will use it. To better capture ite essence, the terms “people's technology nd “indigenous technology” are also used in appropriate technology. According to reference to Criteria for appropriate health technology + Safety. This means that the technology results in minimal risk to the user and that the intended positive outcomes of the use of a technology far outweigh its unintended negative effects. For example, the pertussis vaccine (a component of DPT which is administered in the Expanded Program on Immunization) is not recommended to be given to a child who is 7 years or older because, at this age, the vaccine is already more hazardous than the disease itself. * Effectiveness. The technology should accomplish what it is meant to accomplish For example, medicinal herbs endorsed by the DOH have been tested and have been clinically proven to have medicinal value in the relief and treatment of ailments * Affordability. Measures for _ health promotion and disease prevention are cost: effective in comparison to treatment of diseases. Prevalent childhood conditionssuch as cough and colds, diarrhea, and fever, often require home management only. ‘These cost-effective interventions require an educated community. + Simplicity. The technology that requires readily available simple materials. and that involves a simpler process in its use can be more easily adopted by the people in the community when and where applicable. For example, oral rehydration for management of diarthea is a simple technology that can be administered at home. + Acceptability. Technology is effective only when it is used by those who need it, Thus, culture is an important consideration in determining the appropriateness of a technology. In addition, education regarding a particular technology is essential for its adoption. * Feasibility and reliability. The technology must be easy to apply considering the people's natural settings like the home, school, workplace, and community. Supplies must be constantly available; for example, compared to chest X-ray, sputum examination is feasible in more areas. * Ecological effects. Effects on ecology are an important consideration in choosing or rejecting a particular technology. For example, DOH Administrative Order No. 21, s. 2008 mandated the gradual phase out of mercury in all Philippine health care facilities and institutions. + Potential to contribute to individual and community development. Appropriate technology promotes self-sufficiency on the part of those using it. Traditional and alternative health care RA. 8423 or the Traditional and Alternative Medicine Act of 1997 was signed into law through the efforts of then Secretary of Health Juan Flavier, This created the Philippine Institute of Traditional and Alternative Health Care, which is tasked to promote and advocate the use of traditional and alternative health care modalities through scientific research and product development. R.A. 8423 defined traditional medicine as the “sum total of knowledge, skills, and practice on health care, not necessarily explicable in the context of modern, scientific philosophical framework, but recognized by the people to help maintain and improve their health towards the wholeness of their being, the community and society, and their interrelations based on culture, history, heritage, and consciousness”. Herbal medicine has long been practiced in the Philippines. The DOH through its “Traditional Health Program” has endorsed 10 medicinal plants to be used as herbal medicines in the Philippines due to their proven health benefits as attested by the National Science and Development Board (see Table 3.1). Table 3.2 is a summary of the frequently used forms of medicinal plant preparations. ‘The common methods of preparations (see Table 3.2) of herbal medicines can be used as a general guide only. Always follow the specified preparation for herbal medicines when available. Further, note that a single plant may be prepared in a variety of ways depending on the indication for its use. An example is bawang (garlic), which can be applied/rubbed directly on the affected area for fungal infections or fried to be ingested for control hypertension. ‘The law defined alternative health care modalities as “other forms of nonallopathic, occasionally nonindigenous or imported healing methods, though not necessarily practiced for centuries nor handed down from one generation to another. Some alternative health care modalities include reflexology, acupressure, chiropractics, nutritional therapy, and other similar methods’, Table 3.3 is a summary of frequently practiced alternative health care modalities. 55rtment of Health Table 3.1 The 10 medicinal plants endorsed by the Depa’ a Medicinal plants use/indi an fF ect Lagundi Ash, cough and cas ee | aceite with decoction iysentery, pail Skin diseases (scabies, ulcer, eczema), wounds ‘ction Yerba buena Headache, stomachache a Cough and colds sal Rheumatism, arthritis Massage SP Sambong ‘Antiedema/antiurolithiasis Decoction n Tsaang gubat Diarrhea Decoctior Stomachache Niyog-niyogan Antihelminthic Seeds are used Bayabas Washing wounds. Decoction Diarrhea, gargle, toothache Akapulko Antifungal Poultice Ulasimang bato/ Lowers blood uric acid (rheumatism Decoction Pansit-pansitan and gout) Eaten raw Eaten raw/fried dependent) Bawang Hypertension, lowers blood cholesterol Apply on part Toothache Ampalaya Diabetes mellitus (mild non-insulin- | Decoction Steamed Table 3.2 Medicinal plant preparations Preparation Procedure for preparation Decoction Boil the recommended part of the plant material in water. Recornmended boiling time is 20 minutes. Infusion Plant material is soaked in hot water, much like making a tea. Recommended period of soaking is 10-15 minutes, Poultice Directly apply recommended plant material on the used on bruises, wounds, or rashes. penaiecee tae Tincture ‘Mix the plant material in alcohol ‘Source. Adapted from Comman Medicinal Plants of the Cordilera Region, CHESTCORE, 1989) 56Table 3.3. Alternative health care modalities practiced Term Definition Acupressure ‘A method of healing and health promotion that uses the application of Pressure on acupuncture points without puncturing the skin. Acupuncture ‘A method of healing using special needles to puncture and stimulate specific anatomical points on the body ‘Aromatherapy The art and science of the sense of smell whereby essential aromatic oils ‘are combined and then applied to the bady in some form of treatment. Chiropractic A discipline of the healing arts concerned with the pathogenesis, diagnosis, therapy, and prophylaxis of functional disturbances, Pathomechanical states, pain syndromes, and neurophysiological effects Felated to the static and dynamics of the locomotor system, especially of the spine and pehis. Herbal medicine/ Phytomedicine Finished, labeled, medicinal products that contain as active ingredients aerial or underground parts of the plant or other materials or combination thereof, either in the crude state or as plant preparations. Massage ‘A method wherein the superficial soft parts of the body are rubbed, stroked, kneaded, or tapped for remedial, aesthetic, hygienic, or limited therapeutic purposes. Nutritional therapy ‘The use of food as medicine and to improve health by enhancing the nutritional value of food components that reduces the risk of a disease. Itis synonymous with nutritional healing, Pranic healing ‘A holistic approach of healing that follows the principle of balancing energy. Reflexology The application of therapeutic pressure on the body’ reflex points to enhance the body's natural healing mechanisms and balance body functions. It is based on the principle that internal glands and organs can be influenced by properly applying pressure to the corresponding reflex area on the body. ‘Source: Implementing Rules and Regulations of R.A. 8423 (Tradtional and Alternative Medicine Act of 1997), Philppines counseling, patient education, and diagnosis PRIMARY HEALTH CARE VERSUS PRIMARY CARE As mentioned above, PHC is a strategy for the delivery of health programs. It should not be confused with primary care. According to the American Association of Family Medicine, primary care includes health promotion, disease prevention, health maintenance, and treatment of acute and chronic illnesses a variety of health care settings (e.g, office, npatient, critical care, long-term care, home care, day care). Primary care is performed and managed by a personal physician often collaborating with other health professionals and utilizing consultation or referral as appropriate. It refers to the first contact of a person with a health professional specificallyTable 3.4. Differences between primary health care and primary care Point of comparison Primary health care Primary care Individual Focus client Focus of care Family and community Promotive and preventive through community participation Curative, provided by health professionals Decision-making process Community centered/consultative- Health worker driven Outcome participative Self-reliance/self-help Reliance on health professiona to restore/regain health Setting for services Rural-based satellite clinics, ‘community health centers, health posts that are accessible to all ‘Mostly urban-based: hospitals, clinics Goal Development and preventive care ‘Absence of disease trained for and skilled in comprehensive and continuing care for person. Table 3.4 shows the differences between PHC and primary care. Furthermore, PHC should not be confused with primary nursing. Whereas PHC is a strategy for health care delivery focusing on the community, family, and individuals, primary nursing is a model of nursing care that emphasizes continuity of care by having one nurse providing complete care for a small group of inpatients within a nursing unit of a hospital. Nursing care is directed towards meeting all of the individualized patient needs. SUMMARY Primary Health Care is a philosophy and a strategy. It is not one single program or project rather it is the overarching strategy for the whole public health program. All DOH programs are anchored on the key principles of Primary Health Care. These programs seek to correct the inequities in health, ensuring health care for the most vulnerable population groups in the country. For these programs to be effective and sustainable, these require 58 genuine partnership of different sector, government and privates sectors. And more importantly these PHC programs should be a partnership between the health care providers and the community. And by so doing, these programs fulfill the vision of making all essential health services accessible, affordable, available, and acceptable, therefore achieving ‘our goal of “health is for all”. PEIN e ss Choose a specific Public Health Program (PHC) 2. Identify its goals, objectives, and strategies for implementation. 3. Analyze the program's goals and objectives based on the key principles of PHC: * Accessibility, affordability, acceptabik ity, and availability ‘* Support mechanisms * Multisectoral approach ‘* Community participation * Equitable distribution of health resources * Appropriate technology