Primary health care note

1. Public Health: Introduction

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3. Learning Objectives
Understand the definition of public health
Distinguish between basic clinical and public
health activities and research
Essential functions of public health

4. What is public health?
• Public health is the part of the civic infrastructure
that keeps communities safe and healthy.
• The current generally accepted mission of public
health is:
– “Promote physical and mental health, and prevent
disease, injury, and disability.”

5. Public health
professionals?
Nurses
Physicians
Laboratory technicians.
Educators
Nutritionists
Social workers.
Biostatisticians
Epidemiologists.
Economists
Lawyers.
Community-based or “grassroots” workers might include concerned
parents, grandparents, or civic leaders who volunteer their time.

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7. Definition; Public Health
• ‘Public health is the science and art of preventing disease, prolonging
life and promoting physical health and efficiency through organised
community efforts;
• for the sanitation of the environment, the control of community
infections, the education of the individual in principles of personal
hygiene, the organisation of medical and nursing service for the early
diagnosis and preventive treatment of disease, and the development
of social machinery which will ensure to every individual in the
community a standard of living adequate for the maintenance of
health’. (Winslow, 1920)
Charles-Edward Amory Winslow (1877 – 1957)
Source: Yale School of Public Health

8. Definition of Public Health
• Sir Donald Acheson in 1988 defined it as: ‘the science and art of
preventing disease, prolonging life and promoting, protecting and
improving health through the organised efforts of society’
• The field pays special attention to the social context of disease and
health, and focuses on improving health through society-wide
measures like vaccinations, the fluoridation of drinking water, or
through policies such as seatbelt and non-smoking laws.
• Donald Acheson Report, 1988, UK

9. The Acheson report shows the link between health and
mortality

10. PUBLIC HEALTH IN NIGERIA
• Dr Ladipo I. Oluwole
(1892-1953)
• Graduated from Glasgow
in 1918
• Appointed 1st African
Assistant MOH in1925
• Re-organised sanitary
inspection procedure to
control the spread of
plague in Lagos
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11. The Concept of public health
• Public health is considered to be about the health of people or
communities, as opposed to individual health - it is everyone's
responsibility.
• The concept of public health is dynamic and has changed over the
years due to changes in the health status of the population and the
determining situations of health.
• This means that public health aims to create the right conditions in
order to provide healthy state for the benefit of society.

12. Clinical Medicine VS Public Health
Clinical Medicine Public Health- Population Medicine
Take a history of the current illness
Ask directed questions
Problem identification; anecdotes, focus groups,
basic population health indicators,
Review of symptoms Surveillance statistics, Disease registries
Physical examination of the patient Behavioral risk studies, observational studies; cross
sectional studies, case control
Develop a single or differential diagnosis Develop a hypothesis
Conduct tests to confirm the diagnosis or reduce the
number in the differential
Case control studies, prospective cohort studies,
Evaluates possible modes of treatment-
Clinical studies
Evaluates modes of treatment-
Outcome evaluation
Cost-benefit analysis
Treat the problem Select, modify and implement programs
Monitor results Monitor outcome indicators
Adjust treatment plan as necessary Revise programs as necessary

13. Public Health Functions (I)
• Surveillance, analysis and evaluation of population’s health status
• Monitor health status to identify population or community health
problems
• Diagnose and investigate health problems and health hazards in the
community
• Monitor environmental and health status to identify and solve community
environmental health problems
• Diagnose and investigate environmental health problems and health
hazards in the community
• Act as quickly as possible with efficacy in solving and improving these
problems

14. Public Health Functions (II)
• Develop policies and plans that support individual and
community health efforts
• Once the health problem is identified, public health seeks
the best interventions and strategies to solve the public
health problem;
• And identify health and/or social actors or agents that
can be carried out in the best way possible

15. Public Health Functions (III)
• Health Promotion
• This is a public health function that tries to promote the
health of the population.
Example:
• Implementation of preventive measures; Smoking - free
areas
• Awareness - Raising campaign in all the society sectors

16. Public Health Functions (IV)
• Disease Prevention
There are two strategies to address diseases prevention;
• High risk approach
The high risk approach is aimed at individuals particularly
predisposed to an illness and an individual prevention
manner is offered to them
• Population approach
The population approach attempt to control the factors of
the population as a whole without focusing on a specific
collective matter

17. Public Health Functions (IV)
• Disease Prevention (2)
• There are three levels of prevention;
• Primary Prevention: to intervene before a disease
appears
• Secondary Prevention: to intervene in pre-symptomatic
phases
• Tertiary Prevention: to intervene when the individual is
already ill. Try to mitigate the effects of disease

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20. Public Health Functions (V)
• To develop effective programs and health facilities to
protect health
• The development and implementation of programmes
that promote health improvement of the population as a
whole;
• With the condition that they are based on efficacy
scientific evidence based and that they help to increase
the population’s quality of life

21. Public Health Functions (VI)
• Evaluation of public health policies, strategies and facilities
• Having just implemented, whatever process included in
society to solve or improve the health problems must be
evaluated
• To check its right performance and functioning and
analyse if it is associated with an improvement of the
health problems
Example:
To evaluate the effect caused by the implementation of
these politics and programmes on the number of smokers

22. What are the Essential Public
Health Services?
• The core functions of public health are divided
into 3:
• Assessment.
• Policy Development.
• Assurance.

23. Assessment:
• Monitor health status to identify community health problems.
• Diagnose and investigate health problems and health hazards in
the community.
Policy Development:
• Inform, educate, and empower people about health issues.
• Mobilize community partnerships to identify and solve health
problems.
• Develop policies and plans that support individual and community
health efforts.

24. Assurance:
• Enforce laws and regulations that protect health and
ensure safety.
• Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable.
• Assure a competent public health and personal health
care workforce.
• Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
• Research for new insights and innovative solutions to
health problems.

25. Primary Health Care
Principles, terms and concepts

26. Preamble
• “Primary Care”- 1920 in England. Lord Dawson reported on “First
Contact Medical Care and the Promotion of Primary Health Centre”.
• In 1962, the term was used in Britain to denote General Practice
• Prior to Alma Ata, Nations had one system or the other of health
care delivery.
• Nigeria had BHSS in the 70’s

27. Major events worldwide in the 70s
• Declaration of Health for All (HFA) by the WHO Health
Assembly in 1977
• Adoption of Alma-Ata declaration in 1978 of the PHC
approach as the strategy by which the ultimate objective of
HFA would be attained

28. BHSS in Nigeria
• Objectives:
- Increase access to appropriate health services by the end
of 1975-1980.
- Preventive and health promotion services to be
integrated with curative services.
- Basic Health Units to achieve integration
- Develop new cadre of primary health care workers to
man the health facilities to be constructed

29. BHSS in Nigeria
• Implementation:
- 1 BHU with Four categories of HF
 1 comprehensive HF at apex – 50,000 pop.
 4 PHC centers – 10,000 pop. each
 20 health clinics – 2,000 pop. each
 5 mobile clinics – 40,000 pop. Each
- States refused to comply because it meant constructing 25
HF in 1LGA
- With over N200 million spent, at the end of 1983, most of
the facilities remained uncompleted all over the country.

30. Reasons for failure of BHSS
• Reliance on unsustainable structures and equipment
• Little community participation and inter-sectoral
collaboration
• Selection based on political expediency
• The training of health personnel were also institutional
based
• Same reason for preference of urban posting persists

31. Reasons for a new approach
• Gross inequalities exists btw developed and
developing countries and also within countries –
leading to inequity
• High cost of technology*
• Access problems
• People have a right to participate individually and
collectively in their own health care
• Sustainability of many health interventions in doubt
• Univalent programmes which never translated into a
healthy population

32. Alma Ata USSR 1978 (12/9/78), defined PHC;
• 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 at a cost that the community and the country
can afford to maintain at every stage of their
development
• In the spirit of self reliance and self determination”

33. Definition…
• An integral part of both the country’s health system
• The central function and main process
• Overall social and economic development of the
country.
• First level of contact of individuals, the family and
the community with the National Health System,
• Bringing health-care as close as possible to where
people live and work
• and constitutes a continued health care process.

34. Principles of PHC
• Equity
• Community Participation
• Self Reliance
• Appropriate Technology
• A Multi/inter-Sectoral Approach
• Integration
Political goodwill is a sine quanon

35. Community Participation
• Generally speaking, this concept borders on four
principles; respect for autonomy, beneficience, non-
maleficience and justice. The components are:
- Sharing Project Costs
- Sharing Project Efficiency
- Increasing Project Effectiveness
- Increasing Beneficiary Capacity
- Increasing Community Empowerment.

36. Components of PHC
• Health Education and Promotion
• Immunization against major infectious diseases
• Prevention and control of locally endemic and
epidemic diseases
• Adequate supply of good water and basic
sanitation
• Promotion of food supply and proper nutrition

37. Components of PHC …
• Maternal and child health care including family
planning
• Appropriate treatment of common diseases and
injuries
• Provision of essential drugs and revolving system.
• *Dental health care
• *Mental health care
• *Primary eye care
• *Geriatric care

38. Misconceptions about PHC
• PHC is only of relevance to poor developing
countries which cannot afford modern medical
care.
• PHC is second best medicine acceptable only to the
rural poor and urban slum dwellers.
• PHC is a stop-gap solution to be replaced by
something better at a latter stage.
• PHC is a separate stand-alone service isolated from
the main health care system.

39. Content of Public Health laws 1998
Part I - Introduction
Part II - Appointment of Medical Officer of Health
Part III - Nuisances
Part IV - Duties of occupiers of premises
Part V - Communicable diseases
Part VI - Building regulations
Part VII - Drinking water quality
Part VIII - Market sanitation/street trading and illegal
markets regulation
Part IX - Food and food premises regulation
Part X - Local liquor regulation
Part XI - Abattoir and slaughter houses regulation
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40. Part II -Appointment of Medical Officer of Health
• The Government shall appoint a qualified Public
Health/Community Health Physician to be the MOH for the
purpose of this law in any LGA,
• In the absence of such qualification, a qualified medical
practitioner may be designated as the MOH for the area
• Every Senior Health Officer in the service of the Government of
the State or LGA may perform the duties of MOH
• And while on duty in any place shall have power to direct the
exercise of the powers and duties conferred by this law on any
health officer whether in the employment of the State or LG.
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41. Implementation of PHC; Nigeria
• 1985-1992: PHC Renaissance
• From 1986: Process of reorientation of health services towards
PHC approach
• Stepwise implementation with 52 LGAs at inception
• In August 1987, the federal government launched its Primary
Health Care plan
• Bamako initiative was introduced in 1988
• 1993-1999: Period of low PHC activity
• SOML/PHCUOR/NSHIP/BHCPF/etc

42. Current status of PHC in Nigeria
• Ward Health System: Represents the Current
National Strategy for the delivery of PHC services.
• Aims of WHS:
- To promote full & active community participation at
the grass root level
- To improve access to quality health care and ensure
equity
- To promote local initiatives and encourage poverty
alleviation activities in the ward
- To reinforce political commitment at grass root level
- To reduce morbidity and mortality especially
amongst women and children under five years

43. Committees at PHC level
• Village Development Committee
• Ward Development Committee
• PHC Technical Committee
• LG PHC Management Committee
• State Primary Health Care Board/Agency

44. PHC Organogram
LGA Chairman
Secretary
Medical Officer of Health/PHCC
APHCC APHCC APHCC APHCC APHCC APHCC
Ward level Coordinators/Station heads
Station heads
Village level coordinators
LGPHC Management committee
PHC Technical Committee
Ward Development Committee
Village Development Committee
DPM
Supervisor
for health

45. Health Manpower at the PHC
• Medical Officer of Health
• Doctors/Nurses/Midwives
• Community Health Officer ± midwifery skills
• Public Health Nurse
• CHEW
• JCHEW
• EHO
• Pharmacy technicians
• Others: lab technician, Health attendant and
support staff
• Health assistants

46. MOH, Nigeria
• 1856: the Association of Metropolitan Medical
Officers of Health.
• Ladipo Oluwole
• 2007: Association of Medical Officers of
Health in Nigeria
Managerial functions
Technical functions
Clinical functions

48. ASTANA Conference; October 2018
• Global conference on PHC
• PHC shall be driven by:
(1) Knowledge and Capacity Building
• Apply knowledge, including scientific as well as traditional
knowledge,
• To strengthen PHC, improve health outcomes
• Ensure access for all people to the right care at the right
time and at the most appropriate level of care, while
• Respecting their rights, needs, dignity and autonomy. 48

49. (2) Human Resources for Health
• Ensure decent work and appropriate compensation
for health professionals and other health personnel
working at the PHC level
• HCWs must respond effectively to people’s health
needs in a multidisciplinary context
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50. (3) Align Stakeholder Support to National policies, Strategies and
Plans
• Call on all stakeholders – health professionals, academia,
patients, civil society, local and international partners,
agencies and funds, the private sector, faith-based
organizations and others –
• To align with national policies, strategies and plans across
all sectors, including through people-centred and gender-
sensitive approaches,
• And to take joint actions to build stronger and sustainable
PHC towards achieving UHC 50

51. (4) Empower Individuals and Communities
• Support the involvement of individuals, families,
communities and civil society;
• through their participation in the development and
implementation of policies and plans
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52. (5) Technology
• Support broadening and extending access
to a range of health care services through the use of high-
quality, safe, effective and affordable medicines,
• Including, as appropriate, traditional medicines, vaccines,
diagnostics and other technologies.
(6) Financing
• Call on all countries to continue to invest in PHC to improve
health outcomes 52

53. INVERSE CARE LAW (Nigeria)
-Failure of implementation I
• .
Demand surplus to need
High socio-economic class
Unperceived needs
Unmet needs
Low socio-economic class

54. Leadership challenge
-Failure of implementation II
Hierarchal (traditional)
.
.
Transformational (modern)
.
.
Manager
Leader
Lower level
Lower level

55. Implementation Challenges III
• Poor Political Goodwill
• Organizations with learning disabilities; Poor
institutional memory
• 3 tier-responsibility
• Allocative & managerial inefficiencies
• Lack of human resource planning – developmental
• Mediocrity (Gaps in recruitment policy)

56. Conclusion
• Worldwide and most especially in Africa, countries are
facing health challenges that threaten to undermine future
economic development
• Government and other stakeholders need to close
implementation gap in health promotion by:
“Strengthening leadership and workforces, mainstreaming
health promotion, empowering communities and
individuals, enhancing participatory processes while
building & applying knowledge”

57. -
Thank you