primary health care

“Health For All’’
Dr.Ramesh Pawar
Moderated By: Dr.Ranjan Solanki.
Atma-ata declaration
Primary Health care
National Health Policies 1983 and 2002
Progress and Achievements
Success Stories.
What is Health?
A state of complete physical, mental, and social
well being and not merely absence of disease or
What does health for all means?
“Large numbers of the world’s
people, perhaps more than half,
have no access to health care at
all, and for many of the rest the
care they receive does not answer
the problems they have.”
John Bryant in his book “Health and the Developing World
The Joint WHO – UNICEF
international conference in 1978
at Alma-Ata (USSR)
Declared that
“the existing gross inequalities in the status
of health of people particularly between
developed and developing countries as well
as within the countries is politically,
socially and economically unacceptable.”
ample evidence of a dysfunctional, nonperforming public health system. …The
situation varies across the country and in
some parts of the country it functions very
well. I think on an average, it does not
function well and there are some parts
where it is really functioning incredibly
Montek Singh Ahluwalia
Dy Chairman, Planning Commission
The 30th World Health Assembly
in May 1977 resolved
“The main social target of governments
and WHO in the coming decades should
be the attainment by all citizens of the
world by the year 2000 AD of a level of
health that will permit them to lead a
socially and economically productive
The Joint WHO – UNICEF international
conference in 1978 at Alma-Ata (USSR)
Alma-Ata Declaration called on all the
governments to formulate national health
policies according to their own circumstances
to launch and sustain primary health care as
a part of national health system.
The Alma-Ata conference called for
acceptance of the WHO goal of
by 2000 AD
and ‘Primary Health Care’ as a way
to achieve Health For All
Alma –ata declaration
Health is a fundamental human right and that the attainment of the
highest possible level of health is a most important worldwide social
The existing gross inequality in the health status of the people
particularly between developed and developing countries is
politically, socially and economically unacceptable.
Economic and social development, based on a new international
economic order is of basic importance to the fullest attainment of
health for all.
The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.
Alma –ata declaration
Government have a responsibility for the health of their
people which can be fulfilled only by the provision of
adequate health and social measures.
All government should formulate national policies,
strategies and plans of action to launch and sustain
primary health care.
All countries should cooperate in a spirit of partnership
and service to ensure PHC for all people.
An acceptable level of health for all the people of the
world by the year 2000 can be attained through a further
and better use of the world’s resources.
The Alma-Ata conference defined
“Primary health care is an essential health care
based on practical, scientifically sound and
socially acceptable methods and technology,
made universally accessible to individual and
families in the community, through their full
participation and at a cost that the community and
the country can afford”.
Principles of primary health care
1.Equitable distribution
2.Community participation.
3.Inter-sectoral coordination
4.Appropriate technology
1. Equitable distribution
Some thing for all
and most for those who need the most
“Bahujan hitae bahujan sukhae”
2. Community participation
There must be a continuing effort to secure
meaningful involvement of the community in
the planning, implementation and
maintenance of health services, besides
maximum reliance on local resources such as
manpower, money and materials
3.Intersectoral coordination
"primary health care involves in addition to the
health sector, all related sectors and aspects
of national and community development, in
particular agriculture, animal husbandry,
food, industry, education, housing, public
works, communication and others sectors".
4. Appropriate technology
"technology that is scientifically sound,
adaptable to local needs, and acceptable to
those who apply it and those for whom it is
used, and that can be maintained by the
people themselves in keeping with the
principle of self reliance with the resources
the community and country can afford"
Elements of primary health care
problems and
the methods
of preventing
of food
supply and
supply of
safe water
and basic
and child
health care
ion against
the major
n and
control of
e treatment
of common
and injuries
of essential
National strategy for health for all ......
As a signatory to alma- ata declaration in 1978, the Govt. Of India
was committed to taking steps to provide HFA to its citizens.
In this connection two important reports appeared:
Report of study group on “HEALTH FOR ALL – on alternative
strategy” sponsored by Indian council of social science research
(ICSSR) and Indian council of medical research( ICMR)
Reports of working group on “HEALTH FOR ALL by 2000 A.D. ’’
sponsored by Ministry of health and family welfare, Govt. Of India.
This health policy forms a basis of the national health policy
formulated by ministry of health and family welfare, Govt . Of India in
National Health Policy -1983
NHP 1983 stressed the need for providing primary health
care with special emphasis on prevention, promotion and
 Suggested Planned time bound attention to the following
1.Nutrition, prevention of food adulteration.
2.Mainatince of quality of drug
3.Water supply and sanitation
4.Environmental protection
5.Immunisation programme
6.Maternal and Child Health Services
7.School Health Programme
8.Occupational Health
National Health Policy
India had its first national health policy in
1983 i.e. 36 years after independence.
For better programme planning NHP 1983
recommended an effective Health Information
NHP 1983- Goal
NHP 1983- Goal
Differentials in health status
among rural/urban India
Differentials in health status
among states
Differentials in health status
among socio-economic groups
Achievements Through The
Years 1951-2000
Achievements Through The
Years 1951-2000
Achievements Through The
Years - 1951-2000
But by the end of 2000 century it was clear
that the goals of health for all by the year
2000 AD would not be achieved ......
Factors responsible for this failure
Biased and poor socio- economic development in
the region where it was needed most.
Discriminatory policies due to age, gender and
ethnicity thus preventing access to health care
Millennium Development
Millennium Summit held in September
2000 in New York
Representatives from 189 countries met to
adopt the United Nations Millennium
Poverty eradication and development by
2015 being the core issue
“Millennium Development Goals”
Millennium Development
8 goals
18 targets
48 indicators
Related to health
•3 goals
•8 targets
•18 indicators
National Health Policy 2002
Achieving an acceptable standard of good
health of Indian Population,
Decentralizing public health system by
upgrading infrastructure in existing institutions,
Ensuring a more equitable access to health
service across the social and geographical
expanse of India.
NHP 2002, Objectives……..
Enhancing the contribution of private
sector in providing health service for
people who can afford to pay.
Giving primacy for prevention and first
line curative initiative.
Emphasizing rational use of drugs.
Increasing access to tried systems of
Traditional Medicine
Goals – NHP 2002
1. Eradication of Polio & Yaws-2005
2. Elimination of Leprosy-2005
3. Elimination of Kala-azar- 2010
4. Elimination of lymphatic Filariasis- 2015
5. Achieve Zero level growth of HIV/AIDS-2007
Goals – NHP 2002....
6.Reduction of mortality by 50% on account of Tuberculosis,
Malaria, Other vector and water borne Diseases-2010
7.Reduce prevalence of blindness to 0.5%-2010
8. Reduction of IMR to 30/1000 & MMR to 100/lakh -2010
9. Increase utilisation of public 2010 health facilities from
current level of <20% to > 75%
Goals – NHP 2002....
10.Establishment of an integrated system of
surveillance, National Health Accounts and
Health Statistics-2007
11.Increase health expenditure by government
as a % of GDP from the existing 0.9% to 2.0%2010
12. Increase share of Central grants to constitute
at least 25% of total health spending- 2010
Goals – NHP 2002....
13. Increase State Sector Health spending
from 5.5% to 7% of the budget -2005
14. Further increase of State sector Health
spending from 7% to 8%-2010
Policy prescriptions
Financial resource
1.Increase in health sector expenditure to 6%
of GDP, with 2% by public health investment
by 2010 is recommended by the policy.
2.Existing 15% of central government
contribution is to be raised to 25% by 2010.
Suggested norms for health
NHP 2002 has observed that the attainment
of health indices has been very uneven
across rural-urban divide,
Differentials in health status
among rural/urban India
To overcome the social inequality, NHP
2002 has set an increased allocation of
55% total public health investment for
the primary health sector, 35% for
secondary sector and 10% for tertiary
Crafting of a National Health Policy is a rare
Allow our dreams to mingle with ground realities
that needs are enormous and the resources are
Health needs are also dynamic and keep
changing over time
Had to make hard choices between various
NHP 2002 has given a continuum to NHP 1983,
where primary health care is adopted as the main
strategy through
Private sector/indigenous
system participation
Rise in public investment
The ultimate goal is achieving an acceptable
standard of good health of people of India.
The commitment of the service providers and
an improved standard of governance is a
prerequisite for the success of any health
Steps Towards Health For All-India
1985 – The universal immunization program (UIP) was
launched to provide universal coverage of infants and
pregnant women with immunization against identified
vaccine preventable diseases.
1992-93 – the UIP has been strengthened and expanded
into the child survival and safe motherhood (CSSM)
project. It involves sustaining the high immunization
coverage level under UIP, and augmenting activities
under oral rehydration therapy, prophylaxis for control of
blindness in children and control of ARI.
Steps Towards Health For All-India
1997 – Reproductive and child health (RCH-phase1)
program was launched which incorporated child health,
maternal health, family planning, treatment and control of
reproductive tract infection and adolescent health.
2005-2010 – RCH-phase 2 aims at sector wide, outcome
oriented, program based approach with emphasis on
decentralization, monitoring and supervision which
brings about a comprehensive integration of family
planning into safe motherhood and child health.
Steps Towards Health For All-India
2005-2012 – National Rural Health Mission a
major undertaking by the present united
progressive alliance government. It is also from
a strategic framework to implement the national
health policy 2002. The NRHM subsumes key
national programmes,
Reproductive and child health -2
National disease control programme and
integrated disease surveillance project.
Trends in Maternal Deaths
Levels of MMR by region,1999-2009
Under Five Mortality Rate India,1990-2009
Child deaths are falling, but not
quickly to reach the MDG Goal.
Infant mortality Rate(IMR)- India, 1990-2009
MGD Target….
Trends in Total Fertility Rate
Replacement level TFR, Viz 2.1, has been
attained by
Andhra Pradesh 1.9
Delhi 1.9
Himachal Pradesh 1.9
Karnataka 2.0
Kerala 1.7
Maharashtra 1.9
Punjab 1.9
Tamil nadu 1.7
West Bengal 1.9
Distribution of Deaths in Word- 2004
Source: Global burden of disease :2004 update
Projected Global Deaths: 2004-2030
Source: Global burden of disease :2004 update
India Literacy Rate(1901-2011)
Public health spending in
select countries
Achievement so far…
Samll Pox Eradication:
Smallpox is an acute exanthematous disease caused by infection with the poxvirus
History of Smallpox Eradication
History of Smallpox
Growth of Virus on Flank of a
Calf in Italy
Publicity about vaccine
production at a medical
After WWI
Most of Europe smallpox free
After WWII
Transmission interrupted in
Europe and North America
Stable freeze dried vaccine
perfected by collier.
Small pox eradication…
History of Smallpox Eradication
Pan American Sanitary
Organization decides to
undertake eradication
World Health Assembly adopts
goals to eradicate smallpox
Word Health Assembly decided to
intensify eradication and provide
more funds
History of Smallpox eradication
Small pox eradication
Smallpox eradication strategy
Mass vaccination
campaign in each
country, using vaccine of
ensured potency that
would reach> 80% of
Development of a
system to detect and
contain cases and
Smallpox eradication
Bye-bye Smallpox…..
Small eradication-triumphs
The Faces of Smallpox….
Guinea worm eradication…
Eradication of Guinea Worm
The Source:
Eradication of Guinea Worm…
Affected are people in rural deprived and
isolated communities.
Prevention Strategy
Number of dracunculiasis is
Guinea worm endemic countries in
1991 and 2007
Eradication of Guinea-Worm
The programme has been evaluated seven
times by independent experts
“This is a remarkable achievement made
possible by active inter sectoral collaboration
between the key departments of health, water
supply, and rural development,”
Henk van Norden, the coordinator of Water
Supply—a division of Unicef—which played a
crucial part in the eradication of guinea worm
Guinea Worm eradicated….
Successful Health Research
Successful health research projects in
. Region include dengue vaccine
production in Thailand, hepatitis B
vaccine and anti-snake toxoid
production in Myanmar, leprosy
drug trials and community-based
rehabilitation in India, testing drug
resistance in malaria parasites in
Thailand, and a multicentric study on low
birth weight and its risk factors in India,
Nepal and Sri Lanka
Evaluation of HFA : 1979-2006
Reasons for slow progress:
Insufficient political commitment
Failure to achieve equity in access to all PHC
Slow socio- economic development
Difficulty in achieving inter sectoral action for
Unbalanced distribution of resources
Reasons for slow progress
Weak health information systems and lack of
baseline data
Pollution, poor food safety, and lack of water supply
and sanitation
Rapid demographic and epidemiological changes
Focusing on clinical services while
neglecting services that reduce exposure to
disease is like mopping up the floor
continuously while leaving the tap running
(paraphrased from Laurie Garrett, Betrayal
of Trust)
The Basic Requirements for Sound
PHC (the 8 A’s and the 3 C’s)
Obstacles to the implementation
of the PHC strategy
Misinterpretation of the PHC concept
Lack of political will
Centralized planning and management
What has been considered primary care in well
resourced has been dangerously over simplified
in resource constrained setting
PHC can provide place wide range of problems-would would not
accept that low income countries could focus few “priority disease’’
PHC hub from which patients are guided through health system-it is
not acceptable for low income countries to reduce to stand alone
health post or isolated community health worker.
Patient participation- LIC services restricted to one way delivery
PHC deals with Ds preventive, curative and promotive- only curative
Requires adequate resources and investment then provide much
better value for money-it not acceptable In LIC PHC finance out of
pocket on assumption that it is cheap and should be used by poor
Five common shortcomings of
health-care delivery
Five common shortcomings of
health-care delivery
Inverse care: People with the most means –
whose needs for health care are often less –
consume the most care.
Impoverishing care: Wherever people lack
social protection and payment for care is largely
out-of-pocket at the point of service, they can be
confronted with catastrophic expenses. Over
100 million people annually fall into poverty
because they have to pay for health care.
Five common shortcomings of healthcare delivery…
an average Indian spends a substantial
amount (58%) of his total annual income for
his hospital treatment.
 40% of hospitalized Indians borrow or sell
assets to cover hospital expenses.
 25% of hospitalized Indians fall below poverty
line because of hospital expenses.
Impact of abolishing user fees.
Source :Words health report 2008;primary health care
Five common shortcomings
of health-care delivery…
3.Fragmented and fragmenting care:
 The excessive specialization of health-care
providers and the narrow focus of many disease
control programmes discourage a holistic
approach to the individuals and the families they
deal with and do not appreciate the need for
continuity in care.
 Health services for poor and marginalized
groups are often highly fragmented and severely
under-resourced, while development aid often
adds to the fragmentation
Aspects of care that distinguish
conventional health care from peoplecentred primary care
How Health system Diverted
From PHC core values.
Five common shortcomings of
health-care delivery…
4.Unsafe care: Poor system design that is
unable to ensure safety and hygiene
standards leads to high rates of hospitalacquired infections, along with medication
errors and other avoidable adverse effects
that are an underestimated cause of death
and ill-health
• Lack of Health care staff.
India Health Infrastructure.
Five common shortcomings of
health-care delivery…
5.Misdirected care: Resource allocation
clusters around curative services at great cost,
neglecting the potential of primary prevention
and health promotion to prevent up to 70% of
the disease burden.
The current criticism against health care services is that
they are
(a) Predominantly urban oriented
(b) Mostly curative in nature
(c) Accessible mainly to small part of the population
Commercialization of Health Care
Private health care is clearly associated with profit,
exploitation and preferential service to high income
groups. It result in inefficient, inequitable and poor quality
“Doctor, do you think I need an MRI?”
Success stories…
Success Story-1.
Economic development and investment choices in health
care: the improvement of key health indicators in Portugal.
Portugal recognized the right to health in its 1976
constitution, following democratic revolution.
Political pressure –inequalities
Creation of National Health System-funded by
taxation & complimented by PP insurance schemes
and out –of pocket payments.
System fully establish 1979-83, working on PHC
Eligibility-register to family physician in health
center.(network great success)
Life expectancy 9.2 more than 30yrs back
Double GDP per capita
Decreased IMR by half every eight years.
Multivariate analysis on time series on various
mortality indices since 1960 shows b/o PHC
Factors explaining mortality reduction in
Portugal, 1960-2008
Success stories 2- closing the urban- rural gap
through progressive expansion of PHC coverage
in rural areas in the Islamic Republic of Iran.
In 1970s, Iranian Govt. policies emphasized prevention as a long
term investment, allocation of resources to rural and under
privileged areas and prioritizing ambulatory care over
Network of District Team formed to oversee 2500 village based rural
health centers was establish.
Each center staff by team-GP, midwife , nurse,several health
technicians .
Each rural health center has 1-5 small point of care “Health
Houses’’ (17000,>90% rural population has access to heath care )
Health Houses are staffed by “Behvarz” (MPW) PHC
Network grows and cover 24 million people of villages small citiesbring the pont of care closer to where people live and work
Progressive roll- out of this system has hepled to reduce the urban
and rural gaps in child mortality.
Under-five mortality in rural and Urban areas, the
Islamic Republic of Iran, 1980-2000
Success story-3
Sultanate Oman
In the late 1970s, the Sultanate of Oman had only a handful
of health professionals.
People had to travel up to four days just to reach a hospital,
where hundreds of patients would already be waiting in line
to see one of the few (expatriate) doctors.
All this changed in less than a generation.
Oman invested consistently in a national health service and
sustained that investment over time.
There is now a dense network of 180 local, district and
regional health facilities staffed by over 5000 health workers
providing almost universal access to health care for Oman’s
2.2 million citizens, with coverage now being extended to
foreign residents.
Over 98% of births in Oman are now attended by trained
personnel and over 98% of infants are fully immunized.
Life expectancy at birth, which was less than 60 years
towards the end of the 1970s, now surpasses 74 years
Selected best performing countries in
reducing U-5 mortality by at least 80%, by
Variable progress in reducing U5 mortality, 1975-2006,
in selected countries with similar rates in 1975.
When supplier- induced and consumer
driven demand determine medical device:
ambulatory care in India.
Mr.S is typical patient lives in urban Delhi. Over 70 pvt. Sector
medical care providers within 15 mins walk from her house. She
chooses the private clinic run by Dr.SM &his wife. Above the clinic a
prominent sign says “Ms.MM Gold Medalist , MBBS’’ suggesting that
the clinic is staffed by a highly proficient doctors As it turns out, Ms.
MM is rarely at the clinic. We were told that she sometimes comes
at 4 a.m. to avoid the long lines that form if people know she is
there. We later discover that she has “franchised” her name to a
number of different clinics. Therefore, Ms. S sees Dr. SM and his
wife, both of whom were trained in traditional Ayurvedic medicine
through a six-month long-distance course.
The doctor and his wife sit at a small table surrounded, on one side, by a
large number of bottles full of pills, and on the other, a bench with patients
on them, which extends into the street. Ms. S sits at the end of this bench.
Dr. SM and his wife are the most popular medical care providers in the
neighbourhood, with more than 200 patients every day. The doctor
spends an average of 3.5 minutes with each patient, asks 3.2 questions,
and performs an average of 2.5 examinations.
Following the diagnosis, the doctor takes two or three different pills,
crushes them using a mortar and pestle, and makes small paper packets
from the resulting powder which he gives to Ms. S and asks her to take for
two or three days. These medicines usually include one antibiotic and one
analgesic and anti-inflammatory drug. Dr. SM tells us that he constantly
faces unrealistic patient expectations, both because of the high volume of
patients and their demands for treatments that even Dr. SM knows are
Dr. SM and his wife seem highly motivated to provide care to their
patients and even with a very crowded consultation room they spend
more time with their patients than a public sector doctor would.
However, they are not bound by their knowledge […] and instead
deliver health care like the crushed pills in a paper packet, which will
result in more patients willing to pay more for their services
Needed for an effective response to the health challenges of today’s
UNIVERSAL COVERAGE REFORMS: systems contribute to health
equity, social justice.
SERVICE DELIVERY REFORMS: health services as primary care, i.e.
around people’s needs and expectations.
PUBLIC POLICY REFORMS: reforms that secure healthier communities,
by integrating public health actions with primary care and by pursuing
healthy public policies across sectors
LEADERSHIP REFORMS:Reforms that replace disproportionate reliance
on command and control on one hand, and laid faire disengagement of
the state on the other, by the inclusive, participatory, negotiation-based
leadership required by the complexity of contemporary health systems
India Shinning
“India is shining ok for the glossy magazines,
but if you just go outside metro you will see that
everything about India shining is refuted … [In
the villages] alcoholism is rife and femaie
infacticide and crime are rising. You have to
bribe to get electricity, water. Yes, the middle
and upper classes are taking off, but the 700
million who are left behind, all they see is gloom
and darkness and despair. They are born to fulfil
their destiny and have to live this way and die
this way. The only thing that shines for them is
the sun, and it is hot and unbearable and too
many of them die of heatstroke.”
Let us work together for
“Health for ALL.’’
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