Primary Health Care (PHC)

Concept and definition

In 1978, a transformative shift in the approach to healthcare emerged following the International Conference on Primary Health Care in Alma-Ata, USSR. This marked the emergence the concept of “primary health care. “Prior to the Alma-Ata conference, the concept of primary health care was often synonymous with terms such as “basic health services,” “first contact care,” “easily accessible care,” and “services provided by generalists.” The conference in Alma-Ata played a pivotal role in redefining and broadening the scope of primary health care, emphasizing comprehensive nature. This innovative approach aimed to prioritize essential health services, foster community involvement, and address health issues at their roots, ultimately promoting health equity on a global scale.

The Alma-Ata international conference broadened the scope of primary health care, providing it with a more comprehensive meaning. Empowering wellness through accessible and personalized primary health care       

“Primary Health care is 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 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”

Primary health care is universally applicable, extending its validity to countries at all levels of development, albeit manifesting in diverse forms within each. The concept of primary health care has garnered acceptance globally, recognized by all nations as pivotal for achieving the goal of “Health for All by 2000 AD.” Furthermore, it has been integrated as an indispensable component of each country’s health system.

In Nepal, the Government, under His Majesty, has committed to the objective of achieving health for all. To realize this goal, the government is actively implementing Primary Health Care (PHC) across the nation. PHC represents a novel approach to healthcare, encompassing, at the community level, all the essential factors necessary to enhance the health status of the population. Primary Health Care (PHC) is accessible to all individuals at the initial level of health care. It operates on principles of equity, broader coverage, individual and community involvement, and inter-sectoral coordination, ensuring that everyone has an opportunity to benefit. As it integrates promotive, preventive, and curative services, PHC is also envisaged as an integral component of the country’s plan for socio-economic development.

Elements of primary health care

While the specific services offered may differ among various countries and communities, the Alma-Ata Declaration has identified 8 fundamental components of primary health care. In the context of Nepal, 10 elements of PHC have been adopted, with mental health and dental health incorporated later based on specific needs.

1. Education concerning prevailing health problems &methods of preventing and controlling them.

Health education constitutes an integral component of all health services, and consequently, all health personnel, including nurses, bear the responsibility of instructing individuals on methods to enhance their own health. The focus of health education should encompass prevalent health issues within specific communities. In the context of developing countries, this may include education on conditions such as diarrhea, dysentery, upper respiratory tract infections, leprosy, tuberculosis, among others. In developed countries, emphasis should be placed on issues like HIV/AIDS, child abuse, sexual abuse, drug addiction, and heart disease. The primary emphasis in health education should be on the preventive aspects and strategies for controlling these health concerns. The community health nurse assumes a crucial role in organizing relevant health educational programs tailored to the community’s needs, collaborating with multidisciplinary and multi-sectoral teams.

2. Promotion of food supply and proper nutrition

In developing countries, nutritional deficiency diseases are prevalent, contributing to child mortality, morbidity, and disability. A close relationship exists between nutrition and health, as it is essential for growth, development, protection from infections, and prevention of specific deficiencies. Common issues include protein-calorie malnutrition and vitamin A deficiency, which heighten susceptibility to various infections, such as exophthalmia, night blindness, dry skin, and iodine deficiency diseases. As a nurse, it is crucial to provide counseling and motivation for the cultivation of a variety of foods, the preparation of supplementary food, and the creation of balanced diets. Additionally, guiding individuals on selecting food in sufficient quantity and quality is vital. The nurse also plays a key role in health promotion by encouraging adequate child spacing through the promotion of extended breastfeeding, ensuring safe weaning practices. Moreover, the nurse is responsible for activities such as weighing infants and children, maintaining growth charts, administering Vitamin A supplements, deworming, and providing iron supplements, among other measures.

3. Adequate supply of safe water and basic sanitation

An adequate and safe water supply, along with basic sanitation, is indispensable for the health and well-being of the community. Over 60% of epidemic and communicable diseases are waterborne, with prime examples such as diarrhea, dysentery, and cholera being caused by contaminated water The role of a Community Health Nurse (CHN) is to educate the community on methods of purifying drinking water, avoiding contamination of rivers and wells, identifying sources of safe water, and promoting the construction of household and community latrines. The nurse also encourages the establishment of composting facilities and septic tanks where drainage systems are inadequate. Additionally, the nurse takes responsibility for coordinating with other sectors to ensure the provision of safe water and the maintenance of good sanitation practices within the community.

4. Maternal and child health(MCH) care, including Family planning (FP)

Maternal and Child Health (MCH) serve as crucial indicators for community development. Maternal mortality rates are notably high in developing countries, including Nepal. The primary causes of this elevated rate include post-partum hemorrhage, abortion, and related complications, often exacerbated by factors such as inadequate healthcare management, delivery services, and unstable political situations. Consequently, Community Health Nurses (CHNs) play a pivotal role in delivering comprehensive MCH care, encompassing antenatal, intranatal, perinatal, and postnatal care, as well as care for newborns and infants, and the provision of family planning services.

5. Immunization against major infectious diseases

Certain diseases, including TB, polio, measles, diphtheria, pertussis, tetanus, hepatitis B, and other infectious diseases, can be prevented through timely and proper immunization. Without adequate measures, these diseases may lead to illness, disability, and death. In Nepal, the Expanded Program on Immunization (EPI) was initiated in 1974. The current objectives of the EPI include the eradication of polio, the elimination of neonatal tetanus, the reduction of measles cases and related deaths, and the introduction of new vaccines across various districts in Nepal.

The new vaccination includes Hepatitis B, Hemophilus influenza B, Japanese encephalitis etc. The MR vaccine is also included in National Immunization Program in 2013. So, the role of the community health nurse is to motivate and encourage family to bring their children for complete immunization, motivate pregnant mothers to have full course of TD (tetanus, diphtheria) vaccine and also to have immunization against other major infectious diseases. Health post, health center and other facilities should have equipped with enough supply of vaccine and the cold chain should be maintained.

6. Prevention and control of locally endemic diseases

Endemic diseases are those that frequently occur in specific geographical areas or countries. In Nepal, endemic diseases include diarrhea, common cold, influenza, tuberculosis, malaria, kala-azar, worm infestation, malnutrition, vaccine-preventable diseases, sexually transmitted diseases (STDs), HIV/AIDS, leprosy, among others. These diseases are easily transmitted and often preventable. Therefore, it is imperative for nurses to educate the community about preventive measures by providing information on the mode of transmission, prevention, control, and treatment of these diseases.

7. Appropriate treatment of common diseases and injuries

Treatment of minor ailments and first aid measures can be administered at the village level, while the health post and primary health center are designated for the treatment of common diseases and injuries. Appropriate referral services should be organized for cases that require further attention. The emergency treatment and primary care provided by nurses play a crucial role in reducing morbidity and mortality within the community.

8. Provision of essential drugs

The nurse is responsible for maintaining and utilizing necessary essential drugs to treat minor ailments. Other health workers should also be aware of the available resources and facilities for obtaining essential drugs. The Department of Drugs Administration has developed a list of national essential drugs in 2002 to guide the proper use of medications. Additionally, health centers should be equipped with emergency drugs to address urgent situations effectively.

9. Mental health

According to the World Health Organization’s definition of health, an individual should be physically, mentally, and socially healthy. Mental well-being is crucial, as a person facing mental disturbance may encounter challenges in various aspects of life. It is the responsibility of the nurse to educate the community on stress management, prevention of mental illness, and the proper management of individuals experiencing mental health issues. The increasing prevalence of mental illnesses underscores the importance of addressing mental health concerns. To integrate mental health services with primary health care, the Nepal government has decentralized mental health services to health post and sub-health post levels. Moreover, human resources working at these grassroots levels receive training in the management of mental illnesses.

10. Dental health

The objectives of dental health services encompass the prevention of dental diseases and the treatment of dental disorders. Given the widespread prevalence of various dental problems among the population, which can significantly impact morbidity and diminish the quality of life, Primary Health Care (PHC) nurses play a crucial role. They should conduct school dental programs, offer health education on oral care, provide treatment for oral problems, and educate on the prevention and management of dental issues and tooth disorders. This integration of dental health within the PHC framework aligns with the broader concept of complete health.

Principles of Primary Health Care (PHC)

There are five basic principles of PHC which are as follows:

1. Accessible of health service to all population

 The term “accessibility” pertains to a healthcare system that can be reached and utilized by all individuals. The primary focus of PHC strategy is on equity, ensuring an even distribution of health services, regardless of one’s ability to pay. All individuals, irrespective of their socioeconomic status (rich or poor) and location (urban or rural), should have equal access to health services. Disparities in care between major towns and cities versus rural areas result in inequalities, particularly impacting vulnerable populations in rural areas and urban slums. This phenomenon is identified as social injustice. The inability to reach a significant portion of the population often stems from issues of inaccessibility. Primary health care endeavors to rectify this imbalance by reorienting the focal point of the health care system from urban centers to rural areas. The objective is to make health services more proximate to people’s homes, addressing the challenges of accessibility and ensuring that a broader segment of the population can benefit from essential healthcare services.

2. Maximum individual, community involvement in the planning and implementation of health care services.

According to the World Health Organization (WHO) and UNICEF, community participation is defined as the process through which individuals and families take responsibility for their own health and welfare, as well as that of the community. It involves developing the capacity to contribute to both individual and community development. The active involvement of individuals, families, and communities in promoting their own health and welfare is considered an essential component of Primary Health Care (PHC).

Universal coverage by Primary Health Care (PHC) is unattainable without the active involvement of the local community. Communities should play a role in identifying problems, planning the allocation of resources (manpower, finances, materials), devising health action plans using local resources, and participating in the effective implementation and evaluation of projects. Nurses, in particular, play a crucial role by assessing both factual and perceived needs within the community, engaging them in organizing and managing actions to ensure the success and sustainability of programs or projects. Additionally, community members can contribute not only labor but also financial and other resources to support the goals of PHC.

3. Emphasis on service those are preventive and promotive rather than curative services.

Preventive and promotive health services aim to educate people on maintaining cleanliness and preventing diseases. Various factors, such as drinking contaminated water, poor hygiene and sanitation, and overcrowded living conditions, can contribute to the onset of diseases. Preventive and promotive health measures guide individuals in adopting healthy lifestyles. All components of Primary Health Care (PHC) contribute to disease prevention and health promotion, emphasizing a proactive approach rather than focusing solely on curing diseases. Health education is a potent tool for raising awareness, fostering attitude changes, and influencing practices and behaviors positively among the population. The Primary Health Care (PHC) nurse should prioritize prevention and promotion over cure due to its universality, cost-effectiveness, accessibility, and various other factors. While curative services are essential, nurses should primarily focus on providing preventive care.

In Nepal, it is common for people to seek medical assistance only when they are seriously and chronically ill, leading to more expensive treatments and hospitalizations that involve additional costs for medicines, investigations, lodging, and food. Therefore, the initial preference should be to offer preventive care and health promotion to all individuals starting from the grassroots level.

4. Use of appropriate technology

Medical technology should be made available in a manner that is accessible, affordable, feasible, and culturally acceptable to the community. An example of appropriate technology is the use of refrigerators for vaccine cold storage. These devices are essential for preserving vaccine efficacy, particularly in resource-limited settings. They are relatively affordable, accessible, and can be adapted to fit the cultural and logistical needs of diverse communities.

The principles encompass employing suitable methods and technology to effectively implement all components of Primary Health Care (PHC). For instance, constructing a health post can be achieved by utilizing locally available materials such as bricks and wood, rather than relying on expensive imported items like cement and other supplies that the community may find unaffordable. Alternatively, repurposing an existing building can be considered instead of undertaking the construction of a new one.

5. Integration of health development with overall social and economic development

It is recognized that enhancing health outcomes requires interventions beyond the confines of the formal health sector. Other sectors play equally crucial roles in fostering the health and capabilities of communities. These sectors encompass agriculture, education, communication, housing, public works, industry, and community organizations such as local governments and voluntary organizations. Improvement in health cannot take place without improving the social and economic status of the people.  Different ministries and agencies need to work together to improve all aspects of the country. For instance, while a water supply engineer may construct a tube well in a village, it is essential for healthcare professionals such as nurses or health workers to educate the community on maintaining water cleanliness after extraction from the well. This cooperative approach ensures a comprehensive and sustainable improvement in both health and overall well-being.

Challenging of PHC in the context of Nepal 

Challenges in the context of Primary Health Care (PHC) in Nepal encompass various issues:

1. Population overgrowth: Addressing population growth requires efforts to raise awareness of its adverse effects and provide accessible birth control. The low health professional ratio in Nepal poses a challenge in meeting the increasing public health demand. Infrastructure and human resources need enhancement to cope with the rising population.
2. Malnutrition: Malnutrition is a prevalent issue in PHC, with new cases diagnosed regularly. Factors such as environmental degradation and a shift towards artificial or junk food contribute to the problem. Nutrient-poor diets are a concern, requiring interventions to promote healthier dietary patterns.
3. Poor environmental sanitation: Environmental health challenges arise from technological advancements, population growth, changes in living standards, industrialization, and climate change. Key pillars affected include disease control, water sanitation and hygiene (WASH), built environment, occupational health, and food safety and hygiene. Climate change exacerbates these challenges.
4. Infectious diseases: Emerging infectious diseases pose a significant challenge to PHC. These diseases, caused by various organisms, can be transmitted through various means. Adequate measures must be taken to prevent, control, and manage infectious diseases, considering the changing environmental factors.
5. Economic status: Primary health care, especially primary care, contributes to economic benefits by improving health outcomes, system efficiency, and health equity. Ensuring equitable access to health care and positive health outcomes for all economic classes, including the poor, is crucial.
6. Educational status: The educational status of the community affects the utilization of available primary health services, influencing morbidity and mortality rates. Efforts are needed to enhance health education and awareness, especially in communities with lower educational levels.
7. Gender discrimination: Gender biases and discrimination in health care settings affect patient-provider interactions, leading to health inequalities. Interventions, including legislation, policy changes, gender-sensitive training, and women and men-centered services, are essential to address these disparities.
8. Health service delivery: Effective health service delivery requires understanding user perspectives, raising public awareness, and reducing barriers to care. A package of integrated services based on population needs, infrastructure development, and external support is necessary for delivering quality care.
9. Prevailing social values, norms, and beliefs: Health promotion is crucial in changing social, environmental, and economic conditions to improve public and individual health. Social responsibility for health, reflected in policies and practices, is essential for sustainable health promotion actions.

Addressing these challenges necessitates a comprehensive and collaborative approach involving government bodies, healthcare providers, communities, and external partners to strengthen the primary health care system in Nepal.

Role of community health nurse in working towards the primary health care

Health Educator– Health Education is not only the most important element of PHC but also has an important role in implementing other elements of PHC e.g. preventive and promotive services, MCH/FP etc. Health cannot be obtained and maintained by the people until and unless they know how to obtain healthy practice and maintain health by making appropriate changes in their lives. Nurse comes in contact with community people every day; she knows the need of the community so, nurse acts as an educator by providing teaching and education according to their health needs.

Motivator- Nurse motivates the community people to find their health needs, increase interest to adopt healthy life style and increase awareness regarding health, sanitation, hygiene etc. Until the people are interested and become aware of their needs, they will not consume the health service provided to them. So the nurse increases awareness and motivates them to promote and maintain their own health.

Counselor– PHC nurse counsels the people as per their needs, e.g. she provides counseling services on family planning, immunization, use of safe water, choice to treatment pattern, mental health, drug and alcohol abuse, rehabilitation etc. She can also provide counseling service on social and other problems related to health.

Health care provider– A nurse provides care to patient in PHC and in hospital. In community a nurse focuses mostly on preventive and promotive care, she also provides curative service to sick and injured people either by going to the community or by providing care in the health institution e.g. giving injection, doing dressing, providing other nursing care as per needs of patients.

Supervisor– She supervises subordinates guide & directs their action to meet the pre-determined objectives or goals. A supervisor inspects, directs, helps, lead, guide, teaches, motivates to subordinates or community people and evaluates/reports the progress of the program.

Manager– For achievement of good health only nurse cannot do anything so she should manage the program to be done by other for achievement of the goal. The PHC nurse should act as a manager, manage different programs, organize manpower, money and materials and formulate different plans and policies. She supervises and maintains records, ensures that the equipment is properly working and supplies are up to date. She encourages and motivates staffs to be committed more in organization, productive and happy in their job.

Change Agent– Nurse acts as a change agent to change their attitude, behavior and view of people towards health and eliminate harmful and hazardous practice prevalent in community. She needs perseverance effort and patience as change is not easy task. People usually resist change. As the proverb is that “Change is needful but painful”.

Researcher– The nurse does scientific and systematic investigation of the problem and services of the community so that changes and improvements can be made. She conducts research activities on health problem, health service provided to people, attitude and expectation of people towards health workers, ways of improving health services etc. There are several steps and processes involved in nursing research.

Coordinator- Nurse works with different sectors in the society to increase the effectiveness of the health programme in the community. She works with rich as well as poor, political leaders as well as the persons of different developmental sectors as agriculture, banking, industry, education, communication, animal husbandry to promote the health status of community. She has to co-ordinate with these sectors to get inter-sectoral and multi-sectoral co-operation for maintenance of positive health.

Evaluator- Nurses evaluate the work done and work being done to improve its quality and effectiveness. It is a continuous process and done to find out whether the predetermined goals are fulfilled or not. It also helps to identify the obstacles to determine the changes of programme. Evaluation should be done in all areas. It should be done frequently without any biasness.

Facilitator– Nurses help people to facilitate or provide opportunity to know many things as health facility, education sector, sources of other facilities, sources of income, different ways of waste disposal etc. So the nurse conveys the message to people and also act as facilitator to achieve needed information.

Basic Health Needs

The government identified six basic health needs that are:

Foods:  The Government aims at meeting the average calories intake 2250 kcal/day/head to meet this goal it is required to increase the production of cereals pulses and vegetables.

Clothes: The Government has sets a target of – 11 meters of cloth and a pair of shoes/person; to meet these needs, manufacturing capacity of the industries should be increased.

Shelter/housing: Housing means home should be facilitated with electricity, clean drinking water, proper disposal of refuse, sewage and drainage and road.

Education: The Government aims to provide free primary education. The ministry of education and sports started home visit and school admission program to ensure all children enrolled in school and also to start adult literacy program to increase adult literacy program to increase adult literacy rate.

Health: Government of Nepal came out on the 16 July 1987 with basic minimum health program to attain “Health For All” in detail. The main objects in the health field are:

• Reduction of IMR 111.5 to 45 per 1000 live birth
• Provision of the health worker to population ratio in 1:3000 such as doctor kabhiraj, baidhya, health assistant
• Provision of trained nurse/population 1:600
• Provision of community health volunteer/population 1:500
• Reduction of distance from household to the most peripheral health service unit

Security: There are six aspects of security included in the programme:

• Socio-economic development
• Social welfare
• Development of moral characters
• Supply of essential goods or commodity
• Development project
• Offices that come in frequent contact with general people.

Basic minimum needs are one of the main objectives of the seven five-year plan. The objectives are:

• To increase production at productive employment
• To increase opportunity for production
• To fulfill the basic minimum needs of the people

Strategies of the above program

• To accord overall priority to the development of agricultural sectors
• To put stress on the development of the forest resources and social conservation
• To put emphasis on the development of the water resources
• To emphasis on the development of the industries
• To curb the population growth rate
• To consolidate the foundation of national economic integration
• To decentralize the economic management and invest the economic with greater capabilities and competence
• To strength and consolidate development administration

Policies of basic minimum needs

Basic minimum needs policy takes into action the following areas:

• Food grain
• Clothing
• Fuel wood
• Drinking water
• Primary and skill oriented education and minimum rural transportation facilities

Basic minimum health needs:

• Child spacing
• Oral rehydration
• Maternal and child health
• Basic natal health
• Immunization
• Nutritional services
• ARI

The working policies are:

• Provision of integrated health services
• SHP will be established in each VDC
• There will be community health volunteers in each ward
• Emphasis will be given on domestic production of essential drugs and quality and standard of medicines (drugs) policy
• Training facility for health workers will strengthening
• Preference will be given to local health workers in the recruitment and posting in the rural health institutes

Programs

• National immunization programme
• Nutrition
• Community Based Integrated Management of Childhood Illness
• Family planning
• Safe motherhood and newborn health
• Female Community Health Volunteers programme
• Primary health care out reach
• Demography and out reproductive research
• Disease control
• Malaria control
• National TB control program
• Leprosy control program
• HIV/AIDS and STI control
• Kala-azar elimination program
• Lymphatic filariasis
• Out/inpatient care