Module one starts with the introduction to Primary Health Care and looks at how the Alma-Ata declaration of 1978 emphasizes the importance of social science in delivering, organizing primary health care. We'll also look at the basic issues of human behavior, and explain the social and the ecological model, and how that is an underlying theme throughout the whole course. This is section A. Primary health care was defined in the Alma-Ata declaration, which took place in what is now Almaty in Kazakhstan, in 1978. The World Health Organization, UNICEF and a number of international organizations brought together representatives from many countries and came up with an idea of the serving people with health care, making sure that health for all was a goal for the year 2000. And it's an appropriate time to look back and see if primary health care has made an impact. And of course primary health care working with the people at their own level, this is why we need social science to help evaluate that. Primary health care is defined as essential health care. That doesn't mean that everyone can get a CAT scan by the year 2000, it doesn't mean that everybody will have access to all of the antibiotics and all the fancy drugs they need, but it meant that people would have access to the basics and this they would do through their own efforts. Primary health care is defined as practical and scientifically sound, and socially acceptable. It is also health care that is made universally accessible to individuals and families in the community. Primary health care is accomplished through the full participation of community members, as individuals and groups. Primary health care should be made available at a cost the community cannot only afford, but maintain at every stage of their development, whether it's of extremely poor country, or whether it's an industrialized rich country. Primary health care should be adapted. And the issue of maintenance of health care parallels the words that are often used now in terms of is health care sustainable. Can people keep it going? This is important to consider since many of our participants in this course work with international agencies and on national bilateral donor agencies and NGOs. They have projects in countries and in different parts of the world that are trying to help people establish primary health care and public health. These projects often last for maybe three to five years, and then when the agency withdraws then the question comes, can the program be sustained by the people themselves? So primary health care does look at these issues in terms of the costs and economics of it. And then again Primary health care is carried out, is planned in the spirit of self-reliance and self-determination. These again relate to the issues of sustainability. Primary health care is defined as an integral part of the country's health system. Not just another level or layer, but that primary health care is where health services start, and that in planning and carrying out health care, the integration of all different levels from the tertiary, secondary, primary and the community should be planned together, considered together. Primary health care is also integrated into and planned according to the social and economic development of the country. Primary health care is considered to be the first level of contact with the individual and the family with the National Health System. This again relates back to the issue of forming an integral part of the health system. It's not some place where one starts and then if one is not satisfied, or receive the proper services whether preventive or curative and then stops there, but at the village level health system has links with the next levels of the health care system. Therefore, it is a continuing health care process, that brings health care as close as possible to where people live and work. The Alma-Ata declaration clearly states that primary health care should be delivered in the social-cultural context of the communities and people where it is carried out. It should reflect and evolve from the economic conditions and the social-cultural and political characteristics of the countries and the communities involved. This may represent the formal, political and economic system as well as the informal. Because in many parts of the world there are still village chiefs and village elders and leaders, there are still many people involved in the informal economy, subsistence work, and therefore, primary health care has to take into account such factors that people often get much of their health care from patent medicine sellers, they often get much of their health care from indigenous healers and home remedies. So this part of the economic and health life of the people needs to be considered when planning. Another important thing again where we see the confluence or conjunction of social and medical sciences, is that primary health care should be planned and based on application of the results of research of scientific exploration in the social, biomedical and health sciences. Finally, primary health care should address the main problems of the community, providing promotive, preventive, curative and rehabilitative services for the community. The issue of community needs is central here. And this is something that often gets overlooked. Many surveillance systems are established to monitor the common diseases in the community. Are measles outbreaks common? Is our immunization system working? What is the level of tuberculosis? And often times, we as professionals define community needs in terms of this epidemiological data that's gathered. In primary health care, when we're talking about the full participation of the people concerned, we want to find out what they think are their main health problems. And as we'll see at some point, the issue of culturally defined disease and illness is extremely important. We'll look at that specifically in module two when we talk about explanatory models of how people themselves view their health, their illness and explain them. In the next slides, we'll look at the actual essential components or services, that comprise primary health care. At the time of Alma-Ata, there were eight services defined. Since then, others have been added both by international agencies and by individual country ministries of health, and this of course is in keeping with the spirit of Alma-Ata in terms of locally defined health problems and needs. But I think at this point we'll look at the basic eight components and see how they fit together and also the social and behavioral implications of those components. The next slide shows that health education is considered to be the first essential component of primary health care. Health education is a process of planned learning activities that help people change their health behavior in a voluntary manner, through their full participation. Health education involves obviously providing people with information, but it is much more than IEC. Information Education Communication is a process of involving people in helping themselves identify their own problems and developing their own solutions. In this way, health education concerning the prevailing problems is the basic component, but also health education processes of involving people in identifying needs, involving people in planning to solve their health and related problems is in fact in keeping with the basic strategies, and philosophies of primary health care. The second major component of primary health care, as seen in the picture with people eating at a festival, is the promotion of food supply and proper nutrition. We'll see that again the socio-behavioral side of that concerns people's food beliefs and taboos, the skills that they have in terms of growing and preparing certain food items, economic and political issues in terms of land access so that they can grow these items. The third service is maternal and child health care, including family planning. There are obviously social and cultural concerns about family size, beliefs about limiting or not limiting families in terms of what the ancestors have intended for a person to do, terms of social expectation, roles in society, what a man or a woman is expected to have in terms of the number of children or any children, gender issues get involved in this. So, it's not simply a matter of providing antenatal care to ensure a safe delivery, not simply a matter of ensuring that a woman gets tetanus immunization during pregnancy, but considering the woman's access to education as part of the social issues involved in maternal and child care. A fourth component of primary health care is much more specific, and that has to do with immunization against the major infectious diseases. Right now, there are major efforts afoot throughout the world to eradicate polio through immunization. The social issues involved in immunization are quite many. When immunization coverage is calculated, effort is made to find out why people, mothers do or do not bring their children, what role family members play in encouraging or discouraging. What kind of social support does a woman have? If she has other children, does she have to carry them to the immunization center? Who will watch them? What is the mother's knowledge, and especially father's knowledge so he can encourage the mother of the immunizable diseases? Do people believe that immunization can prevent these diseases? What do they think are the causes of the disease? So, these are some of the social and behavioral issues involved in that component of primary health care. The fifth component or essential element is the prevention and control of locally endemic diseases. And this of course again varies from place to place, even within a country from region to region, or state to state. And primary healthcare therefore again, has to be flexible and adaptable to the local situation. Many of the endemic diseases, because they're common, people have lived with them for many years, they've developed beliefs about the disease, about the treatment, they've developed a lifestyle of how to cope with these conditions. One of the conditions pictured in the slide is Guinea worm disease. There'll be more talk about that, examples of that in module two, but it's important to realize this is a subcutaneous worm, a meter long worm under the skin, after developing for a year in the body, it forms a blister, comes out and lays larva in the stream. When people wait in the stream to collect water. A small crustacean known as a cyclops swallows the larva, it matures within about two weeks, and the person who drinks that larva from the pond water, will get the Guinea worm disease. People where the disease is endemic believe that the Guinea worm is part of their body. They think it's something like a nerve or a tendon, because there's really no cure for it per se, people have learned to live with it. Malaria is another example of how local culture has adapted. People believe that there are different kinds of malaria, and we'll talk about this again in module two. But different kinds of malaria mean that there are different treatments. People believe for example, that malaria is caused by too much heat or working under the hot sun. Some of our preventive measures such as insecticide-treated bed nets, may not seem acceptable or reasonable to people because they don't know the connection between malaria and mosquitoes. So, this again, this issue of prevention and control of locally endemic diseases if not accounting for the social cultural aspects, people's beliefs and practices will never succeed. A sixth important element is adequate water supply and sanitation. Generally all cultures have beliefs and norms about hygiene or cleanliness that are expressed in different ways. And this again will need to be understood before successful water supply and sanitation programs can begin. Another important issue that we've discovered through the Guinea worm eradication program, because providing wells even simple hand-dug wells is enough to prevent guinea worm, but there are political elements. The people who suffer the most are usually the poorest and most remote people. They don't have access to resources, to the political influence to get these wells and resources to their communities. So, again, the understanding of this component is important. The seventh issue is appropriate treatment of common diseases. Just if we said appropriate prevention has to do with people's ideas about what causes disease. People also have beliefs about the appropriate treatment. With the Guinea worm, for example, people don't believe that western medicine can cure the disease. Some people believe with Malaria that it's better to take herbs because herbs make you sweat and you are sweating out the disease whereas Chloroquine and some of the other Western medications do not achieve this. We people also, are concerned about the human interactions between health workers and themselves. And so, these social issues again affect the utilization of services. So, one cannot encourage appropriate treatment unless one understands the social and cultural issues. Finally, the eighth issue, which of course is related to treatment is the provision of essential drugs, making sure that at each level of the health care system, an appropriate formulary or list of drugs is available, that is able to be handled by the health workers and their skills at each level. It also involves collaboration with indigenous healers because much of modern pharmaceuticals of course were developed from herbal sources, and so, new knowledge can be gained through collaboration with indigenous healers. But again, the essential drug issue not only has cultural concerns and issues at the local level, what drugs do people think will work and will not work, people's expectations that have developed over the years about the importance of taking injections versus tablet form, but it also has major national and international issues. Pharmaceutical companies are obviously important economic and political players in the world scene and what drugs are made available, what drugs are put on national lists of essential drugs has political implications. So, these are again, some of the factors to consider. Provision of these eight services is not simply a matter of sitting down and planning who will educate, who will deliver family planning, how can we cite a well for water supply, but thinking about the social, political, economic and cultural issues that make it possible for these services to succeed. Furthermore, the next slide looks at other components of primary health care. Primary health care is supposed to be developed in the context of national development, seeing the interrelationship between other sectors such as, agriculture, works and housing, education with health and planning and working together, so that national development efforts have a maximum health benefit. We have seen examples, of course, where there are national agricultural efforts to provide irrigation. Sometimes, these of course, aid the spread of other diseases such as Malaria and Schistosomiasis. So, we want to make sure that that what work that goes on in the other sectors, actually promotes health, as opposed to damaging it. We have also seen examples and evidence that education, access to education enhances a woman's decision making and assertiveness to take care of herself and her children. So, collaboration among all related development sectors is necessary for successful primary health care. Again, stress on the importance of community self-reliance and participation. What we are concerned about here, is again a political issue that the community members are seen as equal partners in health planning, not simply the politicians that control the money and the health workers who have technical expertise. It is important in primary health care to make full use of existing resources. And this again, relates to the concept of appropriate technology instead of importing expensive equipment. A surgeon in a community near where I work talked to local carpenters and local mechanics, and was able to build his own operating table using a jack from a truck or a lorry to lift the table, et cetera, and was able to build something for one-tenth of what it would have cost to import it. Now, many people praise him. At the same time, they don't think his equipment looks fancy enough for his status as a doctor. But he's making full use of his resources. He makes sure that all of the roofing has rain gutters or rain spouts to collect water because it's difficult in a rural community where he works to get enough water during the dry season. He doesn't always have electricity. The National Grid doesn't always work, but he makes sure that he designed his operating theater so that there is full advantage taken of the existing sunlight. This kind of an attitude is not common. People who have been trained very thoroughly in western education want to copy western ways, but this material, these equipments are not always available, and so an attitude of self-reliance to use these existing resources is extremely important. And all of this, again comes through the ability with proper health education, to encourage communities to participate in making decisions, in finding their own resources to solve their problems. PHC, primary health care relies on an integrated functional and mutually supportive referral system. So, he said primary health care is not just an outpost. It's the first contact with the National Health System. There needs to be ways for a village based health worker to contact a frontline health auxillary, a midwife, a health inspector, a community physician and make sure that these people also, supervise and interact at the local level. There needs to be a close working relationship with all caters of health staff; the preventive, the curative, the indigenous, the public sector, the private sector. Again, all of this has social and political implications. Social in the sense that social stratification occurs in the health system. Cultural in the sense that western and indigenous health workers are not comfortable in communicating with each other. Political in the sense of who controls the power. We have found, for example that up to 85 percent of malaria cases are treated through self-medication, particularly, medicines bought at medicine shops. Health workers do not want to accept this as a reality because it challenges their authority and their power in the health system. The reality is that the health system probably cannot cope with every single person that has malaria every day of the week. But how does one bring about communication and interaction between medicine sellers and health workers? Health workers have the skills that they could pass on through training but are they willing? Again, what about the laws? The political issue of legally sanctioning medicine sellers to sell many of the common drugs that are needed does not exist at present. In reality they sell many kinds of drugs at the village level. So, there needs to be some rationalization of the laws with the reality and needs to bring people together so that all kinds of health workers work toward a common purpose. But this is a very political issue. Again, PHC relying on the expressed needs of the community. These needs vary from place to place, and the needs may not always appear to us as health workers to be related to health. People may say our biggest need is to improve the market. Our marketplace, the stalls are crumbling. The road leading into the market is eroded. We are not making business again. People are not coming to buy our goods. One has to be able to have a broader health development and social perspective on things to see how markets provide an opportunity for communication. Markets provide a chance for people to make money so that they can buy food for their children. They can afford their children's education. Markets, of course, represent an important nutritional component of national health and development. So, we have to be able to interpret community needs so that we ourselves can see the health relevance. And finally, our concern that PHC is a partnership between community members and health workers, between indigenous health systems and western health systems, between the health sector and other sectors including education, agriculture. If this is done, PHC aims to achieve an acceptable level of health for all people. Like I said, it doesn't mean that everyone has access to expensive scans and the most recently developed antibiotic. But it means that people can get the type of health care that's necessary to solve their immediate problems, and referral to the next level for more complicated issues. PHC, also hopes through self-reliance through appropriate technology, to make fuller and better use of existing resources. Okay. PHC hopes to make fuller and better use of existing resources. This occurs, of course, when people can participate, when they can contribute, what they have in the community. When health workers are willing to look themselves at what resources are available, what they can contribute. And this, of course, happens in a situation where there is political peace and stability. Not in a situation where more money is going for armaments. More money is going into politicians pockets and bank accounts. So again, primary health care requires full participation of the citizens of a country in their own development, in their own political system. That being the case, then, it should follow that primary health care can be part of that process. That being the case, PHC hopes that the social and economic development will be accelerated as a result of healthier people and conversely, advancements in social and economic conditions in the country will improve the quality of health care.
