CONTENTS

Page
Primary health organization
1.0 Introduction to Primary Health Care (PHC) ………………………. 2

2.0 Historical Development of Primary Health Care ……………........... 4

3.0 Concept of Primary Health Care ……………………………........... 5

4.0 Pillars of Primary Health Care …………………………………….. 7

Primary care nursing
5.0 Components of Primary Health Care ………………………………. 11

6.0 Community Based Health Care (CBHC) …………………………... 13

7.0 Health and Development ……………………………………............ 18

8.0 Strategies for Implementation of PHC …………………………….. 25

9.0 Planning, Implementing, Monitoring, and Evaluation in PHC ……. 27

10.0 Health Education ………………………………………………….. 32

11.0 Guidelines for Giving Health Education Talk ……………………… 37

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 INTRODUCTION TO PRIMARY HEALTH CARE

1.0 Introduction
Many disparities in Basic Health Services (BHS) necessitated a different approach to provision
of health care. These disparities were revealed by studies carried out by many organisations, e.g.
In 1975, a joint WHO-UNICEF study estimated that only 20% of the rural population in
developing countries received any basic health care on regular basis.
In 1976, an ILO study estimated that about 67% of the population of developing countries lived
in serious poverty.

It was then that the International community expressed the need for urgent action by all
governments, all development workers, and the world community to protect and promote health
for all people in the world. This was to happen through alternative strategies, one of which was
through Primary Health Care as the key to attaining the above target.

2.0 Meaning of the words in PHC

The words PHC were intentionally selected and used to convey specific meanings and messages.

The word Primary in PHC means the first, or basic, or essential, or most important, or most
urgent need(s).

The word Health: is defined by WHO as state of complete physical, mental and social wellbeing
and not merely the absence of disease or infirmity (disability)”. This definition was made 60
year ago and there are many problems associated with it. The definition assumes a human body
as a machine, and well-being is not easy to measure. This is why health indicators are usually
used, as proxies, to measure health.

The word Care: care means looking after, or protection of, or giving attention to, or maintaining
sometime. This care includes the following services:
- prevention
- promotion
- curative
- rehabilitative

Primary care: means those activities undertaken before a person develops a disease.

Secondary care: means services rendered when a disease has occurred, but it is silent; and even
a person might not know that he/she has the disease. The main activity in secondary care is
screening to detect the disease early for early treatment

Tertiary care: is provided when a person shows signs and symptoms of disease to prevent
disability and death.

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PHC: basically in simple terms means looking after or protecting, or maintaining the balance
between all aspects of life; all basic needs and bringing about or maintaining a pleasant feeling in
individual, families and communities.

Curative – dominant health services are not enough; they just cater for about 30% of health.

Primary Health Care is “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 forms an “integral part, both of the country’s health system, of which it is
the central function and the main focus, and of the overall social and economic development of
the community; with the national health system bringing health care as close as possible to where
people live and work and constitutes the first element of a continuing health care process”.

This definition implies that Primary Health Care is an integral part of the overall social and
economic development of the community.

It is indeed the Ministry of Health policy that Primary Health Care be the cornerstone in the
development of health services for the people. The communities as opposed to the health system
are viewed as the focal points for action and as such all plans and resource allocation must be
based on specific needs of the communities.

The Primary Health Care approach is a logical choice by the government as it guarantees
equity, empowerment, self-reliance and participation at all levels. This strategy ensures that
health choices become EASY CHOICES for the people.

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 HISTORICAL DEVELOPMENT OF PRIMARY HEALTH CARE (PHC)

In 1977 the Executive Board of World Health Organisation (WHO) sat in Geneva and discussed
issues concerning social injustice in provision of health services in the world (i.e. the
differences between Have and Have not). They advocated that health be a pre-requisite to social
and economic development.

On 29th September 1978 at Alma Ata, Russia, Primary Health Care Declaration was made with
the objective of Health for all by the year 2000.

Uganda was a signatory at the conference. This means that we must be ready to mobilise and
enlighten individuals, families and communities in order to ensure their full identification with
Primary Health Care, their participation in planning and management of their contribution to its
application.

Although Primary Health Care (PHC) was born during Alma Ata conference of 1978, it had
started at Kasangati Health Centre, the present Kasangati Health Centre V, which is in Wakiso
district.

In 1979, the first conference regarding PHC in Uganda was held in Mweya Safari Lodge
(Mweya PHC Workshop), commonly known as “Mweya Spirit”.

The concept did not take off until the coming of National Resistance Movement (NRM)
government in 1986 with its ten (10) Points Programme, of which PHC was covered in point six
(6). In the same year, Uganda Community Based Health Care (UCBHC) Association was
formed with more than 22 programmes, Non Governmental Organisations (NGO’s), Ministry of
Health (MoH) and Ministry of Local Government MoLG).

In 1990 serious discussions on PHC took off with practical implementations and this has
continued improving up to present time.

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 CONCEPTOF PRIMARY HEALTH CARE (PHC)
By examining the key words used in the definition of Primary Health Care, the concept of
Primary Health Care will be made clear. The following are key words in the definition of
Primary Health Care.

 Essential health care

 Practical, scientifically sound methods and technology
 Socially acceptable methods
 Accessibility
 Full community participation and involvement
 Affordability
 Self-reliance
 Self-determination
 Integration

Essential Health Care

This is health care that meets the local needs of the majority.

Practical and scientifically sound

This means that this health care should be able to cure or solve the problem in question (at hand
or existing).

Socially acceptable methods and technology

The methods and technology used in the delivery of health services should not conflict with the
norms of the community receiving the service.

Accessibility

If this service is to promote health in the community, then it has to be accessible to individuals
and families in that community, (easy reach).

Full Community participation

This is a process by which individuals and families assume responsibility for their own health
and welfare and that of the community. If people are involved in the planning, implementation
and evaluation of health service, then that service will be socially acceptable and at the cost the
community can afford. The service will be “appropriate”.

Affordability (Cost)

The initial course of service and cost to maintain it should be affordable by the community and
country.

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Self-reliance

Individuals and families are encouraged to change from being passive recipient to active partners
with the government or donors.

Self-determination

The community should be able to decide and take action on matters concerning their health and
development.

Integration

All sectors working together towards the socio-economic development of a community, with
health as a nucleus; should work together to promote the health status of their people/community
throughout its referral system.

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 COMPONENTS OF PRIMARY HEALTH CARE
At the Alma Ata conference 8 elements of PHC were identified as being the basic areas for
action to reach health for all goals.
1. Education concerning prevailing health problems.
2. Promotion of food supply and proper nutrition.
3. Adequate supply of safe water and environmental sanitation.
4. Maternal and child health including family planning.
5. Immunisation against major infectious diseases.
6. Appropriate treatment of common diseases and minor injuries.
7. Prevention and control of endemic diseases.
8. Provision of essential drugs.

Those elements are not dynamic and can go to any number as may be determined by prevailing
conditions in various countries.
In Uganda, more elements have been added to the list.
9. Mental health and spiritual health.
10. Dental and oral health.
11. Community based rehabilitation.
12. Occupational health
13. Accident prevention
14. Ophthalmology services

Health Education
Equipping the Community with knowledge and skills concerning prevailing health problems and
methods of preventing and controlling them; this makes people lead better life styles.

Reproduction health/Family Planning

These are services rendered to mothers and children through antenatal, Post Natal and Child
Spacing. The aim is to improve the health status of women and children.

Nutrition and Food Supply

This is the process of improving food production, processing, storage marketing and
consumption with the ultimate goal of improving the health, nutrition status and economy of the
community.

Adequate Safe Water Supply and Environmental Sanitation

This is in terms of amount and distance to the source and safety (wholesomeness). Sanitation is
the control and support of all those factors in the total human environment that have a bearing to
health e.g. Housing, Refuse and Excreta disposal, Vector control, Food hygiene, etc.

Immunisation
This is a process of administration of vaccine to susceptible members of the community so as to
raise their body immunity against infectious diseases.

Appropriate Treatment of common diseases and injuries

Sufficient treatment facilities should be in place for management of common occurring diseases
and injuries in a community.

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Prevention and Control of locally Endemic diseases
All measures of preventing and control of locally endemic diseases (diseases that are always
present in the community) should be taken as PHC activity.

Provision of Essential drugs

This is the supply of drugs required for effective management of most common conditions in the
community.

Mental Health services

These are services directed to the care and rehabilitation of the mentally ill and preventing
mental illness in the community.

Dental/oral health
Management if Dental/Oral services and their prevention.

Community Based Rehabilitative Health service

These include the Physically, Mentally, Socially and economically handicapped and disabled.

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 PILLARS OF PRIMARY HEALTH CARE
These are pre-requisites to the successful implementation of PHC. Four main principles
(strategies) through which the Global Goal of Health for all (HFA) was to be attained were
identified by WHO during the Alma Ata Conference. These were:
 Political Commitment
 Community Participation
 Multisectoral Strategy (e.g. Collaboration)
 Appropriate Technology.

However, individual countries were asked to formulate their own National Health Principles
(strategies) that are relevant and appropriate to their needs.

Like one endeavours to a build a house with foundation, there should be development of strong
pillars to support and sustain the elements of PHC.

 Political commitment

Is that support provided to promote PHC by those who influence decision making at various
levels. These include Policy makers’ e.g.
 Cabinet, Parliament, District Council and Sub County Council
 Administrators e.g. Permanent Secretary, Chief Administrative Officers, Senior
Administrative Secretaries.
 Opinion leaders e.g. religious, traditional leaders, ranging from national to grassroots
levels.

How political commitment is expressed

 Through political statement in favour or support of PHC by highest circles in political
system would be helpful to sustain PHC implementation. E.g. statements by H.E the
President, Prime Minister, Minister.
 Through individual conviction by political leaders by:
- Mobilising the community about PHC
- Soliciting resource internally or externally
- Active involvement in actual implementation of specific PHC
activities/programmes.
 Adequate budgetary allocations for PHC.
 Developing legally backed policies of PHC, i.e. National Health Policy for PHC.
 Re-orienting health services to PHC.
 A policy advocating for developing PHC in health-related ministries
 Launching of specific PHC activities
 Setting aside a day to observe PHC.

NB: The recognisation and support of PHC as a vehicle to achieve Health For
ALL by politicians is of utmost importance.

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  Community participation

This refers to “active involvement of members of the community in the problem identification
and prioritisation, planning, implementation, monitoring, evaluation and decision making on
matters related to Primary Health Care.

Community participation means total involvement of communities in decision about their own
health and development. The emphasis is not with individuals but with the whole community.

For community participation to be sustainable, it should start with the individual, then family and
finally the community.

Since the Alma Ata declaration on Primary Health Care, community participation was
recognised as an important pillar in improving health, particularly among poor and under-serves
population.

Importance of community participation

 A sense of ownership
 Self-reliance
 Acquisition of skills and abilities to sustain the primary health care process
 Efficiency and effectiveness in primary health care implementation
 Equitable distribution of resources among others.

Levels of community participation

Four levels of community participation have been identified

(a) Participation in use of services provided: this refers to active mobilisation of
communities to utilise the services provided e.g. communication programmes.

(b) Participation in pre-planned programmes: this is where communities are invited to take
part in implementation of a programme, although the programme content has been
developed outside the community e.g. protection of water sources.

(c) Community involvement based on local needs assessment and decision of the community:
here, communities are assisted to develop significant skills, enter into analysis, identify
the problems, priorities and develop appropriate plans of action e.g. HIV/AIDS
prevention programmes, community based health care programme.

(d) Community empowerment: here the community becomes aware enough to eventually
assume full.

How community participation is expressed

 Response to community mobilisation
 Drawing up of joint plans
 Definition different roles among community leaders in the community.
 Involvement in developmental projects i.e. provision of labour
 Providing resources and materials for various community development projects.

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  Soliciting of external support (both technical and material)
 Multisectoral collaboration

This is defined as “deliberate actions aimed at encouraging linkage with other health related
sectors to incorporate health goals into their strategies, policies and programmes in order to
achieve Health For All (HFA).
By the nature of elements of PHC such as Food supply and nutrition, Water supply, etc,
multisectoral approach is therefore mandatory. It promotes continuity and suitability of health
services.

Importance of multisectoral collaboration

PHC calls for all relevant sectors both government and NGO, considering its nature. This
therefore means that Multisectoral Collaboration is mandatory.
 The major health problems and their solutions may be found wholly or partially outside
the health sector. Health is endangered at home, in schools and factories in many ways.
The knowledge, skills, competence and means lie in other social and economic sectors
for PHC to produce an impact.
 Health system needs resources for its operation and these resources are not only found in
the Health sector. Therefore, a multisectoral approach offers the best means of
promoting better and effective utilisation of the available resources, which are found in
other relevant ministries and NGOs for achievement of maximum impact on the state of
complete well-being.
 Health is not a monopoly of the health sector but a responsibility of everyone,
individually and collectively.
 There is an inseparable link between health, development and social-economic
development and by nature; a human being does not live in isolation. He/she is
influenced mainly by hereditary and environmental factors and these are known as the
determinants of health (factors that influence health) which are then divided into four
major groups.
- Behaviour (individual, family, community).
- Physical environment
- Demographic characteristics of a community(hereditary or congenital).
- Social services (health and education).

NB: All the above major determinants of health (factors that influence health) are inter-related
 Appropriate technology

This refers to methods and materials that can be used to benefit the community.

Conditions these methods and materials should meet

 Locally and easily available.
 Affordable.
 Of acceptable quality to the community.
 Easy to maintain.
 Easy to learn.
 Should not conflict with people’s culture and norms

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  Suitability.
Importance of Appropriate Technology
 For cost effectiveness
 Cost consciousness
 For better suitability
 Meets the needs of the poor.

How Appropriate Technology is expressed

 Utilisation of locally available resources e.g. homemade fluids to manage dehydration
due to diarrhoea.
 Improving of local capacity i.e. community resource persons (e.g. drug distributors,
traditional bone setters).
 Improved local technology e.g. mud stoves.
 Improved community awareness about health and development, i.e. traditional
communication methods e.g. role plays, drama, stories, etc.

 Other pillars (pre-requisites) that have been added are:

 Equity

This means availing equal opportunities (or fairness). Everyone has been given the opportunity
to have access to basic health care.

 Decentralisation
This is a form of governance Uganda has adopted. Planning, organisation, implementation,
monitoring and evaluation are done at lower level.

It therefore enables decision making and allocation of resources to be done at the lower levels
(district and sub county) and not at the centre. This is done according to priority needs/problems.

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 COMMUNITY BASED HEALTH CARE (CBHC)

1.0 Introduction:
Community based health care (CBHC) is a part of primary health care (PHC). BCHC is the
“people part” of PHC.

The main work in PHC activities is concerned with bringing services closer to the people. The
main PHC activities includes:
- health education
- Uganda national expanded programme on immunization (UNEPI)
- Essential drugs supply to all health units
- Control of diarrhoeal diseases
- Family planning services in rural areas
- TB/Leprosy control programmes
- MCH/Antenatal clinics at health units
- Water and sanitation programmes in rural and urban peer communities, etc.

2.0 NEED FOR CBHC AND PHC

The need for PHC and CBHC arises from the following:

(a) Most illness can be prevented; the most common illnesses are preventable or controllable,
either by the people themselves or a combined effort between the people and government or
other partner (NGO) services e.g. malaria diahohoea/gestroentiritis, respiratory tract infections,
measles and injuries.

(b) High morbidity and mortality rates; a reduction in this suffering can only happen if there
is more “encouragement” and “enablement” of individuals and communities together to have a “
positive attitude “ towards “preventive habits” and to be willing to take part in improving their
local amenities, which also will help prevent and control illnesses.

This encouraging and enabling cannot go on within the walls of the hospitals and health centres.
It must go on in the villages and homes. In other words, the health and development work has to
go to the people, rather than expecting the people to go to the health services and development
projects.

(c) Coverage of health services; even if there was full service in the health units, there are still
few (e.g dental and oral services, mental health services) and they mainly located in the towns
and the rural population have little access to essential health care.

Importantly, some of the health units are still too far away for many parents to take their children
for preventive care services, pregnant mothers to access the care services they need.

3.0 Objectives of CBHC

The main objective in CBHC is to encourage and enable community to take care (responsibility)
for its own health and welfare, if the community can:

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 - Identify its own health problems
- Find solutions for those problems.
- Make its own decisions
- Find (identify) resources outside the community.
- Evaluate its actions and replan.
- Together and individually make healthy behaviours into common practices and habits.

Therefore the main part I CBHC work is to encourage and enable the people community to
develop that sense of responsibility and to change their behaviour.

The two themes in CBHC are to encourage and enable.

To encourage includes helping people understand:

- What is health?
- The value of prevention
- The main cause of illnesses.
- What an individual can do to prevent illnesses.
- What the community can do to prevent illnesses
- What the people can do together
- How they can work together
- Discussing the individual’s and community’s problems as they see them and not
- Discussing problems as seen by the Health care service providers.

To enable includes:-

- Giving the community skills and knowledge to take care of their health and welfare.
- Training community health workers (CHWs)
- Training health committees.
- Connecting the community with resources from outside.
- As advisors in CBHC, help the CHWs and Health committee overcome problems
- As advisor in CBHC make frequent follow-up support visits to the community.

4.0 Difference between PHC and CBHC

PHC activities are mainly concerned with taking services closer to the rural and urban poor
communities. PHC activities are organized from outside, mainly by planners. These activities
have little chance to work at the speed, and be flexible and responsive to the need of the
community. The people are not involved in the organization of PHC activities and decisions.
Also the activities in PHC programmes do not have the flexibility to fit into the specific needs
and speed of any one community. As a result, they do not make best use of the services offered.

These PHC efforts have not yet been able to include a lot of community organization work (to
encourage and to enable) to concentrate on the change of attitude and habits of the individuals,
which is the basis to prevention and control of most common illnesses.

CBHC works very closely with specific communities in such a way that they gain the knowledge
and develop skills to be able to organise their own preventative and control activities. It centres

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on people in the community and less on the health services inputs. Ultimately, the community
can be able to:-

1. Carry out its health work;

2. Call on health services that it will need and;
3. Be wanting to make the best use of the health services available.
NOTE:-
The first health services (essential health care) available to the people (i.e. PHC), are very
important to assist individuals with the problems they cannot solve alone or do not have the
resources to obtain, such as vaccines.

At the same time, the PHC services need the people (the people part of PHC, which is now
CBHC) to be fully aware of how best to use the services so that they can be effective.

In this ways, PHC services and CBHD help to support each other. Simply put, PHC deals with
the physical services while CBHC deals with the people so that they can make use of the
services.
Differences between PHC and CBHC

- PHC - CBHC
- Originated and implemented by health - Originated by community
worker
- Top down - Bottom up
- Foreign to culture and practices of - Relevant to communities culture; hence
communities; hence may not care what all activities initiated have cultural
the culture says and there is often considerations
conflict
- Is concerned with structural change. - Concerned with change in people
- Owned by support system and hence - Owned by the community
community dependence is high
- Is broader and global elements and - Based in the community
content
- Is based on national priority - Is based on the priority of the
community
- Vision of PHC is external - The vision is internal and may be
influenced
- Institutional based - Community based
- Activities controlled externally - Activities controlled internally
- Is rigid, hence it has defined roles - Flexible with unidentified roles
- Is a programme - Is approach
- Is well established - Is evolving
- Well staffed - Is supported
- Working for people - Working with people
- Intersectional collaboration difficult to - Involves the community and
achieve collaboration easy to achieve.
- Less open - More open
- Need for experts - Community responsible for own
planning depending on their needs and

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 problems only come in to help.
- Community imposed programme - Community oriented (identify their
own problems, plan and implement.
- More expensive to implement - Cheaper to implement
- Cafeteria (communities wait to be - Self service (communities participate
served and involved)

5.0 How do PHC and CBHC work together?

To state it better, none of what has been discussed above (under the difference between PHC and
CBHC) should be interpreted as being that PHC or CBHC is better that the other.

They both have their place in improving the health status of the people, who could still be under
served or who are often suffering from preventable diseases.

Take an example:-

The following is the drop-out rate by UNEPI for polio and DPT (diphtheria, tetanus and
whooping cough).

Polio DPT
BUSHENYI 35% 47%

KABALE 34% 53%

KASESE 17% 23%

MBARARA 22% 43%

RUKUNGIRI 32% 34%

Why are there so many dropouts and complete the course?

There are very many reasons:-
- Mothers do not realize that they have to return several times to complete immunizations.
- The clinic comes on a market day.
- The mother does not have time to take the child
- The last injection made an abscess and she does want that to happen again
All these are described by the people as “I would have come to the clinic, but………….?

The CBHC side of this drop-out is work closely with the women and the community together to
overcome the problems that they have (i.e. Get over BUT…….), so they can complete the
vaccinations.

The PHC sides of this drop out is for UNEPI to maintain supply of vaccines and run the clinics,
including outreach and the therefore maintain the service

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PHC deals with the physical services while CBHC deals with the people so that they can make
use of the services.

HEALTH AND DEVELOPMENT

Introduction
When people think about health, they normally think about medical matters such as disease,
hospitals, doctors, nurses, medicines and drugs. However health goes beyond that. Health is a
more of a well being, that is, satisfied, comfortable, contended, fit, well fed, safe and being
happy.

Definition of health
World Health Organisation (WHO) in 1946 gave the definition of health as “a state of complete
physical, mental and social wellbeing and not merely absence of disease or infirmity”.

The broad concept of health refers to WELL-BEING. It has both negative and positive
meanings.

Negative meaning: denotes the absence of disease or illness.

Positive meaning: denotes the state of well-being.

The six dimensions of health (according to Ewels and Simnett, 1992)

The definition of health by (WHO) has been challenged by some scholars, who argue that one,
can never have complete health. That a state of health is never static; the truth is that life and
living are not static.

The two scholars, Ewels and Simnett; 1992 defined health as “having the ability to adapt
continually to constantly changing demands expectations and stimuli”. They put forward six
dimensions of health and that these sixdimensions of health influence each other.

Physical health
This seems to be the most obvious dimension. It is concerned with the mechanistic functioning
of the body.

Mental health
It is concerned with the ability to think clearly and coherently. In others words it concerns the
ability think and make judgement.

Emotional health
Refers to the recognition of and appropriate discharge of feeling states e.g. anger, fear, joy, etc.
Precisely, it includes the ability to recognise emotions e.g. fear, anger, joy, grief, etc. and to
express them appropriately. Coping with stress, tension, depression and anxiety are also in this
dimension.

Social health

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 This is the ability to make and maintain friendship with other people. In other words it concerns
the integration of somebody in social relationships.

Spiritual health
Is the recognition and ability to put into practice moral or religious principals/or beliefs. For
some people it is connected with religious beliefs and practices, while for others it is connected
with personal creeds, principles of behaviour and ways of achieving peace within oneself.

Societal health
Explains the link between health and the way a society is structured, that is, ones health is related
and affected by the surrounding. The societal factors include; helter, peace, food, income,
oppression, political conflict, poverty and the degree of interaction or division within society.

This health cannot be owned, but health only be shared, that is, there is no health for no me
without my brother or sister. There is no health for Uganda without Rwanda, Congo, Britain,
Sudan or America.

ENVIRONMENT
Refers to the sum total of all things, which surround us. The components of the environment
include physical, biological, chemical, social, cultural, economic and political.

DISEASE, ILLNESS AND ILL HEALTH

The terms disease, illness and ill health are often used interchangeably. Disease is the objective
state of ill health, which can be verified by acceptable canons of proof. In our society, these
acceptable canons of truth are couched in the language of Scientific Medicine. For example,
microscopic analysis may yield evidence of change in cell structure, which in turn lead to
diagnosis of cancer or disease.

Disease: is the existence of some pathological or abnormality of the body, which is capable of
detection.

Illness: is the subjective experience of loss of health this is couched in terms of symptoms. For
example, reporting of aches or pains, or loss of functions.
Illness and disease are not the same, although there degree of co-existence. For example,
someone may be diagnosed as having cancer through screening even when there have been no
symptoms. That is, someone who may be diagnosed as having a disease although they have not
reported any illness.

Ill health: when someone reports symptoms and further investigation such as blood tests prove
disease process, the two concepts, disease and illness coincide. In these instances, the term ill
health is used. Ill health is therefore an umbrella term used to refer to the experience of disease
plus illness.

Some people, such as doctors and nurses acquire a specialised view of health. This specialised
view is gained through their professional training.

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During professional training health workers are introduced to their field of knowledge and they
spend much time with other students and practitioners. They learn to use professional jargon and
adopt the meanings of and value systems of their peers. This is called secondary socialisation.
Common diseases and conditions in our communities

Diseases Conditions
 Malaria  Poverty (both in and rural and
 Worm infestations urban areas)
 Scabies  Malnutrition
 ARI (pneumonia, pneumonia) - Kwashiorkor
 HIV/AIDS and STIs - Marasmus
 Measles - Nutritional anaemia
 Cholera - Obesity or overeight
 Typhoid (especially among the
affluent society in urban
 Dysentery
areas)
 Skin infections (ringworms)
 Accident, burns from domestic
 Eye infections (trachoma)
violence

 Alcoholism
 Drug abuse (e.g. marijuana,
marungi)

Epidemiology: refers to the study of diseases, disease patterns and pattern and the effects of
diseases on the health community.

Communicable disease: disease that can be transmitted from one person to another.

Epidemic disease: refers to disease that occurs unexpectedly and may give rise to many new
cases in a short time.

Endemic disease:disease that is present all the time in a community.

Sporadicdisease: disease that occurs only occasionally in a community and without a regular
pattern

DEVELOPMENT
There can little development without healthy people. Increased food production and increase in
income are essential for improvements in health.

Education: this is the first requirement and is indeed a very first important requirement.

Therefore good health is a pre-requisite in any development process; at home, in the community,
nation and internationally. Members of a unit home, community or nation cannot work hard for
political, social and economical development if they do not enjoy good health. They cannot be
productive (they can not engage in gainful occupations). Lack of productivity brings about lack
of income.

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Poverty: Poverty brings about ignorance and disease; therefore poor health.

DETERMINANTS OF HEALTH

The main Determinants of Health are:

(a) Behavioural (Individual, family, community).

(b) Demographic factors (population/heredity)
(c) Environment factors
(d) Health Services.

The above four groups are inter-related. The understanding of linkages and interactions guide
the selection of an intervention to be deployed for the attainment of Health through P.H.C.

Behaviour

Changes in behaviour have significant effect on the health status. Studies have shown that there
is inter-relationship between problem behaviours such as smoking, drinking, and early sexual
activities and the health of the individual and the community. Health promoting behaviours such
as regular physical activity, balanced diet, and use of personal hygiene have been found to have
commendable effects on the health of the individual.

The major health behaviours are: Sports and recreation, enough sleep, relaxation, sex and
reproductive practices, reading and media contact, type and duration of work, travel and
transportation.

Adolescents and young adults are more likely to move to urban areas than the children and aged
with a view of taking advantage of a perceived better economic and social environment. This
factor coupled with the spirit of adventure has made the adolescent more vulnerable. Accidents
and violence, delinquency and psychic problem, alcohol, tobacco and drug abuse, prostitution,
sexual promiscuity with consequent sexually transmitted diseases and unwanted adolescent
pregnancies, HIV infections and AIDS have become major health problems for our youth.

Demographic factors (population/hereditary/congenital)

The population of the world is currently estimated at 5.3 billion. It is expected to grow by one
Billion over the next decade. Other demographic trends observed in developing countries
include: - ageing and increasing urbanisation. The resultant effect of this rapid urbanisation will
worsen the problems of already overstraining social and health services. The diseases/problems
of the elderly are not yet felt in Uganda.

Population growth is a function of the number of births and deaths; therefore the marked increase
in the population growth in the developing world reflects a high fertility rate among the female
population of this region.

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This as a result affects the already poor socio-economic conditions of the developing countries,
thus the deteriorating health status of these countries for example Africa which accounts for 10%
of the world total population, contributes 30% of the over 500,000 Maternal deaths that occur
annually.
Similarly, children below 15 years constitute 50% of the population in these developing
countries. This is a dependant population which requires: education, health care, food, water,
housing, sports and recreational facilities, thus further complicating an already desperate socio-
economic situation.

Some diseases/conditions have hereditary/congenital bearing. These are intrinsic health

determinants which are difficult to control in an individual/community such as Sickle cell,
epilepsy, diabetes.

Environment

This consists of all the external influences that affect the individual from conception to birth. It
includes: atmosphere, soil, water, shelter, food, vectors, parasites, etc.
 Water borne and food borne diseases e.g. Diarrhoea, Dysentry, Cholera, Typhoid.
 Air borne diseases e.g. T.B., Measles.
 Vector borne diseases e.g. Malaria, Trypanasomiasis, Onchocercias, Leshmaniasis,
Filiarosis.
 Environmental contact diseases e.g. scabies, ring warms, lice.

The environment of an individual is determined by the Socio-economic characteristics of the

population to which he/she belongs. This has a pervasive influence on health. The improvement
in health conditions in Western Europe and North America was brought about by the rising
living standards and improved socio-economic conditions for example: -
The incidence of infectious diseases fell in these countries long before effective methods of
treatment were available e.g. Trachoma, Yaws and Tuberculosis.

Health Services

The Health Services in order to be effective must fulfil the following conditions:
a. Availability
b. Accessibility
c. Utilization.

Availability – in terms of Health Resources (Facilities and personnel). In Developing countries

Health Services availability is low in rural areas as compared to Urban. This unfortunately
includes human resources. Heavy emphasis is placed to curative services as opposed to
preventive measures.

Accessibility should be:

Physically – within easy-walking or cheap transportation.
Economic - ability of the individual to cover cost of care.
Cultural - acceptability of the services to those for whom they are provided.
Accessibility reduces as distance from the Health Unit increases. The situation in developing
countries in aggravated by poor road network and transportation system, more so in rural areas.

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Utilization: Utilization of service is expressed as the proportion of people in need of a service
who actually receive it in a given period. It has a direct relationship with the type of health unit,
quality and quantity of health personnel and type of services to be provided.

Development
Many scholars have written on development.
Dr. Roy Shaffer & Mwalimul Julius Nyerere have contributed the following:

“Achieving Balance Development: The essence of development is the Development

of people with a change on their habits. Just changing things without a concurrent
change of attitudes is not a healthy development.

“Development is a changing process of knowledge, altitudes and practices”. If things

do not help change people’s individual knowledge, attitudes and practices, then those
things are not really development”.

“People cannot be developed: They can only develop themselves.

For it is possible for an outsider to build a man a house, but that outsider cannot give
the man pride and self-confidence in himself by walking his own knowledge and by
his participation as an equal in the life of the community he lives in. They are not
beings if they are herded like animals into new ventures.

Development of the people can in fact only be effected by the people themselves”.
(Mwalimu Julius Nyerere)

Indicators of Development
 Good living standards:
(a) Housing
(ii) Food
(iii) Employment
 Good income
 Good governance
 Political stability
 Literacy rate
 Good environmental conservation/management
 Adequate industrial and technological revolution
Development should therefore, be seen as a dynamic process, entailing a change of knowledge,
altitudes and practices conducive to development. This development should be one that the
community can sustain. “Under- Development is created not inborn”.

Ten Guidelines for Building a Just Society

1. Redistribute goods.
Ensure basic needs are met first with priority to the poor.
2. Redistribute power.
3. Change the structures not just the rulers.

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 4. Build structures for participation. Make participation your culture.
5. do not confuse great leaders with structure:
?? Do the improvements continue after she/he has left??
6. Change in structures and attitudes are both needed.
7. Motivation of envy, greed and hate is self-defeating.
8. Do not sacrifice the present generation for the future one.
9. Means affect the end.
10. So live the future you hope for new. The future is a set of embodied values.

SUMMARY:

We cannot begin to address the issues related to the health of our people unless we understand
and appreciate the socio-economic and population dynamics of health. Our approach to the
solution of the health problems of our communities should, therefore, be multisectoral. Health is
at the heart of a complex set of interrelationships. The entire disease pattern in a particular area is
ultimately related to social economic standards, fertility and cultural habits.

Lower wages and purchasing power among the poor and middle class translate into reduced
health care expenditure. The cut backs in government budget result into reduced services in
social sectors.

REFERENCE

Ewles & Simnett: Promoting Health, a Practical Guide; Alden Presss Oxford.

R.S. Downie et al: Health Promotion, Models and values; Oxford Medical Publications.

Macdonald J.J: Primary Health Care; Earth scan.

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STRATEGIES FOR IMPLEMENTATION OF PRIMARY HEALTH CARE

Introduction

The term strategy refers to an art of planning and directing an operation in campaign Or planning
or managing an affair well Or plan or policy designed for a particular purpose. In the case of
PHC the particular purpose is the achievement of health by ALL in the world. It is therefore a
campaign aimed at improving the health of the community through effective and efficient health
services delivery.

Primary Health Care strategies

The following are some of the strategies aimed at effective implementation of PHC activities:

 Prioritisation – much as there may be so many health problems, health care services
should be prioritised such that health problems that affect the majority of the people are
addressed first.

 Ensure Accessibility – the health care should be accessible to all, if not the majority of
the people in terms of distance, availability and attitudes of the service providers (health
care providers).

 Ensure affordability of health care services – the health care should be provided at a
cost individuals, families, communities and government can afford in terms of financial
resources, time, manpower or otherwise.

 Ensure community participation – communities should be active participants in the

health service delivery rather than just being passive recipients. This would enable them
to own the services and hence sustainability of the health services. Community
participation should be undertaken at all stages that include planning, implementation,
monitoring and evaluation of the health service delivery system. Mechanisms should
therefore be put in place for community participation to take root.

 Ensure the use of Scientifically Sound and socially acceptable methods and
approaches – the methods and approaches employed in PHC, should be scientifically
proven and should not sharply contradict the peoples cultures and the socially acceptable
ways of life in the community.

 Ensure use of appropriate technology – the technology used for the delivery of the
services should be appropriate to the communities in terms of operation, affordability of
the replaceable parts and general maintenance.

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 Promotion of intersectoral collaboration – services delivery should be done through
building alliances with other sectors (government, NGOs, etc.). This helps in pulling
resources and sharing the scarce resources to the benefit of service delivery to the people.

 Promotion of self reliance – the services delivery should be done in a way that builds
confidence in the families, communities and government to become self reliant, which in
turn leads to the sustainability of the health care delivery system.

 Ensure political commitment

 Adopt decentralisation system of governance

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PLANNING, IMPLEMENTING, MONITORING, AND
EVALUATION IN PHC

1.0 Introduction
Many programmes (intervention for health promotion) in the field have failed to meet their
targets and goals because of poor or lack of planning, implementing, monitoring and evaluation.
The successful implementation of PHC must ensure that all the activities to be undertaken are
well planned, implemented, monitored and evaluated.

2.0 Learning objectives

At the end of the lecture students should be able to:-
1. Define:-
(a) Planning
(b) Implementing
(c) Monitoring
(d) Evaluation
2. Explain the importance of planning, monitoring and evaluation in PHC.
3. Explain who plans, implements, monitors and evaluates and for who.
4. Explain the characteristics of a good plan.
5. List and describe the planning steps (planning cycle)
6. Describe the tools of monitoring and evaluation.
7. Describe the types of evaluation.

PHC must ensure that all the activities to be undertaken are well planned, implemented,
monitored and evaluated.

3.0 Definitions
Planning
 A systematic way of making decisions and laying down what is or ought to be done in a
period of time.
 It is a continuous process which involves making choices about how to use available
resources in order to achieve particular targets and goals at some time in the future.
 A systematic process of laying strategies to attain a goal/objective.
 A process of drawing strategies to attain an objective/goal.
 A systematic way of designing what you want to do.

Implementing
This refers to putting into action the plan.

Monitoring
Checking of what is happening during the process of implementation.

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Evaluation
Assessing progress of an activity against the objectives.

4.1 The importance of planning

 Enables assess resources needed
 Enables us to effectively utilise scarce resources (i.e. avoid wastage of resources)
 Enables prioritisation of problems.
 Avoid making mistakes.
 Helps in implementation.
 Avoid duplication.
 Help to see where we are going wrong. (I.e. correct direction).
 Creates order.
 Helps in accountability.
 Assist in report writing.
 Confidence building.
 Educational for the planner and the people involved.
 Enable to solicit for more resources. (i.e. get support from donors, government,
community, etc.)
 Enable the identification of alternative strategies and methods

4.2 The importance of monitoring

 Avoid errors during implementation
 Help to readjustments o time.
 Encourages partners.
 Assist in the reallocation of resources.
 Used as continuous data gathering.
 It is a link to evaluation.
 It is educational.
 Involves spirit of responsibility.

4.3 The importance of evaluation

 Helps to explain the achievements (successes i.e. what has been achieved) and failures.
 To see where strengths and weaknesses lie.
 Help with re-planning. (i.e. to help make better plans for the future).
 To critique our work.
 Accountability
 Soliciting of resources.
 Builds confidence
 Builds morale of partners.

5.0 Who plans, monitors, evaluates and for who

All those who are involved in the activities of the plan from national level to the community
level.
 Policy makers

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 Project managers
 District health team
 Health sub district management committee
 Sub county/committees
 Village health committee community health workers and the community.
6.0 Characteristic of a good plan
A good plan should state the following clearly:
1. Problem statement (what is our problem?).
2. Goal/Aim
3. SMART Objectives – characteristics are:
- S = Specific, to the point
- M = Measurable, figures
- A = Achievable or Applicable or Acceptable or Useful
- R = Realistic or Reliable
- T = Time Bound/Conscious (i.e. it is important to attach or tag a period)

Examples of SMART Objectives:-

 Raise the level of awareness from 20% t0 50% about the dangers of intestinal worms
during the next three years.
 Kanguluma B zone in Namutumba subcounty in Namutumba district will have
increased accessibility to safe water from 60% to 80% during the next three years.
4. Strategies (how do we achieve our objectives)
5. Activities/tactics (what would we need to do in order to achieve our objectives; these are
tasks).
6. Resources:- Is something that assists one to undertake and accomplish a given
task/activity.
Types of resources include:– Manpower (Human), Materials (Logistics, Supplies),
Money (Funds) and Moment (Time). The availability of the 4 Ms (Manpower,
Materials, Money and Moment is a determinant in laying strategies for both quantitative
(e.g. change in terms of numbers) and qualitative (e.g. in terms of behaviour change)
indicators.
 Resources are the cornerstone in the implementation of any programme/project.
 It is important to identify appropriate resources at different levels.
 Resources are inadequate universally.
 There is need to identify, acquire/generate and utilise resources effectively and
efficiently.
7. Indictors (what is there to show what has been achieved).
8. Time schedule (when to do the various activities to achieve the set (or a particular)
objective.

7.0 The planning steps

Planning cycle
i) Situation analysis: - as it exists or as it is in the community.
ii) Problem identification: - the health and health related problem of the community
(establishment of the health status of the community).

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 iii) Setting priorities: prioritization of the health problem: - there could be many health
problems which, requires attention or intervention. Which one requires first, second,
third etc attention or intervention.
iv) Setting goals and objectives: - What to be done to overcome the problem.
v) Resource assessment: - Identification of the resources needed (human, funds,
material etc).
vi) Setting strategies and targets: - identification of strategies and methods to achieve
objectives.
vii) Designing programmes and activities: - i.e. development of the plan for
implementation.
viii) Budgeting:- costing ( how much it costs in terms of money)
ix) Designing: - developing an action plan (what, where, when, how and who of us is
responsible, resources and sources of resources, indicators.
x) Implementation- putting into action the plan
xi) Monitoring: - (continuous) checking on what is happening during the process of an
activity against the objectives.
xii) Evaluate.
xiii) Re-plan.

THE PLANNING CYCLE

(Planning steps)

Situation analysis
(Needs assessment)

Re-plan Problem identification

and Prioritisation

Evaluation Setting objectives

Monitoring Identify resources

(Resource assessment)

Implementation Setting strategies and targets

Develop strategies)

Designing an implementation plan

(Designing activities, budgeting, etc.)

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Note:
Some managers only stop at planning and never implement. It is important that the cycle is
completed including implementation.

8.0 The tools for monitoring and evaluation

 Observation
 Interview
 Questionnaire.
 Records
 Reports
 Focus group discussion

9.0 The types of evaluation

For purposes of PHC programmes these can be examined under:
 Process evaluation: - studying the process and see how it is functioning.
 Formative evaluation: - this entails examination of the process after a short period of 3,
6, 9, or 12 months of implementation. Sometimes this is referred to Milestone evaluation.
It also looks at the shape the programme is taking.
 Summative evaluation: - carried out to find impact of the programme after 3 or more
years of implementation or at the end of funding period.

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