PRIMARY HEALTH CARE (PHC)

Objectives

• Demonstrate the concept of primary health care

• Apply primary health care knowledge and skills
in nutrition and dietetics
• Plan community projects and programmes
Course Outline

• Background of Primary Health Care

• Elements of Primary Health Care
• Fundamentals of Primary Health Care
• Primary Health Care Roles and Training Needs
• Community Based Health Care (CBHC)
• Nutrition and Population
• Emerging Issues and Trends
Definition
Primary Health Care (PHC) is a concept that was
conceived by the World Health Organization (WHO)
in 1978, at the alma Ata International conference on
PHC. It was defined as:
• “Essential healthcare 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.”
Definition cont’d..
• Before this time health was perceived as a
responsibility of medical professionals and
hence communities were not involved on
decisions and responsibilities related to health.
• This saw deterioration of health among
populations especially in the developing
countries of the world.
• Most of the health problems that people suffered
from were preventable and led to high
mortalities especially of women and children.
Highlights of the Definition
▫ PHC is universally accessible to individuals and
families in the community
▫ PHC is socially acceptable to all, the health care is
appropriate and adequate in quality to satisfy the
health needs of people and is provided by methods
acceptable to them within their social cultural norms
▫ PHC is affordable ,that is, whatever methods of
payment used, the services should be at a price that
the community can afford
▫ PHC promotes full participation of individuals ,
families and communities
▫ PHC uses appropriate technology that is the use of
methods and technology which use locally available
supplies and equipment
The Concept Of Primary Health Care
• Concept of PHC are ideas about the
implementation of health care for all; usually
identified as the 5 A’s :
 Accessible
 Acceptable
 Affordable
 Available
 Appropriate technology
5 As cont’d…
• Accessible: The services are geographically, financially
and culturally within easy reach to the whole community.
• Acceptable: The quality of health services offered are
appropriate, adequate and able to satisfy the health
needs of people and are provided by methods which are
within their social cultural norm.
• Affordable: The services are provided at a cost that the
community can afford
• Available: The health structures and services are easily
available to the community members and they also help
them to assume responsibility in promoting their own
health
• Appropriate technology: Utilizing existing methods,
techniques and resources within the community.
• In PHC there are five main areas for which
appropriate technology can be applied;
• 1) Food production, storage and preparation
• 2) water and sanitation
• 3) prevention and management of diseases
• 4) Information, Education and Communication
• 5) Maternal health and child welfare - MCH/FP
• Examples of appropriate technology include; hand
water pumps, energy saving jikos, VIP Latrines
• Primary Health Care (PHC) is a strategy of
health care delivery which creates a partnership
between the consumer of the health services and
health care professionals.
• They both actively participate in the
achievement of the common goal of improved
health
• PHC delivery is by the people and for the people.
Goal of PHC
• The global goal as stated in the Alma Ata Declaration
is Health for All by the year 2000 through self-
reliance.
This means that:
• People will use better approaches than they do now for
preventing diseases and alleviating unavoidable
disease and disability and have better ways of growing
up, growing old and dying gracefully.
• There will be even distribution among the population
of whatever resources for health are available.
• Essential health services will be accessible to all
individuals and families in an acceptable and
affordable way.
Assignment

• Outline the September 1978, Declaration of

Alma-Ata ;International Conference on Primary
Health Care (10mks)
Organizational Structure and
Functions of Various
Administrative Levels
Health facilities in Kenya before
devolution were grouped into six levels:

• Level 1 health services — community

• Level 2 health facilities — Dispensaries/clinics
• Level 3 facilities – Health centres/ maternity
• Level 4 Hospitals – former District and sub—
district hospitals (county and sub-county hospitals)
• Level 5 Hospitals – Former Provincial hospitals
(county referral hospitals)
• Level 6 Hospitals – National referral hospitals
Devolution Of Health Services
What is Devolution?

• Refers to the transfer or delegation of power to a

lower level, especially by central government to
local or regional administration.
• Under the Kenyan constitution which was
promulgated in 2010,health services were
devolved to 47 counties in Kenya
Devolution cont’d..

• It provides for one (1) national government and

forty-seven (47) county governments
• The governments at the national and county
levels are “distinct and interdependent,”
• They are expected to undertake their operations
through “consultation and cooperation
Objectives Of Devolution Of Health
Services
(According to the Kenya Health Policy 2014-2030)
a. The promotion of democracy and accountability
in delivery of healthcare
b. Fostering of seamless service delivery during
and after the transition period (everything a
customer needs)
c. Facilitating powers of self-governance to the people
and enhancing their participation in making
decisions on matters of health affecting them
d. Recognizing the right of communities to
manage their own health affairs and to further
their development
Objectives cont’d..
e. Protection and promotion of the health interests and
rights of minorities and marginalized
communities, including informal settlements such
as slum dwellers and under-served populations;
f. Promotion of social and economic
development and the provision of proximate,
easily accessible health services throughout
Kenya
g. Ensuring equitable sharing of national and
local resources targeting health delivery
throughout Kenya;
 
Essential Package of Health Services (EPHS) in Kenya

• The Ministry of Health in Kenya laid out a clear

vision for delivery of the Essential Package of Health
Services (EPHS) in Kenya through the Kenya Health
Policy, in which health and related services will be
available to all Kenyans through four tiers/levels
of care

– Tier 1: Community level;

– Tier 2: Primary Care level
– Tier 3: County level
Level 1/Tier 1:Community Health Services.
• Health Services in this level are implemented
through the community health strategy
• The community health strategy, is a community-
based approach, through which households and
communities take an active role in health and
health-related development issues.
• It utilizes the bottom-up approach in solving health
related problems.
• There should be one community unit for every 5,000
people. Community units are not facility-based.
• This level involves identification of cases that need to
be managed at higher levels of care.
The goals of the community strategy are
1. To enhance community access to health care by
providing health care services for all cohorts and socio-
economic groups at household and community levels
2. Building the capacity (training) of community health
extension workers (CHEWs) and CHWs to provide
community level services;
3. Strengthening health facility-community linkages;
4. Raising the community's awareness of their rights to
health services
• This improves productivity and thus reduce poverty,
hunger, and child and maternal deaths.
• It also improves education performance across all the
stages of the life cycle.
• It is accomplished by establishing sustainable
community level 1 services aimed at promoting
dignified livelihoods throughout the country through the
decentralization of services and accountability.
Intervention in Community health Strategy
• It establishes a level one care unit (community unit) to
serve a local population of 5,000 people.
• Each community unit has a cadre of well-trained CHWs
who each provide services to 20 households.
• For every 25 CHWs there is one CHEW providing
supervision and technical support.
• CHEWS are trained health personnel with certification in
nursing or public health, and are MOH employees.
• CHEWS responsibilities: facilitating trainings in the
community, providing facilitative supervision to CHWs,
and providing a link between CHWs and health facility
Households Responsibilities For Addressing Health
Needs
1. Health promotion:
• Healthy diet for house hold members to meet nutritional needs.
• Building healthy social capital to ensure mutual support in meeting
daily needs as well as coping with shocks in life.
• Demanding health and social entitlements as citizens.
• Monitoring health status to promote early detection of problems
for timely action.
• Taking regular exercise.
• Ensuring gender equity.
• Using available services to monitor nutrition, chronic conditions
and other causes of disability.
2. Disease prevention:
• Practicing good personal hygiene e.g. washing hands, using
latrines
• Using safe drinking water.
• Ensuring adequate shelter, and protection against vectors
that transmit disease.
• Preventing accidents and abuse, and taking appropriate
action when they occur.
• Ensuring appropriate sexual behavior to prevent
transmission of sexually transmitted diseases.
3. Care seeking and compliance with treatment and advice:
• Giving sick household members appropriate home care for
illness.
• Taking children as scheduled to complete a full course of
immunizations.
• Recognizing and acting on the need for referral or seeking
care outside the home.
• Following recommendations given by health workers in
relation to treatment, follow up and referral.
• Ensuring that every pregnant woman receives antenatal and
maternity care services
4.Governance and management of health services:
• Attending and taking an active part in meetings to discuss
trends in coverage, morbidity, resources and client
satisfaction, and giving feedback to the service system
either directly or through representation
5.Claiming rights:
• Knowing what rights communities have in health.
• Building capacity to claim these rights progressively.
• Ensuring that health providers in the community are
accountable for effective health service delivery and
resource use
Level 2/ Tier 2: Primary Care Services:

• These are the dispensaries, health centers and

maternity homes for both public and private
providers.
• According to the Kenya Health Sector Strategic
And Investment Plan (KHSSP), a dispensary
should exist for every 10,000 persons on
average, and
• It should provide an average of 30 outpatient
services (curative, preventive, or health
promotive) per day.
Level 2 cont’d..
• Dispensary units can be static, physical facilities
or mobile facilities for the mobile communities
• Health centers should serve an average
population of 30,000 (catchment area)
• It should be able to handle at least four
deliveries per day.
Level 3/ Tier 3: County Referral Services:

• These are hospitals operating in and managed by

a given county
• They consist of the former level four and district
hospitals in the county
• Include public and private facilities. E.g FBO,
Mission hospitals, private hospitals
Level 4/Tier 4: National Referral Services:

• This level comprises facilities that provide highly

specialized services and
• Includes all tertiary referral and teaching
facilities.
• Provision of health care services is shared
between the national government and county
governments
 LEVELS DESCRIPTION
FOCUS

NATIONAL All PGH’s, and National • Highly specialised health care, for area / region of specialisation
REFERRAL Referrals • Training and research services on issues of national importance
FACILITIES Are general, regional, or
discipline specialists

Referral services

All district, sub-district hospitals, • Comprehensive in-patient diagnostic, medical, surgical and rehabilitative
including NGO / private, form care, including reproductive health services
COUNTY REFERRAL network of County Referral • Specialised outpatient services
FACILITIES Services in a county • Facilitate, and manage referrals from lower levels, and other referrals
• With other County Referral Facilities, form the County Referral System

Referral services

All dispensaries, health • Disease prevention and health promotion services

PRIMARY CARE centres, clinics, maternity • Basic outpatient diagnostic, medical surgical & rehabilitative services
homes • Inpatient services for emergency clients awaiting referral, clients for
FACILITIES Catchment area: 30,000 observation, and normal delivery services
persons • Facilitate referral of clients from communities, and to referral facilities

Referral services

• Facilitate individuals, households and communities adopt appropriate

healthy behaviours
COMMUNITY UNITS No physical facilities • Provide agreed health services
• Recognise signs and symptoms of conditions requiring referral,
• Facilitate community diagnosis, management &referral.
Elements Of Primary Health Care
• In the Alma Ata conference of 1978,eight
essentials of PHC were identified.
• Individual countries were given the liberty to
add any other elements they felt were relevant to
their own country.
• The PHC elements listed at the Alma-Ata
Declaration were:
Elements Cont.
1. Education concerning prevailing health problems
and the methods of preventing and controlling them
2. Promotion of food supply and proper nutrition
3. An adequate supply of safe water and basic
sanitation
4. Maternal and child health care including family
planning
5. Immunization against major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common
diseases(communicable & non-communicabel )
8. Provision of essential drugs
Elements Cont.
• E – Education for Health
• L – Locally endemic disease control
• E – Expanded program for immunization
• M – Maternal and Child Health including
responsible parenthood
• E – Essential drugs
• N – Nutrition
• T – Treatment of communicable and non-
communicable diseases
• S - Safe water and sanitation
Elements Cont.
• The Kenyan government has added more
elements to the ones at the Alma Ata conference.
These are:
 Mental health
 Dental Health
 Malaria control
 STI and HIV/AIDS prevention and control
Elements Cont.
Health Education
• Education that is intended to have a positive
impact on health.
• Process of dialogue with community members to
find out appropriate responses to health
problems as well as empower them with the
knowledge and insight they need to understand
how their behaviour affects their health.
Elements Cont.
Promotion of Food Supply and Proper
Nutrition
• Addressing factors influencing nutritional
deficiency(cultural, economic) especially among
pregnant and lactating mothers, infants and
children.
• Taking suitable measures to prevent and treat
diseases which lead to nutritional deficiency states.
• Support of health promotional measures such as
food hygiene, nutrition education, child spacing,
kitchen gardening and proper food storage.
Phc Elements Cont
Water Supply and Basic Sanitation

• Safe water and sanitation is not available to a

major section of our population yet it is essential
to life.
• Many water-related diseases prevalent in the
communities can be prevented if communities
gain access to safe water and adopt proper refuse
and feacal disposal
Elements Cont.
Maternal And Child Health And Family
Planning

• Mothers and children run a great risk of injury

and disease because their lives are concerned
with beginnings and growth.
• MCH/FP services are therefore aimed at
promoting the health of mothers and children by
reducing the maternal and child mortality rates
and enabling women of childbearing age to have
the desired numbers of pregnancies and at the
right interval.
Elements Cont.
Immunization

• Effective means of prevention against certain

diseases.
• Kenya has implemented immunization activities
through the Kenya Expanded Programme on
Immunization(KEPI) aimed at providing
immunization against 6 killer diseases:
tuberculosis, polio, diphtheria, whooping cough,
tetanus and measles
Elements Cont.
Treatment of Locally Endemic Diseases

• There are many endemic diseases in this

country, some of which are confined to
particular areas
• Preventive care, prompt treatment and control
reduces morbidity and mortality rates
Elements cont’d..
Treatment and prevention of common
diseases and injuries

• Curative care is important in its own right as it

provides a powerful mechanism for teaching
preventive and promotive care
Elements Cont.
Supply of Essential Drugs

• Essential drugs are basic drugs used to treat

minor ailments or conditions at the dispensary
and health centre levels
Fundamentals of Primary Health Care
• Fundamentals of PHC are basic rules or beliefs
that are essential to the existence, development
or success of primary health care.

• The following are the fundamentals of PHC:

Fundamental cont’d…
• PHC reflects and evolves from the economic
conditions and socio-cultural and political
characteristics of the country and communities.
• PHC addresses the main health problems in the
community, providing promotive, preventive,
curative and rehabilitative services accordingly
• PHC includes at least the 8 Elements
(mentioned earlier)
• PHC involves, in addition to the health sector,
other sectors such as agriculture, animal
husbandry, food industry, education, housing,
public works, communication and other sectors.
It demands the coordinated efforts of all these
sectors
Fundamental cont’d…
• PHC requires and promotes maximum
community and individual self-reliance and
participation in the planning, organization,
operation and control of health services, making
fullest use of local, national and other available
resources. (communities are empowered to
participate)
• PHC should be sustained by integral, functional
and mutually supportive referral systems leading
to the progressive improvement of
comprehensive health care for all, and giving
priority to those most in need.
Fundamental cont’d…

• At local and referral levels, PHC relies on health

workers, including physicians, nurses, midwives,
auxiliaries and community workers, as well as
traditional practitioners who are suitably trained
both socially and technically, to work as a health
team and to respond to the expressed health
needs of the community
Principles Of Primary Health Care

• These are the guidelines that govern the

implementation of PHC activities; the
foundations on which PHC is laid.
• These are :
▫ Equity
▫ Manpower development
▫ Community participation
▫ Appropriate technology
▫ Multi- sectoral approach
Principles Cont’d..

Equitable Distribution of PHC:

• According to this principle, the primary health
care must be given to all individuals in equal
amount in community irrespective of their
gender, age, caste, color, urban, rural and social
class.
Principles Cont’d..

Community Participation toward achievement of PHC:

• Participate in decision making regarding policies of
health for community.
• To promote the development of community and the
community’s self reliance.
• To seek the solutions collectively for complicated social
problems, which cause the health problems
• To collect donations and contributions for running the
health and hygiene programs.
• To form the mobilization groups to change the un-healthy
patterns of life in community.
Principles Cont’d..

Manpower Development:
• All the human potentials-knowledge, physical energy
is toward achievement of Primary Health Care.
• To motivate individuals to work as a volunteer in
community.
• To give training the individuals in community
regarding health promotion and prevention of ds.
• To find out the available trained human resources to
achieve maximum Primary Health Care.
Principles Cont’d..

Use of Appropriate Technology:

• According to this principle, technology should be
provided that is accessible, affordable, feasible
and culturally acceptable to the community for
the promotion of Primary Health Care. E.g. use
of refrigerator for vaccine, use of tractor for the
agriculture etc.
Principles Cont’d..

Multi-sectional Approach:
• It is recognized that the health of a community
cannot be improved by intervention within just
the health sector but other sectors are equally
important in promoting the community’s health
and self-reliance.
• These sectors are: Agriculture, irrigation,
education, housing, animal husbandry ,public
works, communication, rural development,
industries, voluntary organizations.
Points To Remember About PHC Principles

• Every individual has a right to a high quality of life

• The community must be allowed to take charge of
the resources available from both within and
outside their environment. This empowers them to
be more responsible and accountable for their
quality of life
• There should be equitable distribution of resources
among the community members so that they can
meet their fundamental and basic needs.
Primary Health Care Roles and Training Needs
• Involve building the capacity of workers to ensure
adequate number of personnel required to implement
PHC.
• Requires reorientation of existing health workers,
development of new categories of workers in health
and related sectors to serve community.
Responsibilities of the Key Implementers of PHC

The key implementers of PHC in Kenya include:

▫ Primary health care workers
▫ The community
▫ The government
▫ Non-governmental organizations
Primary Health Care Workers
• Also known as Community Health Workers
(CHWs) are individuals who are selected by their
community for training on how to deal with village
health problems and treat common diseases.
• Those selected are required to possess the
following qualities:
Be a permanent resident in the community
Be a mature responsible individual
Be acceptable and respected by the whole community
• Be self supporting and ready to volunteer
• Be able to relate to others
• a good communicator
• Be physically fit
• Be of a gender acceptable to the local culture for the
kind of health activities to be undertaken
• Be intelligent, with education/literacy that suits the
community
• Be ready to learn
• Be of an age suitable for training and for continued
work in the community
Role of CHWs
The role of the CHWs depend on the ability of the
community to solve its own problems and what it
perceives as its priorities.
A CHW is expected to be:
A motivator through education and
communication
An example and model of good health behaviour
A link with the health system and other sectors
A technician with certain skills of community
importance e.g. latrine construction or basic
treatment of common ailments.
Roles of CHWs cont’d…
An observer and recorder who is capable of
thinking reacting and assessing progress
An organizer and mobilizer of community
activities
A leader and manager
A person who is receptive to new ideas so as to
form a channel through which new health
information can reach the community
An advisor and a counsellor
Primary Health Care Workers cont’d…
• CHWs are supervised by the community through
leaders of village health committees and health
workers from the nearest health facility to make
sure they are doing the right thing.
• Regular supportive and frequent supervisory visits
are essential for effective PHC activities
• Community participation in the supervision of
CHWs is one of the key determinants of success
for PHC activities

How is Supervision carried out?

 Ways of Carrying Out Supervision
• Motivation-showing appreciation, giving rewards and
providing more education to CHWs
• Support-by providing them with the necessary
equipment and supplies as well as technical back up
• Recognition- credibility of the CHW in the eye of the
community
• Planning-help them plan their objectives and logistics
• Problem solving-assisting them to solve the problems
they encounter in the community
• Training- ongoing education and skills development
for the CHW.
• Performance measurement- the collection of basic
performance measurements and evaluating them
against objectives laid down.
What do you think determines the area
covered by CHWs?
.
Primary Health Care Workers cont’d…
• The area covered by CHWs is determined by the
following factors:
The distance between homes
The population density
The workload of activities in addition to home visiting
Terrain
Family sizes
The frequency and severity of health problems
The demands of the community
Domestic arrangements of the family.
The Community
• The center of focus in the implementation of
PHC.
• Its responsibilities include:
To recognize priority problems relating to health
Decide on what needs to be done to overcome the
problems
Decide on what the community itself can do to solve
the problems
To organize and implement whatever they themselves
can do either on their own or with the support of
governmental or non-governmental bodies.
To monitor and evaluate activities as necessary
Community cont’d..
• The community meets these responsibilities
through the following activities:

Community participation
Community awareness
Community involvement
Community activities
Community participation:
• the process by which a community mobilizes its
resources, initiates and takes responsibility for
its own development activities and shares in
decision making and implementation of all other
development programmes.
Community activities cont’d…
Community awareness:
• the community should be aware of its problems
and the available resources such as manpower,
money, materials, ideas and time.
• This can be achieved through, Participation and
involvement of the community in community
diagnosis or Through exposure of the
community to another with successful
development programmes
• Barazas, churches, schools and development
groups play key roles in promoting awareness
Community activities cont’d…
Community Involvement:
• The active involvement of people living together
in some form of social organization and cohesion
in the planning, operation and control of
primary health care, using local, national and
other resources.
• In community involvement, individuals and
families assume responsibility for their and their
communities' health and welfare, and develop
the capacity to contribute to their own and their
communities’ development.
The National Government
• The national government ministry of health is
headed by the Cabinet Secretary of health.
• Under the minister for Health is the principal
secretary for health.
• The Principal Secretary works with the Director Of
Medical Services who is the technical advisor.
Roles of National government
• Formulation of health policies
• Financing: provide funding to national and county
government
• Take charge of National referral hospitals
• Monitor quality assurance and standards
• Conducting studies required for administrative or
management purposes
• Take charge of National public health laboratories
like KEMRI
• Public-private partnerships eg with NGOs
Roles of National Gov. Cont’d..
• Monitor and evaluate (M & E ) health services and
health programs
• Planning and budgeting for national health services
• Take charge of Services provided by Kenya Medical
Supplies Agency (KEMSA), National Hospital
Insurance Fund (NHIF), Kenya Medical Training
College (KMTC) and Kenya Medical Research
Institute (KEMRI)
• Monitors ports, borders and trans-boundary areas.
(for surveillance of diseases from immigrants)
• Major disease control (malaria, TB, leprosy etc)
 The county governments
• Headed by minister of Health (executive secretary
of health)
• Under the Minister is the Chief Officer of Health
who works with County Director of Health Services
who is a technical adviser.
• Below the county health director are the heads of
departments who include: county public health
nurse, county nutrition officer, county clinical
officer, county public health officer etc
• Health in the County government is under the
Department of Health Services Management
Responsibilities of Department of Health
Services Management
1)Coordinate the provision of preventive, promotive,
curative, rehabilitative and palliative health services;
2) Develop county health policies and laws
3) Coordinate implementation of national health
policies at county level
4) Liaise with regulatory bodies in the enforcement
best health practices
5)Coordinate public and private sector health
programs and systems at the county level;
6) Ensure compliance with norms and standards for
health facilities and health services;
Responsibilities cont’d..
7) Ensure the implementation of rights to health
specified in the Bill of Rights
8) Promotion of primary health care i.e
availability, accessibility, acceptability,
affordability, and of good quality and standards
9) Manage day to day human resources under the
Department;
10) Facilitate capacity building and professional
development for health service personnel;
11) Promote public private partnership to ensure
efficient and harmonious development
Responsibilities cont’d..
12) Oversee the management of county health
facilities
13) License and control establishments that sell food
to the public
14) Control the management of cemeteries, funeral
homes and crematoria
15) Ensure and coordinate the participation of
communities in the governance of health services
16) Procure and manage medical supplies and
commodities;
17) Develop and manage the county health referral
system including ambulance services;
Responsibilities cont’d..
18) Facilitate registration, licensing and
accreditation of health service providers and
health facilities respectively
19) Coordinate and conduct ethical research and
ensure dissemination of research findings
20) Manage solid waste and guarantee
environmental sanitation;
21) Provide for the development, strengthening
and expansion of a county health information
management system
 County Director Of Health
• Technical advisor on all matters relating to health
within the county;
• Supervise all health services within the county;
• Promotes the management, prevention and control
of communicable and non-communicable
conditions;
• Reports periodically to the national ministry of
health on all public health occurrences including
disease outbreaks, disasters and any other health
matters
• Perform other duties as assigned by executive
secretary
County Health Management Team

The County Health Management Team consists of:-

a) The director of health services who is the
chairperson.
b) The administrative officer of the department who
is the secretary
c) All the heads of units in the department at the
county;
d) The medical superintendents of the county
hospital.
Functions of the County Health
Management Team
1. Providing supervision and support to the
management of the county health facilities and the
sub-county health management teams
2. Coordination of all health services in the county
3. Exercising disciplinary measures over health
personnel working in the county
4. Provide leadership and stewardship for overall
health management in the county
Functions of CHMT cont’d..
5. Provide strategic and operational planning,
monitoring and evaluation of health service
delivery in the county
6. Provide a linkage with the national ministry
responsible for health
7. Resource mobilization for county health
services
8. Facilitating county health facilities in the sub
county to comply with the established standards
Functions of CHMT cont’d..
9. Establishing functional referral systems within and
between the counties, and between the different
levels of the health care system in line with the sector
referral strategy
10. Reviewing and monitoring the implementation of
the health bills in the county
11. Consolidation of sub-county quarterly performance
reports which shall form the county report, which
shall feed into the county annual performance report
The County Health Management Team convenes at
least one quarterly; a performance review meeting
with the Sub County Health Management Team
Sub-County Health Management Team
The sub county health management team consists of:-
• The medical officer in- Charge of the sub county who
is the chairperson
• The sub county health administrative officer who is
the secretary
• The heads of units in the departments at the sub
county
• The medical superintendents of the county hospital
within the sub-county
• Any other officer as designated by executive
secretary
Functions of sub-county health
management teams
a. Provide supervision and support to the
management of the county health facilities in the sub
county
b. Carrying out needs and capacity assessment for
sub-county health facilities
c. Exercising disciplinary measures over health
personnel working in the sub county
d. Facilitating county health facilities in the sub
county to comply with the established standards
Functions of SCHMT cont’d…
e. In consultation with the county health
management team, facilitating capacity building
of health personnel at the sub county
f. Coordinating implementation of health policies
in the sub county
g. Reviewing and monitoring the implementation
of health bills in the sub county
The Sub County Health Management Team meets
at least once every month; prepares and submits
quarterly reports of its operation to the county
health management team
Additional Functions Of Sub-county Health
Management Team

1.Formulating relevant health objectives for the Sub-

county, keeping in line with the county and national
health policies.
2.Identifying health problems and needs in the sub-
county.
3.Training and deployment of staff to health facilities.
4.Planning and coordinating health activities for
optimal utilisation of sub-county resources
Additional Functions cont’d..
5.Supervising all health care activities and services
within the sub-county.
6.Collecting and analyzing data on community
health needs and assessing health coverage.
7.Monitoring and supporting the rural health staff
and community health workers
Functions Of The Hospital Board

(a) Providing oversight over the administration of

the hospital
(b) Promoting the development of the hospital;
(c) Approving plans and programs for implementing
county health strategies in the hospital;
(d) Approving estimates before submission to the
Chief Officer of Health;
(e) Overseeing Hospital performance and
improvement of the Hospital
(f) Participating in planning for the hospital
Hospital Board Functions cont’d..
g) Mobilizing resources for hospital improvement
g) Overseeing the financial operations of the
Hospital
h) Ensuring development of hospital human
resource
i) Ensuring communities’ rights are fulfilled and
their needs are adequately met.
j) Maintaining a positive public image
k) Ensuring compliance with environmental
regulations and standards
l) Enhancing relationships and partnerships
COMMUNITY BASED HEALTH CARE
Community Based Health Care
• CBHC involves itself with encouraging and
facilitating the people’s own efforts to convert
PHC philosophy into practice right where they
live .
• Emphasis is placed on community participation
, self reliance and self determination in matters
related to health .
• The CBHC Broad Objective is :To improve the
quality of life and health of the community .
 CBHC Specific Objectives
1 Improving individuals’ and groups’ knowledge, attitude and
practices related to health.
2 Raising awareness to the community members of the
preventability of certain diseases .
3 To encourage individual actions by community members on
personal and environmental hygiene, improvements and
changed lifestyles
4 To improve feeding practices especially of children and
mothers
5 To initiate community activity on health benefitting projects
such as protecting of water sources , kitchen gardening,
poultry keeping e.t.c
6 To train community health workers (CHW) according to the
needs of their community
7 To facilitate effective communication between CHW and
nearest health facility staff
How to start a CBHC Programme (initiating a program)

1. A health worker can start a CBHC programme after

identifying some health problems through the records or
conducting a baseline survey i.e. awareness of health
problems .
2. Discuss the idea with colleagues in a staff meeting, and
identify required resources
3. Involve the community leaders
4. Involve the health officials(county or sub-county level) , for
technical and material support
5. Meet with community members
5 Appoint a Village Health Committee (VHC) through the chief
6 Sensitize the community members to choose community
health workers (CHWs) . The CHWs are to be supervised by
the VHC .
Criteria for selecting CHWs

1. A permanent residence in the community

2 A mature responsible individual
3 Accepted and respected by the community
members
4 Self-supporting and ready to volunteer
5 Able to relate to others and a good communicator
6 Physically fit
7 Intelligent and with literacy that suits the
community
8 Receptive to new ideas
9 Age suitable for training for continuing community
work
Activities of CHWs
1 Home visits /door to door
2 Concerned with personal, environmental and
food hygiene for prevention of common
diseases.
3 Addressing Public gatherings such as chiefs
baraza on matters related to health.
4 Collaborating with the nearest health facility
staff
5 Keeping simple health records from which
evaluation can be made
6 Motivating the community members to
undertake health benefitting projects.
Training of CHWs

• A group of CHWs are trained by the health facility

staff with the help of other resource people
• Training takes place right in the community in a
school, church or under a tree
• Duration is usually 12 weeks basic course in which
two weeks are spent in practices.
• The training must be scheduled away from
planting or harvesting seasons.
• The curriculum should emerge from the
community’s own priority needs
•
 Training CHW cont’d..
The general core content of training usually includes ;
 Communication --------- the art of motivating
people
 Food ------- what to grow, what to feed on and
recognition of malnutrition
 Motherhood ---------- antenatal care ,hygienic
delivery, child spacing etc
 Hygiene -------- personal, environmental and food
hygiene
 Prevention of common diseases in the community
e.g. Malaria , Diarrhoea, intestinal worms etc
Evaluation of CBHC Activities
The trainer , village health committee and CHWs get together
and formulate a workable evaluation method e.g. the CHWs
can record the health activities in the areas they cover i.e.
• Number of kitchen gardens
• Water purification and storage improvement
• Child-spacing methods acceptance
• Number of income-generating activities started (IGAs)
Generally the trainer assesses on ;
 Changed or improved knowledge, attitudes and practices
(KAP) towards prevention of health problems.
 Improved patterns of practice related to identified health
problems i.e. changes in behavior or habits harmful to
health such as smoking , and changes in environmental
conditions such as waste disposal, water purification etc.
People Involved in CBHC
1 A health worker from the H/Centre or
Dispensary to provide technical guidance and
moral support .
2 Community leaders
3 Village health committee (supervises CHWs’
activities)
4 Community health workers (CHWs) selected
by community members in a general baraza and
trained
5 Community members
Role of a Nutritionist in Primary Health
Care
• Work with other healthcare experts to offer a
multidisciplinary healthcare approach.
• Involved in maintaining optimum nutritional
health of the whole population and high risk or
vulnerable subgroups within the population.
• Health promotion and disease prevention, as well
as therapeutic and rehabilitative nutrition services
• Plan and implement food and nutrition programs.
• Organize nutrition education in schools, clinics &
community
Role of Nutritionist cont’d…
• Train other providers (e.g. physicians, nurses, peer
workers) and professionals in other sectors on basic
nutrition and health promotion to complement
expertise
• Assist communities to establish community
programs to promote lower cost healthy eating &
food safety
• Consult with workplace and educational institution
food service to suggest healthy options on the menu
• Work with government ministries to strengthen the
nutrition component of the health curriculum in
schools
Nutrition & Population
• Community nutrition is an approach that
provides long-term solutions, promotes stability
and supplies communities with sustainable
methods to reduce malnutrition, often referred
to as food security.
• To develop long-term solutions, the individual
causes of malnutrition must be identified and
dealt with.
Malnutrition
Malnutrition can be defined as a physiological
state that results from insufficient, excessive
or imbalanced consumption of nutrients
 Categories of Malnutrition

There are two categories of malnutrition:

-Acute malnutrition
-Chronic malnutrition:
Categories of Malnutrition Cont’d
Acute malnutrition is categorized into Moderate
Acute Malnutrition (MAM) and Severe Acute
Malnutrition (SAM), determined by the patient‘s
degree of wasting.
All cases of bi-lateral edema are categorized as
SAM.

SAM is further classified into two categories:

Marasmus and Kwashiorkor. Patients may present
with a combination, known as Marasmic
Kwashiorkor.
Patients diagnosed with kwashiorkor are extremely
malnourished and at great risk of death.
 Categories of Malnutrition cont’d

Chronic malnutrition is determined by a

patient’s degree of stunting, i.e. when a child
has not reached his or her expected height for
a given age.

Treating chronic malnutrition requires a long-

term focus that considers household food
insecurity in the long run; home care practices
(feeding and hygiene practices); and issues
related to public health.
Causes of Malnutrition

The causes of malnutrition are categorized into

three:
• Immediate causes
• Underlying causes
• Basic causes
 Immediate causes
The immediate causes of under nutrition and
malnutrition are generally due to:
• Poor diet
• Diseases
Poor diet
A Poor diet may be due to:
• Not enough food, or a lack of variety of foods in
meals.
• Low concentration of energy and nutrients in meals.
• Infrequent meals.
• Insufficient breast milk and easily weaning.
••
Immediate causes cont..
Diseases
Diseases, especially infectious diseases, cause under
nutrition because a sick child may not eat or absorb
enough nutrients, or she/he may lose nutrients from
the body due to vomiting or diarrhea or have
increased nutrient needs. The diseases most likely to
cause under nutrition are:
• Measles
• Diarrhea
• AIDS
• Malaria
• Intestinal worms.
Underlying causes
They differ from community and family to family but
it is useful to group them into:
• Family food shortages.
• Inadequate care of children and women.
• Unhealthy environment and poor health services.
• Too many children in a family to feed.
 Basic causes
The availability & control of resources at the various
levels of society is a result of four major factors:
• Political factors, such as policies and economic
situations that affect household, district or national
levels of society.
• Ideological factors, such as cultural beliefs,
traditions and customs that influence the nutritional
state of vulnerable groups.
• Environmental factors, such as war or natural
disasters (draught, flood).
• Social factors, such as poverty.
Individuals at risk of malnutrition

• Elderly people, especially those who are

hospitalized or in long-term institutional care

• Individuals who are socially isolated

• People on low incomes (poor people)

• People with chronic eating disorders, such as

bulimia or anorexia nervosa

• People convalescing after illness

Factors Promoting Good Nutrition
• Agricultural production
• Economic stability
• Healthy environment
• Education
• Health care (Prevention and control of disease)
• Healthy social and family life e.g manageable
family size
Challenges Facing Implementation Of PHC
1. Shortage of funds
2. Lack of materials and equipment
3. Shortage of appropriate staff
4. Lack of commitment which can be at the
individual or government level
5. Lack of incentives
6. Lack of information
7. Inadequate community participation
8. Inadequate Inter-sectoral collaboration
9. Rapid turnover of policy makers
10.Lack of manpower training and development
11.Inadequate utilization of services
Importance or purpose of PHC
i. To increase coverage and accessibility of health
services in rural areas.
ii. To further consolidate curative, preventive and
promotive services in both urban and rural areas.
iii. To increase emphasis on MCH/FP services in
order to reduce morbidity, mortality and fertility
rates
iv. To strengthen MOH management capabilities
with an emphasis on the sub county level
v. To increase inter-sectoral collaboration in health
matters or activities.
vi. To increase alternative financing mechanisms for
health care i.e. through funding from NGOs and
cost sharing
In summary.
• PHC is an integral part of the overall social and
economic development of the community
• PHC forms an integral part of the country’s
health system of which it is the central function
and main focus
• PHC emphasizes on community full
participation in the spirit of self-reliance and
self determination
• PHC constitutes the element of a continuing
health care process bringing the health care as
close as possible to where people live and work.
THE END