Primary Health Care Manual 3rd Edition

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DEDICATION

Remembering Prof. Donald A. Hillman

Professor Donald Hillman died on 4th July 2006. He was a world renowned paediatrician, a champion of International Health, and a strong advocate for improving child health worldwide, particularly in developing countries. This third edition of “The Primary Health Care manual for medical students and other health workers” is dedicated to Don Hillman. His work will forever live on through the generations of undergraduate and postgraduate medical students all over the world whom he mentored and influenced in their careers, together with his wife Liz Hillman. Dr. Donald Hillman graduated in Medicine at McGill University in Montreal, Canada in 1949. He received his postgraduate education at the Montreal Children’s Hospital, the Hospital for Sick Children in Toronto and at the Massachusetts General Hospital in Boston. He completed his PhD. in Investigative Medicine at McGill University in 1961. He subsequently became a Professor of Paediatrics and Associate Dean of Postgraduate studies at McGill University, and a Professor in Paediatrics at Memorial University in Newfoundland.

From 1976 to 1989 Don Hillman and his wife Liz Hillman joined the then new Faculty of Medicine at Memorial University of Newfoundland as Professors of Paediatrics. Don Hillman became Physician-in-Chief and Liz Hillman was Director of Ambulatory Education at the Janeway Child Health Centre. In 1989 The Hillmans joined McMaster University in Hamilton in the field of international health. They later moved on to the University of Ottawa in the same field, now generally referred to as Global Health.

Internationally the Hillmans have also had a long and illustrious career having worked in more than 15 countries as consultants or visiting Professors. This includes Kenya, Uganda, Tanzania, Zambia, South Africa, China, Kuwait, Singapore, Laos, Malaysia, Bhutan, India, Guyana, Philippines and Pakistan. In the early 1970s McGill University teamed up with the Canadian International Developing Agencies (CIDA) to support the development of a new medical school at the University of Nairobi in Kenya. In 1974 Don and Liz Hillman accepted a four year appointment in the Department of Paediatrics and Child Health at the University of Nairobi. They worked together with Prof. Nimrod Bwibo and Dr. Alan Ross to strengthen the teaching of Paediatrics and Child Health at the University of Nairobi. This has now grown to be one of the largest undergraduate and postgraduate medical teaching programmes in Africa. Don and Liz Hillman later moved on to Makerere University in Uganda where they managed another CIDA funded project known as CHAMP (the Child Health and Maternal Educational Programme). They also served in senior advisory positions with UNICEF Kampala

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The McGill and Nairobi programmes and the CHAMP programme in Uganda were later to influence the development of the CIDA funded Primary Health Care East Africa (PHCEA) project in the late 1980s which was negotiated and championed by the Hillmans. The PHCEA project focused on improving the teaching of Paediatrics and Child Health in Kenya, Uganda, Tanzania and Zambia, including the exchange of students and staff. This project produced a popular teaching manual - The Primary Health Care manual for medical students and other health workers - which is still in use today in at least five medical schools and is stocked in several libraries. The Hillmans have also supported the development of new medical schools at Moi University (in Eldoret, Kenya), at Mbarara University for Science and Technology (Uganda), and at Gulu University (Uganda). Following their retirement in Canada, they continued their active involvement abroad in international health by serving as consultants or visiting professors. They undertook and completed assignments for Canadian External Services Organization (CESO) in Kenya, India, Guyana, Philippines and Pakistan. At the time of Don's death, the Hillmans were working on a project funded by the Royal College of Physicians and Surgeons of Canada in Zambia, Tanzania, Kenya and Uganda.

In recognition of this lifetime commitment and tremendous contribution to Global Health spanning over thirty-five years, the Hillmans received several awards. This includes the Ross Award (1989), the prestigious Orders of Canada (1994), the James H. Graham award (1995) the Lifetime Achievement Award of the Canadian Society for International Health, recognition by the American Academy of Paediatrics, and honorary doctor of laws degrees.

As we celebrate the life of Don Hillman, we thank him and his wife Liz for the tremendous contribution and lifetime commitment to international health, which will remain an inspiration for many years to come, to all of us including many generations of medical students and paediatricians all over the world. We dedicate this third edition of the “Primary Health Care Manual for medical students and other health workers” to our friend Don Hillman.

May His Soul Rest in Eternal Peace! Prof. Kopano Mukelabai,

Department of Paediatrics and Child Health, University of Zambia, Lusaka, Zambia Formerly:

Chairman of the Department of Paediatrics and Child Health at the University of Zambia

Dean School of Medicine, University of Zambia (1984-1992) Senior Health Adviser in UNICEF (1992-2009)

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PREFACE TO THE THIRD EDITION

The Third Edition of the Primary Health Care manual has finally been produced. Lack of funding due to the global economic recession, has partly contributed to the delay in producing the current manual. We are very grateful to the University of British Columbia and specifically to Prof. Stuart Macleod and his wife Nancy for their concerted efforts to raise the critical funds needed to print the manual. We are also very grateful to Prof. Elizabeth Hillman and the Hillman Foundation for providing extra funds to print more copies of the manual and for providing funds to distribute the manual.

The third edition of the PHC manual is dedicated to our friend and colleague the late Prof. Donald Hillman who died on 4th July 2006. Don Hillman, together with his wife Liz mooted the whole idea of the PHC East Africa Project and the subsequent publication of the PHC manual. We have written an obituary printed in this book to honour the life and work of Prof. Donald Hillman. The PHC manual is still very frequently used to teach both undergraduate and postgraduate medical students. This new edition will be distributed free of charge to seven medical schools in five countries in Eastern and Southern Africa. These are Zambia, Kenya, Tanzania, Uganda, and Ethiopia. The first two editions of the manual proved to be extremely popular among medical students and other health workers. The major preparation of the third edition of the PHC manual took place at a meeting held at the Silver Springs Hotel in Nairobi in October 2008. It was a wonderful and productive meeting with representatives of 10 Universities present, including one representative from UNICEF. Other topics covered during the meeting included; sharing information on the postgraduate curriculum, exchange of staff and students,

and conduction of joint research.

With five years remaining towards the attainment of the MDGs by 2015, the PHC manual will make an important contribution in assisting countries to achieve the health related MDGs. A few new chapters have been added to the manual to make it more comprehensive. We have also included the April 2008 Ouagadougou Declaration on PHC in Africa, which was signed by Ministers of Health from all

countries in Africa.

May the spirit of Don Hillman continue to guide the future direction of the PHC manual and its use by medical students and other health workers!

Finally let me once again thank all my colleagues who participated in the production of this third edition. Their commitment was total as they showed an incredible

patience and understanding in waiting for the final production of the new manual. I also wish to thank Ms. Ruth Matano and Ms. Rosemary Mwasya for assisting us in organizing an extremely successful workshop to revise the third edition of the manual. Ms. Matano also assisted in preparing the final script of the new manual.

Kopano Mukelabai, 31

st

_{March 2010.}

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PREFACE TO THE FIRST EDITION

This manual is designed to meet the learning needs of medical students and other health workers, to achieve competence in the understanding and management of priority problems in Primary Health Care in Zambia, Uganda, Tanzania and Kenya. It is applicable to other countries especially those in Africa with similar health problems.

Each chapter of the manual, has objectives related to an important Primary Health Care topic, and defines the knowledge, skills and attitude required to meet these objectives. The manual is intended to supplement paediatric texts and other reference materials, and is a targeted aid to Primary Health Care problem solving both in tertiary and Primary Health centres, which should both be the major sites for relevant health learning. Some of the chapters contain case illustrations designed to facilitate learning by presenting real-life problems relevant to the topic.

The manual contains self evaluation questions and a list of objectives. Other learning materials supplied by other institutions and organizations like W.H.O., UNICEF, etc. may be very useful. For the manual to be of continuing value, the students and the teachers must add relevant details of priority health problems in their region with particular focus and emphasis on the overall child health programmes. This should include collaborative emphasis on links between the training programmes and the country's health care system, both governmental and non-governmental.

In order to adapt to the rapidly changing field of primary health care teaching, revisions and additions to the problems presented here, must be developed by teachers and students to reflect changing priorities and approaches.

The editor wishes to thank the Canadian Government for providing the crucial financial support through CIDA (Canadian International Development Agency) to the Primary Health Care East Africa Project. Special thanks go to Memorial University of Newfoundland, which was the Canadian collaborating medical school, and its two dedicated faculty members Prof. Donald Hillman and Prof. Elizabeth Hillman.

I wish to acknowledge with thanks the strong support of the Universities of Zambia, Dar-es-Salaam, Nairobi and Makerere, which through their Principals and Deans, gave the widest latitude to their Chairmen of Departments of Paediatrics and Child Health and their staff and students, to successfully implement the Primary Health Care East Africa (PHC/EA) project.

Particular thanks go to the Chairmen of Departments of Paediatrics and Child Health and the Hillmans, who together mooted the whole idea of PHC/EA. Their congeniality, and extreme dedication ensured the smooth implementation of the project's stated objectives.

To Prof. Gabriel Anabwani, the first programme manager of PHC/EA project, who worked so hard to overcome most of the teething problems encountered, I say

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special thanks, and thanks go to all our departmental Secretaries who bore the brunt of retyping the illegible manuscripts. Particular thanks go to Mrs. Jane Thairu, University of Nairobi for typing the draft manuscript on her ACER 910, and to Mrs. Beatrice Mwanamuchende and Ms. Shirley Kapapa of University of Zambia who typed the revised final manuscripts.

Finally my gratitude goes to all our students and fellows whose constant quest for more knowledge was the prime mover for the production of this manual.

The following are thanked for contributing directly or indirectly to the manual: Prof. Donald Hillman, Memorial University, Newfoundland;

Prof. Elizabeth Hillman, Memorial University, Newfoundland;

Prof. Stuart Macleod, Dean, MacMaster University, Hamilton, Canada; Prof. Vic Neufeld, McMaster University, Canada;

Prof. N. Bwibo, former Principal, University of Nairobi, College of Health Sciences; Prof. H. Pamba. former Dean, Faculty of Medicine, University of Nairobi;

Prof. W. Makene - former Dean, Muhimbili Medical Center Dar-es-Salaam;

Prof. G. Mwaluko, former Dean and Director General, Muhimbili Medical Centre, Dar-es-Salaam;

Prof. J. W. Mugerwa, Dean Faculty of Medicine, Makerere University; Prof. R. Owor - Former Dean, Faculty of Medicine, Makerere University;

Prof. Julius Meme, former Chairman, Dept. of Paediatrics and Child Health, University of Nairobi;

Prof, F. Onyango, Chairman, Dept. of Paediatrics and Child Health, University of Nairobi;

Prof. R. Mbise, former Chairman, Dept. of Paediatrics and Child Health, University of Dar-es-Salaam;

Dr. E. Mwaikambo, Chairman, Dept. of Paediatrics and Child Health, Muhimbili Medical Center, Dar-es-Salaam;

Prof. C. Ndugwa, Chairman, Dept. of Paediatrics and Child Health, Makerere University, Kampala;

Prof. K. Mukelabai, Dean and former Chairman of Department of Paediatrics and Child Health, University of Zambia, Lusaka;

Dr. Alfred Mutema, Nairobi; Mr. L. Dierick, Nairobi;

Prof. Peter Kinyanjui, Common Wealth of Learning, University of Vancouver Canada; UNICEF; All Primary Health Care East Africa Fellows; All Faculty members of departments of Paediatrics and Child Health at Universities of Zambia ; Dar-es-Salaam, Makerere and Nairobi. Finally I wish to thank all my colleagues for their maximum cooperation and patience in implementing the PHC/EA project to the end. This manual lends credit to your dedicated and excellent efforts.

Prof. Kopano Mukelabai, Dean School of Medicine, University of Zambia, Former Chairman of the Department of Paediatrics. University of Zambia.

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A MESSAGE FROM DR. HAFDAN MAHLER, FORMER DIRECTOR GENERAL OF THE WORLD HEALTH ORGANIZATION

Health Care Workers and PHC

World Health will improve only if the people themselves become involved in planning, implementing and having a say about their own health and health care. But involvement will not just happen. How serious are we about involving individuals, families and communities? Are we prepared- mentally and professionally to listen to their concerns, to learn from them what they feel is important, to share with them appropriate information, encourage and support them. Are we ready to assist them in choosing from alternative solutions, in setting their own targets and evaluating their efforts?

In many cases, so far, the answer is no. We can go on and on developing plans: nothing will happen unless all health workers, all health managers, and key professionals in other sectors come to realize what is at stake.

First, health workers must understand that the concept of primary health care involves new roles for them and a new outlook. Not only should we be concerned with disease prevention and control, we must also be concerned with health promotion and care - and not least with development in general – and with people. Our health technologies must be based on what the people themselves want and need. In other words, the worker should learn first and foremost to act as a facilitator of action by individuals, families and communities. We must stop trying to fit communities into systems and programs we devise, without a real and deep feeling for the social aspects of health problems or the economic constraints-not to speak of the cultural dissonance that is often the backlash of such programs.

Second, health workers must accept their new roles. They must accept new ideas, must be taken to try them out, to adapt them, to broaden their scope and innovate in the partnership approach. Their main concept must be to find ways of helping individuals and communities become self-reliant. It must be made clear that advocating self-reliance in health matters in no way means abdicating our responsibilities and passing them on to someone else. Both lay persons and professionals are essential. They cannot replace each other, but they must work together.

This brings me to my third point: health workers must have the necessary skills to perform these new roles effectively and to make efficient use of existing knowledge. This calls for a training force fully familiar with accumulated experience and keen to provide the kind and quality of professional preparation needed. It also calls for full backing from health managers for such training.

All health care workers must meet these requirements. This manual helps define the role of health workers in Primary Health Care. Your skills and commitment to this role will be of critical importance to the achievement of Health for All by the year 2000.

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“A world that is greatly out of balance in matters of health is neither stable nor secure. Viewed against current trends, primary health care looks more and more like a smart way to get health development back on track. Thirty years of well-monitored experience tell us what works and where we need to head, in rich and poor countries alike.”

Margaret Chan, World Health Report, Oct 2008 Introduction

Like many great and timely ideas, Primary Health Care emerged in several places at the same time. In China, the success of the barefoot doctors, local village health workers trained in first aid with a focus on prevention, improved health for rural Chinese on a grand scale. In South East Asia, the importance of prevention, local midwives, community involvement and good nutrition was documented in Health in the Developing

World by John Bryant

Africa too was moving towards a focus on more accessible care. In Uganda in the 1960s, Maurice King, a microbiologist teaching at Makerere undertook a locum for a friend in the Karamoja, a remote region of nomadic people with few health care workers. It was an eye-opener and led to his collecting a group of like–minded physicians in Africa for a symposium. From this meeting, a classic text on primary health care,

Medical Care in the Developing World, subtitled a Primer on the Medicine of Poverty

was published. For the first time the relationship between the catchment area of a health facility and the time it takes to walk to and fro appeared in print. Not unexpectedly almost 90 per cent of those seeking care from a health unit were drawn from a radius of less than 5 km – the distance a mother with a child on her back, or a toddler in tow, could walk in a day. This finding led to a reassessment of the role of hospitals and the need for more accessible care.

A pediatrician working in West Africa, David Morley introduced the concept of Under- 5 Clinics dealing with mothers and children, who are the most vulnerable members of the community. In another classic, Pediatrics Priorities in the Developing World, he pioneered an improved design of such clinics to allow more and better care for children and their mothers. About the same time, important aspects of nutrition, such as the onset of kwashiorkor in the older child weaned early when a new child is born, were identified by the Jelliffes and Cecily Williams.

This set the scene for the WHO, UNICEF and the NGOs to pull together the WHO Declaration of Primary Health Care in Alma Ata in 1978 with the goal of Health for All by the Year 2000. At the time there was concern that such a lofty goal was unattainable. But health workers in the developing world were insistent that the goal was needed and could be achieved.

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Objectives:

At the end of this session, the student will be able to: Describe the concept of Primary Health Care.

List 8 elements of PHC Clarify 8 principles of PHC.

Advocate for community participation.

Learning Activities:

Read the Declaration of Alma Ata, WHO, 1978 Report of the International Conference of PHC; Chapter 1, UNICEF State of the World, 2008 and World Health Report 2008 on PHC and Ouagadougou Declaration on PHC and Health Systems in Africa, 2008

Meet with district and local health staff, UNICEF and NGOs to become familiar with existing PHC programs and available reference materials.

Participate in a community meeting in which community involvement in a PHC issue is discussed.

Outline a PHC approach to a specific child health issue.

Definition of PHC:

PHC is spelled out in detail in Article VI of the Declaration of Alma Ata.

“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 the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and 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.”

Alma Ata, 1978

Health is defined as a state of complete physical, mental, social and spiritual well being and not merely the absence of disease or infirmity. These four elements of well being influence each other. When the influence is positive the individual enjoys a healthy life. Conversely when the influence is negative the individual suffers ill health. WHO

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The 8 Elements of PHC

The eight elements or program of PHC spell out MEDICINE and are sometimes referred to as the New Medicine

M - Maternal & Child Health

Child deaths are far more common when births are too many or too close together or occur to mothers who are too young. Children born to women under 20 years of age are almost twice as likely to die in infancy as children born to women in their mid 20s. Births need to be spaced to save lives. When children are born at least two years apart, infant deaths fall from 14% to 6%.

E - Education

Health education needs to be interactive, pervasive and eagerly taken up by all health workers. Female literacy is one of the most important ways to improve a family’s health. Globally four out of ten women are illiterate and in some countries as many as eight out of ten. Educating girls is closely associated with falling infant mortality, decreasing birth rates and improved nutrition.

D – Drinkable Water and Safe Sanitation

Lack of clean, drinkable water causes many diseases. Efforts are needed to make water safe and available for everyone. To result in permanent solutions, women

need to be involved actively in water projects.

I – Immunization

One of the greatest success stories of PHC has been immunization. Small pox was the first disease to be eradicated. Great advances have been made in controlling polio and in combining vaccines. Measles remains a challenge because it I requires an intact cold chain. Another challenge is in immunizing all children against the eight killer diseases in the first year of life.

For almost all children, the most important primary health care worker is the mother.

Teaching Other People May be More Important than Doing it Ourselves.

The Cold Chain

The cold chain refers to the need for refrigeration of the vaccine while getting it to the most rural and remote places New technology developed: temperature monitors, cold boxes,

Purchase and maintenance of kerosene refrigerators

Reliable transport system Retraining of health workers

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C – Control of Endemic Disease

Endemic diseases are those commonly found in a region. Malaria is endemic in Sub-Saharan Africa and meningitis is endemic in the meningitis belt of Northern Africa. Appropriate technology has been identified to assist with control of many endemic diseases including insecticide-treated bed nets in malarial areas and ORS for treatment of diarrhea.

I – Treatment of Illness and Injury

Curative care for illness or injury is but one of the eight PHC programs. Care needs to be provided close to where people live. Appropriate, accessible treatment also needs to be affordable. In many developing countries poor people now pay two- ten times more out of the own pocket for their health care than is provided by the government.

N - Nutrition and Food

Good food is one of the basic determinants of good health. Breast feeding not only provides an excellent source of food for a child but provides important protection from disease in the first few months of life. Breastfeeding for the first two years of life provides valuable protein and energy for children. A

healthy, balanced diet for women in pregnancy results in fewer low birth weight babies and fewer pregnancy complications. In some countries low birth weight babies account for as many of one in five births.

E – Essential Drugs

Essential drugs are the basic drugs needed to treat common illnesses and disease in a country. PED

DRUGS NEEDED Most developing countries have 20

drugs for rural dispensaries and health centers and a somewhat larger but still limited list of drugs for

hospitals. A system to ensure ongoing supply, storage, dispensing and training of staff is a key part of ensuring provision of essential drugs.

Some countries included other programs into the basic health program list such as dental care and mental health but all countries had the basic eight PHC elements.

The 4As

Health care and prevention needs to address the 4As Acceptable

Affordable Accessible Appropriate

“A health system based on PHC cannot be realized, cannot be developed, cannot function and simply cannot exist without a network of physicians and hospitals with responsibilities for supporting primary health care, promoting community health development action, basic and continuing education of all categories of health personnel and research.” Halfdan Mahler, WHO

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Characteristics of PHC

Underlying the eight PHC elements are a number of characteristics or principles. Community Participation

Participation is more than involvement and is much more than contributing labour and time although both are often necessary. Participation means being included in planning, decision-making, implementation and evaluation. Through full participation people grow in knowledge and confidence and can be empowered to make the changes needed to improve their health and that of their families. Participation needs to involve women and the disadvantaged. Intersectoral Collaboration

Health is much more than merely the absence of disease. Health involves the food we eat, the work we do, the relationship we have and the education we receive. To fully achieve health we need to work collaboratively with those in other sectors such as education, agriculture, women’s affairs, local government etc. For example, what is taught in school can be improved to ensure children are taught about important health problems, such as diarrhoea and how it can be managed using ORS.

Prevention

Since there will never be sufficient resources to treat all current and possible diseases, we need to begin to prevent those that can be prevented. Prevention is not only better for people, it also saves money. Most people, given the information and opportunity are more interested in preventing health problems than dealing with disease.

Appropriate Technology

Appropriate technology is technology which the community can afford, implement and maintain. It needs to be simple, effective and scientifically sound so it will be sustainable. Simple solutions have been provided which prevent many illnesses. Examples include: Oral rehydration salts; Child to Child programs in First Aid;

Support Breastfeeding

Allow mothers to have their babies with them

Let mothers put their babies to the breast soon after birth

Help mothers overcome problems Provide correct information to mothers Eliminate routine bottle-feeding Eliminate free samples of breastmilk substitutes

Remove all advertising for breast milk substitutes

The Tippy Tap used

for washing hands, delivers small

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Training of Traditional Birth Attendants (TBA) in prenatal care; Tippy Taps and energy efficient stoves.

Decentralization

Decentralization of health care puts control back into the hands of the local community. Decentralization devolves responsibility for health to district health teams and provides them with the training and the resources to do it.

Integration of Health Services

For the children and their mothers to receive good health care, it is important to provide all the care that they both need at the same place and time. When a mother has spent her day bringing a sick child to the clinic, it is important that she be provided with health education to prevent future episodes, her children are immunized and weighed and contraception advise and antenatal care are provided if appropriate.

Sustainability

Sustainability is the ability to carry on and maintain services. Attention to sustainability is needed at the time programs are first put in place, so that once established, they can be continued. Hopefully many health programs can be sustained by the community with minimal outside assistance.

Equity and Social Justice

Equity involves more than being equal. It requires that resources be distributed according to need. Those who have more need for health services should receive more. Social justice is a way to leveling the playing field for all.

“There isn’t a single problem in global health that we don’t have the means to deal with. It is not even that expensive. It just requires commitment, expertise and resources.” Nils Daulaire, Global Health Council

Approximately three quarters of health budgets are spent on doctors and hospitals providing curative care for a small minority of people, mainly in towns and cities.

Approximately three-quarters of disease in the world is

preventable through primary health care. Primary health care workers cost a tiny fraction of the cost of training a doctor and are often more effective in promoting good health.

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High maternal, infant, and under-five mortality often indicates lack of access to basic services such as clean water and sanitation, immunizations and proper nutrition. Vast differences in health occur within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the high-income area. In a slum in the same city, the rate is 254 per 1000.

Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants.

After thirty years of PHC activity, WHO suggested that many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people, especially in impoverished and marginalized groups. As well, inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability.

When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment. Such lessons take on critical importance at a time of global financial crisis.

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“It is in child health that the greatest of all gains can now be made. Today, a solid scientific consensus stands behind a body of knowledge, traditional as well as modern, discovered or rediscovered, which can enable most families to prevent as well as treat almost all the major causes of child death and malnutrition at a cost which they can afford.”

Halfdan Mahler, WHO

Increasing Relevance of PHC

In calling for a return to primary health care, WHO and UNICEF argue that its values, principles and approaches are more relevant now and inequalities in health outcomes and access to care are much greater today than they ever were before.

In far too many cases, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves. Health care is often delivered according to a model that concentrates on disease, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored.

Specialists may perform tasks that are better managed by other health workers. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. When health is skewered towards specialist care, a broad menu of protective and preventive interventions tends to be lost.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.

Fragmented Health Care

In the developing world, care tends to be fragmented into discrete initiatives focused on individual diseases or projects, with little attention to coherence and little investment in basic infrastructures, services, and staff. Above all, health care is failing to respond to rising social expectations for health care that is people-centred, fair, affordable and efficient.

A primary health care approach, when properly implemented, protects against many of these problems. It promotes a holistic approach to health that makes prevention equally important as cure in a continuum of care that extends throughout the lifespan. As part of

WHO estimates that better use of existing preventive measures could reduce the global burden of disease by as much as 70%.

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this holistic approach, it works to influence fundamental determinants of health that arise in multiple non-health sectors, offering an upstream attack on threats to health. Primary health care brings balance back to health care, and puts families and

communities at the hub of the health system. With an emphasis on local ownership, it honours the resilience and ingenuity of the human spirit and makes space for solutions created by communities, owned by them, and sustained by them.

Working Towards Fairness, Efficiency and Compassion

The core strategy for tackling inequalities is to move towards universal coverage in a spirit of equity, social justice, and solidarity. Fairness, efficiency and compassion in service delivery especially targeting the most vulnerable populations, should be the overarching goals.

Primary health care also offers the best way of coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization,

environmental changes and the ageing of populations. These trends contribute to a rise in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, which create new demands for long-term care and strong community support. A multisectoral approach is central to prevention, as the main risk factors for these diseases lie outside the health sector.

REFERENCES:

UNICEF, State of the World’s Children, 2008.

Alma Ata Declaration, Report of the International Conference on Primary Health Care, 06-12 September 1978, WHO Bulletin, Geneva 1978

World Health Report 2008, PHC

Ouagadougou Declaration on PHC and Health Systems in Africa, April 2008

“Too many of us still think of medical care systems or interventions rather than thinking along new lines in order to understand the determinants of the new problems and to grasp opportunities that reach beyond the health care system….we do not need just a little bit more health education here and there; we need a new approach to action and a strong alliance to move us forward.’

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Upstream Downstream – a parable

It was many years ago that villagers of Downstream recall spotting the first body in the river. Some old timers remember how spartan were the facilities and procedures for managing that sort of thing. Sometimes, they say, it would take hours to pull 10 people from the river, and even then only a few would recover.

Though the number of victims in the river has increased greatly in recent years, the folks of Downstream have responded admirably to the challenge. Their rescue system is clearly second to none: most people discovered in the swirling waters are reached within 20 minutes; many less than 10. Only a small number drown each day before help arrives; a big

improvement from the way it used to be.

Talk to the people of Downstream and they'll speak with pride about the new hospital by the edge of the waters, the flotilla of rescue boats ready for service at a moment's notice, the comprehensive health plans for coordinating all the manpower involved, and the large

numbers of highly trained and dedicated swimmers all ready to risk their lives to save victims from the raging currents. Sure it costs a lot but, say the people from Downstream, what else can decent people do except to provide whatever is necessary when human lives are at stake. Oh, a few people in Downstream have raised the question now and again; "What's going on Upstream? Why are these bodies in the river at all?" But most folks show little interest in what's happening Upstream. It seems there's so much to do to help those in the river that nobody's got time to check how all those bodies are getting there in the first place. That's the way things are sometimes.

Don Ardell

COULD USE AN ILLUSTRATION

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When teeth are together they can break bones. Ankole proverb When spider webs unite they can tie up a lion. Ethiopian proverb The teeth which are together break bone Runyankole proverb There is a path to the top of highest mountain.

Do not look where you fell, but where you slipped. African proverb If you don't stand for something, you will fall for anything African proverb Lack of knowledge is darker than night Hausa proverb When the drumbeat changes, the dance changes Hausa proverb Even the mightiest eagle comes down to the tree tops to rest Ugandan proverb A home without a mother is a desert Eritrean proverb

Elderliness is not a disease, but a richness. Kiganda proverb Who digs the well should not be refused water. Swahili proverb When a lion roars, he does not catch game African proverb “A new model is needed for research in developing countries. A model that promotes locally applied research that enhances capacity and answers that arise from the community. It could be called micro-research and be based, like micro-finance, on small grants for those who have little access to funding opportunities.”

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DECLARATION BY THE International Conference on Primary Health Care and Health Systems in Africa, Ouagadougou, Burkina Faso, 28-30 April 2008

The Conference held in Ouagadougou, Burkina Faso from 28-30 April 2008, declare as follows:

I. Deeply concerned by the many public health challenges that our continent is facing including:

 The high burden of disease;

 The weakness of health systems with inadequate social protection and insufficient financial and human resources for health, a situation worsened by brain drain;

 The widespread poverty among the majority of the population;  The impact of armed conflicts and violence;

II. Recalling the Alma-Ata Declaration of September 1978 inviting all governments and the international community to protect and promote the health of all peoples of the world;

III. Recalling the declaration by Heads of State and government of the Organization of African Unity at its 23rd Ordinary Session in Addis Ababa in 1987 on health as the bedrock of development;

IV. Recalling the commitment made by Heads of State of all countries in the world in September 2000 to achieve by 2015, the eight Millennium Development Goals four of which are related to health;

V. Recalling Regional Committee Resolution AFR/RC50/R1 passed in Ouagadougou in 2000 on Health-for-all Policy for the 21st Century: Agenda 2020;

VI. Recalling Resolution AFR/RC52/R5 adopted in Harare in 2002 on the strategy for accelerating the development of human resources for health and document AFR/RC57/9 on development of human resources for health in the WHO African Region: Current situation and way forward;

VII. Recalling Resolution WHA 58.33 urging Member States to ensure sustainable financing for health, universal coverage and the social security system;

VIII. Recalling the commitment that OAU Heads of State and Government made in 2001 on HIV/AIDS, tuberculosis, malaria and other related infectious diseases during the African Summit in Abuja to allocate 15% of national budgets to health; IX. Recalling Regional Committee Resolution AFR/56/R6 adopted in Addis Ababa in

September 2006 on revitalizing health services in the African Region using the Primary Health Care approach;

X. Recalling Regional Committee Resolution AFR/RC56/R5 passed in Addis Ababa in September 2006 on health financing: a strategy for the African Region;

XI. Recalling the Addis Ababa community health declaration of November 2006 urging States to create an environment conducive to the development of community health and take concrete action to strengthen health systems;

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XII. Recalling the declaration by the third ordinary session of the African Union conference of ministers of health in Johannesburg in April 2007 urging Member States to commit themselves to inter-ministerial collaboration for coordinated, harmonized and comprehensive response to the health challenges that Africa is facing;

XIII. Recognizing the link between health, poverty reduction, good governance, peace and security, gender integration and global commitment to universal access to PHC in order to facilitate the achievement of the Millennium Development Goals; XIV. Considering that a healthy population is not only a development imperative but

also a wealth for African countries;

XV. Considering the scarcity of resources for health in African countries;

XVI. Recognizing that notwithstanding efforts by countries, there remain challenges such as poverty, bad governance, low participation of communities especially women in decision-making process, weaknesses of health delivery systems including inadequacy of motivated and qualified human resources, limited capacity in care provision, weak interface between the community and the formal systems of health delivery resulting, very often, from lack of health awareness; XVII. Recognizing that Africa will need to make increased efforts before it can achieve

the Millennium Development Goals;

XVIII. Aware of the multidimensional nature of health, the importance of, and need for, intersectoral collaboration both internally and externally in order to improve the health status of the populations;

XIX. Realizing the historic opportunity provided by the interest shown in, and importance attached to, health as a factor of development.

The Conference:

1. Reaffirms the relevance and validity, today, of the basic principles and elements of the Alma-Ata Primary Health Care Strategy; 2. Makes a commitment to promote systematically the involvement

and increased participation of communities in health development in order to facilitate the achievement of the Millennium Development Goals and improve the well-being of the peoples of Africa;

3. Strongly recommends;

1. To governments:

(a) To establish mechanisms for effective implementation of previous resolutions, declarations and other commitments to strengthen health systems and implement PHC;

(b) To undertake internal and external advocacy for revitalizing the PHC strategy in order to strengthen health systems;

(c) To accelerate the process of decentralization and deconcentration within the health system in order to meet the expressed needs of the populations;

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(d) To revitalize or establish an appropriate coordination mechanism that brings together the inter-ministerial committee, national health committees and other institutions with a view to harmonizing the complementary roles of the various levels of the health pyramid;

(e) To incorporate, in their national and district plans, priority interventions for revitalizing health services based on the PHC approach;

(f) To implement a programme of action to address the human resources for health crisis including effective deployment, stimulation of better performance and adequate response to brain drain;

(g) To strengthen planning and training with emphasis on public health, employment and human resources management and retention;

(h) To allocate resources in an equitable and sustainable manner based on the needs of the different levels of the health system;

(i) To promote intersectoral collaboration and public/private partnership including civil society in order to achieve the Millennium Development Goals;

(j) To revitalize referral systems to support integrated district health services; (k) To mobilize and bring together all development actors to enhance

cohesiveness and synergy in the choice and delivery of the planned integrated services;

(l) To formulate strategic health financing policies and plans fitting into the overall national development framework especially as regards medium-term expenditure and poverty reduction;

(m) To ensure that the financing plan is included in the national socioeconomic development plan;

(n) To promote health awareness among the population and strengthen the capacities of communities to provide for their own health care and be more involved in health activities;

(o) To ensure more effective monitoring, oversight and evaluation of health activities;

(p) To promote operational research on health systems in a manner that will facilitate evidence-based decision making;

(q) To establish mechanisms and conditions that would enable ministries of health to perform their role of leadership, regulation and good governance;

2. To communities:

(a) To organize themselves to take ownership of the management, protection and promotion of their own health;

(b) To be more involved in monitoring and feedback in regard to health services delivery and support within communities;

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(c) To do advocacy among members of the Diaspora for their effective involvement in development activities.

3. To sub regional, regional and international partners:

(a) To support the implementation of health development policies and plans in response to expressed needs;

(b) To commit themselves to proving technical and/or financial support in the long term to ensure sustainability of health actions;

(c) To increase investments in health systems strengthening;

4. To governments and development partners:

(a) Governments should create, at national level, the conditions (meetings, laws, regulations, etc.) needed to translate into concrete deeds the orientations contained in the reference document and the recommendations of the conference to improve the health status of the populations;

(b) Governments and partners should establish mechanisms to follow-up on the recommendations of this conference;

(c) The WHO Regional Office for Africa should produce a report each year for the Regional Committee and partners on the progress in the implementation of the recommendations of the conference;

(d) Governments, in collaboration with partners, should document best practices and encourage the dissemination and sharing of best experiences among countries of the region;

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CHAPTER 2 CARE OF NEW BORN

Rachel Musoke, Mary Shilalukey Ngoma, Aggrey Wasunna

INTRODUCTION

The fourth millennium development goal (MDG) focuses on reduction of the under five mortality. Many of the programmes that have contributed to the survival of the child under five years have omitted the neonatal period. As a result 38% of all deaths in the first 5 years are in this period. If we do not address the problems of the neonate we are unlikely to meet the global goal improving child survival. Improved survival will thus depend on investment in interventions that cater for newborn care. Within the neonatal period the highest deaths occur in the first 24 hours (25-45%) and up to 75% of deaths occur in the first 7 days. Many of these deaths are also related to the health of the mother. This is the basis of continuum of care approach for mothers, newborns and children (pregnancy, delivery and postnatal care).

Health care should start with the girl child ensuring adequate nutrition and growth followed by cultural changes and life skills that enable the girl to prevent adolescent pregnancy. All pregnant women should get good care during pregnancy and delivery. The aim of care is to ensure intact survival of the mother and her baby. Many problems in this period lead to permanent disability. Majority are predictable. Care starts in the community but there should be a close liaison with the health facility. The SEARCH project, India, Gadchiroli, provides a good example of a culturally appropriate, evidence based community newborn care initiative from which many countries can learn, adapt and replicate.

Though for child survival we tend to stress goal 4 of the MDG all other goals are equally important. For you cannot improve child survival without reducing poverty (goal 1), improving education and equity of women (goals 2 &3), maternal health (goal 5) as well as reducing infections in the mother (goal 6) and environmental sustainability (goal 7) Objectives

At the end of this chapter the student should be able to: Define all terms used in the neonatal period

Describe maternal health and education and their effect on the foetus and baby State principles of antenatal and perinatal care

State principles of neonatal care

List common causes of morbidity and mortality in the neonate Outline strategies that will reduce morbidity and mortality Recognize a sick neonate

Organize neonatal services in a district

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LEARNING ACTIVITIES

Examine and be familiar with a normal newborn

Recognize and infant with birth asphyxia and be able to resuscitate such a baby Recognize, refer or treat and prevent infections of the newborn

Learn principle of cord care

Be familiar with ways of keeping baby warm

Observe and participate in different methods of feeding Recognize other common features of a sick neonate Plan care of low birth weight babies

Plan neonatal services in a district Definitions

Newborn (neonate)/neonatal period: age/period 0-28 days of postnatal life Early neonatal period: 0-7 days of postnatal life

Late neonatal period: 8-28 days of postnatal life

Preterm baby: <37 completed weeks of gestation Low birth weight (LBW): birth weight <2500g

Small for gestational age: birth weight <10th percentile for gestation

Perinatal mortality rate: stillbirths + 7 days postnatal deaths per 1000 births Neonatal mortality: deaths in the first 28 days per 1000 live births

MATERNAL HEALTH & EDUCATION

Delay/space pregnancies

Babies born to young mothers tend to die (most of these pregnancies are unplanned). For healthy outcome for mother and baby the inter-pregnancy interval should ideally be at least 24 months and preferably 36 months. There is thus a need to find ways of providing family planning services to the majority of families

Nutrition

Pre pregnancy:

Ideal is to have a well nourished woman before start of a pregnancy. A stunted child will lead to a stunted adult. Short women have difficulty deliveries. Micronutrient deficiency especially folate may lead to neural tube defects.

During pregnancy:

Macronutrients predispose to LBW

Micronutrients (in particular iron, zinc, vitamin A, folic acid and iodine) lead to LBW, birth defects, pregnancy losses, increased infections.

Infections

During pregnancy:

These may lead to foetal infections, intrauterine growth restriction, and preterm labour or foetal loss

During labour and delivery:

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Maternal Education

This is key for access and utilization of health services as well as self care and care for the baby.

PRINCIPLES OF ANTENATAL & PERINATAL CARE Antenatal care (ANC)

This is a good entry point for health care. About 70% of women in Africa attend ANC at least once during pregnancy. If 90% of women received good quality ANC up to 14% newborn lives would be saved. It is important for health workers in the community to know and record all women who are capable of becoming pregnant and to closely follow up those who are actually pregnant. Women need to be encouraged to attend antenatal care as early as possible.

Focused antenatal care aims to respond to the needs of pregnant women with emphasis on:

Adequate nutrition for the mother

Immunization against tetanus (2 doses in first pregnancy, one for each subsequent pregnancy to a maximum of 5 doses)

Preparation for breastfeeding

Identification of women at risk of poor pregnancy outcome and referring them to equipped delivery units

Treatment/control/prevention of pregnancy disorders (e.g. PET) Screening and appropriate care for HIV infection

Birth and emergency preparedness at home

Advice and support to develop health seeking behaviours Avoiding harmful practices during pregnancy

Being aware of danger signs during pregnancy and child birth and seeking for help early. Danger signs during pregnancy include:

Bleeding from the vagina during pregnancy High blood pressure and severe headache High fever

Swollen hands and face Convulsions

Labour and delivery

Presence of a skilled attendant at each delivery to support a clean and safe delivery as well as immediate care of the baby

Availability of transport and referral between community and health care facility

Emergency obstetric preparedness and prompt referral when severe complications arise. These include:

Prolonged labour Breech position Preterm labour Teenage pregnancy HIV positive mother

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PRINCIPLES OF NEONATAL CARE

The normal neonate

Birth weight 2500-4000g Average 3100-3200g

Head circumference 33-37cm Average 34-35cm according to sex Length average 50cm

Gestation 37 – 41 weeks

Posture is fully flexed when awake

Sleeps most of the time; waking up at 2-3 hourly intervals usually when hungry Survival of a newborn baby depend these principles

Proper resuscitation/care at birth Ascertain the adequacy respiration Provision of warmth

Prevention of infection

Early initiation and establishment of adequate breastfeeding Proper Resuscitation/care at birth

Emphasis in neonatal resuscitation is on: drying, stimulation and covering to prevent hypothermia followed by airway and breathing. Room air is as good as oxygen in neonatal resuscitation. Drugs are rarely necessary.

Basic equipment includes a mucous extractor for clearing the airway. Use of a bag valve and mask may be necessary if baby is not breathing.

Establishment of adequate respiration

Majority of babies do manage to establish breathing without help. That first cry is so vital. It opens up the lungs with a high pressure. But when this does not happen we all panic and may do more harm than good for the survival of the baby. Since asphyxia is not always predictable preparedness is essential. All persons conducting a delivery should be able to adequately resuscitate a baby.

Keeping the baby warm

All neonates need extra warmth at birth but care should be taken not to overheat them. LBW infants, asphyxiated babies and all sick babies in general are at more risk than normal term neonates.

1. At birth

Babies lose heat very quickly because they are wet at birth. Therefore dry them quickly remove the wet towel and wrap in a dry one. Put the baby next to mother and if possible initiate skin to skin nursing (kangaroo care). Delay bathing the baby till after 24 hours of age. Initiate breastfeeding within 30-60 minutes of birth.

For preterm or low birth weight babies, continue with Kangaroo care to keep them warm.

2. Care beyond the delivery room

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Preterm/LBW depend on size and whether well or sick. Well preterm do very well in continued kangaroo care. Sick ones should be managed in a warmed up area. If there is a good follow up programme these babies can be discharged fairly early.

In neonatal units heated rooms with a covered baby can be adequate to keep the babies warm. Incubators are best reserved for sick neonates in large hospitals with appropriate back up services. They are expensive, difficult to maintain and require constant supply of electricity.

Prevention of infections

Clean delivery (clean hands, clean cutting and tying of the cord, clean cloths/towels for wrapping the baby).

Appropriate cord care after delivery: Discourage harmful cultural practices; Use surgical spirit until cord drops off and complete umbilical healing

Initiation of breastfeeding within the first hour of delivery

Reduce overcrowding at health facility partly by avoiding unnecessary admissions and early discharge

Leave baby with own mother all or most of the time

Recognize infected baby and isolate them early. Although clinical features in an infected newborn can be nonspecific, some of the danger signs include:

Fever or lowered temperature Too sleepy or hard to awaken Refusal to feed or feed intolerance Fast breathing and or chest in drawing

Pus or redness in the umbilical cord and or eyes

Breastfeeding

Initiation of breastfeeding within the first hour plays a major role in neonatal survival. As we have seen above it helps to prevent hypothermia and infection. It also helps to establish good breast milk supply and thus the baby will be well nourished from the start. Babies are born with good reflexes (rooting and sucking) for survival and are able to regulate their intake to satisfy normal growth. They will demand to be fed when hungry. If a baby does not demand a feed it usually means he is sick or immature. If breastfeeding is contraindicated, or the mother is too sick to breastfeed an alternative suitable breast milk substitute must be available for feeding the baby.

THE LOW BIRTH WEIGHT (LBW) INFANT

It is estimated that in Africa 14% of all babies born are LBW. These babies are either born too early (preterm) or suffered poor growth in utero resulting from complications during pregnancy. Preterm babies contribute to about 28% of all neonatal deaths. Paying attention to their care will thus reduce neonatal mortality. The most vulnerable are the babies weighing <1500g at birth and < 33 weeks gestation. They have problems of breathing, feeding and maintaining body temperature and have a higher mortality than the bigger LBW infants. These very low birth weight (VLBW) are best looked after in a referral hospital.

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As mentioned under “keeping babies warm” the LBW over 1500g can easily be kept warm using kangaroo care method unless they have additional problems. They may need stabilization for some time in a neonatal unit before being fully transited to kangaroo care and finally discharged into the community.

COUNSELLING AND COMMUNICATION

This is an area often neglected in a busy health care facility. Imparting knowledge to the clients is often relegated to the most junior staff and sometimes a student. This should be a dialogue rather than talking down to the client. All through care information from the client needs to be discussed so that the client understands what is going on. If a problem occurred it should be discussed as to how it can be avoided in future. Parents should be encouraged to seek appropriate care early. The need for continued care at a health facility should be communicated as well as what will be done.

POSTNATAL FOLLOW UP

Most mothers with normal delivery are discharged from a health facility within 24-48 hours of birth while it is also known that most neonatal problems appear in the first week of delivery. It is therefore important to plan an early follow up. Depending on the health care set up in the area this can be a home follow up or at health facility. The first visit is often planned within 7 -14 days. The earlier the better. At this time it is important to check:

Adequacy of feeding

Cord/umbilicus for possible infection

Weight gain – should be back to birth weight

The mother should be encouraged to report any concern about the baby as soon as possible

STRATEGIES TO REDUCE NEONATAL MORTALITY

The common causes of mortality are:

Infections 39% (sepsis, pneumonia, diarrhoea and tetanus) Preterm global 28% but 50% in Africa

Asphyxia global 23% but 24% in Africa. About 30-50% of deaths occur in the first 24 hours of birth

Almost all these conditions are preventable using simple inexpensive solutions that have already been outlined in the chapter but let us summarize them. They all depend on appropriate organization of neonatal care at all levels.

Infections

Treat maternal infection in pregnancy Giving tetanus vaccine to all mothers

Clean delivery, general hygiene and appropriate cord care Early recognition and treatment of the infected baby Early initiation and exclusive breastfeeding

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Where community based newborn care programmes exist, training of community based agents to identify infection and other danger signs in the baby and refer and or provide care such as antibiotic will save newborn lives.

Preterm babies

Maternal nutrition: adequate intake of both macro and micro nutrients Improve ANC screening and management of pregnancy complications

Careful care from birth to prevent infections, adequate feeding and kangaroo care when feasible

Perinatal asphyxia

Screening in pregnancy for those mothers likely to have cephalo-pelvic disproportion Birth preparedness

Emergency obstetric preparedness and prompt referral Skilled attendant at delivery for care of the newborn baby

INITIATE BREASTFEEDING WITHIN ONE HOUR OF BIRTH FOR ALL BABIES UNLESS THERE IS A MEDICAL CONTRAINDICATION. IT SAVES LIVES

ORGANISATION OF NEONATAL SERVICES

This is based on the continuum of care recognizing that most deaths occur at home during child birth and in the first few days post delivery. Integration into and strengthening existing services is important. Often reproductive services omit care of the neonate. But many IMCI programmes have added the ‘N’ (newborn) and ‘C’ (community). In built in this is avoiding of delays – delay in recognition of problems; delay in transport to reach appropriate care; delay in executing care at the health facility.

Supportive government policy and planning is needed. Aim at improving health care systems at all levels. All facilities conducting deliveries should provide essential newborn care including neonatal resuscitation, care of the moderate low birth weights infants and establish a good workable referral system.

Skilled attendant at delivery is defined as a health worker trained in managing normal pregnancy, delivery and immediate postnatal care. He/she should be able to identify, manage or refer mother or baby with complications. Delivery should take place in a setting with needed equipment, supplies and drugs as well as transport for emergencies.

LEVEL 1: HOME/COMMUNITY

Strengthen care at household level by empowering the community to act appropriately. This could be done through community participation so that the community owns the programme. Community health workers chosen by the community can be trained to promote health in the community by providing appropriate information, and identify babies that need care at a health facility. Studies in India and elsewhere show that a