My Journey towards Community Health Nursing(Assignment on PHC)

Introduction

Health has always received the royal patronage and priority of the royal government since the beginning of the planned development in the country in the 1960s.  It has been the attempt of successive monarchs and the Royal Government to make take health facilities as close to people as possible.  With health care services literally provided free of cost till date Bhutan has been described as a true welfare state. Secondly, we are a signatory to the Alma Ata Declaration and have, like many other countries, chosen Primary Health Care as the core health care strategy. As a result, rugged terrain, poor transportation and communication infrastructure have not daunted the royal government from taking the primary health care services to the most remote parts of the country. This is evident from the proliferating numbers of BHUs, Sub-Posts and ORCs (Bhutan 2020, p.54). There is likely to be grains of truth in our claim that 90% of our population live within three hours of walking distance. This Paper describes the concept of Primary Health Care, differentiates it from primary care and primary nursing and, analyses nurses’ roles and involvement in it.

Primary Health Care - Origin of the Concept

The Primary Health Care concept (PHC) is said to have been conceived at Alma-Ata in Soviet Kazakhstan during the international conference sponsored by World Health Organization (WHO) and United Nations Children’s Emergency Fund (UNICEF) (Wass, A. 2000, p.263). The Conference officially acknowledged the PHC concept as the key element to achieving the WHO’s goal of ‘Health for All by Year 2000’ (HFA) in order to bring about changes in the existing inequalities in health care delivery system; it declared that good health should be considered as the fundamental right of every individual in the community with collective duty and equal chances for improvement of the socioeconomic status.

Primary Health Care - Definition

According to the Alma Ata Declaration, Primary Health Care “is an essential care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self determination. 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 the community with the national health system, bringing health care as close as possible to where people live and work” (p.15).

The Guiding Principles of PHC

The five guiding principles of the PHC concept are: (1) Health Prevention and Promotion, (2) Equity, (3) Appropriate Technology, (4) Community Participation, (5) Inter-sectoral Coordination and Decentralization. PHC emphasizes more on prevention of diseases, rather than cure; it facilitates community participation and the recommends technology that is culturally acceptable; it takes affordability of the people in the community into consideration. In general,  PHC is intended to meet the needs of an individual and the community at large through a national health care system by taking the preventive, promotional, and rehabilitative services as close to them as possible by the trained healthcare personnel.

In order to ensure that the universal coverage of first contact care is achieved, PHC functions the following components:

(a)    health education concerning prevailing health problem,

(b)   promotion of food supply and proper nutrition,

(c)    adequate supply of safe water and basic sanitation,

(d)   maternal child health including family planning,

(e)    immunization against major infectious diseases,

(f)    prevention and control of locally endemic diseases,

(g)   appropriate treatment of common diseases injuries and,

(h)   Provision of essential drugs.

The main characteristics of the PHC are equity-oriented, improved healthcare services coverage among the poor and empowerment of the vulnerable groups to have more central role in health system design and operation. PHC services emphasises on health promotion, prevention of diseases and rehabilitation. The services are effective, acceptable to all the members of the community and do not have financial, geographic, organizational, socio-cultural, and gender-based barriers to access. The communities are actively involved in making decisions about resources, selecting priorities, and ensuring accountability. They also evaluate the implemented programs. The approach to health is by involving health service collaboration and multi-disciplinary partnership, in order to prevent the consequences of ill-health as a result of the failure of other sectors; which makes it is important to work together with other sectors for the common goal.

Primary Health Care versus Primary Care or Primary Medical Care

However, PHC is neither Primary Care nor Primary Nursing.  Primary Medical Care or Primary Care is the care received by the individual during his/her first contact with the health care facility. The medical cares are provided by the general medical practitioners or in the out-patient department in the hospital settings. (Source) The medical care providers can also be physicians, nurses, dentist, physiotherapist and other health professionals.  In Bhutanese context, for instance, primary medical care provided at the Basic Health Units is manned by Health Assistants (HA), Auxiliary Nurse Midwifes (ANM) and Basic Health workers (BHW). Here, the care provided by these health workers depends on the severity of the illness and the knowledge and skills of the health workers; if the cares needed by the patients are beyond their knowledge and technical capacity they refer the patients to the next higher medical facilities, for instance, a district hospital or a regional referral hospital.  At the district or referral hospitals, the primary care is provided in the Casualty Units by the nurses on duty or by the physicians on call. In hospitals where there are no separate Casualty Units, the nurses on duty provide the primary care and seek the help of concerned physicians.

Primary Health Care versus Primary Nursing

PHC is not Primary Nursing - primary nursing mainly means that a particular nurse is assigned to take care of a particular patient where the provision of care is still on curative purposes. In this type of care, the level of care is very narrow as the target of the care is not the community, but an individual. And, in Bhutanese context, this system of nursing care does not exist because number of patients admitted almost always outnumbers the nurses on duty. Although it is yet to be officially credited, presently, nurse functions as a multi-skilled personnel taking care of all the patients admitted in a particular. 

Role of Nurses in Primary Health Care

It is observed that the global nursing profession’s response to HFA by adopting the PHC practices was quick and enthusiastic (Patterson, E. 2000).  The International Council of Nurses (ICN) who represented the nurses submitted their statement of commitment to embrace PHC practices to bring effective changes and contribute to the implementation of PHC during the 1978 Alma-Ata Declaration (Krebs, year ??), cited in Patterson, 2000).

After the Alma-Ata Declaration, the WHO in collaboration with international nursing bodies, suggested that nurses should initiate active participation with the inter-professional teams; they would act as leaders in the health care and be the resource to the communities (Patterson, E. 2000). Since then, nursing and midwifery personnel are the major service contributors of the PHC in many countries. A WHO committee in 1984 (K.park, 2004) has defined the role of nurses in PHC as:

1.       Assessing the health status of individuals and communities, mobilizing community involvement,

2.      Providing integrated health care including the treatment of emergencies, and making referrals,

3.      Making epidemiological surveillance, Training and supervising health workers, collaborating with other development sectors, and

4.      Monitoring progress in PHC.   

In many countries, nurses associations have formed their own committees to monitor the strategies of the nursing works in support of the PHC. Primary health care in India is provided by health guides and multi-purpose workers – both male and female health workers. In Australia too, many studies were conducted to assess the contribution to PHC by the nurses who are working in the general medical practices (Patterson, E. 2000).

PHC Practices in Bhutan

The modern health care system was formally established in the year 1960 in Bhutan.  After the Alma-Ata Declaration, Bhutan formally adopted the PHC approach in 1979 (Master Plan for Human Resources for Health in Bhutan, 1998, p5). The present health care system caters PHC to 90 % of the population. The Basic Health Units (BHU) provides the primary level services to the communities and individuals. There are also Out-Reach Clinics to provide the services to those residing in the rural communities (M, Geeta, 2005). Consonant with the PHC principle of involvement of the community,   Village Health Workers (VHWs) was institutionalized in 1978 by Helvetas in Bumthang. The VHWs disseminate information related to health and environment to the communities and serve as links to the higher health care facilities.  

It is the policy of the Royal Government of Bhutan to enhance the quality of the life of the Bhutanese people through improved health care and education (Master Plan for Human Resources for Health in Bhutan, 1998).  It has always been the aspiration of the RGoB that all people are healthy and happy.   PHC activities are carried out by the several programs under the Public Health Department with emphases on preventive and promotive strategies which are supported by adequate curative measures (see Appendix I).

The nurses and other paramedical workers undergo rigorous and long training at the Royal Institute of Health Sciences (RIHS). It churns out different categories of nurses, such as General Nurse Midwives (GNMs), Assistant Nurses (ANs) and Auxiliary Nurse Midwives (ANMs). The training prepares the nurses to work at any level of health care setting and facilities – preventive, promotive or curative aspect although the job description and responsibilities will differ according to the places of posting and the type of nursing category one is trained in. The duties and responsibilities of ANMs according to the Royal Civil Service Commission (RCSC), for instance, are presented in decreasing order according to the percentage of time spent on each activity or in accordance of their importance (see Appendix II).

Conclusion

The PHC has served well and is likely to be around for foreseeable future. However, as simple as it sounds, the concept of PHC demands hard work and genuine efforts for effective results. The concept must permeate the entire health care system and staff manning the system and the members of the community should interact meaningfully. Above all the health care workers, specially the nurses must own the concept and be guided by the principles of PHC while discharging their duties.

The PHC’s main thrust is on social justice, equity and community participation.  The health care services and related technology must not only be socially acceptable but affordable. Further, the services should cater to the needs of the people and, people must be educated and or made aware to prevent eliminate the causes of the ill-health or seek timely medical services.