Lecture 7. Primary health-care

1. Lecture 7. Primary health-care Ass. Prof. Ph.D Daina Lucia

2. WORLD HEALTH ORGANIZATION • WHO is a specialized institution, founded in the period 1947-1949, based on the agreement of the UN member states. • In accordance with WHO regulations, the admission of a state happens at the request and with the agreement of the other members. • WHO membership is not conditioned by the UN membership. • WHO decisions represent recommendations, as WHO is not a supra-national organization that is allowed to control, impose measures, etc.

3. WORLD HEALTH ORGANIZATION • Supports member states with the view of promoting health through the acquisition of knowledge and medical practices. • is an international organization that objectively protects the interests of the 3 main actors of the medical system: •        1.the producers of health services; •        2.the consumer (users) of health services; •        3.health administration:       • - third-party payer; •                         - organizations mediating between 1 and 2.

4. The health care system • All social systems generate advantaged and disadvantaged social groups. • In order to balance the supply-demand relation, 3 stages are needed: • setting priorities; • evaluating services and activities; • planning.

5. THE “HEALTH FOR ALL” STRATEGY, UNTIL 2000 • History • 1977 – the general assembly of WHO members decided upon the main objective that, until 2000, the health state of all people in the world would allow them to have a productive social and economic life. • 1978 – the meeting in Alma-Ata. A series of hypotheses related to health have been elaborated. • 1981 – the general assembly of WHO. The “Health for all” strategy, for each of the 6 regions (Romania is included into the region Europe). • The socialization of the health state (Canada): communities determine individuals to pay for health insurance. • 1984 – A number of objectives were set for each region: 38 objectives for Europe. • 1991 – Lisabona, the revision of objectives.

6. THE “HEALTH FOR ALL” STRATEGY, UNTIL 2000 • In 1975, the general director of WHO, Dr.Halfdan Mahler, who, a year before, had emphasized the fact that “the health-state of the population influences economic development and is influenced by it, being in itself an element that conditions development”, launched the concept of “Health for all until 2000”, suggesting “urgent actions in order to achieve, in a time-span of 25 years that correspond to a generation, what had never been achieved up to then”. • The same year, after the publication of the book entitled “Alternative solutions for meeting basic health needs” (Djukonovic and Mach, 1975), the first resolution concerning primary health care was adopted, which was actually a strategy for accomplishing the objective of “Health for all until 2000”.

7. THE “HEALTH FOR ALL” STRATEGY, UNTIL 2000 • The different activities that were meant for the accomplishment of the “Health for all until 2000” objective culminated with the organization, by UNICEF and WHO, of an international meeting in Alma-Ata, onSeptember 12, 1978, to which the representatives of 134 governments and 67 international organizations took part. • The fundamental document of the conference was the Declaration of Alma-Ata.

8. THE DECLARATION OFALMA-ATA • The international conference of Alma-Ata, on September 12, 1978, focusing on primary health care, emphasized the need for urgent action, on the part of all governments, all people working within the health-care system and of communities around the world, in order to promote the health of all people of the world; the following were declared:

9. THE DECLARATION OF ALMA-ATA • I • Health, which isa state of complete physical, mental and social well being, and not only the absence of disease or disability,is a fundamental human right; the achievement of a health-state at the highest possible level is one of the most important social objectives of the entire world, which demands the joint action of many other economic and social sectors, besides that of the medical system. • II • The flagrant inequalities within and across countries (between developed and developing countries) in terms of healthare unacceptable from a political, social and economic point of view, and therefore represent a common concern for all countries.

10. THE DECLARATION OF ALMA-ATA • III • The economic and social development, based on the new international economic order, presents a crucial importance for the achievement of the “health for all” objective, and for the purpose ofreducing the serious difference in terms of health in developed and developing countries.The promotion and the protection of the population’s health state are essential elements for a permanent social and economic development and contribute to a better quality of life and to the world peace. • IV • People have the right and the duty to contribute, both individually and collectively, to the process ofplanning and implementing health-care practices.

11. THE DECLARATION OF ALMA-ATA • V • Governments are responsible for the health-state of their populations, a state which can be achieved only by preserving an adequate health state and through social measures. In the future decades, a main social objective for governments, international organizations and the communities of the world would be the attainment, for all people of the world, until 2000, of a health state that would allow them to have a productive social and economic life. Primary health care represents a key element in the attempt to gain that objective, which is part of the general development, in the spirit of social equity.

12. THE DECLARATION OF ALMA-ATA • VI • Primary health careis consideredessential medical care,being based on acceptable scientific and social methods and technologies, accessibile to individuals and families belonging to all communities, with their total participation and at costs that the community can afford to maintain at each stage of its development in the spirit of self-confidence and self-determination. • Represents an integral part of a country’s health-care system, to which it is both a central function and a main problem, but also an aspect of the social and economic global development of communities. • Represents the main level of the contact between individuals, families and communities on the one hand and the national health system on the other hand, trying to bring as close as possible the activity in the field of health care and people’s life and work environment, representing a first element of a continuous process of health care.

13. THE DECLARATION OF ALMA-ATA • VII • Primary health care: • 1.reflects and is the result of economic conditions and socio-cultural and political characteristics of different countries and communities and relies on the application of relevant results of the social, biomedical and sanitary research services, and on the experience in the field of public health; • 2.relate to the main problems associated with the health of communities, providing services of: • promotion, • prevention, • cure; • appropriate recovery;

14. THE DECLARATION OF ALMA-ATA • 3.includes at least: • education concerning the predominant health problems and the methods for their prevention and control; • promotion of appropriate nutrition methods; • provision of drinking water, in adequate quantity, and of basic sanitation; • care for mothers and children, including family planning services; • immunization against major infectious diseases; • prevention and control of endemic or regional diseases; • adequate treatment for current diseases or injuries; • provision of essential medication;

15. THE DECLARATION OF ALMA-ATA • 4.involves, besides the health-care system, all the sectorsrelated to it and aspects of national and community development, especially agriculture, zootechny, industry, education, buildings, public works, communities and other sectors,and demands the coordinated effort of all the sectors mentioned above; • 5.requires and promotes, on the part of both individuals and communities, a degree ofself-determination and participation to the planning, organization, management and control of primary health care, making a complete use of local, national and other available resources; thus, the involvement capacity of communities is developed, through adequate education;

16. THE DECLARATION OF ALMA-ATA • 6. integrated, functional reference systems should be promoted, which might determine a progressive improvement of the health state that is as inclusive as possible, giving priority to those who are in much need; • 7.relies, at both the local and the reference level, on persons working within the medical system, including doctors, hospital attendants, midwives, auxiliary staff and specialists in traditional medicine, who should be trained appropriately, from both the social and the technical point of view, and demonstrate the ability to work as part of a team and meet the health-related demands of the community.

17. THE DECLARATION OF ALMA-ATA • VIII • All governments should establishnational policies, strategies and action plansin order to organize and support primary health care practices as part of an inclusive national health-care system, in coordination with other sectors. With this view in mind, it is necessary to demonstrate some political willingness to mobilize national resources and use rationally the available external resources. • IX • All countries shouldcooperate as partners, with the view of providing primary health-care to all people, as the health-state of people living in a certain country influences and is beneficial for any other country. In this context, the WHO/UNICEF report on primary health-care represents a social basis for the functioning and the future development of primary health care in the world.

18. THE DECLARATION OF ALMA-ATA • X • Until 2000 an acceptable level of health for all peoplemight be achieved, through a better and more complete use of global resources, which are now being extensively used for weapons and military conflicts. A real politics for independence, peace and disarmament should ensure supplementary resources, which might be used for peaceful purposes, for the acceleration of social and economic development; in this process primary health care represents an essential part and should therefore receive appropriate attention. • The participants to the meeting of Alma-Ata also set 22 recommendations, based on the definition of primary health-care, included in the declaration of the meeting.

19. Primary health-care • The sources that contributed to the definition of primary health-care are the following: • - the modification of theories concerning development, which led to the establishment of some connections between the health sector and the other sectors, emphasizing the necessity for equity in terms of access to and provision of health services; • - problems associated with the increase of the population number, which determined the need to develop services dedicated to mothers and children; • - a new technological approach to disease and medical services, which does not take into account sufficiently the social, economic and political aspects of life; • - the success of some countries , especially of China, in the medical field, as a result of community involvement in medical actions.

20. Primary health care – basic principles • 1.Equitable distribution: countries should find means to ensure every person’s access to services. • 2.Community involvement: the involvement of individuals in promoting their own health is essential for the future well-being of the community. • 3.Focus on the prevention activity: acquiring knowledge, through education for health and/or the mobilization of communities for immunization; the role of communities in making decisions related to the provision of resources for medical priorities. As prevention is essential for solving the long-term problems of the community, though it is not always the solution to individual problems, preventive services should exist alongside curative services. • 4.Adequate technologies: should be acceptable, cost-efficient, cheap and available at the local level. • 5.Multi-sector approach: the health state is influenced both positively and negatively by a series of factors such as: living conditions, transport, food production, irrigation, water reserves. All these are the responsibility of different governmental sectors, but they all influence the general wellbeing of the community.

21. Primary health care • Among these principles, the basic elements of primary health care are: •        1.Education related to health problems, their prevention and control. •        2.The promotion of correct nutrition. •        3.Providing adequate and sufficient drinking water, as well as basic sanitation •        4.Care for mothers and children, including family planning. •        5.IImmunization against major infectious diseases. •        6.The prevention and control of endemic diseases, with a regional character. •        7.Adequate treatment of current diseases and injuries. •        8.Provision of essential medication.

22. THE “HEALTH FOR ALL UNTIL 2000” STRATEGY, FOR THE EUROPE REGION • The “Health for all” European strategy has been approved, by the representatives of the member states of the region, on the occasion of the 13th session of the Regional Committee, which took place at Fez, in 1980. • This strategy is defined by 2 basic elements: • 1.The health level of the European population is lower than it should be, taking into account the financial resources allocated to the sanitary service and the development of new drugs and medical technologies during the last 30 years. • 2.The existence of inequities in the medical field, despite a rather high level of general development in the region, and of the scientific, economic and educational level of most countries.

23. The principles of the European “Health for all” strategy (1) • 1.”Health for all” involves equity. Therefore, the inequities related to health, among and within countries, should be reduced as much as possible. • 2.The aim is to create a positive perception in relation to health, so as all people might use their maximum physical, mental and emotional capacities. The main emphasis should be placed on health promotion and disease prevention. • 3.People will contribute to the achievement of the “health for all” objective. A well-informed and motivated community, which actively participates to the promotion of health, is a key element for the achievement of a common purpose.

24. The principles of the European “Health for all” strategy (2) • 4.The “health for all” objective involves the collaborative action of all sectors involved. Medical authorities are able to solve only some of the problems; thus the multi-sector co-operation represents the only way to ensure the premises for health, through the promotion of sanitary policies and the reduction of risks related to physical, economic and social environments. • 5.The health system should focus its attention on primary health care, providing the basic health-care needs of all communities and health-care services at people’s residence and workplace, which should be accessible to all and based on the full participation of the community. • 6.Health-related problems are trans-national. Pollution and commerce of unhealthy products represent just some of the problems that can be solved only at international level.

25. The “Health for all in the 21st century” Policy • The World Community adopted, in May 1998, the “Health for all in the 21st century” policy, which aims at fulfilling everyone’s aspiration for health, by eliminating disparities and inequities in terms of access to medical services of the world population. • This policy establishes the global priorities for the first two decades of the 21st century, as well as the 10 aims concerning the creation of conditions necessary for all people to achieve and preserve their highest level of health. • The scientific support of health development is necessary, as well as the process that might lead to a progressive improvement of public health, the achievement of this desideratum involving the consideration of health as a fundamental human right. • The global health for everyone’s safety, as the policy for the 21st century, should have results due to corroborated national and regional strategies and policies, while Heath 21 is the response of the European Region of World Health Organization to this desideratum.

26. The objectives of the “Global Health in the 21st Century” policy • 1. Solidarity for health in the European Region, relating to: • Justice, equity and strong solidarity for achieving health at the international level, trough an efficient collaboration of European member states and the ensuring of equity in terms of access to health for the disadvantaged groups in all countries; • Diminishing differences in terms of health among countries. • Poverty is a major cause of disease and social belonging. A third of the population living in the eastern side of the region, more exactly 120 million people, live in conditions of extreme poverty. • Health was much damaged in regions where the economic development did not manage to ensure adequate incomes for all, where social systems are collapsing and where resources are not properly used. • Such differences are clearly demonstrated by the marked discrepancy, in terms of health, between the population living in Western and, respectively, in Eastern Europe. • In order to reduce such differences, a sustained common effort is needed on the part of international institutions providing funds for the improvement of the health state in disadvantaged countries. 20% of the total assistance for development should be attributed to activities in the social sector, while the external support should be better integrated within development national programs; it has been evaluated that 20% of the GDP should be allocated for the development of basic social services.

27. The objectives of the “Global Health in the 21st Century” policy • 2. Equity in terms of health. • Poverty is the most important risk-factor for health; its extension represents a form of injustice, financial deprivation leading to prejudice and social exclusion, and an increased violence rate. • There are differences between men and women in terms of health, while the educational level produces a gradient risk for health that is similar to that produced by social-class belonging. • A key strategy would be the elimination of financial, cultural or of any other barrier that would restrict the equal access to education. • The situation is applicable mainly for women and poor children from disadvantaged groups. • All sectors of society should assume responsibility for reducing social differences and stimulate the improvement of their health state. • The critical stages in the evolution of a human being: childhood, passage from primary school to another level of education, leaving the family and the setting of a new family, changing the workplace and possible accidents have a great influence upon one’s health. • The pre-natal life and early childhood represent an important base for the health of adults.

28. The objectives of the “Global Health in the 21st Century” policy • 3. A healthy start in life. • Genetic consultation and an appropriate diet, pregnancy without smoking and pre-natal adequate care would prevent the birth of overweight babies and congenial anomalies. • The policy should provide an adequate support to families wanting children and facilities for children care and raising, in a social environment that protects the rights of children; health and social services should identify and provide support in situations when children are abused. • 4. The health of young people. • On the one hand, there is a tendency to reduce accidents, the effects of drugs and unwanted pregnancies; on the other hand, the health policy should help children and young people in making easy and appropriate choices for health. • The educational and work policy should help young people benefit from the best education and the most productive work. • The education for health and the support for young people would reduce the risk of unplanned pregnancies and that of sexually transmitted diseases, including AIDS. • Firm measured should be adopted for the promotion of a healthier work environment, through improved legislation and technologies. • Enterprises should promote campaigns for health, having in view three elements: the promotion of health through their policies; their products should not be harmful for health; they should assume social responsibilities, supporting programs for the health of communities.

29. The objectives of the “Global Health in the 21st Century” policy • 5. Health ageing: till 2020, the population over 65 should have the opportunity to exercise its entire health potential and be socially active. • 6. The improvement of mental health: until 2020, the population should benefit from complete and accessible access to mental health care. • 7. Reducing the transmissible diseases: the different effects of infectious diseases should be substantially reduced through the application of systematic eradication, elimination or control programs in public health. • Polio should be eradicated in of countries in the European region until 2003, • Neonatal tetanos - until 2005, • Mumps infection - until 2010. • until 2010 it is expected to control, through adequate immunization programs, the congenital rubella, B hepatitis, pertussis and diseases caused bye Haemophilus influenzae; • until 2015 each country should implement programs for the prevention and treatment of tuberculosis, malaria, AIDS and other sexually-transmitted diseases.

30. The objectives of the “Global Health in the 21st Century” policy • 8. The reducing of non-transmissible diseases: until 2020 morbidity, invalidity and premature mortality associated with major chronic diseases should be reduced, as much as possible, in the entire Region. • The cardio-vascular diseases, cancer, diabetes, chronic obstructive diseases and asthma create major health problems in the region. Many of these diseases can be eliminated if programs for reducing risk factors such as smoking, unhealthy diet, sedentary life, alcohol consumption and stress are implemented at the level of countries or communities. • 9. Reducing the pathology associated to violence and accidents: by improving emergency services and ensuring a better understanding of prevention measures, many accidents, including the domestic ones or those associated with alcohol consumption, can be reduced. • 10. Ensuring a healthy and safe environment: through national and international programs aimed at avoiding the accidental pollution of water, air or soil. • 11. The adoption of healthy lifestyles: through programs concerning healthy diets, physical activity, sexual habits.

31. The objectives of the “Global Health in the 21st Century” policy • 12. Reducing the harmful effect of alcohol, drugs and smoking: by reducing consumption with 80% at the adult population and with 100% at children. • 13. Ensuring a favorable framework for health: by creating opportunities to live in a healthy physical and social environment at home, at school, at the workplace and in public places, through education and adequate health. • 14. Multi-sector responsibility for health: until 2020 all sectors should acknowledge and accept their responsibility for ensuring health. Member states should develop mechanisms for evaluating the impact of different sectors and policies upon the health state of the population. • 15. The integration of the health sector: until 2010 the populations’ access to primary health care should be improved; the focus should be on families and communities, which should also be supported by a system of secondary and tertiary care, which is flexible and responsible. The multidisciplinary teams of health and social assistance would be actively involved in supporting the health of the community.

32. The objectives of the “Global Health in the 21st Century” policy • 16. Management focused on quality care: until 2010 the member states of the Region would ensure a management of the health sector through programs based on community and individual needs, taking into account the satisfaction of patients in relation to services, the impact of programs on the health state, the cost-effectiveness and the cost-efficiency relation. • 17. Financing health services and allocating resources: until 2010, all states would have developed mechanisms for financing and allocating resources for health, starting from the principles of equity and access to medical care, adequate costs, efficiency and effectiveness, solidarity and optimal quality.

33. The objectives of the “Global Health in the 21st Century” policy • 18. The development of human resources for health: until 2010 all member states would have professionals in the field of health and all the other sectors, who have acquired knowledge, attitudes and specific aptitudes for health protection and promotion. • 19. Research and knowledge for health: until 2005 every state would have benefited from research in the field of health, and from information and communication systems as effective supports for the use and dissemination of knowledge for health.

34. The objectives of the “Global Health in the 21st Century” policy • 20. Recruitment and mobilization of partners for health: until 2005 policies for health would have been implemented for individual, group and organizational involvement of people activating in the private or the public sector, but also the organization of the civil society in alliances and partnerships for health. • 21. Politics and strategies aimed at “health for all” : until 2010 all member states of the WHO Europe Region would have implemented health policies in every country, region or place, which would be supported by institutional infrastructures, managerial processes and innovative leadership.

35. In the field of Public Health, a special emphasis is placed onprimary health care, in correlation with ahealthy lifestyleandthe improvement of life-quality,and therefore it is believed that the objectives of the “health for all” policy are achievable. • The sustained activity for the control of smoking, alcohol and/or consumption, for the promotion of a healthy diet, of physical activity, the reducing of risk factors associated with lifestyles are possible in the context of an inter-sector activity, when public authorities are dedicated to actions promoting health.