Worldwide, countries are facing various public health problems but at unequal intensity. Low and middle-income countries are more suffering from high burden of disease than developed countries (Lopez et al., 2006).
Public health issues in the world have existed for hundreds of years and to cope with them different interventions from different people have been put in place and have been improved over time depending upon new health-related discoveries.
In September 1978, World Health Organisation in collaboration with The United Nations Children’s Fund organised the famous International Conference on Primary Healthcare in Alma-Ata, former Soviet Union, where 3000 delegates from various national governments and international bodies convened to find new ways of dealing with public health setbacks. This conference was a landmark in the promotion of population health around the world given the introduction of the theme of “Health for All” with the slogan “Health for All by the Year 2000” (Wooding, Nagaddya & Nakaggwa, 2012).
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In the Declaration issued at the end of the conference, Primary Healthcare was defined as “essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at 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” (World Health Organisation, 1978).
In this essay, with relevant examples, the explicit meaning of this definition will be discussed. Later on, gaps and lessons drawn from the conceptualisation and implementation of Primary Healthcare in Rwanda will be identified. Finally, the relevance of Primary Healthcare in the Rwandan health system will be examined.
A.EXPLICIT MEANING OF DEFINITION OF PRIMARY HEALTHCARE ACCORDING TO WORLD HEALTH ORGANISATION
The definition of primary healthcare, as it was issued in the Alma-Ata Conference Declaration, was general and needed some precisions and common understanding to avoid any misinterpretation.
To fully grasp the explicit meaning of primary healthcare, as was defined by the World Health Organisation, it worth, firstly, to break it into basic terms:
A.1.Primary healthcare as essential and appropriate activities for promoting the health of the population
Primary healthcare is a set of activities aimed at promoting the health status of the population. Through these activities, prevailing health problems that the community suffer are addressed properly by providing promotive, preventive, curative and rehabilitative services (World Health Organisation, 1978).
World Health Organisation (1978) states that the essential services that primary healthcare would provide were : education on prevailing diseases and the ways of preventing and controlling them; promotion of food supply and proper nutrition; maternal and child healthcare including family planning; adequate supply of safe water and basic sanitation; immunisation against major infectious diseases; prevention and control of local endemic diseases, appropriate treatment of common diseases and injuries; and provision of essential drugs. These services were expected to vary according to the country and community provided their economic and social aspects that they reflect and from which they evolve and health system had the social responsibility to avail essential healthcare to all (World Health Organisation, 1978).
A.1.1.Education on prevailing diseases and the methods of preventing and controlling them
This component of primary healthcare aims to support personal and community social development by informing them through education for health. The enhancement of their life skills leads to behaviour change at individual or collective level in order to tackle health problems prevailing in their community. Additionally, this activity makes people aware of other factors that determine their overall health like environmental factors, lifestyle and genetics. As a result, people are empowered to have informed options to have control over their own health and over those factors determining their health status.
Various ways are used ranging from mass media tools to simple messages transmitted to individuals or to the community regarding the strategies to fight against common diseases in their communities (Wooding, Nagaddya & Nakaggwa, 2012). Further, health educational materials can be developed, supplied in the schools by those working in education sector to be integrated in health system.
To illustrate this activity in the community, the strategies regarding the prevention of malaria should include the education on what is malaria, its causes, signs and symptoms of the disease, treatment and preventive measures in place.
A.1.2.Promotion of food supply and proper nutrition
The Promotion of food supply and proper nutrition in the families and in the community in general is a cornerstone in fighting against ill-health. Under nutrition and micronutrients deficiencies mostly in women in reproductive age and children largely contribute to a global burden of disease (Caulfield & al., 2006).
A.1.3.Maternal and child health including family planning
Maternal and child morbidity and mortality rates, mostly in resource limited countries, are still high and more action is needed to tackle this public health issue. Women and children’s deaths are attributed to the causes which in many cases are preventable and avoidable through collaboration of various stakeholders (Wooding, Nagaddya & Nakaggwa, 2012).
A.1.4.Adequate supply of safe water and improved sanitation
This component of primary healthcare ensures that population has not only access to safe and clean water but also to clean environment. The role of contaminated water and environment in spreading diseases is known. The supply of safe and adequate water, sanitation and disposal of liquid and solid waste play a key role preventing diseases transmission (Howard et al., 2002).
A.1.5.Immunisation program against major diseases
Immunisation against major diseases plays a key role in preventing serious contagious diseases mostly in children like Tuberculosis, measles, tetanus, whooping cough, etc .Women in reproductive age are also vaccinated for Tetanus.
A.1.6. Prevention and control of local endemic diseases
Some persisting diseases in a community contribute to the burden of disease and are attributable to the increasing morbidity and mortality in many countries. Regular screening and appropriate treatment of these diseases done by skilled healthcare workforce with appropriate health technology are key to the control of them (Wooding, Nagaddya & Nakaggwa, 2012).
A.1.7. Appropriate treatment of common diseases and injuries
This component of primary healthcare deals with the treatment of common diseases and injuries that members of the community suffer. These diseases include common infectious diseases that prevails in the community, skin lesions due to injuries, infections or other disease conditions that affect the skin all of which contribute to the burden of disease.
A.1.8.Provision of essential drugs
The provision of essential drugs contributes greatly in effective management of common pathological conditions in the community. They are of an utmost importance in preventing and treating diseases which have a greater impact on lives of millions of people around the world. “Essential drugs save lives and improve health” (Balkan et al., 2013).
A.2.Primary healthcare as essential activities based on practical, scientifically sound and socially acceptable methods and technology
To achieve its ultimate goal, “which is better health for all”, primary healthcare should be evidence-guided. Primary healthcare practice has to be based on scientifically-proved methods, techniques, equipments and drugs (World Health Organisation, 1978).
To avert health problems, various methods, techniques, equipments and drugs are used in prevention, diagnosis, treatment of diseases and patient rehabilitation once the disease in treated. Selection of health technology to be used has not to be only based on scientific evidences but also on its affordability and acceptability in the context of local value, culture and belief (World Health Organisation, 2011). For example, primary healthcare providers should use those healthcare technologies that enable clients to have access to high quality, safe and cost-effective healthcare.
A.3.Primary healthcare should be made universally accessible to individuals and families in the community
All members of the community should equally and universally have access to health services regardless of their social economic standing, religion, sex, age, race, language or geographic location and to ensure that it is effectively achieved, the concept of equity should be taken into consideration.
The availability of health services itself is not the assurance that the primary healthcare would be successful. There are other components to be addressed to ensure that health services made universally accessible are appropriately used by all members of the community. World Health Organisation (1978) recommended that states government should make use of available resources effectively by increasing the funds allocated for health and firstly giving priority to the extension of primary healthcare to disadvantaged communities.
Countries should make sure that all barriers including social economic barriers are properly addressed by reducing exclusion and social economic disparities to help those in need to have access to health services.
A.4.Primary healthcare should involve full participation of community members 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
The participation of communities in primary healthcare care activities forms an integral part in the health system. Central level should take into consideration the role of communities that play in primary healthcare activities planning process. To achieve this, communities have to be enabled to understand their role, especially in primary healthcare strategies and in the development process at community level in general, by providing with them the guidance and the necessary information that they do not have at their level. Once community members fully understand the part they play in the national primary healthcare strategy and in the overall development process at community level, then they are able to give their contribution in the formulation of primary healthcare programmes by examining themselves the health problems that they face in their community, setting priorities, adjusting national solutions to their local communities and organising themselves and put in place support and control mechanisms (World Health Organisation, 1978). Also, the effectiveness of primary healthcare depends on the use of means that are affordable and acceptable by both the community and the country.
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The necessity of involvement of other health system components and other sectors that contribute to general country’s social economic development is of paramount importance in the implementation of primary healthcare programmes as “health cannot be attained by the health sector alone” (World Health Organisation, 1978).The linkage between primary healthcare and other sectors in the context of community development needs a coordinated effort in planning process at the community level. The joined effort from various community development stakeholders results in a sort of collaboration which has a greater impact on primary healthcare.
As an illustration of the above, malnutrition reduction programme in less than five should involve community members, healthcare workers, and agricultural worker as they might have the key information that can help in planning process. Additionally, community members can actively participate in the implementation of some components of the programme jointly with other development initiatives from other social economic development sectors.
B.GAPS AND LESSONS DRAWN FROM THE CONCEPTUALISATION OF PRIMARY HEALTHCARE IN RWANDA
The implementation of primary healthcare in Rwanda has been proven to be effective in recent years. Despite the four years of civil war and genocide that left more than one million of people dead, thousands of hundreds displaced and health system totally collapsed, Rwanda has made remarkable progress in improving the health status of its population (Rodriguez & Samuels, 2011).
The above remarkable progress is imputable to various factors including ambitious political will that predominantly played in key. Health sector reforms which included community health insurance commonly known as “mutuelle de santé” and a boost of health services done by providing the incentives to healthcare staff through performance-based financing schemes have also been a cornerstone in the achievements of such results. Furthermore, strong leadership, strong health policies together with involvement of community health workers in participatory decentralisation and effective coordination of donations from health and development partners have been implemental in implementation of primary healthcare strategies.
B.1.Lessons to be leant
Primary healthcare conceptualisation and implementation, in Rwanda case, offers great lessons to be learnt for future primary healthcare initiatives either in Rwanda itself or elsewhere in the world mostly in resources-limited countries.
Rodriguez and Samuels (2011) highlighted that putting in place a strong leadership and accountability mechanisms at all levels, involvement and creation of ownership of health services seekers, collaboration of all stakeholders in planning process supported by evidence-based policies are more likely to help in achieving the desired outcomes of primary healthcare as it has been shown for Rwanda’s experience.
In spite of the above mentioned remarkable achievements that Rwanda has made in implementation of primary healthcare, there is still chasm to be addressed.
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