CONTENTS

Page

1.
0 I
ntr
oduct
iont
oPr
imar
yHeal
thCar
e(PHC)………………………. 2

2.
0 Hi
stor
icalDevel
opmentofPr
imar
yHeal
thCar
e…………….
..
..
..
..
.. 4

3.
0 ConceptofPr
imar
yHeal
thCar
e…………………………….
..
..
..
..
.. 5

4.
0 Pi
ll
arsofPr
imar
yHeal
thCar
e…………………………………….
. 7

5.
0 Component
sofPr
imar
yHeal
thCar
e………………………………. 11

6.
0 Communi
tyBasedHeal
thCar
e(CBHC)………………………….
.. 13

7.
0 Heal
thandDevel
opment…………………………………….
..
..
..
..
..
. 18

8.
0 St
rat
egi
esf
orI
mpl
ement
ati
onofPHC…………………………….
. 25

9.
0 Pl
anni
ng,
Impl
ement
ing,
Moni
tor
ing,
andEval
uat
ioni
nPHC…….
27

10.
0 Heal
thEducat
ion………………………………………………….
. 32

11.
0 Gui
del
inesf
orGi
vingHeal
thEducat
ionTal
k……………………… 37

1
 I
NTRODUCTI
ONTOPRI
MARYHEALTHCARE

1.
0Int
roduct
ion
Manydi spariti
esi nBasi cHealt
hServices(BHS)necessi
tat
edadi ff
erentappr
oacht o
provi
sionofheal thcar e.Thesedisparit
ieswerereveal
edbyst udiescarr
iedoutby
manyor ganisations,e.g.
In1975,aj ointWHO- UNICEFstudyest i
matedthatonl
y20%oft her ur
alpopulat
ionin
devel
opingcount r
iesreceivedanybasichealt
hcareonregul
arbasis.
In1976,anI LO studyest imatedthatabout67% oft hepopulati
onofdevel oping
countr
iesli
vedi nser i
ouspover t
y.

Itwast henthattheInter
nati
onalcommuni t
yexpressedt
heneedforurgentactionby
allgovernments,alldevel
opmentwor ker
s,andthewor l
dcommuni t
ytopr ot
ectand
promoteheal t
hf orallpeopl
ei ntheworld.Thiswast ohappenthr
oughal t
ernati
ve
strat
egies,oneofwhi chwast hroughPri
maryHealthCareasthekeytoatt
ainingthe
abovetarget.

2.
0 Meani
ngoft
hewor
dsi
nPHC
ThewordsPHCwer
eint
ent
ional
lysel
ect
edandusedt
oconveyspeci
fi
cmeani
ngsand
messages.

ThewordPri
mar yinPHCmeanst
hef
ir
st,orbasi
c,oressent
ial
,ormosti
mpor
tant
,or
mostur
gentneed(s)
.

ThewordHealt
h:isdef
inedbyWHOasst at
eofcompl etephysical
,mentalandsoci al
wel
lbei
ng and notmerelythe absence ofdisease orinfir
mity(di
sabili
ty)”
. This
def
ini
ti
onwasmade60yearagoandt her
earemanypr oblemsassociatedwi t
hit.The
def
ini
ti
onassumesahumanbodyasamachi ne,andwell
-beingisnoteasytomeasur e.
Thi
siswhyhealthi
ndi
catorsar
eusuallyused,asproxi
es,tomeasurehealth.

Thewor dCare:car emeanslookingaf

ter
,orprotecti
onof,orgivi
ngat
tent
iont
o,or
maint
ainingsometime.Thi
scareincl
udesthef
oll
owi ngser
vices:
- pr eventi
on
- pr omotion
- cur ati
ve
- r ehabil
it
ati
ve

Pr
imar
ycar
e:meanst
hoseact
ivi
ti
esunder
takenbef
oreaper
sondevel
opsadi
sease.

Secondarycare: meansservi
cesrender
edwhenadi seasehasoccur r
ed,butiti
s
si
lent;andevenaper sonmightnotknow thathe/
shehast hedisease. Themain
acti
vit
yinsecondar
ycareisscr
eeni
ngtodetectt
hediseaseear
lyf
orearlytr
eatment

2
Terti
arycare:ispr
ovi
dedwhenaper
sonshowssi
gnsandsympt
omsofdi
seaset
o
preventdi
sabil
it
yanddeat
h.

PHC:basical
lyinsimpleter
msmeansl ooki
ngaft
erorpr ot
ect
ing,ormai
ntai
ningthe
bal
ancebetweenal
laspectsoflif
e;allbasi
cneedsandbringi
ngaboutormaint
aini
nga
pl
easantf
eeli
nginindi
vidual
,famil
iesandcommuni t
ies.

Curati
ve–domi
nantheal
thser
vicesar
enotenough;t
heyj
ustcat
erf
orabout30%of
healt
h.

PrimaryHealt
hCar ei s“Essent
ialHealt
hCar ebasedonpr acti
calsci
entifi
cal
lysound
and soci
allyacceptable methods and technology made universal
ly accessi
bleto
i
ndivi
dualsandfamiliesinthecommuni t
ythroughtheirf lpar
ul ti
cipat
ionandatacost
thatthe community and count y can af
r for
dt o mai nt
ain atevery stage ofthei
r
devel
opmentinthespi rtofsel
i f
-rel
ianceandself–det erminati
on.

Pri
mar yHeal
thCarefor
msan“ i
ntegr
alpart,bot
hoft hecount
ry’
shealt
hsystem,of
whichitisthecentr
alfuncti
onandt hemai nfocus,andoftheoverallsoci
aland
economicdevel
opmentoft hecommuni t
y;withthenati
onalheal
thsystem bri
ngi
ng
healt
hcareascl
oseaspossiblet
owher epeoplel
iveandworkandconst
it
utesthefi
rst
el
ementofacontinui
nghealt
hcareprocess”
.

Thi
sdefini
ti
onimpli
esthatPr
imaryHeal
thCarei
sani
ntegr
alpar
toft
heover
allsoci
al
andeconomicdevel
opmentofthecommunit
y.

I
tisi
ndeedtheMi nist
ryofHeal
thpoli
cythatPri
maryHealthCar
ebethecorner
stonei
n
t
hedevelopmentofheal t
hservi
cesforthepeople.Thecommuni t
iesasopposedto
t
hehealt
hsyst em arevi
ewedast hefocalpoi
ntsforact
ionandassuchallpl
ansand
r
esour
ceallocati
onmustbebasedonspeci fi
cneedsofthecommuniti
es.

The Pr
imaryHeal t
h Care appr
oach isal ogi
calchoi
ce byt he gover
nmentas it
guar
anteesequit
y,empower ment,sel
f-
rel
ianceandpart
ici
pationatalllevel
s. Thi
s
st
rat
egyensuresthatheal
t cesbecomeEASYCHOI
hchoi CESf orthepeopl
e.

3
 HI
STORI
CALDEVELOPMENTOFPRI
MARYHEALTHCARE(
PHC)

In1977t heExecuti
veBoar dofWorldHealt
hOrganisati
on(WHO)satinGenevaand
discussedissuesconcerningsoci
alinj
usti
ceinprovisi
onofhealthservi
cesinthe
wor l
d(i.
e.t
hediff
erencesbetweenHaveandHavenot).Theyadvocat
edthatheal
thbe
apr e-
requi
sit
etosocialandeconomicdevel
opment
.

On29th September1978atAlmaAta,Russi
a,PrimaryHeal
thCar
eDecl
arat
ionwas
madewi ththeobj
ect
iveofHeal
thf
oral
lbytheyear2000.

Ugandawasasi gnator
yatt heconf er
ence. Thismeansthatwemustber eadyto
mobil
iseandenli
ghtenindividual
s,famil
iesandcommuniti
esi nordertoensurethei
r
ful
lident
if
icat
ion with Primary Healt
h Care,thei
rparti
cipat
ion in pl
anning and
managementoftheircontr
ibuti
ontoitsappli
cat
ion.

Alt
houghPri
maryHealthCar
e(PHC)wasborndur i
ngAlmaAtaconfer
enceof1978,i
t
hadstar
tedatKasangat
iHeal
thCent
re,t
hepresentKasangat
iHeal
thCent
reV,which
i
sinWakisodist
ri
ct.

In1979,t
hef i
rstconf
erenceregar
dingPHC inUgandawasheldinMweyaSaf
ari
Lodge(MweyaPHCWor kshop)
,commonlyknownas“MweyaSpi
ri
t”
.

Theconceptdidnottakeoffunti
lthecomingofNati
onalResi
stanceMovement(NRM)
governmentin1986wi t
hit
st en(10)Point
sProgr
amme, ofwhichPHCwascover edi
n
pointsix(6).Inthesameyear ,UgandaCommuni t
yBasedHeal t
hCar e(UCBHC)
Associati
on was formed wi t
h mor et han 22 pr
ogrammes,Non Gover nmental
Organisat
ions(
NGO’ s)
,Ministr
yofHeal th(MoH)andMi ni
str
yofLocalGovernment
MoLG) .

In1990seri
ousdi
scussi
onsonPHCt ookof
fwi
thpr
act
icali
mpl
ement
ati
onsandt
his
hascont
inuedi
mprovi
nguptopr
esentti
me.

4
 CONCEPTOFPRI
MARYHEALTHCARE(
PHC)

Byexamini
ngthekeywordsusedint
hedef
ini
ti
onofPri
maryHealt
hCar
e,t
heconcept
ofPri
mar yHeal
th Car
ewi l
lbemadeclear. Thefol
lowi
ng ar
ekeywordsint he
def
ini
ti
onofPri
maryHealt
hCare.

 Essent i
alheal thcare
 Practical,scienti
fi
callysoundmethodsandt
echnol
ogy
 Sociallyaccept ablemet hods
 Accessi bil
it
y
 Fullcommuni t
ypar t
icipat
ionandi
nvol
vement
 Affordabi l
it
y
 Self-
reliance
 Self-
det ermination
 I
ntegr ation

Essent
ialHeal
thCar
e

Thi
sisheal
thcar
ethatmeet
sthel
ocalneedsoft
hemaj
ori
ty.

Pr
act
icalandsci
ent
if
ical
lysound

Thismeansthatthi
shealthcar
eshoul
dbeabl
etocur
eorsol
vet
hepr
obl
em i
n
quest
ion(
athandorexi
sti
ng)
.

Soci
all
yaccept
abl
emet
hodsandt
echnol
ogy

Themethodsandt
echnol
ogyusedinthedel
iver
yofhealt
hser
vicesshoul
dnotconf
li
ct
wit
hthenormsoft
hecommunityrecei
vingt
heservi
ce.

Accessi
bil
it
y

I
fthisser
vicei
stopromot
ehealt
hinthecommunit
y,theni
thast
obeaccessi
blet
o
i
ndivi
dual
sandfami
li
esint
hatcommunit
y,(
easyr
each)
.

Ful
lCommuni
typar
ti
cipat
ion

Thi
sisapr
ocessbywhi
chi
ndi
vidual
sandf
ami
l
iesassumer
esponsi
bil
it
yfort
hei
rown

5
healthandwelfar
eandthatofthecommunit
y.Ifpeopl
earei nvolvedinthepl
anning,
i
mpl ementat
ionandevaluati
onofheal
thservi
ce,thenthatser vicewil
lbesocially
acceptabl
eandatthecostthecommuni
tycanaf
ford.Theservicewi l
lbe“
appropr
iate”
.

Af
for
dabi
li
ty(
Cost
)

Theini
ti
alcour
seofservi
ceandcostt
omai
ntai
nitshoul
dbeaf
for
dabl
ebyt
he
communit
yandcount
ry.

Sel
f-
rel
iance

Indi
vidual
sandfami
li
esareencour
agedtochangef
rom bei
ngpassi
ver
eci
pientt
o
acti
vepartner
swi
tht
hegover
nmentordonor
s.

Sel
f-
det
ermi
nat
ion

Thecommunityshoul
dbeabl
etodeci
deandt
akeact
iononmat
ter
sconcer
ningt
hei
r
heal
thanddevel
opment.

I
ntegr
ati
on

Allsect
orswor
kingt
ogethertowardsthesocio-economi
cdevelopmentofacommunit
y,
withhealt
hasanucleus;shouldwor ktogethertopromot
et hehealt
hstatusoft
hei
r
people/
communityt
hroughoutit
sreferr
alsystem.

6
 COMPONENTSOFPRI
MARYHEALTHCARE
AttheAlmaAt aconf er
ence8el ement sofPHCwer ei dent
if
iedasbei
ngt
hebasi
c
ar
easforact iont oreachheal t
hforal lgoals.
1.Educat ionconcer ningprevail
ingheal thproblems.
2.Pr omot i
onoff oodsupplyandpr opernut r
it
ion.
3.Adequat esuppl yofsafewat erandenvi r
onment alsanit
ati
on.
4.Mat er nalandchi l
dhealthincludingf amilyplanning.
5.Immuni sationagainstmaj orinfecti
ousdi seases.
6.Appr opr iatetreatmentofcommondi seasesandmi nori
njur
ies.
7.Pr event ionandcont r
olofendemi cdiseases.
8.Pr ovisionofessent i
aldrugs.

Thoseelement sar enotdynami candcangot oanynumberasmaybedet

ermi
nedby
prevai
li
ngcondi t
ionsi nvari
ouscount ri
es.
InUganda,mor eel ementshavebeenaddedt othel
ist
.
9.Ment alhealthandspi ri
tualhealt
h.
10.
Dentalandor alhealt
h.
11.
Communi tybasedr ehabili
tat
ion.
12.
Occupat i
onalheal t
h
13.
Accidentpr eventi
on
14.
Ophthalmol ogyser vi
ces

HealthEducati
on
EquippingtheCommuni t
ywithknowl
edgeandskill
sconcerni
ngprevai
li
ngheal
th
probl
emsandmet hodsofpr
event
ingandcont
rol
li
ngthem;thismakespeopl
elead
bett
erli
festyl
es.

Reproduct
ionhealt
h/Fami l
yPlanning
Theseareservi
cesrenderedtomothersandchil
drenthr
oughant
enat
al,
PostNataland
Chil
dSpacing.Theaimi stoimprovetheheal
thstat
usofwomenandchildr
en.

Nutri
ti
onandFoodSuppl y
Thisistheprocessofi
mpr ovi
ngf
oodproduct
ion,pr
ocessi
ng,st
oragemar ket
ingand
consumption wit
htheulti
mategoalofimproving t
hehealt
h,nutri
ti
on stat
usand
economyoft hecommunit
y.

7
AdequateSafeWat erSuppl
yandEnvi r
onment alSani
tat
ion
Thisisintermsofamountanddi st
ancet othesourceandsaf et
y(whol
esomeness)
.
Sanit
ati
on ist he contr
oland supportofal lthose fact
orsinthe tot
alhuman
envi
ronmentt hathaveabearingtohealt
he.g.Housing,RefuseandExcr
etadi
sposal
,
Vectorcont
rol,Foodhygi
ene,etc.

Immuni
sati
on
Thi
sis a process ofadminist
rat
ion ofvacci
ne t
o suscepti
ble members oft
he
communit
ysoast orai
sethei
rbodyimmunityagai
nsti
nfect
iousdiseases.

AppropriateTr eat
mentofcommondi seasesandi nj
uri
es
Suffi
cientt reatmentf aci
li
ti
es shoul
d be in place formanagementofcommon
occurri
ngdi seasesandi nj
uri
esinacommuni ty.
PreventionandCont r
oloflocal
lyEndemicdiseases
Allmeasur esofpr eventi
ngandcontrolofl
ocall
yendemi cdi
seases(
diseasest
hatar
e
al
wayspr esentinthecommuni t
y)shouldbetakenasPHCact i
vit
y.

Provi
sionofEssent
ialdr
ugs
Thisisthesupplyofdr ugsrequi
redf
oref
fect
ivemanagementofmostcommon
condi
ti
onsinthecommuni t
y.

Ment alHeal
thServi
ces
Thesear eservi
cesdi rect
ed tothecar
eand r
ehabi
li
tat
ion oft
hement
all
yil
land
preventi
ngmentalil
lnessinthecommuni
ty.

Dent
al/Oralheal
th
ManagementifDent
al/
Oralser
vicesandt
hei
rpr
event
ion.

Communi t
yBasedRehabi
li
tat
iveHeal
thServi
ce
Theseincl
udethePhysi
call
y,Mental
ly,Soci
all
yandeconomi
cal
lyhandi
cappedand
di
sabled.

8
 PI
LLARSOFPRI
MARYHEALTHCARE
These are pr
e-r equisit
es t othe successf
ulimplementat
ion ofPHC. Fourmain
pri
ncipl
es(str
ategi es)throughwhicht heGlobalGoalofHeal
thforal
l(HFA)wast
obe
at
tainedwereident if
iedbyWHOdur i
ngtheAlmaAt aConfer
ence.Thesewere:
 Poli
ti
cal&Admi ni
strati
veCommi tment
 Communi tyPar ti
cipati
on
 Multi
sect oralStrategy(e.
g.Coll
aborati
on)
 AppropriateTechnol ogy.

However,i
ndi
vidualcountri
eswer easked tofor
mulat
et hei
rown Nat
ionalHeal
th
Pr
inci
ples(
str
ategi
es)thatarer
elevantandappr
opr
iat
etothei
rneeds.

Li
keoneendeavour
stoabuil
dahousewit
hfoundat
ion,t
her
eshoul
dbedevel
opment
ofst
rongpi
ll
arst
osuppor
tandsust
aint
heel
ementsofPHC.

 Pol
it
ical&Admi
nist
rat
ivecommi
tment

Ist
hatsuppor tprovidedtopr omot ePHCbyt hosewhoi nf
luencedecisi
onmakingat
var
iousl
evels.Thesei ncludePol i
cymaker s’e.
g.
 Cabinet, Parli
ament,Distri
ctCouncilandSubCount yCouncil
 Admi nistratorse.
g.Per manentSecr etar
y,ChiefAdminist
rat
iveOffi
cer
s,Seni
or
Administrati
veSecretaries.
 Opinion l eaders e.
g.r eli
gious,t
raditi
onalleader
s,ranging fr
om nati
onalto
gr
assroot slevel
s.

Howpol
it
icalcommitmentisexpressed
 Throughpol
it
icalstat
ementi nfavourorsupportofPHCbyhi
ghestcir
clesi
n
pol
iti
calsyst
em woul d be helpfulto sust
ain PHC i
mpl
ementat
ion.E.g.

9
 stat
ement sbyH. Et hePr esident,Pri
meMi nister,Mini
ster.
 Throughi ndividualconvi cti
onbypol it
ical
leader sby:
- Mobi li
si ngthecommuni tyaboutPHC
- Sol icit
ingr esour ceinternall
yorexternall
y
- Act ive i nvolvement i n act ual i mpl ementati
on of speci f
ic PHC
activit
ies/progr ammes.
 Adequatebudget aryal locati
onsf orPHC.
 Developingl egall
ybackedpol i
ciesofPHC, i.
e.Nat i
onalHeal t
hPolicyf
orPHC.
 Re-ori
entingheal thser vicestoPHC.
 Apol i
cyadvocat i
ngf ordevelopingPHCi nheal th-
rel
atedmi nist
ri
es
 Launchingofspeci ficPHCact ivi
ti
es
 Setti
ngasi deadayt oobser vePHC.

NB:Therecognisati
onandsuppor
tofPHCasavehi
clet
oachi
eveHeal
th
ForALLbypoli
ti
ciansisofut
mosti
mport
ance.

 Communi
typar
ti
cipat
ion

Thisrefer
st o“act
iveinvol
vementofmember softhecommuni tyint hepr obl
em
i
denti
ficat
ionandprior
it
isat
ion,planni
ng,impl
ementat
ion,moni
tor
ing,evaluat
ionand
deci
sionmakingonmat t
ersrelat
edt oPri
maryHeal
thCare.

Communitypart
ici
pat
ionmeanstotali
nvol
vementofcommunit
iesindeci
sionabout
thei
rownhealt
handdevelopment
.Theemphasisisnotwit
hindivi
dual
sbutwit
ht he
wholecommunity.

Forcommunit
yparti
cipat
iont
obesust
ainabl
e,i
tshoul
dst
artwi
tht
hei
ndi
vidual
,then
fami
lyandf
inal
lyt
hecommuni ty.

Sincet heAlmaAt adecl

arat
iononPrimar
yHealt
hCare,communit
ypar
ti
cipat
ionwas
recognisedasani mpor
tantpil
lari
nimprovi
ngheal
th,par
ti
cul
arl
yamongpoorand
under-servespopul
ati
on.

I
mpor
tanceofcommuni typart
icipati
on
 Asenseofowner shi
p
 Self
-reli
ance
 Acqui si
ti
onofskil
lsandabi li
ti
estosust
aint
heprimaryheal
thcarepr
ocess
 Effi
ciencyandeffecti
venessi npri
maryheal
thcarei
mplementat
ion
 Equitabledi
str
ibuti
onofr esourcesamongother
s.

Level
sofcommuni
typar
ti
cipat
ion

Fourlevel
sofcommunit
ypart
ici
pat
ionhavebeenidenti
fi
ed
a)Par
( t
ici
pat
ioni
nuseofservi
cesprovi
ded:t hi
srefer
stoact
ivemobi
li
sat
ionof
communiti
est
outi
li
set
heservi
cesprovi
dede.g.communi
cat
ionpr
ogrammes.

10
 b)Par
( t
ici
pati
oninpr
e-pl
annedprogr
ammes:thi
siswher
ecommuni ti
esarei
nvi
ted
totake parti
nimplementat
ion ofa pr
ogramme,alt
hough t
he progr
amme
cont
enthasbeendevelopedoutsidet
hecommunitye.g.pr
otecti
onofwater
sour
ces.

c)Communi
( t
yinvol
vementbasedonl ocalneedsassessmentanddeci si
onoft he
communi t
y:here,communiti
esareassi st
edt odevel
opsignif
icantskil
ls,ent
er
i
ntoanalysi
s,i
denti
fytheprobl
ems,pr i
orit
iesanddevelopappropri
ate plansof
acti
one.g.HIV/AIDS pr
eventi
onpr ogrammes,communi t
ybasedheal thcare
programme.

d)Communi
( tyempowerment
: her
ethecommuni
tybecomesawar
eenought
o
event
ual
lyassumef
ull
.

Howcommuni typart
ici
pationi sexpr essed
 Responset ocommuni tymobi l
isat i
on
 Drawi ngupofj oi
ntpl ans
 Definiti
ondiff
erentrolesamongcommuni tyleadersi
nthecommunit
y.
 Involvementindevel opment alpr oject
si.e.provi
sionofl
abour
 Providingresourcesandmat eri
alsf orvariouscommunitydevel
opmentpr
oject
s.
 Solicit
ingofexternalsupport( bot htechnicalandmateri
al)
 Mul
ti
sect
oralcol
labor
ati
on

Thisi sdef i
nedas“ deli
ber
ateactionsaimedatencour agingli
nkagewi thotherhealth
rel
ated sect orst oi ncor
porate healt
h goalsi ntot hei
r str
ategies,polici
es and
programmesi nordertoachieveHealthForAll(HFA).
Bythenat ureofel
ement sofPHCsuchasFoodsuppl yandnutri
ti
on, Watersupply,et
c,
multisectoralapproachistheref
oremandat ory.Itpr
omot escontinuit
yandsui tabi
li
ty
ofheal t
hser vi
ces.

I
mpor
tanceofmul
ti
sect
oralcol
labor
ati
on

PHCcal l
sf oral lrelevantsector sbothgover nmentandNGO,consi deri
ngi tsnatur e.
Thi
sthereforemeanst hatMul t
isectoralColl
abor ationi smandat or y.
 Themaj orhealthproblemsandt hei
rsol uti
onsmaybef oundwhol l
yorpar tially
outsidet heheal th sector. Heal thisendanger ed athome,i n schoolsand
factoriesi nmanyways.Theknowl edge,ski l
ls,compet enceandmeansl i
ei n
othersoci al andeconomi csect orsforPHCt opr oduceani mpact .
 Heal t
hsyst em needsr esour cesf orit
soper at
ionandt heser esourcesar enot
onlyf oundi nt heHeal t
hsect or.Ther efore,amul ti
sector alappr oachof f
erst he
bestmeans ofpr omot i
ng bet terand ef fective util
isat i
on oft he availabl e
resour ces,whi ch aref ound i n other r elevantmi ni stries and NGOs f or
achievementofmaxi mum i mpactont hest ateofcompl et ewel l-bei
ng.
 Heal t
hi snotamonopol yoft heheal t
hsect orbutar esponsi bili
tyofever yone,
i
ndividual lyandcol l
ecti
vel y.
 Ther eisani nseparablelinkbet weenheal th,devel opmentandsoci al
-economi c

11
 developmentandbynat ure;ahumanbei ngdoesnotl i
veinisolati
on.He/sheis
i
nfluencedmai nl
ybyher editaryandenvi r
onmentalf actor
sandt hesear
eknown
ast hedeter
mi nantsofheal t
h( factor
st hatinf
luenceheal th)whi charethen
di
videdintofourmaj orgroups.
- Behaviour(indivi
dual,family,communi t
y).
- Physicalenvironment
- Demogr aphicchar acteri
sti
csofacommuni t
y(heredi
taryorcongenit
al).
- Socialservi
ces( healthandeducat i
on).

NB: Al
ltheabovemaj
ordet
ermi
nant
sofheal
th(
fact
orst
hati
nfl
uenceheal
th)ar
e
i
nter
-r
elat
ed
 Appr
opr
iat
etechnol
ogy

Thi
sref
erst
omet
hodsandmat
eri
alst
hatcanbeusedt
obenef
itt
hecommuni
ty.

Condi
ti
onsthesemet hodsandmat eri
alsshoul
dmeet
 Locallyandeasi l
yavailabl
e.
 Af f
ordable.
 Ofaccept ablequal i
tyt
othecommuni t
y.
 Easyt omai ntai
n.
 Easyt olearn.
 Shoul dnotconf l
ictwit
hpeople’
scult
ureandnor
ms
 Suitabil
it
y.
I
mportanceofAppr opriateTechnol
ogy
 Forcostef fecti
veness
 Costconsci ousness
 Forbet t
ersuitabili
ty
 Meet stheneedsoft hepoor.

HowAppropr i
at eTechnol ogyisexpr essed
 Util
isation ofl ocally avai
labler esources e.g.homemade f l
uids to manage
dehydr ationduet odi ar
rhoea.
 Impr oving ofl ocalcapaci tyi .
e.communi tyresour
ce persons (e.g.drug
dist
r i
but ors,t
radit
ionalboneset ters)
.
 Impr ovedl ocaltechnologye.g.mudst oves.
 Impr ovedcommuni tyawar enessaboutheal t
handdevel opment,i
.e.tr
adit
ional
communi cati
onmet hodse.g.roleplays,drama,stor
ies,
etc.

 Ot
herpi
ll
ars(
pre-
requi
sit
es)t
hathavebeenaddedar
e:

 Equi
ty

Thi
smeansavail
ingequaloppor
tuni
ti
es(orfai
rness)
.Ever
yonehasbeengi
vent
he
oppor
tuni
tyt
ohaveaccesst
obasicheal
thcar
e.

12
  Decent
ral
isat
ion
Thi
si saf orm of gover
nance Uganda has adopted. Planni
ng,or
gani
sat
ion,
i
mplement
ati
on,moni
tori
ngandeval
uati
onaredoneatlowerl
evel.

Itt
heref
oreenablesdecisi
onmakingandallocati
onofresour
cestobedoneatt he
l
owerlevels(di
str
ictandsubcount
y)andnotatthecent
re.Thi
sisdoneaccor
dingto
pri
ori
tyneeds/pr
oblems.

COMMUNI
TYBASEDHEALTHCARE(
CBHC)

1.
0 I
ntr
oduct
ion:
Communit
ybasedheal
thcar
e(CBHC)i
sapar
tofpr
imar
yheal
thcar
e(PHC)
.BCHCi
s
the“
peopl
epar
t”ofPHC.

Themai nworki nPHC act i

viti
esi sconcer nedwithbr i
ngingservi
cesclosert
othe
peopl
e.Themai nPHCact ivit
iesincludes:
- healtheducat ion
- Ugandanat i
onalexpandedpr ogrammeoni mmunizat
ion(UNEPI)
- Essent i
aldrugssuppl ytoallhealthunit
s
- Cont r
olofdi arrhoealdiseases
- Fami lyplanningser vicesinruralareas
- TB/ Leprosycont r
olprogrammes
- MCH/ Antenat alcli
nicsathealthunits
- Wat erandsani tati
onpr ogrammesi nruralandurbanpeercommuniti
es,
etc.

2.
0NEEDFORCBHCANDPHC

13
Theneedf
orPHCandCBHCar
isesf
rom t
hef
oll
owi
ng:

(a)Mosti l
lnesscanbepr event
ed;themostcommoni l
lnessesar epreventabl
eor
contr
oll
able,ei
therbythepeoplethemsel
vesoracombi nedef for
tbetweent hepeople
andgovernmentorot herpart
ner(
NGO)servicese.g.mal
ari
adi ahohoea/
gestroenti
ri
ti
s,
respi
rat
orytracti
nfecti
ons,measl
esandinjuri
es.

(
b)Highmor bidi
tyandmor tali
tyrat
es;areducti
onint hi
ssufferi
ngcanonlyhappenif
t
hereismor e“ encour
agement ”and“ enablement”ofi ndi
vidualsandcommuni ti
es
t
ogethertohavea“posi t
iveatti
tude“towards“preventi
vehabi t
s”andtobewill
ingto
t
akepar ti
nimpr ovi
ngtheirlocalamenit
ies,whichalsowi l
lhelppreventandcontr
ol
i
ll
nesses.

Thisencouragi
ngandenablingcannotgoonwi thinthewallsofthehospit
alsand
healt
hcentr
es.Itmustgooninthevil
lagesandhomes.I notherwords,
theheal
thand
devel
opmentwor khastogot othepeople,rat
herthanexpecti
ngthepeopl
et ogoto
theheal
thservi
cesanddevel
opmentprojects.

(c)Cover
ageofhealthservi
ces;eveniftherewasfullser
vicei
nt heheal
thunit
s,t
here
aresti
llfew (
e.gdentalandor alser
vices,mentalhealt
hservices)andtheymai nl
y
l
ocatedinthetownsandtheruralpopul
ationhaveli
tt
leaccesstoessenti
alheal
thcare.

Impor tant
ly,someofthehealt
hunit
saresti
llt
oof arawayformanyparent
stotake
theirchi l
dren f
orprevent
ivecar
eservi
ces,pregnantmother
sto accessthecare
servicestheyneed.

3.
0 Obj
ect
ivesofCBHC
Themai nobj ecti
vei nCBHC i stoencour ageandenabl ecommunit
ytotakecare
(r
esponsibi
lit
y)f oritsownheal t
handwel f
are,i
fthecommunitycan:
- Identifyitsownheal thprobl
ems
- Findsol utionsf orthoseproblems.
- Makei tsowndeci sions
- Find( i
dent if
y)resour cesout
sidethecommuni t
y.
- Evaluat eitsactionsandr epl
an.
- Toget herandi ndivi
duallymakehealthybehaviour
sint
ocommonpract
icesand
habits.

Ther
efor
et he main partICBHC wor ki sto encour
age and enabl
et he peopl
e
communitytodevel
opthatsenseofr
esponsi
bil
i
tyandtochangethei
rbehaviour
.

Thet
wot
hemesi
nCBHCar
etoencour
ageandenabl
e.

Toencour
agei
ncl
udeshel
pingpeopl
eunder
stand:

- Whatishealth?
- Thevalueofprevent
ion
- Themai ncauseofil
lnesses.

14
 - Whatani ndi
vidualcandot opreventil
lnesses.
- Whatt hecommuni tycandotopr eventil
lnesses
- Whatt hepeopl ecandot oget
her
- Howt heycanwor ktogether
- Discussingthei ndivi
dual’
sandcommuni ty’
sprobl
emsast heyseet
hem and
not
- Discussingproblemsasseenbyt heHeal thcareser
vicepr
ovi
der
s.

Toenabl
eincl
udes:
-

- Givi
ngt hecommuni t
yskill
sandknowl edgetotakecar eoft
heirheal
thand
welfare.
- Trai
ningcommuni tyhealt
hwor kers(CHWs)
- Trai
ninghealthcommi t
tees.
- Connect i
ngthecommuni tywit
hr esour
cesfrom outsi
de.
- Asadvi sorsinCBHC,hel ptheCHWsandHeal t
hcommi tteeovercome
problems
- As advi sorin CBHC make f r
equentf ol
low-
up suppor tvisi
tstot he
communi t
y.

4.
0Di
ff
erencebet
weenPHCandCBHC

PHCact i
vit
iesaremainlyconcernedwithtakingser vicesclosertot
her uralandurban
poorcommuni t
ies.PHC acti
vit
iesareor ganizedf rom out si
de,mainlybypl anners.
Theseacti
viti
eshavelit
tl
echancet owor katthespeed, andbef l
exi
bleandr esponsive
totheneedoft hecommuni t
y.Thepeopl earenoti nvol vedintheorganizat
ionofPHC
acti
vit
iesand decisi
ons.Also theact i
vit
iesi n PHC pr ogrammesdo nothavet he
fl
exibi
li
tytofiti
ntothespecif
icneedsandspeedofanyonecommuni ty.Asar esult
,
theydonotmakebestuseoft heser vi
cesof f
ered.

ThesePHCef fort
shavenotyetbeenabletoincludeal otofcommunit
yorgani
zat
ion
work(t
oencour ageandtoenabl
e)toconcent
rateont hechangeofat
ti
tudeandhabit
s
oftheindivi
duals,whi
chist hebasi
st opreventionandcont r
olofmostcommon
i
ll
nesses.

CBHCwor ksveryclosel
ywi t
hspecif
iccommuni
ti
esinsuchawayt hattheygainthe
knowledgeanddevel opski
ll
st obeabl
etoor
gani
setheirownprevent
ati
veandcont r
ol
acti
vit
ies.Itcent
resonpeopleinthecommuni
tyandlessonthehealt
hservicesi
nputs.
Ult
imat el
y,t
hecommuni tycanbeableto:
-

1.Carr
youti t
sheal t
hwor k;
2.Cal
lonheal t
hser vi
cest hati
twil
lneedand;
3.Bewant i
ngtomaket hebestuseoft hehealt
hservicesavai
labl
e.
NOTE:-
Thefir
sthealthservices(essent i
alheal
thcare)avail
abletothepeople(i
.e.PHC),ar
e
ver
yimportanttoassi sti
ndivi dual
swi t
hthepr obl
emst heycannotsolvealoneordo
nothavet
her esourcestoobt ain,suchasvaccines.

15
Atthesamet
ime,t
hePHCservi
cesneedthepeopl
e( t
hepeoplepar
tofPHC,whichi
s
now CBHC)t
obef ul
lyawar
eofhow besttouset heservi
cessot hatt
heycanbe
eff
ecti
ve.

Inthisways,PHCser vicesandCBHDhelptosuppor
teachother
.Si
mplyput,PHC
dealswiththephysicalservi
ceswhi
leCBHCdeal
swiththepeopl
esothatt
heycan
makeuseoft heservi
ces.
Dif
ferencesbet
weenPHCandCBHC

- PHC - CBHC
- Originatedandi mpl ementedby - Ori
ginat
edbycommuni
ty
heal t
hwor ker
- Topdown - Bottom up
- For eigntocultureandpr acti
cesof - Relevanttocommuni t
iescult
ure;
communi ti
es;hencemaynotcar e henceallacti
vit
iesinit
iatedhave
whatt hecult
uresaysandt herei
s cul
turalconsi
der at
ions
oftenconf l
ict
- Isconcer nedwi t
hst r
uctur
al - Concer
nedwi
thchangei
npeopl
e
change.
- Ownedbysuppor tsystem and - Ownedbyt
hecommuni
ty
hencecommuni tydependencei s
high
- Isbr oaderandgl obalelementsand - Basedi
nthecommuni
ty
cont ent
- Isbasedonnat i
onalpr i
ori
ty - Isbasedont hepr iori
tyoft he
communi ty
- Vi
sionofPHCi
sext
ernal - Thevi sioni sinter
nalandmaybe
i
nf l
uenced
- Instit
ut ionalbased - Communi tybased
- Act i
vitiescont r
oll
edexternal
ly - Activit
iescont roll
edi nternall
y
- Isrigid, henceithasdefinedrol
es - Flexiblewi thunident i
fi
edr oles
- Isapr ogr amme - Isappr oach
- Iswel lest abli
shed - Isevol ving
- Wel lstaf f
ed - Issuppor ted
- Wor kingf orpeople - Wor kingwi thpeopl e
- Intersect i
onalcollabor
ati
ondiffi
cul
t - Involvest hecommuni tyand
toachi eve coll
abor at ioneasyt oachi eve.
- Lessopen - Mor eopen
- Needf orexper ts - Communi tyr esponsi bl
ef orown
planningdependi ngont heirneeds
andpr oblemsonl ycomei ntohelp.
- Communi
tyi
mposedpr
ogr
amme - Communi tyor iented( i
dent i
fythei
r
ownpr obl ems, planand
i
mpl ement .
- Moreexpensi
vet
oimplement - Cheapert oi mpl ement
- Caf
eter
ia(communi
ti
eswaitt
obe - Selfser vice( communi ties

16
 ser
ved par
ti
cipat
eandi
nvol
ved)

5.
0 HowdoPHCandCBHCwor
ktoget
her
?

Tost at
eitbett
er,noneofwhathasbeendiscussedabove(undert
hedi
ff
erence
betweenPHCandCBHC)shouldbeint
erpr
etedasbeingthatPHCorCBHCi
sbet t
er
thantheot
her
.

Theybothhavet
hei
rpl
aceini
mprovi
ngtheheal
thstatusofthepeople,whocoul
dst
il
l
beunderser
vedorwhoar
eoft
ensuff
eri
ngfr
om preventabl
ediseases.

Takeanexampl
e:-

Thefol
lowi
ngisthedr
op-
outr
atebyUNEPIf
orpol
ioandDPT(
dipht
her
ia,
tet
anusand
whoopi
ngcough)
.

Pol
io DPT
BUSHENYI 35% 47%

KABALE 34% 53%

KASESE 17% 23%

MBARARA 22% 43%

RUKUNGI
RI 32% 34%

Whyar etheresomanydr opoutsandcompl et

ethecour se?
Thereareverymanyr easons:-
- Mot hersdo notr eali
zethattheyhavet or eturn severalti
mest o complet
e
immuni zati
ons.
- Thecl i
niccomesonamar ketday.
- Themot herdoesnothavetimetotakethechil
d
- Thel astinj
ecti
onmadeanabscessandshedoeswantt hattohappenagain
Allt
hesearedescr i
bedbyt hepeopl
eas“Iwoul dhavecomet othecli
nic,
but………….?

TheCBHCsi deofthi
sdr op-outisworkclosel
ywi
ththewomenandt hecommunit
y
toget
hertoover
comethepr oblemsthatt
heyhave(i
.e.GetoverBUT…….)
,sot
heycan
complet
ethevacci
nat
ions.

ThePHCsidesoft
hisdropouti
sforUNEPItomai
ntai
nsupplyofvacci
nesandr
unt
he
cl
ini
cs,
incl
udi
ngoutr
eachandthether
efor
emaint
aint
heservi
ce

PHCdealswit
hthephysi
calser
viceswhi
leCBHCdeal
swi
tht
hepeopl
esot
hatt
hey
canmakeuseoft
heservi
ces.

17
 HEALTHANDDEVELOPMENT
I
ntr
oduct
ion
Whenpeopl ethinkaboutheal
th,theynormallyt
hinkaboutmedicalmat ter
ssuchas
disease,hospit
als,doct
ors,
nurses,medi
cinesanddrugs.Howeverhealt
hgoesbeyond
that.Healthisamor eofawellbeing,
thatis,
sati
sfi
ed,comfor
tabl
e,contended,
fit
,wel
l
fed,safeandbeinghappy.

Def
ini
ti
onofheal
th
Worl
dHealthOrganisat
ion(WHO)in1946gavethedefi
nit
ionofhealt
has“ astateof
compl
etephysi
cal,mentalandsoci
alwel
lbei
ngandnotmer el
yabsenceofdiseaseor
i
nfi
rmit
y”.

Thebr
oadconceptofheal
thr
efer
stoWELL-
BEI
NG.I
thasbot
hnegat
iveandposi
ti
ve
meani
ngs.

Negat
ivemeani
ng:denot
est
heabsenceofdi
seaseori
ll
ness.

Posi
ti
vemeani
ng:denot
est
hest
ateofwel
l-
bei
ng.

Thesi
xdi
mensi
onsofheal
th(
accor
dingt
oEwel
sandSi
mnet
t,1992)

Thedefini
ti
onofhealthby(WHO)hasbeenchal
lengedbysomeschol
ars,whoar gue
thatone,canneverhavecompl
etehealt
h.Thatastateofheal
thi
sneverstat
ic;the
trut
histhatl
if
eandli
vingar
enotstat
ic.

Thet woscholar
s,Ewel
sandSi mnett
;1992definedheal
thas“ havi
ngtheabil
it
yto
adaptconti
nuall
ytoconst
antl
ychangingdemandsexpectat
ionsandstimul
i”
. They
putforwar
dsixdimensi
onsofheal
thandthatt
hesesixdi
mensionsofheal
thi
nfl
uence
eachother
.

Physicalheal
th
Thisseemst obet hemostobvi
ousdi
mensi
on.I
tisconcer
nedwi
tht
hemechani
sti
c
funct
ioningofthebody.

Mentalheal
th
Iti
sconcernedwiththeabil
it
ytothi
nkclearl
yandcoher
ent
ly. I
not
herwor
dsi
t
concer
nstheabi
li
tyt
hinkandmakej
udgement.

Emot i
onalheal th
Referstother ecogni
ti
onofandappr opri
atedischar
geoffeel
ingst atese.
g.anger,fear,
j
oy,etc.Pr ecisel
y,i
tincl
udest heabil
it
ytor ecogni
seemotionse. g.fear,anger,joy,
gri
ef,etc.andt oexpressthem appropr
iat
ely.Copingwit
hstr ess,tensi
on,depression
andanxi et
yar ealsoi
nt hi
sdimension.

18
Socialheal
th
Thisistheabili
tyt
omakeandmai ntai
nfr
iendshipwithot
herpeopl
e.I
not
herwor
dsi
t
concernstheint
egrat
ionofsomebodyi
nsocialrel
ati
onshi
ps.

Spiri
tualheal
th
Istherecogni
ti
onandabi l
it
ytoputint
opr acti
cemoralorr
eli
giouspri
nci
pals/orbeliefs.
Forsomepeopl eiti
sconnectedwithrel
igiousbel
ief
sandpr acti
ces,
whil
ef orothersi t
i
sconnect edwi t
hper sonalcr
eeds,pri
nci pl
esofbehaviourandwaysofachi eving
peacewi t
hinonesel
f.

Societalheal
th
Explainsthelinkbet weenheal t
handt hewayasoci et
yisst ruct
ured,thatis,ones
heal
t hisrel
atedandaf fect
edbyt hesur
roundi
ng.Thesociet
alfact
orsinclude;hel
ter
,
peace,f ood,income,oppr ession,pol
iti
calconf
li
ct,povert
y and t he degree of
i
nteracti
onordi vi
sionwithi
nsociet y.

Thi
shealt
hcannotbeowned,butheal
thonl
ybeshared,t
hati
s,ther
eisnohealt
hf or
nomewi t
houtmybr ot
herorsi
ster
.Thereisnohealt
hforUgandawithoutRwanda,
Congo,
Bri
tai
n,SudanorAmeri
ca.

ENVIRONMENT
Referst
ot hesum t
otalofallthi
ngs,whichsur
roundus. Thecomponent softhe
envir
onmentincl
ude physi
cal
,biol
ogical
,chemi
cal,soci
al,cul
tur
al,economi
c and
poli
ti
cal
.

DISEASE, I
LLNESSANDI LLHEALTH
Thet ermsdi sease,
ill
nessandi l
lhealt
hareof t
enusedinter
changeably.Diseaseisthe
objectivestateofillhealth,whichcanbever i
fiedbyacceptablecanonsofpr oof.In
oursoci et
y,theseaccept ablecanonsoft r
utharecouchedint helanguageofScient
ifi
c
Medi cine. Forexampl e,mi croscopi
canal ysi
smayyi el
devi denceofchangei ncel l
st
ruct ure,
whi chinturnleadt odiagnosi
sofcancerordisease.

Disease:istheexi
stenceofsomepat
hol
ogi
calorabnor
mal
it
yoft
hebody,whi
chi
s
capableofdet
ect
ion.

Il
lness: ist hesubj ect
iveexperienceofl ossofheal tht hisiscouchedi nt ermsof
sympt oms.Forexampl e,repor
ti
ngofachesorpai ns,orlossoff uncti
ons.
Il
lnessanddi seasear enott hesame,al t
hought heredegr eeofco- exi
stence. For
exampl e,someonemaybedi agnosedashavi ngcancert hroughscreeningevenwhen
therehavebeennosympt oms.Thati s,someonewhomaybedi agnosedashavi nga
diseasealthought heyhavenotr eport
edanyi l
lness.

Il
lhealth:whensomeoner eport
ssymptomsandf urt
heri
nvesti
gat
ionsuchasbl ood
t
estsprovediseaseprocess,thetwoconcept
s,di
seaseandil
lnesscoi
ncide.Inthese
i
nstances,t
het er
mi l
lhealt
hisused.I l
lheal
thisther
efor
eanumbr el
laterm usedto
r
efertotheexperi
enceofdiseaseplusi
ll
ness.

19
Somepeople,suchasdoct
orsandnursesacquir
easpeci al
isedvi
ewofheal
th.Thi
s
speci
ali
sedvi
ewi sgai
nedt
hrought
hei
rprof
essionalt
rai
ning.

Duri
ngpr ofessi
onalt
rai
ninghealthworkersareint
roducedtothei
rfi
eldofknowledge
andtheyspendmucht imewi t
hot herstudent
sandpr act
it
ioner
s.Theylearntouse
prof
essionaljar
gonandadoptt hemeaningsofandvaluesystemsofthei
rpeers.This
i
scalledsecondarysoci
ali
sat
ion.
Commondi seasesandcondi
tionsinourcommuni ti
es

Di
seases Condi
ti
ons
 Mal aria  Pover ty(bothinandr ur
aland
 Wor mi nfestat
ions ur
banar eas)
 Scabi es  Mal nutriti
on
 ARI( pneumoni a,pneumoni
a) - Kwashi orkor
 HIV/ AI DSandSTI s - Mar asmus
 Measl es - Nut r
it
ionalanaemi a
 Chol era - Obesi tyorover ei
ght
 Typhoi d (especial
lyamongt he
affl
uentsoci et
yinurban
 Dysent ery
areas)
 Skini nf ect
ions(ri
ngworms)
 Acci dent,burnsf r
om domestic
 Eyei nf ecti
ons( t
rachoma)
vi
olence

 Al
coholi
sm
 Dr
ugabuse(e.
g.mar
ij
uana,
marungi
)

Epi
demiol
ogy:r ef
erst
othestudyofdi
seases,di
seasepat
ter
nsandpat
ter
nandt
he
ef
fect
sofdiseasesont
heheal
thcommunit
y.

Communi
cabl
edi
sease:di
seaset
hatcanbet
ransmi
tt
edf
rom oneper
sont
oanot
her
.

Epi
demicdi
sease:ref
erstodi
seaset
hatoccur
sunexpect
edl
yandmaygi
ver
iset
o
manynewcasesinashor
tti
me.

Endemi
cdi
sease:
diseaset
hati
spr
esental
lthet
imei
nacommuni
ty.

Sporadicdisease:di
seaset
hatoccur
sonl
yoccasi
onal
lyi
nacommuni
tyandwi
thout
aregularpatt
ern

DEVELOPMENT
Ther
ecanbel it
tl
edevel
opmentwi thoutheal
thypeopl
e. I
ncreasedf
oodpr
oduct
ion
andi
ncreasei
nincomeareessent
ialfori
mprovementsi
nhealt
h.

Educati
on: thi
sist
he f
ir
str
equi
rementand i
sindeed a ver
yfi
rsti
mpor
tant
requi
rement
.

20
Theref
oregoodheal thisapr e-requisi
tei
nanydevel opmentpr
ocess;athome,i nthe
community, nat
ionandinter
nat i
onally.Membersofauni thome,communi t
yornat i
on
cannotwor khardforpoli
ti
cal
, socialandeconomicaldevel
opmentift
heydonotenj oy
goodhealth.Theycannotbepr oduct i
ve(
theycannotengageingainfuloccupat
ions).
Lackofproductivi
tybri
ngsaboutl ackofincome.

Pover
ty:Pover
tybr
ingsabouti
gnor
anceanddi
sease;t
her
efor
epoorheal
th.

DETERMI
NANTSOFHEALTH

Themai
nDet
ermi
nant
sofHeal
thar
e:

(
a) Behavioural(I
ndi vidual
,fami
ly,communi
ty)
.
(
b) Demogr aphicf actors(popul
ati
on/her
edi
ty)
(
c) Envi
ronmentf actors
(
d) Healt
hSer vices.

The above f
ourgroups ar
ei nt
er-
related.The under
standing ofli
nkages and
i
nter
acti
onsguidet
heselect
ionofanintervent
iont
obedepl oyedfort
heattai
nment
ofHealt
hthr
oughP.H.C.

Behavi
our

Changesi nbehaviourhavesigni
fi
canteff
ectont hehealthstatus.Studieshaveshown
thatthereisi
nter-
relati
onshi
pbetweenproblem behaviourssuchassmoki ng,dr
inki
ng,
andear l
ysexualact ivi
ti
esandthehealt
hoft heindivi
dualandt hecommuni t
y.Health
promot i
ngbehaviour ssuchasr egularphysicalacti
vity,balanceddi et
,anduseof
personalhygienehavebeenf oundtohavecommendabl eeffectsont hehealt
hofthe
i
ndividual.

Themaj orhealthbehavi
oursare:Spor
tsandr
ecr
eati
on,enoughsl
eep,rel
axat
ion,sex
andreproductivepracti
ces,r
eadingandmediacont
act,typeanddurati
onofwor k,
tr
avelandtransport
ati
on.

Adol escentsandyoungadul t
sar emor el
ikelytomovet our banareasthant hechil
dren
andagedwi thavi ew oftaki
ngadvant ageofaper cei
vedbet tereconomicandsoci al
environment .Thi sfact
orcoupledwiththespi r
itofadventurehasmadet headolescent
mor evul nerable.Accidentsandvi ol
ence,delinquencyandpsychi cproblem,alcohol,
tobaccoanddr ugabuse,prostit
uti
on,sexualpr omiscuitywithconsequentsexual ly
transmi t
teddi seasesandunwant edadol escentpregnancies,HIVinfecti
onsandAI DS
havebecomemaj orhealt
hproblemsf orouryouth.

Demogr
aphi
cfact
ors(
popul
ati
on/
her
edi
tar
y/congeni
tal
)

21
Thepopul ati
onoft hewor ldiscurr
entl
yest imatedat5. 3bill
ion.Itisexpectedtogrow
byoneBi ll
ionovert henextdecade.Ot herdemogr aphictrendsobser vedindevelopi
ng
count r
iesi ncl
ude:-agei ngandi ncreasingur banisat
ion.Ther esult
anteffectofthi
s
rapidur banisat
ionwi l
lwor sentheproblemsofal readyover str
ainingsocialandhealt
h
services.Thedi seases/problemsoftheel der
lyarenotyetf elti
nUganda.

Popul ationgr owt hisaf unctionoft henumberofbi rthsanddeat hs;therefor

et he
markedi ncreasei nthepopul ationgr owt hi nt hedevel opi
ngwor ldreflect
sahi gh
fer
ti
lityr ateamongt hef emal epopul ationoft hi sregion.
Thisasar esultaf f
ectst heal r
eadypoorsoci o-economi cconditionsoft hedeveloping
count ri
es,t hust hedet eriorat
ingheal t
hst atusoft hesecount r
iesf orexampl eAf ri
ca
whichaccount sf or10% oft hewor ldt otalpopul ation,contri
but es30% oft heover
500,000Mat ernaldeathst hatoccurannual ly.
Similarly,childrenbelow15year sconst it
ute50%oft hepopul at
ioni nthesedeveloping
count ri
es.Thi sisadependantpopul ationwhi chrequi r
es:education,healt
hcar e,f
ood,
water,housi ng,sportsandr ecr eati
onalf acili
ties,thusf urt
hercompl icati
nganal ready
desper atesoci o-economi csi t
uat i
on.

Somedi seases/condi
ti
onshaveheredi
tar
y/congeni
talbearing.Thesear
eintri
nsi
c
healt
hdeterminantswhichar
edi
ff
icul
ttocontroli
nani ndi
vidual
/communi
tysuchas
Sickl
ecell
,epi
lepsy,di
abet
es.

Envi
ronment

Thi
sconsistsofalltheexternalinfl
uencest hataffecttheindivi
dualf rom concept
ionto
bi
rt
h.I
tincludes:atmospher e,soil
,water,shelter
,food,vectors,parasites,
etc.
 Wat erborneandf oodbor nediseasese. g.Diar
rhoea, Dysentry,Cholera,
Typhoid.
 Airbor nediseasese. g.T.B.
,Measles.
 Vect or bor ne di seases e. g. Mal ari
a, Tr ypanasomi asis, Onchocercias,
Leshmani asis,Fil
i
ar osis.
 Environment alcontactdiseasese.g.scabi es,r
ingwar ms, l
ice.

Theenvironmentofani ndivi
dualisdet er
mi nedbytheSocio-economi cchar acteri
sti
cs
ofthepopulati
ontowhi chhe/ shebel ongs.Thishasaper vasiveinfluenceonheal th.
Thei mprovementinheal thcondi t
ionsi nWest ernEuropeandNor thAmer i
cawas
broughtaboutbyther i
singli
vingst andardsandi mprovedsocio-economi cconditi
ons
forexample:-
Thei nci
denceofi nfecti
ousdi seasesf ellinthesecountrieslong bef oreef f
ecti
ve
methodsoft r
eatmentwer eavail
ablee.g.Trachoma, YawsandTuber culosis.

Heal
thSer
vices

TheHeal
thServicesinor
dert
obeef
fect
ivemustf
ulf
ilt
hef
oll
owi
ngcondi
ti
ons:
a.Availabi
lit
y
b.Accessibili
ty
c.Ut i
li
zati
on.

22
Avail
abil
it
y–i ntermsofHeal t
hResour ces(Faci
li
ti
esandpersonnel)
.InDevelopi
ng
countr
iesHealt
hSer vi
cesavail
abili
tyislowinr ur
alareasascomparedtoUrban.This
unfor
tunatel
yincludes human r esources.Heavy emphasisis placed t
o curat
ive
servi
cesasopposedt oprevent
ivemeasur es.

Accessibil
it
yshoul dbe:
Physical
ly–wi thineasy-walkingorcheaptr
ansportat
ion.
Economi c-abili
tyoftheindi
vi dualt
ocovercostofcare.
Cult
ural-acceptabili
tyoftheser vi
cestot
hoseforwhom t heyareprovi
ded.
Accessibil
it
yr educesasdi st ancefrom t
heHeal t
hUni tincreases.Thesituat
ionin
devel
opingcount riesinaggr avatedbypoorroadnetworkandt r
ansport
ati
onsystem,
moresoi nruralareas.

Util
izati
on:Uti
li
zationofservi
cei
sexpressedastheproport
ionofpeopl ei
nneedofa
servicewhoact uallyr
eceivei
tinagivenperi
od.Ithasadi rectrel
ati
onshipwit
hthe
typeofhealthunit,qual
it
yandquant
ityofhealt
hpersonnelandt ypeofservi
cestobe
provided.

Devel
opment
Manyschol
arshavewr
it
tenondevel
opment.
Dr
.RoyShaffer&Mwal
imulJul
iusNyer
erehavecont
ri
but
edt
hef
oll
owi
ng:

“Achievi
ng Balance Development:The essence ofdevelopmentist he
Developmentofpeopl ewit
hachangeont hei
rhabit
s. Justchangingthi
ngs
withoutaconcurrentchangeofat
ti
tudesi
snotaheal t
hydevelopment.

“Developmenti
sachangingprocessofknowledge,al
ti
tudesandpr act
ices”
.
Ifthi
ngsdonothel pchangepeople’
sindivi
dualknowl edge,at
ti
tudesand
pract
ices,t
henthoset
hingsar
enotreal
lydevelopment”
.

“Peoplecannotbedeveloped:Theycanonl ydevelopthemsel
ves.
Foritispossibl
eforanout sidertobuil
damanahouse,butt hatoutsi
der
cannotgivethemanprideandsel f-
conf
idenceinhimselfbywalki
nghisown
knowledgeandbyhispar ti
cipati
onasanequali nt heli
feoft
hecommuni ty
helivesin. Theyarenotbei ngsiftheyareher dedlikeani
malsint
onew
ventures.

Devel
opmentofthepeopl
ecan inf actonl
ybeef
fect
ed byt
hepeopl
e
t
hemselves”
.(Mwal
imuJul
iusNyer
ere)

Indi
cat
or sofDevelopment
 Goodli
vingstandards:
(a)Housi ng
(ii
)Food
(ii
i)Employment

23
  Goodi ncome
 Goodgover nance
 Pol i
ticalstabil
it
y
 Literacyr ate
 Goodenvi r
onment alconser
vati
on/management
 Adequat eindustri
alandtechnologi
calrevol
ution
Devel
opmentshoul dtherefor
e,beseenasadynami cpr ocess,ent
ail
ingachangeof
knowledge,al t
it
udes and pr acti
ces conducive to development.This development
shoul
dbeonet hatt hecommuni tycansustain. “Under -Devel
opmentiscr eatednot
i
nborn”.

TenGuidel
inesf orBui l
dingaJustSoci ety
1.Redi str
ibutegoods.
Ensurebasi cneedsar emetf i
rstwit
hpr i
orit
yt othepoor.
2.Redi str
ibutepower .
3.Changet hest ructuresnotj usttheruler
s.
4.Bui l
dst r
uct uresf orparti
cipati
on.Makepar t
icipat
ionyourcul
tur
e.
5.donotconf usegr eatleaderswi thst
ructure:
??Dot hei mpr ovement scont i
nueaf t
ershe/ hehasleft
??
6.Changei nst ructuresandat tit
udesar ebothneeded.
7.Mot ivati
onofenvy, gr
eedandhat ei
sself-
def eati
ng.
8.Donotsacr if
icethepr esentgener at
ionforthef utur
eone.
9.Meansaf fectt heend.
10.Soli
vet hef utureyouhopef ornew.Thef utureisasetofembodiedval
ues.

SUMMARY:

Wecannotbegi ntoaddr esst heissuesr el

atedtothehealt
hofourpeopleunlesswe
understandandappr eciat ethesoci o-
economi candpopulati
ondynamicsofheal t
h.
Ourappr oacht ot hesol uti
onoft hehealt hprobl
emsofourcommuni ti
esshould,
theref
ore,bemul t
isectoral.Heal t
hisatt heheartofacomplexsetofi
nter
rel
ati
onshi
ps.
Theent i
rediseasepat terni napar t
icul
arar eaisult
imat
elyrel
atedt
osocialeconomic
standards,f
erti
li
tyandcul tur
alhabits.

Lowerwagesandpur chasingpoweramongthepoorandmiddl
ecl
asstr
anslat
eint
o
reducedhealthcar
eexpendi t
ure.Thecutbacksi
ngover
nmentbudgetresul
tint
o
reducedser
vicesi
nsocialsect
ors.

REFERENCE

Ewl
es&Si
mnet
t:Pr
omot
ingHeal
th,
aPr
act
icalGui
de;Al
denPr
esssOxf
ord.

R.
S.Downi
eetal
:Heal
thPr
omot
ion,
Model
sandval
ues;Oxf
ordMedi
calPubl
icat
ions.

24
Macdonal
dJ.
J:Pr
imar
yHeal
thCar
e;Ear
thscan.

STRATEGI
ESFORI
MPLEMENTATI
ONOFPRI
MARYHEALTHCARE

I
ntr
oduct
ion

Theterm st
rat
egyr ef
erstoanar tofplanninganddi r
ect
inganoper at
ionincampaign
Orplanni
ngormanagi nganaf f
airwellOrpl anorpolicydesignedf orapart
icul
ar
pur
pose.I nthecaseofPHCt heparti
cularpurposeistheachi
evementofhealthby
ALLinthewor l
d. Iti sther
eforeacampai gnai medatimprovingthehealt
hoft he
communitythrougheffect
iveandeffi
cientheal
thservi
cesdel
iver
y.

Pr
imar
yHeal
thCar
est
rat
egi
es

Thefoll
owingar
esomeoft
hest
rat
egi
esai
medatef
fect
ivei
mpl
ement
ati
onofPHC
act
ivi
ti
es:

 Pri
orit
isat
ion– muchast heremaybesomanyhealt
hpr obl
ems,heal
thcare
ser
vicesshouldbepri
ori
ti
sedsucht
hatheal
thpr
obl
emsthataff
ectt
hemajori
ty
oft
hepeopl eareaddr
essedfi
rst
.

 EnsureAccessi
bil
it
y– thehealt
hcar eshouldbeaccessibl
etoall
,ifnott
he
majori
tyofthepeopleintermsofdi st
ance,avai
labi
li
tyandatt
it
udesofthe
ser
vicepr
ovider
s(heal
thcar
eprovider
s).

25
 Ensure aff
ordabi
li
ty ofhealt
h care servi
ces – t
he health care shoul
d be
provi
ded ata costindivi
duals,famil
ies,communit
ies and governmentcan
affor
dintermsoffi
nancial
resources,
time,manpowerorotherwise.

 Ensurecommuni typar ti
cipation–communi t
iesshouldbeact iveparti
cipants
i
nt hehealthservicedeliveryr atherthanjustbeingpassi vereci
pient
s. Thi s
wouldenablethem t oownt heser vicesandhencesust ainabi
li
tyoftheheal th
ser
vices. Communi t
ypar ti
cipationshoul dbeunder t
akenatal lstagest hat
i
nclude pl
anning,i mplement ati
on,moni tori
ng and evaluati
on oft he health
ser
vicedeliver
ysyst em. Mechani smsshoul dther
eforebeputi npl acef or
communi t
yparti
cipati
ont otaker oot.

 Ensuret heuseofSci ent

if
ical
lySoundandsoci allyacceptabl
emethodsand
approaches – the methods and appr
oaches empl oyed i
n PHC,should be
scient
if
icall
yprovenandshouldnotsharpl
ycont
r adictthepeopl
escul
tur
esand
thesociall
yacceptabl
ewaysoflif
einthecommuni ty.

 Ensureuseofappr
opriat
etechnol
ogy–thetechnol
ogyusedfort
hedel
iver
yof
theservi
cesshoul
dbeappr opr
iat
etothecommuni t
iesinter
msofoperat
ion,
aff
ordabi
li
tyoft
herepl
aceabl
epart
sandgeneralmai
ntenance.

 Promotionofi nt
ersector
alcoll
aborat
ion– servi
cesdeli
veryshouldbedone
thr
oughbui l
dingalli
anceswithothersect
ors(government,NGOs,etc.
). This
helpsinpull
ingresourcesandshar i
ngthescarceresourcestothebenefitof
servi
cedeli
verytothepeople.

 Promotionofsel
frel
iance–t heservi
cesdeli
veryshoul
dbedoneinawayt hat
buil
dsconfi
denceinthef ami
li
es,communiti
esandgovernmenttobecomeself
rel
iant
,whichinturnl eadstot hesustai
nabil
it
yoft heheal
thcaredel
ivery
system.

 Ensur
epol
it
icalcommi
tment

 Adoptdecent
ral
isat
ionsyst
em ofgover
nance

26
PLANNI
NG,
IMPLEMENTI
NG,
MONI
TORI
NG,
ANDEVALUATI
ON
I
NPHC

1.
0Int
roduct
ion
Manypr ogrammes( i
nter
vent
ionforhealt
hpr omoti
on)inthefieldhavefail
edt omeet
thei
rtargetsandgoal
sbecauseofpoororl ackofplanning,i
mpl ementi
ng,moni tor
ing
and evaluati
on.Thesuccessfulimplementati
on ofPHC mustensur et hatal lthe
acti
vit
iestobeundert
akenarewellpl
anned,implemented,monitoredandevaluated.

2.
0Lear
ningobj
ect
ives
Att
heendoft helectur
est
udent
sshoul
dbeabl
eto:
-
1. Def ine:
-
(a)Planning
(b)I
mpl ement i
ng
(c)Moni t
oring
(d)Evaluati
on
27
2.Expl
ainthei
mpor tanceofplanning,
moni t
ori
ngandeval uat
ioninPHC.
3.Expl
ainwhopl ans,i
mplement s,
monitorsandevaluatesandforwho.
4.Expl
ainthecharacter
ist
icsofagoodpl an.
5.Li
standdescribetheplanningsteps(pl
anningcycle)
6.Descr
ibethetoolsofmoni t
ori
ngandeval uati
on.
7.Descr
ibethetypesofevaluati
on.

PHCmustensur
ethatallt
heact
ivi
ti
est
obeunder
takenar
ewel
lpl
anned,
impl
ement
ed,
moni
tor
edandeval
uated.

3.
0Def
ini
ti
ons
Pl
anni
ng
 Asyst emati
cwayofmaki ngdecisionsandl ayingdownwhati soroughttobe
doneinaper i
odoft i
me.
 Iti
sacont i
nuouspr ocesswhi chinvolvesmaki ngchoi cesabouthow touse
avai
lableresourcesinor dert oachieveparticulartargetsandgoal satsome
ti
mei nthefutur
e.
 Asystemat i
cprocessofl ayingstrat
egiestoattainagoal/object
ive.
 Aprocessofdr awingstrategiestoattai
nanobj ecti
ve/goal.
 Asystemat i
cwayofdesi gningwhatyouwantt odo.

Impl
ementi
ng
Thi
sref
erstoput
ti
ngi
ntoact
iont
hepl
an.

Monitorng
i
Checkingofwhati
shappeni
ngdur
ingt
hepr
ocessofi
mpl
ement
ati
on.

Eval
uati
on
Assessi
ngpr
ogr
essofanact
ivi
tyagai
nstt
heobj
ect
ives.

4.
1Thei
mpor
tanceofpl
anni
ng
 Enablesassessr esour cesneeded
 Enables us t o ef fectivel
y ut i
li
se scarce resources (i
.e.avoi
d wastage of
resources)
 Enablespr ioriti
sat i
onofpr oblems.
 Avoidmaki ngmi stakes.
 Helpsini mpl ement ati
on.
 Avoiddupl icat i
on.
 Helptoseewher ewear egoingwr ong.(I
.e.corr
ectdir
ecti
on).
 Createsor der.
 Helpsinaccount abilit
y.
 Assistinrepor twr i
ting.
 Confidencebui lding.
 Educationalf ort hepl annerandt hepeopl einvol
ved.
 Enablet osol icitformor eresources.(i.
e.getsupportfrom donor
s,gover
nment,

28
 communit
y,et
c.)
 Enabl
ethei
denti
fi
cat
ionofal
ter
nat
ivest
rat
egi
esandmet
hods

4.
2Thei
mpor
tanceofmoni
tor
ing
 Avoiderrorsduringi mplementat
ion
 Helptoreadjustment sot i
me.
 Encouragespar t
ner s.
 Assisti
nt hereall
ocat i
onofresources.
 Usedascont i
nuousdat agatheri
ng.
 I
tisal i
nkt oevaluation.
 I
tiseducat i
onal.
 I
nvolvesspi r
itofresponsibil
it
y.

4.
3Thei
mpor
tanceofeval
uat
ion
 Helpstoexplaint heachievements(
successesi.
e.whathasbeenachi
eved)and
fai
l
ures.
 Toseewher est rengthsandweaknessesli
e.
 Helpwi t
hre-planning.(i
.e.t
ohelpmakebetterpl
ansfort
hefut
ure)
.
 Tocrit
iqueourwor k.
 Accountabil
ity
 Soli
cit
ingofr esources.
 Buil
dsconfidence
 Buil
dsmor aleofpar tner
s.

5.
0Whopl
ans,
moni
tor
s,eval
uat
esandf
orwho
Allt
hosewhoar ei nvol
vedi ntheact
ivi
ti
esoftheplanfrom nat
ionall
eveltot
he
communi tylevel
.
 Pol icymaker s
 Pr ojectmanager s
 Di stri
cthealthteam
 Heal t
hsubdi st
r i
ctmanagementcommi tt
ee
 Subcount y/commi t
tees
 Vi l
lageheal t
hcommi tteecommuni
tyhealt
hworkersandthecommunity.
6.
0Char
act
eri
sti
cofagoodpl
an
Agoodplanshoul
dst atethefol
lowingclearl
y:
1.Probl
em st
atement( whatisourproblem?).
2.Goal/
Aim
3.SMARTObj ect
ives–char acteri
sti
csare:
- S =Speci fi
c, t
othepoint
- M =Measur abl
e,fi
gures
- A =Achi evableorAppl i
cableorAccept
abl
eorUsef
ul
- R =Real ist
icorReliable
- T=Ti meBound/ Conscious(i.
e.iti
simpor
tantt
oat
tachort
agaper
iod)

Exampl
esofSMARTObj
ect
ives:
-

29
  Rai se t he l evelofawar eness f rom 20% t 0 50% aboutt he danger s of
int est inalwor msdur i
ngt henextt hr eeyear s.
 Kangul umaBzonei nNamut umbasubcount yi nNamut umbadi strictwi ll
havei ncreasedaccessi bil
it
yt osaf ewat erfrom 60%t o80%dur i
ngt henext
thr eeyear s.
4.Strategi es( howdoweachi eveourobj ect i
ves)
5.Activities/ t
act ics( whatwoul dweneedt odoi nor dertoachi eveourobj ect i
ves;
thesear et asks) .
6.Resour ces: -Issomet hingthatassi stsonet ounder takeandaccompl i
shagi ven
task/ act ivity.
Types of r esour ces i nclude:– Manpower ( Human) ,Mat erials( Logi stics,
Suppl ies) ,Money( Funds)andMoment( Time) . Theavai labi l
it
yoft he4Ms
(Manpower ,Mat erial
s, MoneyandMomenti sadet erminantinl ayingst rategies
forbot hquant i
tative( e.g.changei nt ermsofnumber s)andqual it
ative( e.g.in
termsofbehavi ourchange)i ndicat ors.
 Resour ces ar e t he cor nerst one i n t he i mplement ati
on of any
pr ogr amme/ project.
 I tisi mpor tantt oidentifyappr opr i
ater esourcesatdi f
fer entlevels.
 Resour cesar einadequat euni ver sall
y.
 Ther ei s need t oi dentify,acqui re/generat e and ut ili
se r esour ces
ef fectivel yandef fi
cientl
y.
7.Indictor s( whati sther etoshowwhathasbeenachi eved).
8.Timeschedul e( whent odot hevar iousact i
vit
iest oachi evet heset( ora
particul ar )obj ect i
ve.

7.
0Thepl
anni
ngst
eps

Pl
anni
ngcycl e
i
) Situationanal ysis:-asi texi stsorasi tisint hecommuni t
y.
i
i) Probl em i dent i
ficati
on:-t he heal th and heal thr elated pr oblem oft he
communi ty(est abli
shmentoft heheal t
hst atusoft hecommuni t
y).
i
ii
) Set tingpr iori
ties:pr i
or i
tizationoft heheal t
hpr obl em:-t herecoul dbemany
health pr oblems whi ch,r equires at t
ention ori ntervent ion. Whi ch one
requi r
esf ir
st,second, t
hirdet cat tentionori nt ervent ion.
i
v) Set tinggoal sandobj ectives:-Whatt obedonet oover comet hepr oblem.
v) Resour ceassessment :-I dent i
fi
cat ionoft her esour cesneeded( human,
funds, materialet c)
.
vi
) Set tingst rategiesandt ar gets:-ident i
fi
cationofst r
ategi esandmet hodsto
achieveobj ect i
ves.
vi
i) Desi gningpr ogr ammesandact ivit
ies:-i .
e.devel opmentoft hepl anfor
implement ation.
vi
ii
) Budget i
ng:-cost i
ng(howmuchi tcost sint ermsofmoney)
i
x) Desi gning:-devel opinganact i
onpl an( what ,wher e,when,howandwhoof
usi sr esponsi ble,resour cesandsour cesofr esour ces, indi
cat or
s.
x) I mpl ement ation-put tingi ntoact i
ont hepl an
xi
) Moni t
or i
ng:-( continuous)checki ng on whati s happeni ng dur i
ng the
processofanact i
vit
yagai nstt heobj ectives.

30
 xi
i) Evaluate.
xi
ii
) Re-plan.

THEPLANNINGCYCLE
(Pl
anni
ngst
eps)

Sit
uati
onanalysi
s
(Needsassessment
)

Re-
plan Pr
obl
em i
dent
if
icat
ion
andPri
ori
ti
sat
ion

Eval
uat
ion Set
ti
ngobj
ect
ives

Moni
tor
ing I
dent
if
yresour
ces
(
Resour
ceassessment
)

I
mpl ement
ati
on Set
ti
ngst
rat
egi
esandt
arget
s
Developst
rat
egi
es)

Desi
gninganimplement
ati
onplan
(
Designingact
ivi
ti
es,
budget
ing,et
c.)

Not
e:
Somemanagersonlyst
opatpl
anni
ngandneveri
mpl
ement
.Iti
simpor
tantt
hatt
he
cycl
eiscompl
etedi
ncl
udi
ngi
mplement
ati
on.

8.
0Thet
ool
sformoni
tor
ingandeval
uat
ion
 Observati
on
 I
ntervi
ew
 Questi
onnair
e.
 Records
 Reports
 Focusgroupdiscussi
on

9.
0Thet
ypesofeval
uat
ion
31
Forpur
posesofPHCpr ogr ammest hesecanbeexami nedunder :
 Processevaluati
on:-st udyi
ngt heprocessandseehowi tisfuncti
oning.
 Format i
veevaluation:-t hi
sent ai
lsexaminat
ionoft hepr ocessaf t
erashor t
periodof3,6,9,or12mont hsofi mplementat
ion.Somet imest hi
si sref
erredt
o
Milestoneeval
uati
on.I talsolooksattheshapet heprogrammei staki
ng.
 Summat i
veevaluation:-carri
edoutt ofi
ndimpactoft heprogrammeaf t
er3or
mor eyearsofi
mpl ement ati
onoratt heendoffundingper i
od.

32