Section 4.1: Primary Health Care (PHC) & Universal Health Care (UHC) in the Philippines

Primary Health Care (PHC) and Universal Health Care (UHC) in the Philippines

Community Health Nursing (CHN) in the Philippines operates within a complex, evolving healthcare delivery system. It is fundamentally guided by the global principles of Primary Health Care (PHC) and legally reinforced by the landmark Universal Health Care (UHC) Act (Republic Act No. 11223). Together, these frameworks shift the focus of healthcare from a purely curative, hospital-centric model to a preventative, promotive, and community-driven system that recognizes health as a fundamental human right.

1. Primary Health Care (PHC): Global Origins and Core Principles

Primary Health Care was formally defined and adopted during the International Conference on Primary Health Care in Alma-Ata, USSR, in 1978. The Declaration of Alma-Ata expressed the need for urgent action by all governments, health workers, and the world community to protect and promote the health of all people. It declared that health is a state of complete physical, mental, and social well-being, and that the existing gross inequality in the health status of people, particularly between developed and developing countries, is politically, socially, and economically unacceptable. The ultimate goal of PHC was "Health for All by the Year 2000."

In the Philippines, PHC was institutionalized through Letter of Instruction (LOI) 949 signed in 1979, making the country one of the early adopters of this developmental approach. The core philosophy of PHC is that health is a basic human right and that individuals and communities must be empowered to achieve self-reliance. This philosophy is operationalized through five core principles (often referred to as the pillars of PHC):

• Active Community Participation: This is the cornerstone of PHC. Communities are not mere passive recipients of healthcare services; they are active partners and decision-makers. They must be involved in every stage of the nursing process: from identifying their own health problems (community assessment) to planning, implementing, and evaluating interventions. Community participation is critical because health initiatives succeed only when local residents feel a sense of ownership. A key example in the Philippines is the utilization of Barangay Health Workers (BHWs), who are trained community volunteers serving as links between families and formal health facilities.
• Equity (Equitable Distribution of Health Resources): Under this principle, healthcare resources, services, and opportunities must be distributed fairly, ensuring that those with the greatest needs (the poor, marginalized, and vulnerable populations) receive priority. In the Philippines, this means focusing resources on Geographically Isolated and Disadvantaged Areas (GIDA)—remote islands, mountainous regions, and conflict-torn communities that have historically been underserved. Equity contrasts with equality; equality means giving everyone the same resources, whereas equity means distributing resources according to need to achieve fair health outcomes.
• Intra- and Inter-Sectoral Linkages (Intersectoral Collaboration): The determinants of health extend far beyond the biomedical sphere. Factors such as clean water, basic sanitation, food security, education, and economic stability directly influence health outcomes. Therefore, achieving "Health for All" requires the coordinated effort of the health sector alongside other sectors:
  • Education (DepEd): Schools promote health literacy, hygiene habits (e.g., the Fit for School program), and basic nutrition.
  • Agriculture (DA): Food security, local agricultural productivity, and nutritional diversity directly prevent malnutrition.
  • Public Works and Infrastructure (DPWH): Safe road access to clinics, clean water supply systems, and sanitary toilet facilities.
  • Local Government (DILG): Administrative support, funding allocation, and legislative ordinances (e.g., smoke-free environments, sanitation ordinances).
• Use of Appropriate Technology: PHC advocates for technologies, medicines, and methods that are scientifically sound, adaptable to local needs, culturally acceptable, and financially feasible. In the Philippines, appropriate technology is exemplified by:
  • Traditional and Alternative Medicine Act of 1997 (Republic Act No. 8423): Promotes the use of scientifically validated herbal medicines. The Philippine Institute of Traditional and Alternative Health Care (PITAHC) and the Department of Health (DOH) officially advocate ten herbal medicines (mnemonic: LUPISASATAMA or SADALAMUSA):
    1. Lagundi (Vitex negundo): For cough, asthma, and fever.
    2. Ulasimang Bato / Pansit-pansitan (Peperomia pellucida): For lowering uric acid in gout.
    3. Bawang (Allium sativum): For lowering blood cholesterol.
    4. Bayabas (Psidium guajava): Antiseptic for washing wounds and mouthwash for toothache.
    5. Yerba Buena (Clinopodium douglasii): Analgesic for body pain and headache.
    6. Sambong (Blumea balsamifera): Diuretic for fluid retention and dissolution of kidney stones.
    7. Akapulko (Senna alata): Antifungal for ringworm, tinea flava, and athlete's foot.
    8. Niyog-niyogan (Combretum indicum): Anthelmintic for roundworm infections (taken 2 hours after dinner).
    9. Tsaang Gubat (Ehretia microphylla): For stomach aches and abdominal colic.
    10. Ampalaya (Momordica charantia): For mild, non-insulin-dependent diabetes mellitus.
  • Oral Rehydration Salts (Oresol): A simple, low-cost solution of salt and sugar used to prevent dehydration in pediatric diarrhea.
  • Homemade weighing scales (e.g., Salter scales) and localized health monitoring charts used by BHWs.
• Support Systems (Referral Networks): Primary care facilities cannot resolve every medical condition. A functional support system ensures that when a client's needs exceed the capability of a primary clinic, they are referred to a secondary or tertiary facility through a seamless, coordinated pathway.

2. Universal Health Care (UHC) Act (Republic Act No. 11223)

Signed into law in 2019, the Universal Health Care (UHC) Act aims to ensure that all Filipinos are protected from financial hazards and receive quality healthcare services. The law restructures the Philippine health insurance system and service delivery. Key components include:

Service Packages

The UHC Act clearly delineates health services into two major packages:

• Population-Based Health Services: These are public health interventions aimed at groups, communities, or the general public. Examples include immunization campaigns, disease surveillance, environmental sanitation programs, vector-control programs, and large-scale health promotion. These services are funded by the DOH and Local Government Units (LGUs) and are provided free of charge to the public. Public health nurses are key implementers of these programs.
• Individual-Based Health Services: These are clinical interventions targeted at individuals, including outpatient consultations, inpatient hospital care, laboratory tests, diagnostic procedures, and prescription medicines. These services are funded primarily through PhilHealth benefits.

Healthcare Networks under UHC

To optimize service delivery and prevent fragmentation, UHC introduces two levels of integration:

• Primary Care Provider Network (PCPN): A coordinated group of public and private primary care providers (such as RHUs, private clinics, and community centers) that serve as the initial point of contact for patients. Under the UHC Act, every Filipino must register with a primary care provider. This provider acts as a "navigator" and coordinator, ensuring that the patient receives continuous preventative care and is only referred to specialized centers when medically necessary.
• Health Care Provider Network (HCPN): A larger, integrated network of health facilities including primary care clinics, secondary hospitals, and tertiary medical centers. The HCPN coordinates care across all levels, ensuring that referrals are smooth, medical records are shared securely, and patients do not face out-of-pocket delays or financial catastrophe.

3. Structure of the Philippine Healthcare Delivery System

The healthcare delivery system in the Philippines is dual-structured, consisting of a public sector and a private sector. The public sector is highly decentralized due to the Local Government Code of 1991 (Republic Act No. 7160).

Devolution of Health Services under RA 7160

Devolution refers to the transfer of power, authority, and financial responsibility for health service delivery from the national DOH to the Local Government Units (LGUs). This decentralized system split responsibilities as follows:

• Municipal and City Governments: Responsible for primary care. They fund and manage Barangay Health Stations (BHS) and Rural Health Units (RHUs).
• Provincial Governments: Responsible for secondary and tertiary care at the provincial level. They fund and manage provincial and district hospitals.
• National Government (DOH): Retains policy-making, regulatory, licensing, and technical advisory roles. The DOH directly manages specialized national tertiary hospitals, regional medical centers, and disease-control programs.

Clinical and Administrative Consequences of Devolution: Devolution led to fragmentation of care, varying quality of health services depending on the financial status of local governments (wealthier municipalities could build better clinics, while poor municipalities struggled), and political interference in hiring health personnel. To address these issues, the UHC Act mandates the integration of local health systems into provincial-led and city-wide health systems to pool resources and standardize care.

Levels of Health Care and Facility Classification

The delivery of care is organized into three distinct tiers:

1. Primary Level of Care: This is the first contact point between the community and the healthcare system. Services are predominantly preventive and promotive, focusing on early detection and basic treatment.
   • Facilities: Barangay Health Stations (BHS)—the most peripheral units staffed by midwives and BHWs; Rural Health Units (RHUs) or Health Centers—staffed by municipal health officers (doctors), public health nurses, and midwives; and private clinics.
   • Services: Immunizations, prenatal and postnatal care, family planning, tuberculosis DOTS treatment, basic wound care, and health education.
2. Secondary Level of Care: Serves as the first referral level for cases that cannot be resolved at the primary level. These facilities provide basic inpatient services, minor surgical procedures, and moderate diagnostic testing.
   • Facilities: Municipal, district, and provincial hospitals.
   • Services: General medicine, basic pediatrics, obstetrics and gynecology, general surgery, and basic laboratory/X-ray services.
3. Tertiary Level of Care: The highest level of specialized healthcare. It handles complex, high-risk, and life-threatening conditions requiring specialized equipment, advanced diagnostics, and subspecialist care.
   • Facilities: Regional medical centers, training hospitals, and national specialty centers (e.g., Philippine Heart Center, National Kidney and Transplant Institute, Lung Center of the Philippines, Philippine Children's Medical Center).
   • Services: Intensive care units (ICU), specialized surgeries (e.g., cardiothoracic, neurosurgery), advanced cancer therapies, hemodialysis, and specialized diagnostic procedures (e.g., CT, MRI).

Roles of the Rural Health Unit (RHU) and the Public Health Nurse (PHN)

The Rural Health Unit (RHU), also called the Health Center, is the primary public health facility at the municipal level. It serves as the hub for implementing national and local health programs. The Public Health Nurse (PHN) is the cornerstone of the RHU. The PHN is a registered nurse who applies nursing concepts and public health practice to promote, protect, and preserve the health of populations. The roles of the PHN are multi-faceted:

• Clinician / Care Provider: Evaluates patients at the RHU, provides nursing care, conducts physical assessments, and administers treatments under protocol.
• Educator / Counselor: Conducts health teachings on nutrition, family planning, hygiene, and disease prevention.
• Supervisor / Manager: Supervises Barangay Health Stations, midwives, and BHWs. The PHN manages vaccine supply lines, monitors program targets, and compiles epidemiological reports.
• Coordinator / Collaborator: Acts as the liaison between the community, the RHU, and external agencies (intersectoral collaboration).
• Researcher / Epidemiologist: Conducts disease surveillance, identifies health trends in the municipality, and maintains the Field Health Services Information System (FHSIS).
• Community Organizer: Uses COPAR principles to mobilize community members and form community health organizations.