Primary health care workers see patients before any other trained health workers. Primary health care workers diagnose common and important health problems and prescribe medicines. However, they may have little formal medical training and little access to help and advice. They often work in health centres with few medicines or resources. Good training for primary health care workers is, therefore, very important.

Since the first edition of Diagnosis and Treatment was published in 2000, through Voluntary Services Overseas, non-communicable diseases have overtaken infectious disease as the primary causes of death in developing countries. This new edition reflects the new priorities that primary health care workers have as they face the challenge of providing care with limited resources and uncertain levels of support from supervising clinicians.

Who is this manual for?

This manual teaches primary health care workers how to make a diagnosis for most of the patients that they will see. The manual also recommends options of treatment that are safe and effective to improve patients’ health.

Keith Birrell and Ginny Birrell now work as volunteer doctors in Zambia. They have teamed up with Ian Cross, another primary care practitioner with a wealth of experience working around the world in low resource settings. All three have a background in training doctors in the UK, and clinicians in developing countries.

This second edition has evolved to meet the changing needs of clinicians who work in primary care units. This is a training manual for primary health care workers who work in first-level clinics, dispensaries and health centres in the developing world. Primary health care workers include nurses, medical assistants, doctors, health aides, village health workers and other paramedical health workers.

This manual will help to teach these primary health care workers how to diagnose common illnesses and how to prescribe rationally. The manual is based on a training course that was first developed in Tanzania by VSO doctors and their local colleagues. A wide range of health experts has helped to adapt that original training course to make it relevant to primary health care workers throughout the developing world.

The manual has been updated after working in rural Zambia, in a primary health care setting. Our combined experience of managing non-communicable and communicable disease, in diverse settings, has ensured that the manual is relevant to the conditions and circumstances that are prevalent in modern day developing countries.

Rational prescribing means giving the correct medicine in the correct dose for the correct length of time. It means that medicine is only prescribed if it is needed. Rational prescribing helps health workers to provide good care for their patients and to make the best use of limited supplies of medicines.

The medicines recommended in this manual are based on WHO guidelines for the use of essential drugs. The care and treatment advice in this manual is also consistent with the most important aspects of WHO's Integrated Management of Childhood Illnesses (IMCl) programme.

How can you use this manual?

The manual can be used as:

• a course guide for trainers and supervisors of primary health care workers
• a self-study guide for primary health care students

Part 1 of the manual starts with the basic skills which health workers need for rational prescribing.

Chapter 1 tells you how to use this manual.
Chapter 2 explains how triage, how to recognise seriously ill patients and how to treat very severe febrile disease
Chapter 3 explains how to take a history
Chapter 4 discusses communication
Chapter 5 introduces you to shared decision-making
Chapter 6 suggests lifestyle medicine options
Chapter 7 gives you suggestions to improve sexual and emotional health

Part 2 has 15 lessons about the most important and common health problems in developing countries.

Part 3 contains 28 appendices which include reference charts, a list of medicines and their uses, and details about health problems which are only common in some areas. They provide more detailed practical information about diagnosis, treatment and procedures.

Many appendices are used during the lessons. The lessons teach primary health care workers:

• how to diagnose and treat illness
• when to send patients to hospital
• how to give advice to prevent illness.

Trainers can use the lessons as part of a training course for primary health care workers. If you are a primary health care worker, or a student of primary health care, you can use the lessons to teach yourself.

If necessary, trainers and students should adapt the manual so that it is consistent with the national drug policy and clinical care guidelines in your country. The advice in this manual is not intended to replace national drug and care policy. You should adapt the course to fit guidance in your country wherever the treatment and prescribing advice in the manual is different from your national policy.

You can change the order of the lessons and start with the most important or most common health problems in your country. The manual does not include all illnesses. You can ask a doctor or an experienced prescriber to produce extra lessons about other illnesses that are important in your country. You can also leave out parts of lessons about illnesses that are not important where you work.

We suggest that you download a copy of the manual so that you can access it in places where you do not have access to the internet. The manual will be regularly updated online. The find text facility allows you to search for any word that is mentioned in the manual. Some pages in the manual may be useful for you to have easy access to as you consult. In the days before the internet and smartphones we used to suggest printing some tables and appendices off and pinning them to the wall of your consulting room. You may prefer to label some reference materials in your favourites tab.

Diagnosis and Treatment is open-source. This means that you can access the manual free-of-charge. The authors have no conflicts of interest and work as volunteers in Zambia and elsewhere. You are welcome to reproduce any part of the manual for the purposes of education so long as you do not gain financially from this. If you wish to republish any of the materials in the manual please contact the authors for permission: link

If you wish to suggest additions, or corrections, to the manual we would be grateful for your recommendations. Please contact the authors. In many low-resource settings it is often not possible to offer patients a choice of treatments. But where possible we advise clinicians about alternative treatments if the normal treatment is not available.

In the shared decision-making chapter we give you a feel for the ways in which you can share decisions regarding treatment with your patients. Often lifestyle choices are more effective than medications. Therefore we have included a chapter about lifestyle medicine. To reflect the importance of preventing non-communicable diseases such as heart attack and stroke we have created a toolkit called Reduce my chance of heart attack or stroke.

Reduce my chance of heart attack or stroke is the first of a new collection of toolkits to help patients and clinicians to make evidence based shared decisions together. patientcentre.org will host these toolkits.

Existing toolkits for shared decision-making are currently available via realgeneralpractice.org/shared-decision-options/

Students wishing to improve their communication skills and learn more may wish to view realgeneralpractice.org/communication-skills/

Notes on language

Health workers and patients are male, female or non-binary. That is why, in this manual, we sometimes use 'she' when we talk about health workers and patients, and sometimes we use 'he'. We use 'mother' to describe the carer of child patients.

Girls are often at a greater disadvantage than boys. However we have decided to use 'he' when we talk about child patients with their mothers, so that it is always clear that 'he' is the child, and 'she' is the child's carer.

If you would like to find out more please contact us via:

• info@realgeneralpractice.org
• Kakumbi Rural Health Clinic Mfuwe, Zambia