TECHNICAL PAPER # 21
UNDERSTANDING PRIMARY HEALTH CARE
FOR A RURAL POPULATION
By
James E. Herrington, Jr., M.P.H.
Technical Reviewer
Helen R. Hamilton
VITA
1600 Wilson Boulevard, Suite 500
Arlington, Virginia 22209 USA
Tel: 203/276-1800 * Fax:
703/243-1865
Internet: pr-info@vita.org
Understanding Primary Health Care for a
Rural Population
ISBN:
0-86619-221-1
[C]
1985, Volunteers in Technical Assistance
PREFACE
This paper is one of a series published by Volunteers in
Technical
Assistance to provide an introduction to specific
state-of-the-art
technologies of interest to people in developing countries.
The papers are intended to be used as guidelines to help
people choose technologies that are suitable to their
situations.
They are not intended to provide construction or
implementation
details. People are
urged to contact VITA or a similar organization
for further information and technical assistance if they
find that a particular technology seems to meet their needs.
The papers in the series were written, reviewed, and
illustrated
almost entirely by VITA Volunteer technical experts on a
purely
voluntary basis.
Some 500 volunteers were involved in the production
of the first 100 titles issued, contributing approximately
5,000 hours of their time.
VITA staff included Maria Giannuzzi
and Leslie Gottschalk as editors, Julie Berman handling
typesetting
and layout, and Margaret Crouch as project manager.
James E. Herrington, Jr., M.P.H., the author of this paper,
has
worked over the past six years with the Senegal Sine-Saloum
Rural
Health Project, a model primary health care program; as a
Peace
Corps Volunteer; as Public Health Advisor with the U.S.
Agency
for International Development; and as a short-term
consultant for
program and management issues.
He received a B.S. from Texas A&M
University and a M.P.H. from the University of North
Carolina at
Chapel Hill. VITA
Volunteer Herrington is currently Health Promotion
Specialist and Assistant Administrator for the Western
Medical
Group, a nonprofit rural primary health care organization in
North Carolina. The
reviewer of this paper, Helen R. Hamilton,
is also a VITA Volunteer.
She has been an Assistant Librarian for
the International Health Project of the American Public
Health
Association (APHA) and a cataloger for the Clearinghouse on
Infant Feeding and Maternal Nutrition, APHA.
VITA is a private, nonprofit organization that supports
people
working on technical problems in developing countries.
VITA offers
information and assistance aimed at helping individuals and
groups to select and implement technologies appropriate to
their
situations. VITA
maintains an international Inquiry Service, a
specialized documentation center, and a computerized roster
of
volunteer technical consultants; manages long-term field projects;
and publishes a variety of technical manuals and papers.
PRIMARY HEALTH CARE FOR A RURAL POPULATION
By
VITA Volunteer James E. Herrington, Jr., MPH
I. INTRODUCTION
On January 1, 2000, the World Health Organization's goal of
"Health for All" is supposed to become a
reality. Will the
world's six billion people truly have access to essential
health
and medical care by this target date?
At present, a majority of
the world's rural inhabitants do not have access to
essential
health care, cannot afford the limited health care that may
be
available, and usually have little, if any, control over the
health care system of their country.
A lot has to be accomplished
if basic health and medical care services are to be extended
to
all the world's rural poor.
Nevertheless, since the declaration
of the World Health Organization's "Health for
All" goal in 1978,
progress has been made in increasing the numbers of rural
people
who have access to essential health care services.
Much of this
progress is due to the establishment of primary health care
(PHC)
systems in many developing countries.
Simply stated, primary health care is
.... essential
health care made universally accessible to
individuals and
families in the community by means acceptable
to them through
their full participation and at a cost
that the community
and country can afford. It forms an
integral part both
of the country's health system of which
it is the nucleus
and of the overall social and economic
development of the
community.(*)
As the above definition indicates, the PHC system is not
only
aimed at helping the rural poor lead better physical,
mental, and
social lives, but also at encouraging their participation in
the
decision-making process of achieving overall well-being and
not
just treating the diseases or ailments that afflict them.
(*) World Health Organization, Primary Health Care:
A Joint Report
by the Director General of the World Health Organization and
the
Executive Director of the United Nations Children's Fund
(New
York, New York:
World Health Organization, 1978).
NEEDS SERVED BY THE PHC SYSTEM
The PHC system aims to fulfill four basic needs.
First, it
strives to reduce the high rate of morbidity and mortality
(disease
and death) among rural people.
In many developing countries,
50 percent of the children die before their fifth birthday
from three diseases--diarrhea, malnutrition, and
pneumonia--and
their associated complications.
The PHC system is an effective
means of preventing these childhood killers and other less
severe
diseases.
Second, the PHC system attempts to make essential health
care
accessible and affordable to rural people, who usually have
very
meager incomes. In
many developing countries, the nearest health
care facility to a rural village may be several, if not
many,
kilometers away. A
sick family member who is transported at
substantial time and financial cost to the nearest health
facility
may find long waiting lines and an exhausted supply of basic
drugs and medical material.
If the health facility runs out of
medicine, the patient's family may have to purchase it at a
private pharmacy, where the cost may be five times greater
than
at the health facility.
Because the PHC system attempts to bring
health care closer to more people, it reduces the enormous
amounts of money, time, and energy that rural people often
spend
under their present health care system.
Third, the PHC system promotes local self-reliance and
self-determination
by encouraging a rural community to fully participate
in the planning, organizing, and managing of the PHC system.
The health problems of a community are more effectively
addressed
if members of the community are educated and understand how
to
attack the problems themselves rather than depending on
people
outside the community to do it for them.
Outsiders, though well-intentioned,
may make poor or unwise decisions for a community
simply because they may not know the dynamics of that
community.
A community's best resource is often its own members.
The PHC
system encourages the community to rely on itself and to set
realistic goals and objectives toward meeting its needs.
Fourth, the PHC system is not an isolated program.
Rather, it
forms an integral part of the social and economic
development of
a community and country.
The PHC system strives to improve the
health of people not only through the provision of essential
medical care and active participation in decision making at
the
local level, but also through linkages with other sectors
within
the community that make an impact on a community's social
and
economic well-being.
Establishing links with the agriculture
sector ensures production of nutritious food for families;
establishing
links with the water and sanitation sector promotes
plentiful supplies of clean water and safe disposal of human
waste; establishing links with the housing sector fosters
the
construction of houses that protect people against
disease-carrying
animals and insects and foul weather; establishing links
with
the educational sector helps communities understand and
address
their health problems as well as encouraging health
education
activities in the schools.
Finally, establishing links with the
public works and communication sectors ensures better roads
so
rural populations can have greater access to urban and other
rural areas, thereby promoting increased social interaction,
communication of information, and accessibility to medical
facilities
and supplies.
In sum, primary health care is not an isolated activity but
rather a system that encourages integration and linkage of
the
health sector with other sectors.
As a result, PHC fosters the
social and economic development of a community and country
in
addition to reducing disease or disability through medical
intervention.
THE BASIC THEORY OF THE PHC SYSTEM
The primary health care system is founded on the principle
that
health is a fundamental human right to be enjoyed by all
people,
rich or poor, in all countries, industrialized or
developing.
Because health is more than just the delivery of medical
services,
the PHC system attempts to address people's "health
needs"
through an integrated approach utilizing other sectors such
as
agriculture, education, housing, and social services, in
addition
to medical services.
This integrated approach encourages active,
horizontal relationships between people and their local
services
as opposed to the traditional top-down or vertical
relationships
where people are simply recipients, passively participating
in a
health program.
The PHC system employs the concepts of a "village
health committee"
and "community health workers."
A village health committee
is usually composed of local residents, chosen without
regard to
political affiliation, sex, age, or religion.
The committee actively
participates in planning, organizing, and managing the
primary health care system serving their village.
By representing
the village as an organized and collective voice of the
community
before the government, the committee can assist in ensuring
that
the national health care service actively supports its
community
health workers. The
village health committee is an important
vehicle not only for promoting better physical health for
community
members, but also for improving their overall social and
economic health.
Fundamental to the PHC system is the realization that the
major
killer diseases in rural communities in the Third World are
preventable and that the majority of victims of these
diseases
are children under five years of age.
Illnesses such as diarrhea,
malnutrition, pneumonia, measles, diptheria, tetanus, and
malaria,
which strike children, can be prevented through relatively
effective and low-cost methods.
The PHC system advocates, for
example, immunization against measles and
diptheria-pertussistetanus
(DPT) for children and tetanus toxoid immunization for
women in their childbearing years (15 to 44); breast feeding
and
the use of oral rehydration therapy (ORT)(*), and the
chloroquinization
of children (use of antimalarial drugs) on a regular basis
in areas where malaria is a problem.
Thus, preventive medicine is
the major emphasis of the PHC system.
Since childhood killer diseases most severely affect
children
living in rural locations, the PHC system encourages
countries to
shift their national health care strategy emphasis from
urban to
rural areas. In
developing countries, the majority of health care
services often are based in large urban centers and serve
only a
small percentage of the country's total population.
Rural people
usually experience great difficulty in reaching urban-based
health care facilities.
The cost of getting to an urban center
may exceed a family's or individual's ability to pay.
As a result,
a child's opportunity to be immunized or a minor illness
may not receive medical attention until the child becomes so
ill
that the child's parents are forced to seek emergency care
without
regard to cost. Even
so, the child may become permanently
disabled or die because medical treatment was obtained too
late,
if at all. The PHC
system is based on the premise that when
preventive medicine is taken to the rural areas, childhood
diseases
can be dramatically reduced at low cost to the community
and country.
(*) Oral rehydration therapy (ORT) is a simple solution of
water,
sodium (salt), glucose (sugar), and bicarbonate of soda that
can
be made at home and given as a drink to a child with severe
diarrhea in order to replace important body fluids lost due
to
dehydration associated with this disease.
For more information on
the proper proportions for the oral rehydration solution,
please
consult: Pan
American Health Organization, Oral Rehydration
Therapy: An
Annotated Bibliography, 2nd edition, Washington,
D.C.: Pan American
Health Organization, 1983; and World Health
Organization, The Management of Diarrhoea and Use of Oral
Rehydration
Therapy, a Joint WHO/UNICEF Statement, Geneva, Switzerland:
WHO, 1983.
A key factor in the delivery of preventive medicine through
the
PHC system is the use of "community health
workers." Community
health workers are local individuals who may also be the
traditional
healer or midwife in the village.
They receive training
from national health personnel, who themselves have received
instruction on training techniques, and have an intimate
understanding
of the PHC system.
The community-health worker training
program lasts from two weeks to three months, depending on
local
needs and skills.
The community health workers work on a part-time,
or sometimes voluntary, basis to address basic health needs
identified by the village with technical assistance from
national
health personnel.
The PHC system recognizes that local people with little or
no
formal education can be trained to:
(1) deliver high-quality
basic first-aid; (2) recognize signs and symptoms of more
serious
conditions; (3) deliver babies under more hygenic
conditions; and
(4) educate their fellow villagers in understanding the
disease
processes in their community.
HOW THE PHC SYSTEM IS APPLIED
The application of the primary health care system to a
particular
country or a specific community depends largely on the
economic
conditions and the sociocultural characteristics of the
country
and the community.
The PHC system is flexible as well as highly
dependent on active support from the community.
Thus, two communities
may differ in their approach to primary health care, yet
both may achieve positive results.
In other words, the PHC system
does not adhere to one strict set of methods or ways of
operating.
However, a PHC system should include eight essential
elements:
1.
health education;
2.
promotion of better nutrition;
3.
clean water and improved sanitation;
4.
promotion of maternal and child health;
5.
immunization;
6.
disease prevention and control;
7.
treatment of common diseases and injuries;
and
8.
provision of essential drugs.
Ideally, all eight elements should be a part of the PHC
system,
although some may be phased into the system at various times
due
to local community priorities and economic and sociocultural
constraints. A
community should strive to include as many of
these elements as possible in their PHC system, but should
also
recognize its limitations and take one step at a time.
As the
Wolof (a language of Senegal, West Africa) proverb says,
"Slowly,
slowly one catches the monkey in the forest."
Health Education
The PHC system should include health education, which is
more
than just mass media campaigns, though these are
useful. Health
education helps people to consistently, freely, and
rationally
change their personal and social behaviors to prevent and
control
illnesses. Community
health workers can give advice on health
matters to community members while treating illnesses in the
village health hut, in addition to providing home health
counseling
and community group education.
It is important to bear in
mind that the advice of a community health worker who is
experienced
and respected in the village will more likely be followed
than that of a community health worker who is inexperienced
and
not respected.
Promotion of Better Nutrition
Promoting better nutrition involves helping people learn how
to
improve the family food supply and child-feeding practices
to
prevent nutritional illnesses.
For example, breast feeding should
be strongly encouraged over formula or bottle feeding since
breast milk contains nutritious vitamins essential to a
baby's
growth and strong antibodies which fight disease in a baby's
body. A baby's
growth can be watched by the mother when the
community health worker regularly weighs and measures the
baby.
Use of fresh vegetables in the family's meals should also be
encouraged to help children and mothers of childbearing age
stay
strong, healthy, and less likely to become seriously ill
from
minor diseases like colds.
Clean Water and Improved Sanitation
A basic, fundamental need of all people is a safe and
adequate
supply of drinking water.
Use of hand-dug wells (usually 3 meters
in diameter), which are covered to protect against dirt,
insects,
and animals, and regular cleaning of household water
containers
(jugs, canaries, etc.) are important ways of preventing
waterborne
diseases. Basic
sanitation facilities such as latrines and
garbage pits are significant means for containing disease
away
from people.
Promoting community and personal hygiene is also
important.
Promotion of Maternal and Child Health
Promoting the health of mothers and children involves
prenatal
care, safe and hygenic deliveries, postnatal care, child
care,
and family planning.
The community health worker, who may also be
the traditional midwife, can improve health care for mothers
and
their children at home and within the community.
The health
worker can watch for signs of anemia, i.e., lack of iron in
blood
(for example, a pale mucuous membrane of the eye), in
pregnant
women, practice clean and sanitary birthing procedures, and
encourage
women to space their births through family planning
methods so that children already in the family can receive
adequate
nutrition and care.
Immunization
Immunization of infants and children under five can prevent
them
from contracting major killer diseases such as diptheria,
measles,
poliomyelitis, tetanus, tuberculosis, whooping cough, and
yellow fever.
Community health workers can assist in organizing
the village to participate in immunization activities and
help
village leaders understand that the village children will be
protected from certain illnesses by being regularly
vaccinated.
Disease Prevention and Control
Community health workers can help in wiping out
disease-carrying
flies, rats, water snails, and mosquitoes.
By administering
chloroquine to young children and mothers on a regular basis
during the peak malaria season(s), community health workers
can
help reduce and prevent severe disability and death due to
malaria.
They can also help to prevent the spread of infectious
diseases by advising villagers to wash their hands often and
to
isolate infectious individuals from the community until they
recover from the infectious disease.
Treatment of Common Disease and Injuries
Recognizing and treating diseases and injuries is an
important
means of protecting children from disability and death.
For
instance, almost all children under five years of age in
developing
countries experience diarrheal disease and risk becoming
severely dehydrated due to a loss of body fluids.
As mentioned
earlier, the use of oral rehydration therapy is a simple,
low-cost,
home-prepared method of replacing lost body fluids in
children. Community
health workers can teach mothers how to
recognize signs of severe dehydration (e.g., loose,
nonelastic
skin, sunken eyes, lethargy) and how to prepare the oral
rehydration
solution. Cleansing
and bandaging wounds, stabilizing broken
limbs, and recognizing signs and symptoms of more serious
illnesses
and injuries are some examples of how community health
workers can treat disease and injury within the PHC system.
Provision of Essential Drugs
The regular availability of basic drugs for people living in
rural areas is an important aspect of the PHC system.
The community
health workers of the Sine-Saloum region of Senegal, West
Africa, use the following basic drugs to treat illnesses in
their
area:
o
aspirin (for pain, fever);
o
chloroquine (for malaria);
o
piperazine (for worms);
o
aureomycine 1% (for eye infections);
o
aureomycine 3% (for skin infections);
o
ferrous sulfate (iron for anemia);
o
alcohol (for cleansing equipment and swabbing
around
infected skin
areas; and
o
oral rehydration powder (for dehydration due
to diarrhea).
Obviously, the above list is not intended to be
comprehensive.
Yet the Sine-Saloum community health workers' drug supply is
regularly available at an affordable cost due to the list
being
short and simple.
The Senegalese government's efforts to decentralize
their drug distribution system from the national to the
village level aids in providing a local source of affordable
medicines.
Summary
The eight essential elements of the PHC system can be
carried out
at the local level by using locally-selected community
health
workers. Health
workers may receive technical training and supervision
from government health personnel but are ultimately responsible
to the community they serve.
Since most local residents know their own community's needs
and
strengths best, it is quite reasonable that local villagers
can
be trained to deliver some, if not all, of the eight
elements
essential to the PHC system described above.
HISTORY AND DEVELOPMENT OF THE PHC SYSTEM
For centuries most communities have relied on some type of
traditional
healer and/or midwife for their health problems.
Even with
the advent of industrialization and greater medical
sophistication,
a scarcity of physicians in the rural areas of many
developing
nations still exists today.
Traditional midwives and healers
still play a prominent role in the delivery of medical care
to many rural people.
A traditional healer is often consulted
first by sick individuals and their families.
Western or industrialized
medical care is often sought only when the traditional
remedy has not worked satisfactorily.
In some developing countries, the scarcity of doctors in
rural
areas has made it necessary to train medical assistants
(often
called auxiliaries) such as medecins africains (francophone
Africa),
the barefoot doctors of China, the feldshers in the USSR,
and the licentiate (people who are licensed to practice
medicine)
in India and Pakistan, to name a few examples.
These health
personnel function essentially as doctors in rural areas
where
there are no physicians.
The World Health Organization (WHO),
shortly after its establishment in 1946, promoted the
training of
medical auxiliaries as a means of meeting the health needs
of
rural populations.
WHO has been instrumental in providing organization,
research, and information on medical auxiliaries as primary
health care workers and promoting the development and use of
trained non-physicians and traditional practitioners to meet
rural people's health needs.
Other organizations, such as UNICEF
and Catholic Relief Services, have also promoted the use of
medical auxiliaries and community health workers in areas
where
physicians are not available.
During the past two decades, the interdependence of health,
agriculture,
education, and other sectors that have a direct impact
on rural people's lives has received increasing recognition.
Health care has become linked to the economic and social
development
of a country.
Providing more primary health care services to
rural people helps to foster the economic development of a
country,
for example, because it reduces the number of productive
workdays lost due to illness during peak agricultural
periods.
The development of stable vaccines against measles, polio
and
smallpox, and the use of local personnel to administer them
has
led to the greater use of vaccines as part of primary health
care
at the local level.
The adoption of simple, primary health care
measures has substantially reduced the number of deaths of
children
under age five from diarrhea, malnutrition, and pneumonia.
By and large, primary health care has been and continues to
be
viewed as the most effective and least costly means for
combatting
childhood diseases.
In 1978, WHO sponsored a conference in
Alma Ata, USSR, for practitioners and researchers to discuss
primary health care and formulate recommendations for its
implementation.
Since that time, many developing countries have adopted
and are attempting to implement a national primary health
care
strategy, with the goal in mind of "health for all by
the year
2000."
II. ALTERNATIVES TO
THE PHC SYSTEM
There are basically four alternatives to the PHC system:
1.
comprehensive hospital-based medical care;
2.
semi-comprehensive nonhospital-based medical
care;
3.
transmissible and environmental disease
control; and
4.
nutrition supplementation.
COMPREHENSIVE HOSPITAL-BASED MEDICAL CARE
Modeled after Western health care systems, the comprehensive
hospital-based medical care system provides primary through
tertiary
services in one central location at the national and
sometimes
regional levels.
Primary services treat immediate and usually
minor cases of illness, and frequently include maternity
care. Secondary
services involve short-term hospitalization and
minor surgery such as repair of lacerations, circumcisions,
and
incisions and drainage of infections.
Tertiary services treat
patients with chronic or severe illnesses, such as tuberculosis
and cancer, that require a longer period and more
sophisticated
personnel and equipment for treatment.
The hospital may hold between 100 and 500 beds, use high
technologies
and sophisticated medical equipment, and require substantial
amounts of financial and personnel support.
Typical services
offered might include complete laboratory analysis,
radiology,
surgical capabilities, labor and delivery facilities, and
emergency
treatment. Moreover,
nuclear medicine, chemotherapy, immunotherapy,
and computerized axial tomography (CAT) scanning
capabilities are becoming more prevalent services offered in
hospital-based medical care systems.
Staff required for this type of health care system are
usually
highly trained, skilled professionals.
Such individuals are
needed to operate the sophisticated equipment, perform the
multitude
of lab tests, diagnose and treat difficult and complicated
illnesses, and provide skilled nursing care.
A large administrative
staff is usually needed to coordinate the inputs of
equipment,
supplies, and personnel required for optimum performance of
the facility. Large
amounts of energy are needed to run the
hospital facility and operate its high-tech equipment.
Hospital efficiency is sometimes measured by the percentage
of
beds occupied to the total number of beds available.
A high
percentage of occupied beds supposedly indicates that the
hospital
facility is operating with greater efficiency.
Capital investments in hospitals are substantial.
Maintenance and
operating costs are also very high due to the sophisticated
equipment used, the large amounts of resources required, and
the
highly skilled nursing care needed for tertiary and
intensive
care patients.
Personnel costs are also high since the medical
staff of a hospital facility would usually include several
physicians,
obstetricians, general surgeons, pediatricians, and various
specialists and subspecialists.
Table 1 lists the advantages and disadvantages of using
comprehensive
hospital-based care to provide health services to rural
populations in developing countries.
SEMI-COMPREHENSIVE NONHOSPITAL-BASED MEDICAL CARE
Semi-comprehensive nonhospital-based medical care facilities
are
usually located in small urban centers at the regional and
district
levels in developing countries.
These facilities are sometimes
called health centers, dispensaries, or health posts.
They
offer primary and secondary medical care following a
scaled-down
model of hospital-based care.
One of these facilities may have
between 10 and 25 beds, and may serve within its
geographical
area between 40,000 and 200,000 people, depending on the
degree
to which the national health care system extends into the
rural
areas.
The health center differs from a hospital facility in that
it
uses less sophisticated equipment and technology and
requires
only moderate amounts of financial and personnel
support. Services
typically offered might include diagnosis and treatment for
primary and secondary illnesses, small laboratory services,
screening capabilties, immunizations, limited nursing care,
and
minor surgery. This
type of facility would be staffed by one
physician with two to five medical auxiliaries, nurses,
midwives,
and/or sanitation aides.
The physician and medical auxiliary or
nurse would perform the administrative duties.
In some countries
with a scarcity of physicians, a nurse or medical auxiliary
may
serve as the administrator, medical director, and trainer of
the
health center.
Table 1.
Advantages and Disadvantages of a Comprehensive
Hospital-Based Medical Care System
Advantages
Disadvantages
All care facilities are under
Does not significantly reduce
one roof or within close
high rates of infant mortality
proximity to one another.
and morbidity.
Wide range of illnesses
Very expensive to build and
are treated.
maintain; can drain the national
budget very quickly; rarely
Gives the appearance that the
cost effective, especially where
country is "well developed" due
third-party payment (insurance)
to sophistication of facility.
is not common.
Urban populations have easier
Caters to small portion of
access to high-quality primary,
country's population--usually
secondary, and tertiary care.
urban residents; rural people
have little or no access
to facility.
Places greater importance on
secondary and tertiary care,
less importance on primary
care.
Basically, curative care or
intervention,
not preventive
care.
The community plays no role in
the development or day-to-day
operation of the hospital
facility.
Health centers emphasize curative rather than preventive
care.
They serve the surrounding urban population and rural
communities
that are nearby. Due
to limited staff and facilities, long waiting
times may be normal and medicines and medical material may
be
in short supply or depleted.
The farther a facility is from major
cities, the longer will be its supply lines and the greater
the
amount of time required to fill its drug and material
stocks.
This is especially true where transportation systems are
poor due
to inadequate roads, lack of fuel, and harsh geographic and
climatic conditions.
Similar to a hospital, the greater the
distance the facility is from rural communities, the more
time
and money it will cost people living in rural areas to use
the
facility.
Table 2 lists the advantages and disadvantages of adopting
semi-comprehensive
nonhospital-based medical care systems to provide
health services to rural populations in developing
countries.
Table 2. Advantages
and Disadvantages of a Semi-Comprehensive
Nonhospital-Based Medical Care System
Advantages
Disadvantages
Extends health care coverage
Principally offers curative
of nation to smaller urban
care.
centers and some rural
communities near facility.
Caters only to urban population
and rural communities located
Can treat primary and
nearby (within 10 kilometers).
secondary illnesses.
Will not always have medicines
Provides nursing care
or materials if isolated from
for acutely ill.
major supply centers.
Offers more hygienic and
Offers little in the way of
skilled birthing care.
preventive medicine.
Can offer minor surgery if
Does not significantly reduce
skilled personnel are
high rates of infant mortality
present.
and morbidity.
Less costly than
Community participation plays
hospital care.
little or no role in decisions
made concerning care offered
at the health facility.
TRANSMISSIBLE AND ENVIRONMENTAL DISEASE CONTROL
In many developing countries, efforts to control the
vectors(*)
that carry human disease, such as mosquitoes and snails,
have
been very effective.
For example, outbreaks of malaria, yellow
fever, and dengue fever can be controlled through regular
spraying
of insecticides to kill the particular mosquitoes that act
as
carriers of these diseases.
Programs to control onchocerciasis
(*) A vector is an agent, such as an insect, capable of
mechanically
or biologically transferring a pathogen from one organism to
another.
(river blindness) are being carried out in the Volta River
basin
in West Africa over a 20-year period.
Vector control is a long-term
problem that is often compounded by the fact that some of
the disease carriers and pathogens become resistant to the
insecticides.
Water and sanitation programs are also effective in
preventing
waterborne and fecal-oral diseases when properly carried out
and
maintained. These
activities consist of developing clean water
sources and sanitary disposal of human waste, which often
requires
the regular maintenance of equipment (such as water pumps)
and persuading the target population to use new water
sources and
waste disposal sites.
Vector control is an attractive health care strategy because
it
requires minimal personnel and equipment.
This effort, however,
is usually carried out through mobile teams and therefore
requires
reliable transportation, the cost of which can increase
sharply depending on the costs of fuel and maintenance.
Unlike vector control, water and sanitation efforts require
substantially
more equipment (e.g, drilling rigs, pumps, maintenance
tools), and more personnel to train the local population in
the
upkeep of water pumps, for instance.
Yet the greatest labor
requirement is in educating and motivating the target
population
to change its habits in order to obtain maximum benefit from
the
new water sites and waste disposal facilities.
Vector control and water and sanitation efforts can be very
effective and efficient strategies for controlling disease
if
personnel are well trained and affordable equipment and
replacement
parts are regularly available.
Disease levels can be reduced
dramatically over the long term if these efforts are carried
out
regularly and consistently.
However, the increasing resistance of
organisms to pesticides requires the continual development
of new
toxic substances and alternative methods for organism
control.
Moreover, if replacement parts and locally-trained personnel
are
not available to repair pumps or disposal sites when they
break
down, these control efforts will fail since people will
revert to
their previous, less hygenic methods of water gathering and
waste
disposal.
Vector control is comparatively inexpensive but must be
administered
over indefinite periods of time or until the vector has
been eliminated.
Water and sanitation programs, are, on the other
hand, quite expensive since installation of community water
systems
requires a substantial investment in equipment, material,
and skilled labor.
Tables 3 and 4, respectively, list the advantages
and disadvantages of vector control and water and sanitation
programs in developing countries.
Table 3. Advantages
and Disadvantages of Vector Control Programs
Advantages
Disadvantages
Relatively inexpensive.
Must be continued indefinitely.
Can effectively reduce
Insects and mollusks or the
death and disease rates
pathogenic organisms become
with regular spraying
resistant to pesticides.
over the long term.
Does not involve much
community participation.
Is rarely an intersectorial
effort (involving education,
agriculture, or social services).
Table
4. Advantages and Disadvantages of
Water
and Sanitation Programs
Advantages
Disadvantages
Can produce dramatic reduction
Very expensive in capital
in waterborne disease rates if
and maintenance costs.
water supplies are installed
within the house.
Public water faucets do not
always bring about reductions in
waterborne disease rates since
water may be stored in unclean
containers in the house.
Extremely difficult to change
people's personal and social
habits.
Does not usually involve active
community participation.
Rarely involves
other sectors
such as education, agriculture,
and social services.
NUTRITION SUPPLEMENTATION
Nutrition supplementation programs typically distribute food
such
as grains, powdered milk, and canned meats to mothers with
infants
in an attempt to supplement their daily caloric and protein
intake. In addition,
these programs often bring together women
with children for baby weighings, lectures on nutrition, and
demonstrations, as part of the food distribution
strategy. Advocated
as an efficient and effective method to reduce childhood
malnutrition, food supplementation may be necessary but by
itself
is rarely sufficient.
Food products for these programs are often supplied through
donor
agencies such as the U.S. Agency for International
Development
"Food for Peace" program and through private
voluntary organizations
such as Catholic Relief Services.
The food products are
often transported to social service or health care centers
within
the country and distributed as part of their regular
activities.
A social service worker or medical assistant would be
assigned
the responsibility of organizing baby weighings and health
talks
at which time food is distributed to the mothers attending
the
sessions. Little
active community participation is required.
Most
mothers and children are passive recipients.
There is little evidence to suggest that nutrition
supplementation
programs alone can reduce childhood morbidity and mortality
rates. Moreover, an
adverse dependency on outside food donations
is created with these types of programs--rather than
encouraging
self-reliance and self-sufficiency through home gardens,
food
drying and preservation, and better eating habits.
Nutrition
supplementation programs often find their donations sold to
supplement
cash incomes or eaten by family members other than the
targeted infants and mothers.
In some instances, food supplements
may be diluted to last longer and thereby diminish their
nutritional
effectiveness. If
not eaten when first opened, canned
meats may be improperly preserved and cause food poisoning.
The cost of nutrition supplementation programs is relatively
expensive due to the long logistical supply lines and
transportation
and storage costs involved in getting the food from the
donor source to the field.
In countries where transportation
systems are poor and the rural population is isolated, costs
will
be greatly magnified.
The relative advantages and disadvantages of using nutrition
supplementation programs to improve the health status of
rural
populations in developing countries are listed in Table 5.
Table
5. Advantages and Disadvantages of
Nutrition
Supplementation Programs
Advantages
Disadvantages
Some mothers and children will
Creates psychological dependency
benefit from the nutritional
on outside donations
value of the donated food.
("handout syndrome").
Relatively easy to implement.
Food is often diverted for cash
income needs rather than going
Essential in famine areas where
to women and children.
little or no food is available.
Alone, nutrition supplementation
has no significant effect
on decreasing childhood
morbidity and mortality.
Costly due to transportation
and storage requirements.
Involves little or no
community participation.
III. DESIGNING THE
PHC SYSTEM RIGHT FOR YOUR NEEDS
PHC SYSTEM VERSUS ALTERNATIVE HEALTH CARE SYSTEMS
None of the alternatives to the PHC system described above
places
an emphasis on actively involving the target community in
improving
its own health status.
Most of the alternative health care
systems are top-down approaches and concentrate on curative
rather than preventive medicine.
Unlike PHC, these systems may
not significantly reduce the high rates of infant mortality
and
morbidity due to their inaccessibility to rural people, high
costs, other medical priorities, or long-term implementation
requirements.
Unique to the PHC system is the use of local resources, in
terms
of personnel and experience, to address local health
problems. By
training one or two local residents (who may also be the
traditional
healer or midwife) as community health workers in simple
first-aid, preventive health, birthing, and sanitation
techniques,
and supplying them with a simple array of essential
drugs, materials, and supervisory support, a community can
potentially
reduce its high death and disease rates, particularly
those for children less than five years old.
Through the use of
community health workers, the health care coverage of a
country
can be dramatically increased.
Self-reliance and self-determination are significant
components
of the PHC system that are lacking in the alternative
systems. In
the PHC system, health is seen from a much broader
perspective
than simply the elimination of disease or infirmity.
The social
and economic development of a community and country is
strongly
related to primary health care efforts.
Health care is linked to
other sectors such as agriculture and education, all of
which can
mutually benefit from collaborative efforts.
POSSIBLE PROBLEMS TO CONSIDER IN DESIGNING A PHC SYSTEM
In designing a PHC system it is important to avoid the
temptation
to copy or emulate a successful PHC system from elsewhere
without
critically assessing the needs and strengths of the targeted
community. Given
health care is not only a right but a responsibility,
community support and participation are essential in all
phases of PHC planning, organization, and management.
Joining
with health planners in a collaborative relationship,
community
leaders can provide a wealth of information and support
necessary
for an effective and successful PHC system.
It is important to diagnose the community in terms of not
only
what it lacks but also where its strengths lie.
In this initial
stage of PHC development, the community should participate
in
answering questions such as these:
o
Where do people go for medical care?
o
How much does medical care cost?
o
What illnesses are afflicting the entire
population,
especially
children?
o
Where is drinking water obtained and what is
its quality?
o
How do people dispose of human and other
wastes?
o
Who are the influential people in the
community?
o
How are important decisions made?
o
Who do people go to for counsel?
o
How are children educated about health?
o
What is the degree of control villagers feel
they have
over their
own health?
In selecting community health workers, it is important to
emphasize
the need to employ respected individuals who have their
roots in the community and are not likely to use their
positions
for political or religious gain.
The ability to read and write is
not essential; however, community health workers should be
keen
listeners and learners.
Young people who have received some
formal education are mistakenly viewed as better equipped to
be a
health worker. They
often become discouraged, however, since the
position usually is part-time and pays little.
Village health committees should also be composed of
respected
individuals from the local community without regard to age,
sex,
education, or religious or political affiliation.
Health is the
concern of everybody and exclusive to no one.
In designing the best PHC system for a specific community,
community
leaders and local health personnel should consider the
eight essential PHC elements described earlier, bearing in
mind
the specific sociocultural characteristics of the community.
Above all, the PHC system should be tailored to local needs,
emphasize local strengths and resources, and work with other
sectors involved in the community.
IV. THE FUTURE OF
THE PHC SYSTEM
The future of the PHC system depends largely on the degree
to
which it is successful in raising the health status of rural
people. Certainly,
there are numerous factors, such as drought
and famine, that can influence the health of a community,
which
are beyond the control of anyone.
Yet the aspects of a PHC system,
including greater emphasis on community participation, use
of community health workers and village health committees,
the
intersectorial approach, as well as the eight essential
elements
of a PHC system discussed earlier, need to be tested and
analyzed
under field conditions to determine their usefulness in
raising
the health status of rural populations.
The development of more
effective training methods and materials, improved drug
distribution
schemes, and realistic financing requirements and methods
are some examples of areas within the PHC system that need
further
research.
Only through intensive field-based research, analysis, and
dissemination
of findings on actual PHC systems will decision makers
and governments be able to modify their primary health care
strategies. Through
such efforts, the goal of "health for all by
the year 2000" is more likely to become a reality,
especially for
rural people.
BIBLIOGRAPHY/SUGGESTED READING LIST
Bryant, John. Health
and the Developing World. Ithaca, New
York:
Cornell
University Press, 1969.
Elliott, C.
"The Principles and Practice of Primary Health Care."
Contact.
Special Series No. 1. St. Albens, Harts,
England:
Teaching Aid at
Low Cost, April 1979.
Gollady, Frederick.
"Community Health Care in Developing Countries."
Finance and
Development. 17 (1980):
35-59.
Harrison, Paul. The
Third World Tomorrow. New York, New
York: The
Pilgrim Press,
1983.
Hetzel, B.S., ed.
Basic Health Care in Developing Countries.
Oxford,
England: Oxford University Press, 1978.
Johns Hopkins University.
The Functional Analysis of Health Needs
and
Services. New York, New York:
Asia Publishing House,
1976.
King, Maurice.
Medical Care in Developing Countries.
Nairobi,
Kenya:
Oxford University Press, 1966.
Morley, David.
Paediatric Priorities in the Developing World.
London,
England: Butterworth, 1973.
Pan American Health Organization.
Oral Rehydration Therapy:
An
Annotated
Bibliography. 2nd Edition.
Washington, D.C.:
Pan
American Health
Organization, 1983.
Steuart, G.W.
"Community Health Education."
A Practice of Social
Medicine.
Edinburgh, Scotland:
E. & S. Livingstone, Ltd.,
1962.
Uphoff, N.T.; Cohen, J.M.; and Goldsmith, A.A.
"Participation in
Rural Health
Care Programs." Feasibility and
Application of
Rural
Development Participation. Ithaca, New
York: Cornell
University
Press, 1979.
Werner, David. Where
There Is No Doctor. Palo Alto,
California:
The Hisperian
Foundation, 1977.
World Health Organization.
Health--A Time for Justice:
Primary
Health
Care. Geneva, Switzerland:
World Health Organization,
1978.
World Health Organization.
Primary Health Care: A Joint
Report
by the
Director-General of the World Health Organization and
the
Executive-Director of the United Nations Children's Fund.
New York, New
York: World Health Organization, 1978.
World Health Organization.
The Management of Diarrhoea and Use of
Oral Rehydration
Therapy. A Joint WHO/UNICEF Statement.
Geneva,
Switzerland: WHO, 1983.
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