It is customary to begin at the top of the professional pyramid when discussing the personnel hierarchy and gradually work down to the lower echelons as time and space permit. For reasons which will become obvious the order has been reversed in this text.
The mother
When we consider the provision of health care for the child it is surely the mother who should receive top priority. It is she who spends more time with the child than anyone else and it is she who will inevitably be the one to provide health care in the first instance. It is the mother who ultimately decides how to space her preg-nancies, how long to breast-feed, when to have her child immunized, whether to opt for traditional or 'Western' healing methods, etc.
Thus, as the principal care-giver of her family, the mother must have the necessary knowledge and skills to enable her to give her children the best that is available under the prevailing circumstances.
The objectives are to empower the mother to:
• recognize the need and create a suitable environ-ment for fully breast-feeding her infant;
• provide a domestic environment free of human and animal excreta;
• provide potable water sufficient for the child's needs;
• provide optimal nutrition at all times but parti-cularly during periods of ill-health;
• initiate oral rehydration as soon as the child develops diarrhoea;
• distinguish between upper and lower respiratory infections so that she can deal appropriately with the former and call for more skilled assistance for the latter;
• recognize potential hazards for children which could result in accidents and take appropriate preventive action;
• recognize the need for intellectual stimulation of the under five-year-old and enrich the child's life with
simple toys fashioned from material available in the home;
• recognize the need for regular attendance at the under-fives clinic for weighing and immunization;
• recognize the value of the Road to Health Card;
• deal with minor injuries to avoid sepsis;
• protect the low-birth-weight infant against hypo-thermia and common infections;
• determine the optimal birth interval and use measures to control fertility;
• recognize the importance of skilled antenatal super-vlslOn.
Where it is not possible to provide the above for everyone in a family the needs of the most vulnerable must be given priority. It is constantly necessary to reinforce and update the mother's knowledge and skills at every contact with other health care workers.
Ideally training for motherhood is integrated into the school curriculum providing a foundation for primary child care.
The father must also be seen as a key figure in the welfare and nurturing of his children (Fig. 1. 4.1).
Ideally he should be considered already during the prenatal phase so that he enters parenthood with a well-adjusted attitude. The traditional exclusion of fathers from the day-to-day care of their children is changing rapidly, as the nuclear family replaces the extended family where these duties and responsibilities were shared by the females in the home. The mother was chosen by nature to be the initial carer of the infant but there is nothing to say that in due course the father cannot take over this function quite adequately. Health workers thus need to be reminded that the father must be included in the health care of his children whenever possible, but especially whenever any important deci-sion must be made.
There are, of course, many cultural barriers to overcome, as in many communities the care of infants is regarded as unmanly. However, an altered role identity of the mother and father will be more readily accepted as the nuclear family becomes the predominant unit in society. The agent of change will be the mother, as health workers are more likely to be in touch with her.
School curricula and entertainment media can play an important role here by introducing these new concepts.
Nevertheless, it will be up to the mother to make room for the father in this process of child rearing. The milieu within the family must be such that a bond can form between the father and his child and it is the mother who is usually in a position to facilitate this. Physical contact and the responses of the infant to her father's approaches are probably the two most important factors in shaping this intimate relationship.
The workers 41
Fig. 1.4.1 Father giving oral rehydration therapy in the primary health care of his child.
The village health worker
The next category of worker who is in constant contact with the community is the Village Health Worker (VHW). As discussed in Chapter 3 (p. 26ff) this worker is best chosen by and is in the main accountable to the community. The title notwithstanding, there is as great a need for a health worker within the community of the urban poor as there is in rural areas. VHWs form a vital link in the total health care scheme and unless theit;
position is given appropriate recognition projected goals will not be achieved. Health professionals can provide technical expertise and knowledge but it requires someone from within the community to interpret this into operational terms at the workface.
The functions of VHWs as health scouts and promoters and their relationship to other workers are outlined in detail in Chapter 3, but a few important principles with regard to their service responsibilities must be laid down here:
42 Delivering the services
• VHW s are the mainstay for the mother. Their traInIng must therefore equip them with the knowledge and skills necessary for this important task.
• Certain clinical skills beyond those of the mother must be displayed by VHWs: signs and stages of dehydration; recognition of loss of consciousness of an infant, of lower respiratory infection and of other common and life-threatening conditions; first-aid care of the convulsing child. Furthermore, they need to be aware of their limitations in the management of the sick child.
• VHW s must have some therapeutic measures at their disposal. This varies from one region to another and is largely determined by the availability of health workers with a more sophisticated training.
It is very important, however, that the latter fully accept the principle that, given the knowledge, attitude and skills, VHW s can be trusted to use a considerable range of drugs efficiently. Table 1.4.1 gives a list of suggested drugs, which obviously needs to be adjusted to the prevailing disease pattern. Treatment of patients suspected of suffering from tuberculosis or leprosy is ordinarily not initiated by VHWs but the drugs are included here to make the medication for long-term therapy readily accessible.
• A well-functioning communication and transport system is essential for efficient two-way referral, as has been demonstrated by the 'barefoot doctor' system.5 Prestige and self-esteem will be appreciably enhanced when patients are referred to VHW s for follow-up in the community. Similarly, defaulters can be traced and underlying reasons for this ascer-tained by the community worker.
• The activities ofVHW s must be well integrated with those of the nearest static structure, whether a dispensary, clinic or hospital. They can be involved in the weighing of infants, in health education and in the discussion of those at risk. Health professionals can also use this opportunity to obtain information regarding current trends and beliefs In the community.
Table 1.4.1 Drugs for use by village health workers (VHWs) Oral rehydration salts
Aspirin or paracetamol Penicillin
Sulphonamides
Drugs for malaria, tuberculosis and leprosy Anthelmintics
Antibiotic eye ointment
Diazepam (used p.r. in convulsions)
• VHWs can play an important role in community development. Group organization, critical analysis of problems and decision-making are skills which VHWs will find very useful in this process.6 It is of considerable advantage if VHW s have the ear of local decision-makers, as programmes such as water and sanitation improvement require their coopera-tion. VHWs using tact and diplomacy can bring about significant political change, as the problems of maternal and child health provide an entry point which is generally not threatening and thus acceptable.
• Maintaining a record of births and deaths is an essential function and must be regarded as the barest minimum of data collection.
The medical assistant, auxiliary or nurse/
midwife
Health workers at this level will have obtained a formal training course, the nature and extent varying consi-derably from one region to another. In some countries there may well be several categories of worker at this level, but for the sake of simplicity we will confine our-selves to one. Similarly, their skills and functions will differ from place to place, depending to some extent on disease prevalence and available resources. With regard to maternal and child health, however, certain generalizations can be made concerning the essential functions of these workers. It is assumed that the workers are based at a static structure, such as a clinic, the service function of which is described in greater detail below.
To be effective the workers must be able to identify with the mother of the most disadvantaged group in the community and be sensitive to people's interpretation of health problems. Together with the VHWs they develop schemes which address poverty in the community as a whole. Health workers need to recognize that poverty and lack of appropriate knowledge are the ultimate causes of ill-health amongst the disadvantaged. Hence, they must learn to help people towards a critical analysis of their health problems in order to find some fundamental solutions.5 Over and above that, the impoverished mother needs to be given practical advice which will help her to cope with her immediate dilemma.
Job description
Clinical expertise The following are essential skills:
• diagnosis and management of common and
life-threatening childhood infections: pneumonia, otitis media, measles, pertussis, meningitis and impetigo amongst others;
• management of the child with diarrhoea, including intravenous resuscitation but recognizing the importance of the oral route;
• knowledge of the nutritional requirements of the neonate through to childhood, with particular skills in coping with all the problems occurring in breast-feeding as well as the diagnosis and management of protein energy malnutrition;
• management of the child with fever and in particular the dangers and management of malaria;
• primary care for the child with asthma;
• primary care for the unconscious and the convulsing child;
• knowledge of the indications for and skills for performing a lumbar puncture where more skilled personnel is not available and initial therapy for septic meningitis and cerebral malaria;
• recognition and participation in the management of the abused child and where necessary forming the nucleus of a child protection team;
• simple laboratory procedures (in the absence of a technician) such as urine and CSF microscopy, Pandy's test and haemoglobin estimation.
Underjives clinic The workers must take the initiative and responsibility for establishing and maintaining these clinics. Although this is generally seen as a pre-dominantly preventive/promotive activity, a high degree of clinical acumen is required to detect minor ailments and deviations from normal. Furthermore, sensitivity for the skills and potential of the VHW s are called for, as the VHW s should be involved in the functions of this clinic.
Maternal health Workers need to maintain a steady awareness of the mother's needs and refer her for nutri-tional supplementation, antenatal supervision and fertility control where necessary. Many a young mother will require moral support and possibly even protection when faced by domestic violence. Where this is a common phenomenon there may be a need for a women's refuge to provide shelter in times of crisis.
At-risk register Constant vigilance must be maintained for those at risk so that they may benefit from this service. Workers can playa vital role in case discussions which are held at the clinic at regular intervals and assist in the review of risk criteria.
Data collection The workers are responsible for keeping the databank up to date by ensuring regular input from
The workers 43 VHWs and their own field of work. For further details see 'The functions of the clinic' later.
Health education The importance of promoting literacy and basic knowledge pertaining to health cannot be overemphasized. This will require constant updating of their own knowledge as well as practising a wide variety of communication skills. Above all, the workers must bear in mind that they constantly serve as role models.
Hence, whenever possible the message must be reinforced by living it out in one's personal life.
Surgical skills Where these skills fulfil a supportive function in maternal and child health care (e.g. tubal ligation) they must be promoted. On the other hand, workers at this level may have been trained to perform surgical procedures (e. g. herniotomy) which enhance the workers' prestige, but are neither urgent nor do they make any impression on the overall welfare of the community. Therefore, this aspect of the work must be reviewed critically, particularly with regard to evaluating whether staff time and expertise are used effectively in relation to presenting problems.
The doctor
The main responsibility for delivering the service usually falls on doctors. Yet the training they receive rarely equips them with skills other than those pertain-ing to clinical intervention. Fortunately, several medical faculties have recognized that if their graduates are to have a palpable effect on the goal of 'health for all by the year 2000' , they require considerably more than diagnostic and therapeutic skills. Students from these universities are no longer confined to academic hospitals but are encouraged to move out to smaller institutions and the community. Formal training can be provided by health professionals in peripheral units where students experience a wider spectrum than can be offered in tertiary-level hospitals. It is hoped that there they will be encouraged to learn from those with a less sophisticated training than their own. This requires a degree of humility which is rarely imbued in an academic environment. This may also engender the flexibility necessary to adjust to Third World conditions from the sophisticated atmosphere of most medical faculties.
Doctors commonly find that the demands made on them exceed their time and energy, hence it is wise to learn at an early stage to make equitable allocations to the three main components ofthe work, clinical, mana-gerial and educational.
44 Delivering the services Clinical skills
In spite of having had exposure to some of the common tropical diseases in their training, doctors not uncom-monly experience difficulty, initially, in coping with many of the presenting problems and recognizing their manifestations with ease. As the rest of the team is likely to be well-acquainted with these problems, this demands a willingness to learn from others.
Usually, it comes as a surprise to young graduates that they have to work within the constraints of limited resources and that they have to rely largely on clinical judgement by using their eyes, ears, hands and noses.
On the other hand, being well acquainted with the latest diagnostic tools and modalities of therapy, young graduates may well be in a position to make this contri-bution to the pool of local knowledge.
As doctors, we need to remind ourselves that each one of our patients is a member of a family and a community. Prevailing attitudes and beliefs and the dynamics within the family may have a marked bearing on the severity and outcome of presenting problem.
Each contact provides an opportunity to impart knowledge which is likely to have a ripple effect in the community. One has a better chance of dispelling taboos and beliefs which hinder development by gradually chipping away at them in this manner, rather than by open confrontation.
Life-saving procedures As the most highly trained health workers, doctors are expected to perform life-saving procedures, particularly when working in isolated posts. Therefore, anyone in this type of situation should be competent to carry out the procedures mentioned in Table 1.4.2 on infants and small children.
GOBI The four measures identified by UNICEF as the most effective means of bringing about a 'childhood survival and development revolution' are: growth charts, oral rehydration therapy, breast-feeding and immunization (GOBI). They require careful study.
There are many aspects of these apparently simple tools which have a bearing on the medical profession, who tend to regard them with some disdain.
Table 1.4.2 Life-saving procedures Laryngoscopy
Endotracheal intubation Tracheostomy
Cardio-pulmonary resuscitation Intravenous fluid replacement Lumbar puncture
Intercostal drainage
Growth charts These are also known as Road to Health Charts (RTHC). (See Fig. 1.4.2.) This home-based health record which every child should possess has been designed for and is recommended by WHO.
As the child's total health record, it contains vital information and needs to be maintained meticulously and protected both in the hospital or clinic and the home.
The RTHC is an important instrument in the hands of the mother as it is easy to grasp the significance of her child's weight record in relation to the standard per-centile curves. It reflects the effect of illnesses and other important life events, demonstrating the need for an adjustment to the diet. Provision is made on the ~a.rd
for perinatal data, immunization dates and fertIlIty control measures.
In itself the R THe is of considerable clinical value/
but when doctors are seen to use the chart and make appropriate entries thereon, only then will it be regarded as a document of some significance by the community.
From the clinical point of view, it alerts doctors at an early stage to malnutrition as the weight curve flattens out before clinical features become apparent. Full con-valescence from an infection can be gauged by the weight curve regaining its position in relation to the centile lines.
Oral rehydration therapy (OR T) Diarrhoea is unques-tionably the most serious single child health problem in any disadvantaged community. Dehydration is respon-sible for the high mortality, whereas subsequent mal-nutrition results in chronic ill-health and susceptability to further infections. It thus follows that all doctors working in the subtropics and tropics must be well acquainted with all issues impinging on OR T. .
From the clinical viewpoint the value of OR T, In
preference to intravenous fluids, must be appreciated and the dangers of antidiarrhoeal mixtures and undesirable side-effects of antibiotics acknowledged.
There is a distinct risk that this great life-saver is brought into disrepute by incorrect practices, such as prolonged OR T or administering clear fluids to the exclusion of all feeds. As incorrect mixing is one of the most serious mistakes, constant warnings must be issued regarding the dangers of using excessive salt.
Alternatives to the generally accepted formula may have to be used in many situations where sachets are not readily available in every home. The well-recog-nized sugar and salt home brew, or even rice-water, may have to be promoted where conditions demand it. 8,9 In their capacity as managers, doctors must ensure that a continuous supply of the preparation is available at all peripheral units, as well as of the necessary