53 primary health care new music - old harmony

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PRIMARY HEALTH CARE

NEW MUSIC - OLD HARMONY

The concept of primary health care now espoused by the World Health Organization (WHO) and the UN

Children's Fund (UNICEF) has resulted from the

conflict between the need to reach all the people with health care and the scarcity of resources

available for health in most developing countries.

Identified as a root cause of the inadequate care in less developed countries is the fact "that

their patterns of medical care and education of health personnel are copied closely from the

Western countries" (Health and the Developing World, J. Bryant).

With the entry of WHO into the arena, primary health care has received a new boost. A vast

army of researches, health and development planners, with WHO, UNICEF and the World Bank in the van-

guard, are seeking new formulae, new policies and approaches and new projects through which all

people may achieve better health. The seven

principles formulated and revised by WHO in 1975 have been accepted by most agencies and institu-

ti ons as gui deli nes :

* Primary health care should be shaped around the life patterns of the population it should serve and should meet the needs of the community.

* Primary health care should be an integral part of the national health system, and other

echelons of services should be designed in support of the needs of the peripheral level for technical supply, supervisory and referral support.

COMMUNITY PARTICIPATION I N DECIDING ON AND SUPPORTING PREVENTATIVE HEALTH PLANS

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* Primary health care activities should be fully integrated with agriculture, education, public works, housing and communications*

* The local population should be actively involved in health care activities to match health care with local needs and priorities. Community

needs require a continuing dialogue between the people and the services.

* Health care should rely on available or untapped community resources.

* Primary health care should use an integrated

approach of preventive, promotive, curative and rehabilitative services for the individual,

family and community. The balance between

these services should vary according to community needs and may well change over time.

* The majority of health interventions should be undertaken at the most peripheral practicable

level of the health services by suitably trained workers.

The overall goal is better health. Old patterns focusing on hospitals and advanced technology are largely irrelevant for developing countries and, in fact, often not very suitable for the countries

where they originated. In its search for an

appropriate health technology the WHO has made another discovery: Health is political! As

Halfdan Mahler, WHO Director-General, declared in 1976 to the World Health Assembly: "For all the speed with which disease technology has been flou-

rishing in recent years, it has been failing in its purpose because the social, economic and political contexts in which it is being applied have changed.

The extension and refinement of this technology on the one hand and its increasing complexity and

cost on the other, have led to a contradiction between the technical potential and the socio-

economic ability to apply it to all who need it."

This, however, is not the only contradiction, and I would like here to examine a number of assump-

tions underlying present attempts at improving the

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health of the underprivileged masses of our world.

The first assumption is that health care produces health. To contradict this there is evidence put forward by such sober organizations as the World Bank, that socio-economic conditions have a much more profound influence on the health of a population than the health service. In preparation for a WHO Conference on Recent Trends in Maternal and Child Health in Europe (Moscow 1 9 7 4 ) , a survey was

conducted where European national programmes were

given a score for quality of c a r e , on the basis that the more varied the items which a service offered

and the larger the number of people who use it, the higher the score. The scores were plotted

against maternal and perinatal mortality statistics for the same European nations, but high scores on quality of service did not automatically corres-

pond with low mortality, except in countries with a high standard of living.

Although most speeches, papers and projects now emphasize the importance of socio-economic conditions and stress the need for intersectoral inte- gration, the political implications of this are seldom pursued. If unfavourable socio-economic conditions are seen as the fate of the losers in a competition for resources and power at the various

levels (international, national and l o c a l ) ; it

may not be an easy task to persuade the winners to give up their privileges. Instead we find health planners taking upon themselves the task of deve-

loping health care which will compensate for the

unfavourable political environment without creating any disturbance. We find institutes of develop-

ment studies attempting to develop a set of indica- tors with which to assess the "quality" of health care, basing the evaluation on cost-benefit

analyses of the relationship between services

provided and measurable health changes resulting from them! It is a relief, then, to come across admissions such as the following from an address

by Cvjetanovic to the Ciba Symposium Human Rights in Health, 1973: "I shall ignore the ur.quanti f i - able aspects of different socio-economic systems

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61 and their respective merits and disadvantages for

health. These are indeed of great i m p o r t a n c e ,

but at present we lack a methodological framework to do them j u s t i c e . "

I would like to argue that the methodological framework is lacking because we are afraid to face up to

the challenge of the "unquantifiable". The re-

sult is that most health planners draw attention to the s o c i a l , economic and political f a c t o r s , and

then go on to ignore them.

HEALTH CARE DOES NOT PRODUCE GOOD HEALTH.

Health care does not produce good health. The most we can expect from an effective health service

is good c a r e , while the need for care is determined by other f a c t o r s , most important of which may be

the extent of poverty and the ideology of the

prevailing economic policy. But even effectiveness of care is a questionable concept where there is

poverty. There is an unresolved conflict of

interest between those who have power, money and

knowledge and those who have none. In communities where disease is related to poverty and injustice,

it is a mistake to believe that an "effective"

health service can be neutral. If we hesitate to take s i d e s , if we refuse to identify with any

interest group within the community, we shall

inevitably be co-opted by the strong necessity to serve their interests. The second assumption, that health care can be politically n e u t r a l , is not valid.

The reality of the conflict between the haves and the have-nots also contradicts another assumption, that a poor, rural village is a homogeneous,

harmonious communi ty. Unless profound political changes have been introduced on a national scale in order to counteract oppression of the weak by the strong, rural villages consist of several

c o m m u n i t i e s , divided by a g e , sex, s t a t u s , religion, caste and class interests. The health sector has failed to transcend these divisions in the p a s t , and every new project or policy which refuses to

«

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T h e idea t h a t e a c t i v e l y i n v o l v e s the i m p l e m e n t a t i rough a cont i nui ng le and the s e r v i c e r u e t u r e d s o c i e t y . s p o n s e to p r o j e c t s

out of thei r pove ti c c o - o p e r a t i on ,

r, unti1 i t b e c a m e t o r s , w h o w e r e in s w h e r e the p o o r d

and a p a t h y r e p l a c p e a t e d l y b i t t e n , n s hard to f i n d .

s t h e it

ass the d i n on o f s i s

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id n o t ed t h e ow s h y , DANGERS OF C0-0PTI

A W H O / h e a l t h of hea w o r k e r

p r i n c i

1978).

and ea of he overco Some s bas i c

t i v e n e f o l 1 o w Si n e e F a m i 1 y B o t s w a a s s o c i s i d e r a ti n g v from t need t e c o n o m

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has b e e n t I w a s very in whi ch I d the idea ted w o r k e r s o w o u l d by e loss o f t b e r .

c c e s s ful ew type e h e a l t h

in W H O urn, M a y

re c h e a p this t y p e 1 to h e l p ca ti on .

a s s e s s , e f f e c - t t h e p e c t .

e r , the rai ned i n

c l o s e l y had c o n - of r e c r u i -

to c o m e defi ni tion he

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63.

The p r o b l e m t h e n was how t o pay t h e m . As d a i l y p a i d c a s u a l l a b o u r e r s t h e y w o u l d h a v e no g u a r a n t e e o f p e r m a n e n t e m p l o y m e n t , no r i g h t s t o h o l i d a y s o r s i c k l e a v e , t h e y w o u l d r e c e i v e no i n c r e m e n t s f o r e x p e r i e n c e , and a t t h e end o f t h e i r w o r k i n g l i f e

t h e y w o u l d " r e t i r e " w i t h o u t any p e n s i o n . I n a l l t h e s e r e s p e c t s t h e y w o u l d be no d i f f e r e n t f r o m t h e m a j o r i t y o f t h e r u r a l p o p u l a t i o n , b u t we f e l t t h a t

i t w o u l d be u n r e a l i s t i c t o e x p e c t FWEs t o a c c e p t s u c h c o n d i t i o n s a f t e r t r a i n i n g when no one e l s e ha t o . The p r e - s e r v i c e t r a i n i n g l a s t e d o n l y 11 week b u t e x p e r i e n c e and s u p e r v i s i o n o v e r s e v e r a l y e a r s w o u l d mean i n d e f i n i t e o n - t h e - j o b t r a i n i n g .

On t h e o t h e r h a n d , t h e l e a p f r o m p a y m e n t as c a s u a l l a b o u r e r t o t h e l o w e s t r u n g on t h e l a d d e r i n

l o c a l g o v e r n m e n t s e r v i c e i n v o l v e d m u l t i p l i c a t i o n o f t h e m o n t h l y s a l a r y by a f a c t o r o f t h r e e , as w e l

as t h e i n t r o d u c t i o n o f a number o f o t h e r p r i v i l e g e Over t h e y e a r s t h e d i f f e r e n t i a t i o n i n r u r a l i n -

comes has i n c r e a s e d , and FWEs a r e e x t r e m e l y w e l l p a i d t o d a y . T h i s means t h a t FWEs i d e n t i f y w i t h t h e b u r e a u c r a t i c c l a s s n o w , and no l o n g e r w i t h t h e r u r a l p o o r . T h e r e i s a l s o c o n s i d e r a b l e c o m p e t i -

t i o n t o be s e l e c t e d f o r t r a i n i n g as FWEs, w h i c h t h e b e t t e r - e d u c a t e d d a u g h t e r s and n i e c e s o f t h e r i c h e r f a m i l i e s o f t e n w i n . FWEs a r e now s a y i n g t h a t t h e p o o r a r e e x t r e m e l y " d i f f i c u l t t o u n d e r - s t a n d " , as w e l l as u n c o - o p e r a t i v e .

L i f t e d o u t o f t h e c o n t e x t o f p o v e r t y and c o - o p t e d i n t o t h e b u r e a u c r a t i c s t r u c t u r e , FWEs h a v e l o s t t h e i r i d e n t i f i c a t i o n w i t h t h e p e o p l e t h e y a r e s e r v i n g , and t h e r e f o r e t h e i r e f f e c t i v e n e s s as a v e h i c l e f o r c h a n g e . The e f f e c t o f t h e s t a t u s p r o m o t i o n o f t h e FWEs has been t o d e p o l i t i c i z e h e a l t h o n c e m o r e , and r e n d e r r u r a l h e a l t h c a r e i n n o c u o u s i n p o l i t i c a l t e r m s , b u t p e r h a p s a t t h e c o s t o f d e c r e a s i n g e f f e c t i v e n e s s .

The i n v e n t i o n o f t h e v i l l a g e h e a l t h w o r k e r s i s t h u s no g u a r a n t e e t h a t a p r o j e c t w i l l h a v e any

r e l e v a n c e t o t h e h i t h e r t o u n d e r p r i v i l e g e d . The l a n g u a g e , s o c i o - e c o n o m i c b a c k g r o u n d , e d u c a t i o n and t r a i n i n g o f t h e v i l l a g e h e a l t h w o r k e r s a r e n o t d e c i s i v e f o r t h e i r e f f e c t i v e n e s s i n c o m m u n i c a -

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ting with the poor. The basic question is

whether they are identified with the deepest as- pirations of the underprivileged, and whether

the political system in which they work will per- mit such identification.

HEALTH IS POLITICAL.

co-operatives and workplaces

My argument with the new policies for a more equi- table distribution of health resources is that

although the vocabulary and the technology have changed, it is not intended that anything else

shall. Health is political. It has to do with the fair distribution of the basic requirements which make health possible, and it is unrealistic

to expect that effective measures for change should be adopted by a class or a government which profits from the present bias in distribution. Or in

the words of C. Elliott in his book "Patterns of Poverty": "Ruling groups have little incentive to undertake the structural changes and the budgetary cost of the kind of direct intervention that is

usually required to secure equity of access for the excluded, as long as confidence in the

(existing structure) is maintained. When it

breaks down - there is an incentive to set in train no more than sufficient change to restore confidence

in the system."

The world-wide concern about the inadequacy of the old system of health care is an indication of a

certain amount of lack of condifence on the part

The present level of ill health threat to the groups in power

being undermined, and whose own from potential epidemics.

The old kind of health service, which was almost exclusively curative, served to disguise the true nature of ill health. The new emphasis on pre-

ventive health care has revolutionary potential.

Health education is eminently suitable for

conscientization programmes to enable people to realise that they and their children are prey to preventable disease because they are poorly fed, lack good housing and adequate clothing, because of the consumers.

i n the world i s a whose prestige is

1 i ves are at ri sk

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t h e y a r e u n s k i l l e d and unemployed REAL HEALTH CARE.

65

EDUCATION FOR PARTICIPATION

IN C O M M U N I T Y

AND P O L I T I C A L LIFE

H e a l t h e d u c a t i o n h a s it l e a d s to a w a r e n e s s B u t i f p e o p l e a r e t o

r e l e v a n t w a y in t h e i r t h e y a l s o h a v e t o p a r e x e r c i s e o f p o w e r .

At t h e m o m e n t m o s t h e p l a n n e r s , a r e k e e p i n g t h e c a s u a l t i e s o f t h e o p i n g a p p r o p r i a t e t e c

r e d u c e t h e d a m a g e to d u t y is to r e l i e v e s u b e y o n d c u r a t i v e a n d p s e r i o u s a b o u t p r e v e n t t h e e v i d e n c e w e a r e c m e a n s , a n d t o u s e t h e A s e v e r e p r o b l e m in t p e r c e n t a g e o f e x p a t r i o f a 1 m o s t a l l c o u n t r i p a r t i c u l a r l y w e a k p o s p o l i t i c a l i n v o l v e m e n t a w a y t o w o r k p o l i t i c o u r s e l v e s a c e o m p i i c e s

r e v o l u t i o n a r y p o t e n t i a l , i f , o r g a n i z a t i o n a n d a c t i o n , p a r t i c i p a t e i n a r e a l a n d

o w n h e a l t h c a r e , i t m e a n s t i c i p a t e i n t h e c o n t r o l a n d

a l t h w o t h e m s e c o n t i n h n o l o g y a m i n i m f f e r i ng a l i i a t i i v e c a r ol l e c t i

i n f o r m hi s c o n a t e s i n

e s . E i ti on w

H o w a l l y w e

i n a c

r k e r s , I v e s b ui n g c

a n d w urn.

, b u t ve c a r e w e h ng t o ati o n t e x t i

t h e h x p a t r i h e n i t e v e r ,

s h a l l o n f i d e

i ncl u s y c o n f 1 i o r k i n N a t u r o u r d e.

a v e t see w pol i t s the ealth ates

come u n 1 e s

b e m n e e t

udi n o u n t ct,

9 ha ally

uty If w o 1c

hat ical

lar ser are s to s we akin rick

g the i ng deve- rd to

our goes e a r e ok a t

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-i.

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A D E Q U A T E

WATER SUPPLY

LITERACY

SAFE

S A N I T A T I O N

METHODS OF INCREASING L A N D

P R O D U C T I V I T Y

IMMUNISATION AGAINST

MAJOR DISEASES

N U T R I T I O N , H E A L T H , HYGIENE T R A I N I N G

SKILLS RELATED TO EMPLOYMENT

A N D INCOME OPPORTUNITIES

C H I L D - C A R E A N D

HOME RUNNING

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If There Are No Side Effects,

DRUG \ / UNITED STATES \ / MEXICO

Tetracycline

A N T I B I O T I C U S E D A G A I N S T V A - R I O U S I N A C T I O N S ; L h D t R l . E

L A B O R A T O R I E S .

Ovulen

(BIRTH CONTROL PILLS. G. D.

S l A R t fcCO.|

I N U . S . . U S E D F O R < O N I R A C I P -

n o N O N L Y . I N S O M F L A I I N A M I R

ICANCOUNTKH s. ShARl t Rl COM Ml NDS 1 r ALSO FOR RfcGUt A I INC.

Ml NSIRL'AI < VCI i;S. PREMLN S I R L A l U N M O N . AND M l N().

P A l ' i A f H O H l I.MS.

Imipramine

A N T I - D I PRI SSANT; C l h A -

Gfciu>|

IN U S .USED FOR DLPRIVsTON

O N L V I N SOME L A T I N A M E R I C A N

C'Ot'N I RIES. C l B A - G E I G V RECOM- MEND*. IT ALSO FOR SbMl.l X\ . U I R O N K PAIN AND ALCOHOLISM.

Caution against use:

B> i n l a n d , children: during preg- nane). \wih liver or kidney impair- m c m O i i t e i can be faia)) or if overly sensitive lo iiahfc

Adverse reactions publicized:

Vomiting, diarrhea. nausea, upset stomach, rashes, kidney poisoning Can poison fetus.

If patient has tendency u> blood c l o t . ' liver dysfunction, abnormal vaginal bleeding. epilepsy, migraine, asthma, heart trouble.

v

Adverse reactions

publicized: "

Nausea, lifts of hair, nervousness, jaundice, high blood pressure, weight change, headaches.

II patient has heart disease, history of urinary retention, history of seizures, manic disorder or is on typhoid medi- cation. Not recommended lor children or during pregnancy

Adverse reactions

publicized: _ _

Hypertension, stroke, stumbling, de- lusions, insomnia, numbness, dry mouth, blurred vision, constipation, aching, nausea, vomiting, loss of appciitc. diarrhea. sweating.

B> infanis. children, during pregnancy or if overly sensitive to light.

V o m i t i n g , diarrhea, nausea, upsci stomach.

If pattern has tendency to blood clot liver dysfunction

Nausea * eight change

During hrst trimester of pregnancy

Dry m o u l h . constipation, itching, sweating

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6/

This Must Be Honduras

CENTRAL AMERICA BRAZIL

No IK

Nunc

II patient has tendency to blood clot luce tfyNluniluin

Nausea, weight Chang*

If patient ha* heart disease.

None

By infants, children, during pregnancy.

Vomiting, nausea, upset stomach, rashes

II patient has tendency 10 Wood clot,

None

Ifpa iiw r: ha* heart duttJUC- Noi recommended fur children or dunng pregnancy.

None ,

V

^ARGENTINA

None

If patient has tendency to blood clot

None

)

May exaggerate response lo alcohol.

Adverse react'^ns publicized:

None "'"'

Source: Culled from The Phy siclan's Desk Reference—<&« standard handbook for U.S. doctors, containing information drug comp antes supply about their products—and comparable foreign guidebooks.

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The money required to provide adequate

food, water, education, health and housing

for everyone i n the world h a s been estimated

at $17 billion a year.

It i s a huge s u m of money t a s

• * • ct> « *

much a s t h e world s p e n d s on arims every

two weeks.

The Now Internationalist