Child health services in Colombia: Developing preventive health care strategies in university-Level hospitals

P.ubL Hith, Lond. (1982) 96, 31--42

Child Health Services in Colombia: Developing Preventive Health Care Strategies in U niversity- Level H ospitals Treila Krueger" M.P.A.

Department of Sociology. The University of California, Davis California 95616, U,S~4. t Thi's report is based on a study o f the history, extent, and impact of preventive health care practices for children in Colombia. Its purpose was to provide Colombia universitylevel hospitals with a preventive medicine strategy for improving their child health services. Information was collected in Colombia with the assistance of the Children's Hospital (Lorencita Villegas de Santos) and the Ministry of Health. Visits were made to hospitals and health eentres throughout Colombia, and health officials, doctors, professional staff, and parents were interviewed in the cities and surrounding rural areas of Bogota, Cali and Medellin. The medical problems of childhood in Colombia were characterized and the role of the medical profession in the design and implementation of health policies in Colombia was investigated. A review was conducted of relevant major field projects in Colombia and the role of the university-level hospital was examined. The study brought to light several concepts and components of preventive medicine which could be adopted at all university-level hospitals; specific attention, however, was given to the Children's Hospital (Lorencita Villegas de Santos) in Bogota. The extreme diversity of population groups in Colombia makes generalizations about the effectiveness of methods difficult. Thus, the emphasis of the proposed model is on the design of a possible approach, appropriate to one major medical institution, not on methods which are applicable to all other institutions. The model suggests that selected health themes, together with an integration of preventive and curative medicine, be developed through research, teaching, and service intervention, involving modification ,of the medical curriculum to include student training assignments with target communities.

Introduction In spite o f developments in medical m a n p o w e r training, greater use o f m o d e r n technology and increasing health resources, problems c o m m o n to m a n y developing countries exist in Colombia. These include lack o f integration a n d co-ordination between existing health services on all levelsY, 2. ~2 Two m o r e fundamental problems are: the lack o f emphasis on preventive medicine a n d the lack o f integration between'curative a n d preventive medicine. While curative medicine m a y be relatively suc,ce~ssful in the t r e a t m e n t o f illness and injury, it does n o t prevent diseases in a c o u n t r y where income a n d educational levels are extremely low for a m a j o r i t y o f the people, s I n C o l o m b i a t h e 1 t university-level hospitals are considered the models in delivering * Treila Krueger, M.P.A. (L.B.J. School o f Public Affairs, University of Texas, Austin) is completing Ph.D. work in sociologyat the UniversityofCalifornia, Davis. MsKrueger specializesin medical soc/ologywith emphasis on health care issuesin Latin America.This report is based upon research initiated in 1978-1979 when the author was associated with the Children's Hospital, Lorencita Villegasde Santos, Bogota, Colombia. t Correspondence to: T. Kmeger, P.O. Box 60966 Sacramento, California 95860 U.S.A. 0033-3505/82]0 ! 0031 + 12 $t31.00]0

© 1982 The Society of Community Medicine

32

T. Krueger

major medical services: in research, training o f medical students, use o f modern medical technology? Given this leadership role in the overall health care system, the course o f events taking place in such an environment shapes, to a large extent, future directions in-health practice patterns. But these institutions have not practiced preventive medicine nor encouraged proper health patterns among all classes o f citizens, apparently because of the traditional role and image ofmedicaI doctors in Colombia and the dominance of the medical profession in health policy-making. The impact o f this system orientation has been most severe on the children, especially those o f the most disadvantaged?. 3 Although the percentage o f the Colombian national budget devoted to health is approximately the same as England's, 5 (i.e., more than 10%), in Colombia, childhood diseases and death rates remain high. University-level hospitals seldom serve the medical needs o f the poorest population groups, except possibly through a referral from a small local hospital or a health promoter. N o r do they often serve the most affluent who use private medical practitioners and special clinics. In relation to child health care, the 1975 national health plan included reducing morbidity and mortality by expanding preventive efforts in some areas of the country. 6 But as Tables 1 and 2 illustrate, there was actually a decrease in maternal-child preventive activities between 1975 and 1976 and in promoter activities for the same population group between 1976 and 1977. 7 To encourage the preventive medicine approach and to ensure that it is given higher priority at all levels in the health services (i.e., regional a n d local hospitals, health centers and posts and community health promoters), the university-level hospital should serve as a model o f proper preventive medicine practices. What is needed is a preventive medicine strategy integrated with curative practices and a commitment by policymakers to its effective realization. T^Bt~ I. Comparison of Colombian activities in maternal-childhealth care 1975-1976 Contacts Activity Control of pregnancies Promotion of breast feeding Pre-school interventions Family planning control Interviewsand health assessments of children 0-I4

1975

!976

136,764 132,249 148,927 164,048 1363,967

113,323 114,018 I 15,003 146,715 1,466,800

Source: Ministryof Health, Report to the Honorable Congress of the Republic of Colombia, 1974-78. TABLE2. Health promoter activities in Cotornbia

Persons referred to health center by promoters Visits to pregnant mothers and to children Group educational activities carried out by promoters

1976

1977

218,107

189,760

381,055

315,499

62,673

46,265

Source: Ministry of Health, Report to the Honorable Congress of the Republic of Colombia, 1974-78.

Child Health Services hi Colombia

33

The Medical Realities of Childhood in Colombia

While Colombia has been unable to develop and maintain adequate health care services for a majority of people, much progress has been made over the last two decades in at least recognizing the problems and designirt~ theoretical models. The results of such research, however, have either been shelved without serious application or found to be inapplicable in dealing with actual problems, tn studies conducted at the University dei Valle in Cali, it was found that . . . . . . 64~'~ of available medical services reach only one-third o f the population and over 57% of Colombians die without any medical attention. Half of those who die in Colombia are under 5 years of age, and a large percentage ofsuch deaths are due directly to preventable or controllable diseases, a Compared with the United States Infant death rates during the first 6 months of life in Colombia are about six times greater, and during the next 4 years of life, thedifference reaches nearly 30-fold. x Infant mortality rates in Colombia, as compared to other Latin-American countries, are still high. The 1980 World Population Data sheet indicates that the infant mortality rate (per I000 live births) in Venezuela and Argentina was 45; in Uruguay, the rate was 46; in Chile it was 40, compared with Colombia at 77, 8 Some of the primary causes of death of these children, such as diarrhoea and respiratory problems, have increased over time. The primary causes o f childhood death in Colombia, including malnutrition, diarrhoea, respiratory infections, measles, and auto accidents are illustrated in Table 3. In addition to these, burn accidents and a decline in breast feeding are the major preventable child health concerns needing attention in Colombia) .x°,1~ Poor registration/documentation imply that the extent of current health problems is inadequately demonstrated through existing morbidity and morality rates. Data obtained from major hospitals in Bogota indicated that at least 3000 children are admitted to these institutions/year with burns severe enough to require intensive care treatment over long periods of time. x~ M a n y more cases, however, are not reported and many children never reach an institution for assistance. In the few studies on breastfeeding in developing countries (e.g., Mexico and Chile), the common pattern is one of a consistent decline). 10 Studies conducted in Bogota show that the duration of breast feeding is steadily declining in the lower income segments o f the Bogota population which is considered to be highly susceptible to malnutrition, l° The Role of the Medical Profession in Health Policy-making

Latin-American cultures traditionally have placed great emphasis on the idea that physicians must personally respond to patients rather than delegate authority to nurses or other health personnel. In the Colombian health system, a shortage o f qualified staff in relation to the need for health services further complicates the problem. Doctors scarcely have time to treat their share of sick patients and so further neglect preventive medicine. 1.1~ In a large hospital, for example, where each physician m a y see over I00 patients daily, a suggestion that auxiliaries screen patients, handle simp!e and routine procedures, and refer the rest to a physician, is often rejected. It would appear that a physician's role should be determined by the actual health needs of the population, but such a view is discouraged by the Colombian medical profession and is an obstruction in the process of planning and implementing most health care services. 1 The historical patient--doctor relationship is also a most obvious explanation o f the dominance of Colombian physicians in top health policy-making positions including the

1970

1970

1976

1970

Bronchitis

Measles

Helminthiasis

Malnutrition

1976

Malnutrition

Accidental suffocation

Aulo-relaled accidents Diarrhoea and enteritis Pneumonia and related infections

5-14 years

Diarrhoea and Diarrhoea and Diarrhoeaand Diarrhoeaand enteritis enteritis enteritis enteritis Pneumonia and Pneumoniaand Pneumoniaand Pneumoniaand related infeelions relatedinfections relatedinfections relatedinfections Respiratory Malnutrition Malnutrition Auto-related diseases related accidents to pre~iatal underdevelopment Other causes Bronchitis Bronchitis Measles of prenatal mortality

1976

1--4years

Source: Ministry of Health, 1978, Report to the Honorable Congressof the Republicof Colombia.

Respiratory diseases related to prenatal underdevelopmcnt Other causes of prenatal mortality

1 (Most common) Diarrhoea and enteritis Pneumonia and 2 related infections Bronchitis 3

Order

Less than I year

TABL'~3. Five primary causes of death in Colombia by age group (I 970 and'1976)

t.~

Child Health Services in Colombia

35

Ministry of Health. Although Colombian physicians hold tight control over the design and functioning of the health system, they usually lack training in management techniques, communication and information systems, program planning and budgeting3. ~3This results in planning inefficiency,: particulafly in recognition of problem areas. The major policy impact of physicians controlling the health system is that most'money is allocated to curative processes and high-level technology in university-level hospitals, rather than to preventive programs.

Child Health Fidd Projects and Programs Several major field projects and programs in Colombia, largely supported by universities and private organizations, have attempted to focus on child health. Some of these interventions have demonstrated success in reaching communities. Others show promise for the future. All of the efforts, however, are limited in scope and exist as separate entities rather than an integral part of the national system. The Candelaria child health project from 1968-74 has been one of the most notable field interventions aimed at reducing malnutrition and disease in infants under six. 14 Until recently, the Candelaria effort was heralded as one of the great experiments ever undertaken in rural Colombia. Of late, however, analysts have realized that not only was Candelaria an atypical community in that it was relatively well-off in comparison to similar sites, but that the theoretical model on which it was originally based is not at all generalizable to other communities. It appears that the methods and strategies of reaching people in various communities need to differ, require preparation and must involve the people as active participants, rather than passive recipients, if positive ehangeis to occur. Because Colombia has such a wide cultural, ethnic, and topographical diversity, interdisciplinary treatments adapted to the unique qualities of each region must be considered in the design of each intervention. Two current programs addressing child health problems are PmMOPS(urban) and CIMDER (rural).15.18 And the "watchdog'" efforts of PRIDESare important in monitoring use of Health Resources and in evaluating administrative planning methods o f some health agencies,17 but there is no national delivery system for any of these programs and a lack of integration in currently existing operations. R.INOAEC also developed a rural health strategy for alleviating health problems in communities around Cali and in a few other regions, but again such efforts are not tied c0hesively to the national health system. 18 The "Vivamos Mejor" program (Let's Live Better) began in Call communities as well, with a preventive orientation toward child health care. While the outreach is limited, the project has been successful in matching appropriate preventive methods with .selected communities.~ The ~Human Ecology Research Foundation in Cali also has been instrumental in developing studies on mental and physical development of preschool chS]dren with extension of results to some communities3°

Development of Preventive Health Care Strategies In spite of the marginal success of current programs, lack of formal leadership has limited the adoption of proper health policies acrossthe country. A preventive medicine strategy involving the university-level hospitals is needed to complement existing field efforts and to serve as a model for communities to emulate. The role of a teaching hospital in integrating preve~dve and curative services and promoting proper health policies can be of primary importance in improving t h e health status of a population.

36

T. Krueger

However in Colombia, such hospitals have little experience in applying preventive techniques; this means that a systematic approach to institutional~delivery of preventive care simply does not exist. However, if individual institutions undertake experimental projects targeted for specific population groups, a body of.successful methods for preventive care delivery will start to emerge. Such. spot-testing of techniques is possible when a nationwide concerted effort is not. One of the most obvious limitations is that the Colombian Health System lacks integration between activities at national, regional and local levels, Integration is also lacking among health care services on municipal levels in a given area. Another problem is the extreme diversity of the population combined with the rugged geographical terrain. These characteristics have continued to serve as obstacles to improved health care service throughout the country. Thus, even when services are available, they are not necessarily utilized or effectively delivered. Thirdly~ the lack of qualified personnel to work in preventive service is a serious obstacle. The difficulties involved in training and locating good human resources to fill the needs on a national basis are immense A fourth obstacle is the medical profession's reluctance to delegate authority. As a resul:t, existing resources such as nurses and auxiliaries are not effectively utilizedY, 12 An important premise of preventive medicine is that there is much that individuals and families can do to pl'¢vent disease, protect their health, and increase their own quality of life, given that they are exposed to appropriate models and acquire the motivation to change. Because of limited experience in devising preventive strategies for specific target groups, ignorance of the dynamics of influencing communities to accept health programs, and lack of preventive orientation at university-level hospitals, it is not possible to begin a national program of preventive medicine with much confidence. But the application of models adapted to the individual needs of teaching hospitals, in addition to being politically, economically and socially feasible, may provide many insights from which to extend results and derive improved strategies.

Description of the Proposed Model The integration of preventive and curative services in university-level hospitals requires the development 6.f objectives consistent with e~sting responsibilities of the institution. The objectives for a children's university-level hospital include the following:

General objectives (1) To improve the physical and mental health of children. (2) To increase individual participation and motivation in resolving health problems and to enable greater prevention of major childhood diseases before illness progresses to a point requiring extensive and costly treatment. (3) To provide information about the causes, consequences, and solutions of common health problems in those population groups lacking knowledge and motivation for appropriate utilization of basic health care services. (4) To educate and assist communities in appropriate health care practices such as use of safe drinking water and sanitary hygiene measures, correction of poor nutrition habits and proper food preparation, breastfeeding, dental health care, prevention of accidents, and need for appropriate immunizations.

Child Health Services in Colombia

37

Component objectives

Service (I) To develop and evaluate preventive health care services aimed at improving the overall health status of children and their families. (2) To reduce infant mortality through health care promotion, disease prevention, and appropriate rehabilitation. (3) To incorporate a continuous feedback mechanism providing relevant information and services to promote preventive health care behaviours in the family. (4) To design preventive procedures utilizing diverse interpersonal and group methods, informal education strategies, and mass communication techniques. (5) To realize on-going preventive health care services, aimed at hospital in-patients and out-patients, through effective utilization of doctors, hospital auxiliaries, and volunteers. Teaching (1) To incorporate into the formal medical curriculum at both undergraduate and postgraduate levels, the development of preventive activities. (2) To invite participation of selected professionals in the programming, development, and evaluation of preventive health care services. Investigations are an essential part of the model. Their objectives are as follows: (1) To contribute to the development of prevehtive health technology and for operational analysis. (2) To monitor specific health needs of relevant communities and identify effective educational mechanisms. (3) To motivate hospital staff to participate. (4) To stimulate interest in government and private sectors.

Integrating Preventive Medicine Programs in University-Level Hospitals In order to realize these objectives, the organizational structure must be clearly defined. The integration of preventive health care strategies in university hospitals could be accomplished as illustrated in Figures 1, 2 and 3. The focus of~such preventive health care strategies, as shown in Figure 1, should!be on service, teaching and investigations. These components are aimed directly at hospital in-patients/out-patients and their families, medical professionals, and eonsultati0ns b y doctors outside the institution. An information system is necessary to improve the quality of preventive-curative services and to obtain knowledge for apphcation in the training of medical personnel. Such information provides insight into the health practices of specific communities and the effectiveness o f daily operations within the institution. As indicated in Figure 2, the preventive program(s) can respect the existing infrastructure of the hospital. The program(s) will supply feedback to all internal departments involved as well as to external groups. Figure 3 shows the relationship of preventive activities in the hospital with internal and external entities. The hospital conserves its power and control over the entire operation, but maintains open communications with other entities involved in the intervention. The integration of preventive and curative approaches, as illustrated in Figure 2, should ideally include the hospital departments such as nutrition, lactation, odontology, preschool,

38

T. Krueger

University-level-

" 1 J

hospit01

l ....

Progrom

I

T

Service

r

,

....

~ _

eonsuJ~otions I

.l

,oo=o

......]

/

I........ Professionoi~" |

~1 Tarqetcommunities J

of thehOSl~ital

Figure I. Components of preventive medicine program for a University level hospital. The information was designed by the author to illustrate the necessary components of a preventive medicine program in a university-level hospital, and their interrelationships.

obstetrics and social work plus the external consultations division and possibly others depending on type of institution. Full participation may best be achieved by a gradual integration into the system as opposed to trying an initial full-scale implementation. Each department actively participating can perform its normal functions wl-Jle also focusing on preventing health problems through suchactivities as increasing immunizations, promotion ofsanitary measures to block transmission of diseases, control ofcontacts through isolation, disinfection, and improved hygiene habits, proper patient examinations, nutrition and breast feeding education, dental health care, prevention of accidents, and similar measures. The application of preventive methods in a university hospital implies that such activities are formally incorporated into the medical students' curriculum. Hence, students and medical residents can be involved in health education, and learn through teaching and applying preventive measures to their communities.

Child Health Services hz Colombia Hospiloldeporlmenls Loctation

OdonloloQy

1 t

k) i~

Support groups ~E_D.E.NY l.C.a~ °

I ~ ' ~

Exlemol

I

s=io, ,,o k

l/j/

Nutrition

F

I

Pie-school Obsietrics

cooso,,o, oo

39

Ir

I~~

Ill

i I

Progrom(s) ~I

o.~.P? O~hers

TalevisianQnd rnQ~s communico'tion specialists

I I ~

I~l|

Photo~,iraphers I

Produclionof

mQleriols

I

I

Malerials

I

'°'"o=°'__. l

L

Figure 2. Relationship of preventive medicine program(s) with activities o f the university=level hospital. The information was designed by the author to illustrate the position of a preventive rneclieine program in relation t o internal hospitat departments and external support functions. *C.E.D.E.N. = Non-Formal Education Development Center; I.C.B.F. = Colombian Institute of Family Welfare; D.N.P. = National Planning Department.

Development of Plans Preventive health care themes of university hospitals would be determined by the type of institution. Relevant themes for children's hospitals include general care of the child, nutrition, dental health, immunizations, accident prevention, and other basic health care issues. Development of more specific themes in various hospital departments (e.g. nutrition, lactation and others as described in Figure 2) would involve formulation of departmental objectives, refinement and application of methods and materials, and evaluation tasks. Methods The application of pre~,entive health care services in a children's hospital begins with a diagnosis of the initial situation to determine the attitudes, habits, and knowledge of the target families (with emphasis on the maternal-child relationship) in regard to the following themes: vaccinations, breast feeding, nutrition patterns, diarrhoea, water sanitation, accidents and related health care topics. As shown in Figure 1, a program can be developed simultaneously in the areas of investigations, teaching, and service. The first step deals with educati6n for health care professionals, a revision of the medical curriculum and initial training of medical students, selected professionals, and volunteers to prepare for participation in the intervention efforts. The second step involves the application of preventive methods to patients. Consultations outside the hospital comprise the third level of the intervention.

40

I

T. Krueger

1t o.":o,o'".: I

HoSpital

Other mstltulions end agencies i.......

Advisor

1

I M~nistry~ofHeol~h I.......... ColombionInstrtute of F~mily Welfore

(Z.C.,B.E)

.t ASC'O'EAME" I

Program( s}

-~

Fi: [

-I

Other programs

!

Administration

Professionals

~--~

Non-professionols

I

J ' .,0,o,,&oo.,= 1I~. Foundotion

I

,,

1_

_1

COlTiriluni|le$

Figure 3.'Relationship of program in hospital with other entities. This information was designed by the author as an example of the ideal relationship between preventive medicine services in university hospitals and external entities. * A . S . C . O . F . A . M . E . = Colombian Association of Medical Schools; for other abbreviations see legend of Figure 2.

Preventive services and teaching can be implemented at all stages of the patient's hospital stay: (1) in the reception area, interpersonal discussions, displays of posters and photographs, distribution of leaflets and video-taped messages; (2) in the ward, interpersonal and group discussions; (3) in lecture rooms, question/answer sessions and group activities; (4) in the doctor's consultalion office, interpersonal counselling; (5) in hospital departmental areas, administration of immunizations, promotion of breast feeding, instruction in food preparation and nutrition habits, etc. The research-investigation part of the intervention should began on-going process for the life of the program. Such efforts can determine the health and nutrition status of target communities and serve as a guide for continued'development of the program. It also provides a basis for evaluation ofres,ults through initial, intermediate, and final assessments. In addition, the investigations wii ! provide data to evaluate the organization and administration of the service, and the extent to which each hospital department is carrying on preventive activities. Epidemiological studies will also measure the effectiveness of professionals in applying preventive strategies, the relevant needs of target groups, and the degree of preventive-curative integration within the institution.

Child Health Services in Colombia

41

Eduealional Media

Preventive health strategies should be an integral part of regular ,service delivery. Studies show that university hospitals serve as health care leaders, especially so when people are ill and need both general and speci~ized medical assistance. The hospital setting provides unique opportunities to reach patients and their families, many perhaps, for the first time. Through direct contact with medical personnel and use of informal educational techniques combined with mass media (including radio and T.V.), families can receive qualified health care guidance. Preventive health care methods and materials should incorporate the findings of learning theory, marketing, and behavioral sciences. For each preventive health theme, the use of informal, interpersonal materials like ~ealth guides, playing cards with selected themes, certificates, brochures, family albums, etc., can reinforce more structured activities like video-taped programs, radio and television spots, group workshops, slide presentations by mothers in food preparation clinics, and mental/social stimulation measures for hospital inpatients. Past experience in working with Latin-American people has demonstrated that theatrical techniques can be successful. Such activities may include, for example, the organization of theatrical groups formed by mothers/children to represent the preventive aspects of a specific theme. This idea may take the form of role playing where the mother represents the doctor and the doctor acts as mother. It appears that such interactions produce a more effective social climate and better communication exchange in groups and interpersonal situations and thus may also serve as a reliable feedback mechanism for evaluation purposes. Evaluation

It has been found in past community efforts that the methods used are often inadequate and inappropriate for particular audiences. The most notable example in Colombia relates to the renowned Candelaria project, which gained international recognition for its relatively successful application in one community and later failed when its proponents tried to apply the same theoretical model and methods to other communities. One evaluation technique especially suitable for use in the institutional setting is the examination of data through post-test measures of one group of participants (mothers and children)and similar pre-test measures of new groups entering the program. Thepost-test data of the first group exposed to the program can be compared with the pre-test data of the next group receiving the program to determine the relative effectiveness of the intervention. Other methods would include data collectionthrough observation, questionna?ixes,and interviews. In the Children's Hospital, Lorencita Villegas de Santos in Bogota, a nutrition project has demonstrated effectiveness in reaching several hundred mothers and children per month. Nutrition supplementation has been used as an incentive for increasing interest and participation among mothers in proper food preparation and education clinics. Conclusions

A preventive health care strategy should not only create awareness of health-related problems and solutions, but should also promote positive health attitudes and build bridges between doctors and patients, and their families. The major lessons which first need to be learned center around knowledge of target communities irnpacted by the service, greater

42

T. Krueger

acceptance of preventive medicine by doctors in university-level hospitals, incorporation of medical students and residents into a preventive medicine department, and development of effective methods. It has been said that ...despite increasing health resources and manpower, impressive developments in medicine and nursing education and great forward strides in understanding these diseases, the major causes of mortality and morbidity have been lightly influenced in Colombia. a The magnitude of these problems is great, increasingly complex and not likely to improve in the near future. The need for greater attention to preventive medicine in university-level hospitals is clear and significant. References 1. Bryant, J. (The Rockefeller Foundation) (1969). Health and the Developing World. New York: Cornell University Press. 2. Department of National Planning. (1974). La Politica de Salud. 3. Velasquez, G. (1972). Community Medicine As An Experimenl in Health Care. Cali, Colombia: University del Valle. 4. Blutstein, H. et al. (1977). Area Handbook for Colombia. Washington, D.C.: Foreign Area Studies, American University. 5. lllich, I. (1976). Medical Nemesis: The Expropriation of Health. New York: Pantheon Books. P. 42. 6. Ministry of Health. (1977). E1 Plan Nacional de Salud. Bogota, Colombia. Pp. 10--2. 7. Ministry ofHealth. (1979 ). Informe A I HonorabIe Congreso dela Republica de Colomb ia,1974-19 78. Bogota, Colombia. 8. Population Reference Bureau, Inc. (1980). World Population Data Sheet. Washington, D.C. 9. Berg, A. (1973). The Nutrition Factor. Washington, D.C.: The Brookings Institution. 10. ~Vlora,L O. et al. (1978). X! International Congress of Nutrition, "'The Current Situation and ]'rend of Breastfeeding in Urban Bogota." Rio de Janeiro, Brazil. Pp. 1-3. ! I. Children's Hospital Loreneita Villegas de Santos, (1978). Informe de Estadistica Correspondiente AI: dno 1977, Bogota, Colombia. 12. Argandona, M. & Kiev, A. (1972). Mental Health in the Developing World: A Case Study In Latin America. New York: The Free Press. 13. Ministry of Health, Office of Planning. (1977). Area Critica de Organizacion y Aitmtnistracion, Bogota, Colombia. 14. Ministry of Health. (1975). Documents on the "' Promotora" Program in Candelaria, Colombia, 1968-74. Bogota, Colombia. (See also Archives of,the Rockefeller Foundation on Candelaria.) 15. l~odriquez, J. (1977). From the National Conference on Health Research and Planning, Programa de lnvestigaciones en Modelos de Prestaeion de Servicios de Salud. (I'RLMOPS). Cartagena, C~lombia. 16. Echeverri, O. (1978). Reports from the Multidisciplinary Rural Development Research Center. (CINDER). Cali, Colombia: Universit] del Yalle. 17. U~niversitydelValle. (1978).InformeGeneraI.ProgramadelnvestigacionyDesarrollodeSistemas de Salud. (PRIDES).Cali, Colombia. 18. A~bab, F. (1978). Conference on Community Education, Engineering for rural welfare. Cali, Colombia: Foundation for the Teaching and Application of Sciences. (FUNDAEC),June. 19. Bertrand, W. & Bertrand, J. (1979). Health education among the economically deprived of a Colombian city. International Journal of Health Education 22. 20. McKay, H. & Sinisterra, L. (1978). Improving cognitive ability in chronically deprived children. Sci~ce 200, 21 April, 270-8.