Evaluating primary health care and nutrition programs in the context of national development

Sm. SC,. Med. Vol. 19. No. 3. pp 225-235, 1984 Printed in Great Britain. All rights reserved

Copyright

0277-9536/X4 $3.00 + 0.00 (’ 1984 Pergamon Press Ltd

EVALUATING PRIMARY HEALTH CARE AND NUTRITION PROGRAMS IN THE CONTEXT OF NATIONAL DEVELOPMENT THOMAS

Human Services Design Laboratory,

J. MARCHIONE

Case Western Reserve University, University Circle, Cleveland, OH 44106, U.S.A.

Abstract-This paper illustrates an evaluation model incorporating research techniques of both primary health care and social anthropology. The case in point is the Jamaican Government’s Community Health Aide Programme, which employs over 1300 auxiliary health workers to serve the low-income population of the island. The study demonstrates a cardinal principle of the anthropological approach-a grounded and holistic understanding of the social and environmental context is necessary to translate data into useful information. The study demonstrates connections between the distribution of care, the power of the cosmopolitan medical profession, and the Jamaican political patronage system. Finally, the impact of the program is assessed on child growth measures against the background of the Jamaican economy as it evolved from 1970 to 1980.

INTRODUCTION

In recent years, the linkage of health care delivery systems to the wider society has become increasingly clear to students of society, health planners and human rights specialists. It has been observed that even the more powerful primary care models must be adapted to different social contexts, and even then their successful implementation depends on a preexisting ‘political will’ to satisfy the basic needs and rights of all citizens of the society in question [l, 21. Social medical researchers have found that health care systems are linked to (1) the national development strategy chosen [3,4], (2) the structure of the society [5, 61 and (3) the historical (often colonial) legacy [3, 71. Political economy plays a strong role in health care delivery system persistence and change, although it may not be as determinate as some Marxist analyses have claimed [8]. From a normative perspective, the human right to primary health care and nutrition has been recently reaffirmed by the World Health Organization in its goal of health for all by the year 2000 [9]. The rights to health care and nutrition are rights of long standing in the international rights system [lo, 111, in which health care is one of many interrelated political and economic rights. Successful national development can be thought of as the progressive satisfaction of not any one. but at least a significant set of these interrelated rights [4]. It. follows, therefore, that evaluation of health care programs should not be done without consideration of the country’s wider social structure, development process, and overall progress in the implementation of human rights. In this paper. an evaluation framework is presented which illustrates how both national development goals and health care delivery goals can be taken into account. The case in question is an evaluation of Jamaica’s Community Health Aide Programme which was intensively studied by the author from 1973 to 1975 and periodically followed through 1980. This program also provides an

example of a type of primary health care program which has emerged in many countries as a more cost effective approach than more sophisticated programs for achieving specific health goals [12, 131. THE EVALUATION

FRAMEWORK

A cardinal principle of the social anthropological approach to health program evaluation is that research should begin with a grounded and holistic understanding of the particular societal and physical environmental context [14, 151. Without such contextual grounding, dam cannot be transformed into useful information. This is especially true for those reading with an eye to the comparison and application of programs in other contexts. From this viewpoint, primary health care and nutrition program evaluations should: (1) Take a holistic account of the specific program’s societal context, not merely as program ‘background’, but as part of the analysis. (2) Explicitly state normative or value-orientations used in defining evaluation criteria. (3) Generate a better understanding of the social processes underlying health problems. Some anthropological researchers go further and state that evaluation models are themselves a part of development theory. Thus, models of evaluation are determined by the development strategies and political ideologies adapted by researchers [16]. Elzinga [ 171 proposes four paradigms of development and four corresponding evaluation modes: (1) neoclassical, free market capitalist development theory is consistent with cost-benefit evaluations focused on program operation at micro-level; (2) the ‘noncapitalist road’ paradigm backed by the Soviet Union for which no specific evaluation model is spelled out; (3) the dependency paradigms which would focus on programs as instruments of global imperialist domination; (4) the self-reliant development paradigm, in

225

226

THOMAS J. MARCHIONE

National I

Development Process (Political Economy)

I

I

d

\

Structural Consequences

Structural Constraints

Health Program

Fig. I. Health in development context. micro-level program goals and consequences are viewed in relation to the specific inward directed development goals of the government policy. Elzinga has classified this author’s model as a prime illustration of the last type. Such a rigid classification is an unnecessarily limiting one. One need only insure that programs are simultaneously evaluated by program goals and goals consistent with dominant values of the wider society. These wider goals may be derived from inward directed or outward directed development strategies. The evaluator must be able to make explicit the perspective of the national development strategy or otherwise must clarify the value base from which overriding judgements are being made. Evaluations should employ one level based upon the internal health goals and management concerns of the primary care program and a second level based on goals external to the program, but consistent with the national development strategy of the country in which the program is implemented (see Fig. 1) [14, 181. The framework illustrated here includes four types of evaluation, two types associated with each evaluation level (see Table 1). Level one focuses upon matters internal to the program at the micro-level, i.e. to what extent the program is achieving goals stated by program planners. It includes effort evaluation (or process evaluation), the performance of the program according to service level goals and role expectations, and outcome evaluation, the degree of measurable progress made in reaching desired health goals [19]. Level two focuses upon social processes and goals external to the program or macro-level social and cultural elements interacting with the program [14, 161. It includes priority evaluation or the assessment of the program relative to external processes or goals served in the wider development strategy, and euuluation of theory-in-action which examines the degree of correspondence between the program’s approach to change and the known sources of ill-health in the particular social structural and physical environmental context. No evaluation should be considered complete without evaluation at both internal and external levels. although the types of evaluation chosen may vary. which

Table

I. Comprehensive

LW2l

Type __.~_

Internal

ElTort or process

External

Theory-in-actlon Priority

Outcome

primary

health

care evaluation

Criteria .____~. _~ Service quantity, quality and distribution goals Health behavior and health status change targets Processes producing &health National developmental goals

THE PROGRAIM

CONTEXT

National development process The application of the evaluation framework must ‘begin with a thorough understanding of the society and the development strategy in which the program is imbedded. The focus of this research is the parish of St James in the Cornwall Region of the western end of the semi-tropical republic of Jamaica. St James’ population was estimated at 115,000 in 1975, representing 6% of the nation’s population of 2.0 I million people. The parish capital, Montego Bay, is the main population center with 409; of the parish population and a major international tourist attraction. The rural areas are dominated by an economy of plantation and peasant agriculture. The history and social structure of the parish parallels in many ways that of the island as a whole. Since the time of European contact in the fifteenth century the region has been transformed by island-wide and international changes: nevertheless, cultural and economic dependence upon Europe and North America has persisted. At the time of independence in 1962, the black agricultural laborer and peasant farmer remained overwhelmingly in the majority and overwhelmingly more poor than the often lighter-skinned professional, office worker, businessman or large farm owner [20]. In the tirst IO years (1962-1972) following independence, the Jamaican Labor Party (JLP) vigorously employed the neo-classical development strategy which accepted this structure of inequality and dependence as a means to foreign investments in tourism. bauxite mining and agricultural exports [21]. From 1972 to 1980, the ‘democratic socialist’ (self-reliant development) strategy of the Peoples National Party (PNP) dominated the political and governmental aspects of the parish and represented a challenge to this historical pattern [22, 231. Following a series of internal political struggles and international political+conomic repercussions, PNP efforts floundered and in 1980 the JLP was selected to reinstitute the neo-classical development strategy v41. Health and nutrition problems and primary

heulth cure

In the early 1970s community survey data suggested that for children under 2. malnutrition was an associated or underlying cause of death in over 50”,, of all deaths in the Kingston area. and. if one speculated about the synergism of nutrition and infection, nutritional problems assumed even greater importance [25]. Although Jamaica’s infant mortality rate ranked fourth out of 24 nations m Latin America

Evaluating

PHC and nutrition

and the Caribbean at that time [26] the decline in mortality rates abated following the eradication of malaria in 1962 [27]. Nutritional status surveys demonstrated that young child malnutrition remained unimproved [28, 291. A considerable proportion of hospital bed days were being consumed by ill and malnourished children in 1972 [27]. The distribution of health personnel was heavily weighted toward urban and coastal areas, and health dollars were increasingly expended on curative, rather than preventative services [ 181. During the 196221972 period, the JLP’s contribution to St James included the construction of the 400 bed Cornwall Regional Hospital in Montego Bay, but rural and primary care services, such as public health nutrition, remained virtually unimproved. Malnutrition, especially in young children, was approximately 10% (in Gomez II and III) and hospital malnutrition wards in western Jamaica were overcrowded [lS, 301. Mortality rates and malnutrition in the western parishes were conspicuous enough to become a political issue in the 1972 elections. The Community Health Aide Programme was implemented in late 1972 immediately following the victory of the PNP party. St James and adjoining Hanover parish had trained and deployed over 300 health aides by January of 1973. Since then, over 1300 aides have been trained and deployed islandwide as part of an expanded primary care effort. The program has been presented as one component of a concerted attack upon primary health care delivery problems, especially those of maternal and child health services [3 11. The basic program was designed to provide a force of new auxiliary health care workers at the local level [32]. Women with relatively little education were to be recruited, trained for two months and returned to their home communities to work in first aid, public health education, and routine clinic health work [ 141. The work included nutrition education such as encouraging breast-feeding, earlier introduction of solid food to infants, more timely use of clinic facilities, and the like. The Community Health Aide (CHA) would work under the supervision of the existing network of public health nurses. In addition, the CHA was given health clinic responsibilities in conjunction with clinic nurses and district medical officers. CHAs are now paid JS2100* a year. Both training and running costs show a considerable saving over the use of professional health workers to provide the same services. An added bonus expected was that aides would be less likely to leave community service for more prestigious jobs than would the more highly trained health personnel. In 1982, the program had been in operation 10 years. The balance of this report is an evaluation of both the internal and external aspects of the program for the parish of St James. Evaluations in other parishes are discussed when pertinent to the argument.

*The Jamaican dollar was equivalent to US $1.11 in 1973; in 1982, it had fallen to an official

rate of US$O.65.

programs

INTERNAL

EVALUATION:

227 THE PROGRAM

EFFORT

The program effort

The effort evaluation set out to determine (1) how well were the Community Health Aides deployed in relation to need? (2) how well did they perform their assigned daily tasks, such as home visiting? (3) how well were they received by the community? (4) how well were they trained, supervised, and coordinated within the health team? For future recruitment, planners wanted to know what personal characteristics of recruits and what aspects of training were related to good performance in the field. These concerns, plus an understanding of the society, suggested independent variables which might relate to the service level in the recipient population. The variables for analytical purposes were defined according to administrative goals and requirements. It was, of course, assumed that the Community Health Aides would not only be available to, but also seek out needy householders to promote a variety of health and nutritional measures-especially to those households in ‘deep rural’ areas. Precise definitions of goals and objectives were developed from the CHA’s job description, and through sets of informal interviews with program organizers. From these, it was possible to define specific target groups to be benefited and to operationalize a set of measures of service. For instance, a key variable was the frequency of CHA’s visits to households with children under 3 years of age. Using the contents of initial interviews and related materials, a questionnaire and educational testing instrument were constructed to gather a variety of information about the personal characteristics of the 110 health aides, their work in the field. and the effectiveness of their training. With the data from the questionnaire, a random sample of 20 CHAs was selected which was stratified by age and residence. Census books kept by each CHA were obtained and a random subsample of serviced households containing children under 3 years of age was selected from each sampled CHA’s area. Thus, a sample of 200 households was selected for systematic interviewing in early April of 1973. A follow-up survey of 300 randomly selected households was conducted in 1975. An island-wide study along these lines was completed in 200 households in 1978, done by the Department of Social and Preventative Medicine at the University of the West Indies [33]. Effort evaluation-results

The principal dependent variable in the effort evaluation was the frequency with which households at high risk were visited by the aides. Visiting frequency averaged 0.38 visits per week or one visit every 20 days. However, this ranged from as much as one visit per week for one aide to one visit per 50 days for another. The activities the aides performed in the households did not significantly differ as a function of the frequency of contact with the household; the activities were primarily advice and instruction, referrals, and first aid treatment. Consequently, the qualitative differences between aides’ visits, although important, did not invalidate the visiting frequency as the key indicator of effort [18].

228

THOMAS

Table 2. Variables

J.

MARCHIONE

in the effort evaluation

analysts

(N = 20) Correlar~ons wrh contact frequency

Variables

I. Contactfrequency

Means

Age of the CHA Exam score Locality orientation Relative SES

0.38 27.25 87.25 2.10 I .08

6. Community acceptance 7. Aides/population 8. Supervisory load

82.30 4.89 27.00

*Significant

“significant

2. 3. 4. 5.

at the 0.05 level, F-test:

Units

Simple r

Weekly visits per household Years 0.25 ;/, correct -0.75** 1.00 is least. 3.00 is most 0.45* 1.00 is no difference in SES 0.06 between aide and commumty “/, of CHA’s households 0.12 Aides per 2500 persons 0.42’ Per public health nurse -0.17

A number of variables affected the frequency of CHA contact with the community and the target group. Two overriding variables were deployment and supervision (Table 2). Deployment and supervision The amount of contact an aide had with any single household in her assignment area was simply a function of the geographic size and population of the assignment area (r = 0.42, see Table 2). Some areas were heavily covered with health aides while others had a very sparse coverage. In inverse proportion to coverage was the effect of supervision. Areas with a high density of health aides tended to overload the supervisory capacity of the public health nurses in charge. This tended to produce an adverse effect on the contact frequency between health aides and target households. Evaluators at the University of the West Indies examining an island-wide sample of CHAs made this same observation, adding that “recruitment from various districts had been uneven, resulting in deployment of aides away from [their home communities] to attempt a more even coverage of the population” [33]. The distribution of aides was indeed quite uneven from parish to parish -in 1978. Hanover parish, an important area for an international primary health care demonstration project, had more than twice the density of health aides compared to the rest of the island. Also, within St James, some areas were overloaded with health aides and some had few in residence. One public health nurse had as few as 8 to supervise, while another had as many as 40. This maldistribution was related to the influence of party patronage. PNP areas were favored. Thus in parishes and districts loyal to the party, disproportionate numbers of aides were trained. A fuller discussion of this point is given further on in this paper under the heading of ‘concentration vs equity’. CHA churacteristics Although uniform performance criteria still do not exist, in 1973, the aide recruiters were seeking a set of criteria for selecting new aides. For this purpose, assignment area and the supervisory load variables were controlled statistically and the relationship of aide visiting frequency and five other variables were determined. These were age, locality orientation of aid, training examination score, relative social economic status and acceptance by the community in the

r controlling for 7 and 8 0.49’ -0.61” 0.57’ 0.27 0.04 -

at the 0.01 level. F-test.

aide’s area. The results of this analysis are given in the last column of Table 2. Age. Older health aides (over 25 years old) were more energetic home visitors than were the younger and more inexperienced women. Of course, the older aide was most likely to be a settled community member, to be married, and have considerably more child-rearing experience than the younger aides. Thus, they were much more credible health workers in the high risk households. Locality orientation. As anticipated. locality orientation, defined as the number of local versus cosmopolitan social network links, affected visiting efforts. The more locally oriented health aide had a significantly higher contact frequency with the household in her assignment area (r = 0.45). Training examination score. Health aides who did the best on the examination following the training period were the least likely to be regular and frequent home visitors to the households in their respective areas. Less literate aides and those with more traditional concepts of nutrition scored lower on this examination. The examination was as much a test of the intracultural differences between the recruits as judged by their trainers, the public health nurses, as it was a test of clinical knowledge. In a sense, the examination can be thought of as a test of the ‘professional-orientation’ of the health aide as judged by public health nurse trainers. This effect was further confirmed in an analysis of aide visits to a random sample of 300 households in the 1975 follow-up. Aides with lower training scores were much more likely to visit households frequently than were high scorers (d.f. = 2, x’ test, P < 0.001) [l4]. Community acceptance. It is important to note that the level of program acceptance was very high in the parish of St James. Eighty-two percent of sampled households served agreed that CHAs were doing a good job. Island-wide in 1978, 94”/, of households sampled agreed that the CHAs were doing a good job [33]. In St James, however, this measure was not very strongly related to the CHA’s contact frequency as compared to the strong relationships found with the other variables. There is little indication that the results of this evaluation were employed in program planning. Professionals continue to press for higher educational qualifications for aides as a condition to granting greater responsibility while community opinion supported the view that aides were already performing

Evaluating

PHC

Table 3. Primarv

and nutrition

health care moeram

programs outcome

229

evaluation

outcomemeasures Sampled 1973:

1975:

1978:

groups

Treatment high Treatment low Control Treatment high Treatment low Control Whole uarish

(iv (N (N (N (N (N (h’

= = = = = = =

204) 107) 205) 182) 220) 123) 1611

a

b

c

d

e

f

g

8.7 8.1 5.7 4.1 5.3 3.5 9.3

16.2 17.7 8.9 26.0’ 21.7’ 11.7.

50 32 35 52 36 31

68 49 61 63 67 78

62 53 28 76* 66’ 49’

31 33 32 36 29 29

18 22 25 37’ 23 37

*Change significant at 0.05 from 1973 to 1975. Outcome measures: a-_“, children O-36 months of age malnourished according to Gomez II and III; mothers wth 3 or more children under the age of 5: c-_% infants being breastfed at the time interview; d--9; of I year olds sharing 90% of’ mother’s, dietary items; e-_% households using grown food in the family diet; f-_9b reported attendance at recent child welfare clinic session; reported attendance at recent family planning clinic session.

well and should be given broader responsibilities and training [33]. A central aspect of the program which overrides the effort evaluation considerations is that health aides have been recruited by parish councilors and other party functionaries based on political criteria. Health professionals and the community have had little to say regarding who will be trained. Conthe question of applying evaluation sequently, findings to recruitment procedures is subordinated to political processes beyond the scope of the program. INTERNAL

EVALUATION:

OUTCOME

The outcome evaluation assessed the impact of the program on mothers and their preschool children. The behavioral outcomes expected by the program included: Increased utilization of clinic services Better child diets from the family food pot More use of home grown foods from family gardens More prevalent breast-feeding. These behavioral changes were expected in turn to reduce young child malnutrition, morbidity, and death. In addition, maternal fertility was to be reduced. The methodology for this type of evaluation was straightforward. Measurable variables were designated and a quasi-experimental design was employed to determine changes over time in the program variables in two ‘treatment’ populations and one control population. Roughly 300 households with a total of 500 children were randomly chosen in 1973 and again in 1975 from the St James population. Outcome

evaluation-results

The evaluation of seven different expected outcomes of the program showed only one change which could be clearly attributed to the program (i.e. attenTable 4. Infant

mortalitv

rates

1970-1973 (mean)

1974

1975

1980

26 36 30 29

34 18 22 26

29 11 11 23

28’ 25* 24* 27

St James Parish Hanover Parish Trelawny Parish All Jamaica Source: Jamaican Department (*) determined by [39]

of Statistics

[l6] and corrected

rates

Vi,; of the home g-_%

dance of mothers at family planning clinics, Table 3). Although changes did occur in both treatment and control groups, significant changes associated with the new program were not found for fertility levels, young child nutritional status, or any of the dietary variables [18, 341. Some of the variables measured were admittedly crude and could have glossed over more subtle changes. Also, since the parish as a whole appeared to have changed, it was possible that program effects diffused to households that had not received direct service from the program, thus invalidating the control. Nutritional status. Although’ the impact of the CHA program on nutritional status of preschoolers proved insignificant, the nutritional status of children &36 months of age in the St James population probably improved due to generally better services and economic conditions from 1972 to 1975 [35]. By 1978, another survey showed declines back to levels similar to 1973 as economic conditions deteriorated [36]. In Hanover, an adjoining parish, convincing evidence suggests that nutritional status of children improved from around 10 to 4% malnourished according to Gomez II and III over the period 1973-1975, due to the new primary care program [12, 371. In 1978, the figure held at 6.5% malnourished [36]. However, in Hanover, the program benefited from outside management and service personnel provided by the Cornell Medical School. Hanover contained nearly twice as many aides per population as any other parish [33]. And, compared to other parishes, it had a relatively continuous supply of food aid from the U.S. that was distributed by the health aides to children found to be malnourished. Whereas external food aid to St James fell from 0.4 lb/person in 1973 to 0.2 lb/person in 1974, Hanover was the only western parish to get an increase (from 0.3 lb/person to 044lb/person or about 40 lb for every malnourished child in the parish) [38]. Clearly, the external influence of the Cornell personnel and U.S. food aid could account for the improvements in Hanover compared to St James. Infant mortality. The sample included in the St James study was too small to yield meaningful mortality data. Consequently, official data from the government has been used to estimate program outcomes by comparing parish mortalities with Jamaica as a whole (Table 4). Unfortunately, these data prove to be quite inconclusive for two major reasons (i) the under-reporting

THOMAS J. MARCHIONE

230

of deaths in the western parishes including St James and Hanover, i.e. two-thirds of deaths were unreported in 1980 according to a recent study by the University of the West Indies Medical School [39] and (ii) deaths of children residing outside St James were being attributed to St James due to the new 400 bed hospital which opened in Montego Bay, St James, in 1974. Thus, deaths from adjoining parishes were being attributed to St James, thereby inflating its mortality rate while deflating those of the adjoining parishes (including Hanover). Unfortunately, the uncertainties of the mortality reporting throw into doubt the reliability of all mortality data that purport to show health improvements as a result of the CHA program. On balance, the health outcome of the program seems positive, but quite minimal relative to the impact on health of other aspects of Jamaica’s development, and relative to the consequences of the program as a means of achieving other development goals. EXTERNAL

EVALUATION:

THEORY-IN-ACTION

In the evaluation of theory-in-action, the task before the researcher is to unearth the disease theory implied by the health program and to assess it in relation to known epidemiology of the diseases in question. Although it appeared that the CHA program had made little impact on the health and nutritional outcomes in St James, a closer examination of the nutritional status of children under three years of age showed significant improvement. This improvement, however, occurred quite independently of the levels of service the child’s family received from the health program [see column ‘a’ in Table 31. In fact, in the rural areas, malnutrition levels decreased from 9.5% in 1973 to 4.5% in 1975, a statistically significant difference at 0.05 [12, 35, 40, 411. Over the same period, the urban levels of malnutrition remained unchanged at approximately 57: A number of Jamaican studies show clearly that the more important elements affecting the health and nutrition of the people are factors relating to matters of access to resources, such as land and income, family coherence and perhaps matters related to maternal age and fertility [40]. From an epidemiological study in the households, it became evident that the nutritional status of children could be explained by variables of this nature. In fact, 25”/:, of the variance of weight for age could be explained by variables which were clearly more socio-economic or socio-cultural than they were related to health per se [40, 411. In 1973, children in households on small subsistence plots with one or more absent parent. with high maternal fertility and young maternal age were the more malnourished. From 1973 to 1975, the overall development program in Jamaica resulted in better income, employment and family conditions for the rural farming household. Consequently, there was an even more marked improvement in young child nutrition in farm households in St James from 1973 to 1975 [35]. Therefore, from the point of view of theory-inaction, it appears that the primary health program

activities were not very closely connected to thr factors most relevant to the health and nutritional outcomes desired. In other words. there is evidence of failure of theory-in-action. The positive aspects of the program are rather more clearly seen in its contribution to the broader development goals of the country. In fact. it may have been the progress Jamaica made in achieving its wider self-reliant development goals which explains the nutritional improvement from 1973 to 1975. EXTERNAL

EVALUATION:

NATIONAL

PRIORITIES

The evaluation of the health program in relation to national development priorities examines the institutional character of the program in relation to social political goals. rather than health improvement per se.

From 1972 to 1980, the CHA program was only one part of Jamaica’s overall strategy of democratic socialism. The elements of this policy were very similar to the self-reliant ‘inward’ looking development strategy spelled out by non-aligned nations [23, 42, 431. The general goal of self-reliant development is increased national self-reliance without autarchy. The purposes of the policy were directed toward changes in the structures of Jamaican society. The societal goals were (I) socio-economic equity. (2) increased participation of the people in the political process, (3) dissociation from traditional dependent relationships with developed countries. (4) greater self-reliance on indigenous technologies, skills and resources. The relationship of this policy to Jamaica’s primary health program was spelled out in 1978: 1. The health of the people is a basic element of development and health care is a fundamental human right. 2. Jamaica’s health policy developed as a natural outflow of the overall Jamaican philosophy of democratic socialism. Falling within this common conceptual framework. the Ministry of Health’s policy blends into the total national developmental program and harmonizes with the policies of other governmental sectors. Health services are not only a complex of purely medical measures. They are an essential component of the socio-economtc and other measures which are being used to protect and rmprove the well-being of every indivtdual and of the commumty as a whole. 3. The concept of democracy and the concept of equality. which are tenets of the government’s philosophy. have particular relevance for the health policy [3l].

Thus. Jamaica’s development priorities were not directed at economic growth per se. although this was not precluded, but rather at the transformation of political, economic and social structures which characterized its underdevelopment. Under the PNP, development programs were designed to affect the processes generating socio-economic inequality. governmental autocracy, and national dependency. From this viewpoint, the primary care program must be viewed either as contributing to processes of development change or contributing to processes by which existing societal structures are reproduced. In Jamaica. I have identified four pairs of opposing processes: (I) centralization versus decentralization of decision making; (2) concentration versus equit-

Evaluating

PHC

and nutrition

able redistribution of needed goods and services; (3) professionalization versus deprofessionalization of services; (4) national dependency versus national self-reliance which runs through the other three processes, but stands alone in some respects. Centralization

us citizen participation

The new primary care effort using CHAs envisioned recruitment and management along more decentralized, citizen participatory lines than is customary in Jamaica’s health services. The Jamaican government’s bureaucracy and the Jamaican professional hierarchy reflects its colonial legacy of centralized decision making. The CHA program designers sought to use the party mechanism to avoid these hierarchies in planning and implementation, therefore, neither communities nor lower level bureaucrats were openly consulted regarding the implementation of the program. A prominent government physician who was not consulted said the program was implemented in “the dead of night, as it were”. This occurred. in part, because many health professionals, in and out of the government bureaucracy, opposed the program and would have probably mobilized to block it if it had been instituted more openly. Consequently, although the goal was participatory, the implementation was necessarily from the top down. The parish public health nurses were particularly opposed to this imposition, and continued to object to the lack of input from health professionals in the recruitment of health aides. Eventually, medical professionals did restrict the program’s scope and the CHAs’ role responsibilities. And, as was shown already, ‘professional’ training and recruitment was a detriment to community service goals. Project planners attempted to avoid the constraints imposed by health professional authorities by appealing directly to the rural peasant community. The CHAs, rather than being selected by the health establishment. were recommended by parish level district councilors. These elected officials, in cooperation with Ministers of Parliament in Kingston, are the unofficial brokers of jobs in Jamaica and, although they are clearly distributing limited jobs according to party patronage, their selections are probably more likely to correspond to local popular interests than would selection controlled by health professionals. In fact. the results of the two surveys of community acceptance of the program have demonstrated overwhelming approval of the CHAs work, despite the obvious favoritism in selection [18, 331. Another way the health plans of Jamaica sought to go beyond the limitations to all these hierarchies was through the establishment of local health committees [31]. The committees were designed to provide a ‘symmetrical’ relationship between health receiver and health provider-to ‘articulate’ community, professional and scientific concern. The committees were composed of local health personnel, including CHAs and community members. Among the purposes of the committees were determinati,ons of health needs and active community involvement in primary care [31]. In St James. 13 committees were initiated in 1972-1973. but only one committee was still meeting by 1975. The committee members were appointed by

programs

231

the central government and had no budget for their activities. The committees were expanded and revised in 1977, but in 1981, a study indicated that the fifty health committees created island-wide needed revitalization. They clearly had not assumed a role of any significance [44]. The new decentralized management approach ran into difficulties for a number of reasons. CHAs were paid from the Ministry of Health in Kingston and supervised by the Public Health Nurses who also were paid from Kingston and were under project supervision through the Chief Nursing Officer in Kingston. Although recruitment involved local parish councilors, the district midwives and public health inspectors who were paid by local government budgets did not have a recognized status vis-ti-vis the new health aides. In fact, some of the proposed functions of the CHAs would have duplicated those of the midwives and public health inspectors; understandably, the midwives and public health inspectors were initially resistant to the program. District level coordination of different sectors of the health system, including viable health committees, continues to be a significant management problem in Jamaica [44]. Concentration

us equit)

A principal goal of the PNP government was the equitable redistribution of national assets, goods and services to satisfy a range of basic needs and rights of all citizens. In this regard, the CHA program was a qualified success as a mechanism for creating employment and for extending access to primary health care. As an employment measure, the CHAs program provided employment at relatively good salaries to over 1000 unemployed, largely rural, lower class women. Unemployment stood at 24:; in 1972 when the PNP took office [27] and the special employment program of the PNP lowered this figure to 20:,: by 1976 [45]. Although CHAs had a relatively limited role, they reached out to areas which were quite isolated from the existing services at that time. Up to this time, these areas were only periodically served by non-resident midwives, health inspectors, and public health nurses, and were visited quite infrequently by physicians. The facilities were dilapidated health stations with a minimum of medical supplies. The CHA brought these communities the continuous presence of the primary care system and a link to the wider health and welfare system which was well appreciated and desired by the poor and isolated citizen. The major qualification to this positive achievement was the distortion of CHAs’ distribution due to party patronage. Jamaica’s long standing commitment to multi-party politics represents a successful democratic institution for popular participation. In Jamaica, elections are generally fair and turnout is often in excess of 807; of eligible voters [16]. However, the party structure is a two-edged sword. Party politics in the daily life of communities in the Caribbean, especially Jamaica, cannot be understressed. Politics in lower class Jamaica is not only an important social activity, it is lifeblood [22, 46, 471. Loyal clients receive employment. eligibility for government programs, promotions. government contracts and numerous other favors from central gov-

THOMAS J. MARCHIONE

232

ernment political patrons and their local agents [48]. Two types of party influences on the Jamaican health aide program tended to distort realization of health care rights: the recruitment and consequent deployment of CHAs based on political party patronage, and the influence of politics on the quality of primary care services rendered. As was discussed previously, the deployment of CHAs was quite uneven. The maldistribution of health aides could be partially traced to the fact that certain areas which were in political favor provided more recruits to the program since PNP party officials heavily influenced selection. Since the program was designed to return individuals to their home communities, maldistribution of aides tended to become a problem. Although the average number of aides in pro-government versus opposition districts was not grossly imbalanced in St James parish, one needy area loyal to the opposition JLP received one aide while one area considered a government party stronghold with similar needs and of similar size had 14 aides. In 1975, another parish showed a ten-fold difference in aide density in government strongholds vs opposition areas (Table 5). The island-wide evaluation done in 1978 found this problem to be a persistent one, causing aides to also work outside of their home communities, although the program was designed to recruit CHAs from all communities requiring services [33]. The influence of politics on party CHAxommunity relationships also posed a threat to the primary care goals. The aides, it was claimed, would preach government politics rather than preventive health and nutrition in the households. This problem never materialized to any great extent. Although some antagonisms were clearly present between members of the opposition and the health aides in one or two communities, overall program acceptance was very high and aides concentrated on their essential health and nutrition tasks. Medical professionalization

us deprofessionalization

Medical professional dominance and centralization was a structural impediment to citizen participation. Although professional medical persons in the government engineered the program, the professional societies opposed it, including the Jamaica Medical Association. It was also opposed by practicing health professionals in the government who were commonly unmindful of citizen input to programs. In addition. the opposition affected the program plans and operations. A major goal of self-reliant development is the use of appropriate health technology. In Jamaica, this clearly implies a step away from the heavily West-

Table

5. Distributmn

of health

ades

Area

Total upon the Pansh

in a push CHA’s

Deep rural JLP* districts Deep rural PNP’ districts Rural towns Capital ‘city‘

*Based

ernized. high technology medicine which was the dominant model taught at the University of the West Indies (UWI) from 1958 onward [18]. In this context. the CHAs program was a major step toward providing a new cadre of workers with health skills. knowledge and service attitudes appropriate to the most prevalent primary care needs of poor Jamaicans [49. 501. It was a major innovation for Jamaica to expand the pilot CHA program along with its general effort to reorient medicine from hospital-based curative care to community-based primary care. Professional opposition came quickly from numerous quarters. such as the private medical associations [18]. From the time of the first pilot health aide program in Jamaica in 1967 until the final implementation in St James parish, the role of the Community Health Aide was diluted considerably. Initially, even the small pilot project begun at the University of the West Indies Department of Social and Preventive Medicine was vigorously opposed by the nursing profession, especially by private nursing services and by public health nurses. The designers of this program stressed that the health aide would not conflict with nurses. To insure this, the program came under the strict and direct supervision of public health nurses. Later recommendations by the Pan American Organization which would have given the aide responsibilities for midwifery similar to the Venezuelan Simplified Medicine Program were not implemented [51]. Trained nursing staff became quite agitated when the community began to call the health aides the ‘new nurses’ and began to demand more health services than the aides were trained or allowed to provide. Similar antagonisms arose regarding the high pay given to the health aides compared to trained assistant nurses. Predictions of health professionals regarding the general inability of health aides to keep health problems confidential and the potential for medical malpractice by relatively unsupervised aides proved to be unfounded. In fact, the evidence regarding the effects of the selection and training of health aides presented in the effort evaluation suggested that transmitted values and recruitment by the nursing profession attenuated needed CHA effort at the community level-a reproduction of the proclivity of Jamaican nurses to migrate to the United States and European countries. Consider that the CHAs most highly rated by nurses were more likely to leave the service and were less likely to render household services. There were 1888 nurses in public service in Jamaica in 1974, many of whom were trained at the University of the West Indies. In parishes such as St James, nursing posts usually have exceeded the number of trained persons

Council

Elecuons

smxlar

to St James (1975)

Districts

CHA‘s; distnct

3 2s 40 ?I

6 5 9 7

0.5 5.0 4.4 30

89

25

3.3

of 1974

Evaluating PHC and nutrition programs willing or available to fill them. Before the onset of economic difficulties in the late 1970s the country lost 2900 nurses through emigration [52], the largest single professional, technical and kindred occupational group of emigrants in that period from 1962 to 1974. In 1981, half to one-third of public health nurse and district midwife posts were unfilled [44]. This reflects the continuing cultural dependence of the professions on standards of practice and desirable lifestyles established in the United States and Great Britain. In this program, the nurses served as a model for this life-style among the CHAs, although they were not alone responsible for these aspirations. Dependency us self-reliance

The attempt to shift from structures of neocolonial dependence toward structures of national self-reliance was an over-riding development policy of the PNP government. Self-reliant development as defined by the non-aligned movement incorporated the goals of decentralization of authority, equitable distribution of national assets and reliance on appropriate indigenous skills. In this context, the new primary health program using CHAs was one of many programs designed not only to deliver a particular service, but to also reform social structures. We have already seen how the persisting legacies of dependence were a source of struggle during the establishment of the CHA program. A clear vehicle for continuing dependency relations was international medicine, which tended to inject elements of continuing reliance on developed countries as a part of project implementation. Since the Jamaican government received funding for its primary care effort from external sources, this opened the way to reliance on new types of foreign expertise and opened the program to foreign influences. There is a well recognized propensity for Jamaican officials to respect outside expertise while local expertise often remains unheeded. Influence is exerted indirectly through the orientation of trained medical people toward U.S. and European medical practice and life style. For instance, the genesis of the CHA program was closely linked to the early health aide programs developed by the Office of Economic Opportunity at the experimental health center in the Bronx, New York [18, 491. The influence was exerted directly when the Cornell Medical School gained entree to Jamaica to do a pilot study of the primary care program in Westmoreland parish in western Jamaica in the early 1970s. As the program expanded island-wide following the PNP’s election. the Cornell Medical School was given control of the program in Hanover, an adjoining parish to St James. The medical school stationed at least one senior professional in the parish and had rotations of medical students flown in from the U.S. to run mini-clinics to which CHAs brought and referred householders. The project director (a North American physician) worked closely with the highest levels of the Jamaican government and U.S. Agency for International Development convincing the U.S. Ambassador of the value of the primary care effort using CHAs. In Hanover, the program included introducing a food supplementation program where CHAs would weigh children and chart their weight

233’

on growth graphs identifying individuals to be given free supplements. The supplements were provided through the U.S. PL480 program which sells or grants food surpluses grown by U.S. farmers. As discussed previously, Hanover was the only parish in the western part of Jamaica which received an undiminished supply of these food commodities through the food crisis in 1974. The program appeared to be run very efficiently. Periodic reports were made quarterly on children seen, recovered, or deteriorating. The press wrote of dramatic reports of 50% reductions in malnutrition and mortality rates in children under four years of age [37]. Indeed the statistics presented were impressive looking. However, skepticism in these results was well-founded, as recent mortality data suggest (see ‘outcome evaluation’). Even given its superiority in producing short-term health outcomes, the Hanover CHA program fell far short on the wider development goals. The foreign medical school had, in its rush to get things moving in Hanover, bypassed the local health personnel and public health nurses; the normal clinic schedules for rural areas were ignored and the poor quality of public health was strongly implied. Furthermore, the Jamaican Government exacerbated the situation by allowing funds to be used for the travel and accommodation of foreign medical students and faculty while largely ignoring the financial needs of local Jamaican health professionals and medical students seeking involvement in the project. Aside from providing brief clerkships to a handful of students, the Cornell sponsored program gave little financial support to the University of the West Indies Medical School which would eventually assume the islandwide responsibilities for the new program. In general, the structure in Hanover was not one that was repeatable throughout the island or sustainable when the heavy reliance on Cornell was removed. The Hanover project illustrates well how internal project goals might be achieved at the expense of ‘external’ development priorities. The Hanover project injected outside food aid contrary to. the self-reliant policy of ‘grow our own food’ of the Jamaican government; it used U.S. health professional management, outside medical workers and absorbed a large proportion of local resources, i.e. CHAs available for the whole island. Dubious outcome results and cost benefit data are now presented as an illustration of the superiority of ‘well managed’ primary care programs. Such models are at best illustrations of how evaluations can be internally valid with regard to health goals, but externally invalid in relation to development priorities. SUMMARY

AND CONCLUSIONS

The primary health care program implemented by the Jamaican government in 1972 was evaluated according to health goals internal to the program and according to development goals of the wider society external to the program. In combination, four sets of criteria were applied which give a mixed, yet positive assessment of the program’s impact. Internally, the program was successful in estabhshing a health system employing over one thousand

234

THOMAS J. MARCHIONE

health aides who were deployed in previously underserved rural communities containing mothers and young children at high nutritional and health risk. Although this health delivery effort was distorted by the patronage politics of Jamaica’s two party system, the evaluation of program effort proved positive. Also, at an internal level, the assessment of the health and nutrition outcome goals remains mixed and still somewhat unclear. In St James parish, no positive effects were observed with the exception of increased usage of family planning services by mothers. In Hanover, however, positive impacts on nutritional status and mortality of young children have been reported by other researchers. However, recent data suggest that mortality improvements may be overstated and questionable because of the unreliability of government mortality recording procedures. From a perspective external to the program, there is evidence that its methods for improving health in St James were based on faulty theory-in-action. Whereas the program relied upon increasing use of primary care centers and nutritional behavioral change, the epidemiology of malnutrition tended to be strongly linked to access to jobs, land, income, and the household’s social support system. In fact, the wider development accomplishments of Jamaican society from 1973 to 1975 appear to explain observed improvements in young child nutritional status in rural St James more than does the health program per se.

The program’s major achievements may have been its contribution to the wider development goals of national self-reliance and human rights which were external to its health goals. Consistent with these wider goals, it sought to (i) extend equitable access to primary health care and employment, (ii) involve communities in decisions affecting their health care, (iii) implement appropriate professionalized medical technology and (iv) generally to initiate a self-reliant health system. The record of the program was probably greater in extending equity than it was in the other goals because of the formidable opposition faced in preexisting structures of neo-colonial dependence, centralization, and professional medicine. It is ironic that greater health benefits are being demonstrated by U.S. evaluators for the primary health care program in Jamaica in the parish where self-reliant goals were more compromised (i.e. Hanover vs St James) [ 121. It must be recognized that such results have considerable significance in promoting one view of development versus another. In the case of Jamaica under self-reliant, democratic socialist development, an appropriate evaluation must include an ‘external’ perspective which rates the program on the grounds of its capacity to transform the society in such a way that basic political rights and economic rights are more likely to be realized, along with health improvement. There is good reason to believe that these wider benefits will improve health status in the long term more than will targeted efforts at health care, especially when they are subject to the vicissitudes of international intervention. Cost-benefit or other strictly internal evaluations tend to provide empirical confirmation for the superiority of continuing dependence on health

inputs from dominant countries. The short-term health benefits of such an approach are offset by the loss of self development in infrastructures needed for longer-term improvement in life quality. including health status. Such an approach also tends to discount progress in fulfilling rights other than the right to primary health care. Efforts to follow the primary health program closely in the later 1970s proved difficult in the highly charged political environment during that period. Investments designed to produce new self-reliant structures proved to be too costly and unpopular with dominant North American and Jamaican capital. Jamaica’s economic dependence on tourism. bauxite, agricultural exports, and oil imports made the PNP government vulnerable to economic decisions outside its control. So, by 1977, the self-reliant policies of the PNP were significantly trimmed back in accordance with conservative economic stabilization programs imposed as loan conditions by the International Monetary Fund. A general disillusionment set in as unemployment increased, along with prices and shortages [24]. Although nutritional status appeared to be somewhat improved in 1978 over 1972, the economic situation in the households rapidly began to deteriorate in the following years [36, 451. In 1980, Jamaican people chose to return to a dependent neo-classical national development goal and re-elected the JLP. The new primary care program remains today as a new kind of legacy for Jamaica, a ‘social gene’ intended to produce more self-reliant structures in the midst of a government elected to reinstitute development through increasing reliance on outside intervention.

REFERENCES 1. Joseph S. C. Outline of national primary care system

2. 3. 4. 5. 6.

7. 8.

development: a framework for donor involvement. Sot. Sci. Med. 14C, 177-180. 1980. Joseph S. C. and Russell S. S. Is primary care the wave of the future. Sot. Sci. Med. 14C, 134-144. 1980. Janzen J. M. The comparative study of medical systems as changing social systems. Sot. Sci. Med. 12, 121-129. 1978. Eide A. Choosing the path to development. The impact for human rights. Bull. Peace Prop. 4, 349-360. Litman T. J. and Robins L. Comparative analyses of health care systems-a socio-political approach. Sot. Sci. Med. 9, 573-581, 1971. Elling R. H. Regionalization of health services: sociological blocks to the realization of an ideal. fopius and Utopias in Health (Edited by Ingman S. and Thomas A.). Mouton, The Hague, 1975. Thomas A. E. Health care in Ukamki, Kenya: a socialist critique in Topias and Utopias in Health (Edited by Ingman S. and Thomas A.). Mouton. The Hague, 1975. Baer H. On the political economy of health. Med. Anthrop. Newslert. 14, I. 1982.

9. World Health Organization. Declaration of .4lma Ata, Report on the International Conference on Primary Health Care. Alma Ata, U.S.S.R., ICRHC,‘ALA:‘78. IO. 1978. 10. U.N. General Assembly, December, 1966. I I. U.N. General Assembly. Universal Declaratton of Human Rights. U.N. Dot. Ai December. 1948. 12. Gwatkin R.. Wilcox J. and Wray J. Can Health and Nutrition Make a Yifference” Overseas Development Council, Washington, Monograph 13, 1980.

Evaluating PHC and nutrition programs 13. Walsh J. A. and Warren K. Selective primary health care: an interim strategy for disease control in developing countries. Sot. Sci. Med. 14C, 145-163, 1980. 14. Marchione T. J. Evaluation in a Caribbean context. Sociocultural factors affecting a Community Health Aide Program. Nutrition and Food Science: Present Knowledge and Utilization (Edited by Santos W. et al.). Plenum Press, New York, 1980. 15 Paul B. (Ed.) Health, Culture, and Community: Case Studies of Public Reactions IO Health Programs. Russell Sage Foundation, New York, 1955. 16 Knutsson K. E.. Gebre-Medin M., Hultcrantz G., Tobisson E. and Wallstram E. Food and Nutrition in National Development: An Evaluation of the Tanzania Food and Nutrition Centre. TFNC and Swedish Inter-

national Development Authority, 1979. 17 Elzinga A. Evaluating the evaluation game: on the methodology of project evaluation, with special reference to development cooperation. SAREC Report (RI) Swedish Agency for Research Cooperation with Developing Countries. Stockholm, 1981: 18 Marchione T. J. Health and nutrition in self-reliant national development: an evaluation of the Jamaican Community Health Aide Programme. Ph.D. Dissertation, University of Connecticut. University Microfilms, 1977. 19. Suchman E. A. Evaluation Research: Principles and Practice

20

21.

22. 23. 24.

25. 26. 27. 28. 29.

in Public Service and Social Action

Programs.

Russell Sage Foundation. New York, 1967. Smith M. G. The Plural Society in the British West Indies. The University of California Press, Berkeley; 1965. Jefferson 0. The Post-War Economic Development of Jamaica. Institute for Social and Economic Research, University of the West Indies, Jamaica, 1972. Kuper L. Changing Jamaica. Routledge & Kegan Paul, London. 1976. Manley M. The Politics of Change: A Jamaican Testament. Andre Deutch, London. 1974. Girvan B. R. and Hughes W. The IMF and the Third World: the case of Jamaica 1974-80. Dev. Dialogue 2. 113. 1980. Puffer R. R. and Serrano C. V. Patterns of Mortality in Childhood. PAHP, Washington, DC, 1973. Sivard R. World Military and Social Expenditures 1974. Institute for World Order, New York, 1974. Jamaican Department of Statistics. Statistical Yearbook of Jamaica 1974. Government Printer, 1975. Fox H., Campbell V. S. and Harris J. The dietary and nutritional status of Jamaican infants and toddlers. Bull. Scient. Res. Count. 8, 3 l-51, 1968. Gurney J. M.. Fox H. and Neil1 J. A rapid survey to assess the nutrition of Jamaican infants and young children in 1970. Trans. R. Sot. trop. Med. Hyg. 66, 653-662.

1971.

30. Cook R. The cost of malnutrition in Jamaica. Ecol. Fd Nutr. 1, 61-66, 1971. 31. Jamaican Ministry of Health. Primary Health Care: The Jamaican Perspective: A Reference Manual for Primary Health Care Concepts and Approaches in Jamaica. Min-

istry of Health. 1978. 32. Fendall N. R. E. Auxiliaries

in Health

Countries.

The Johns

Care: Programs

Press, Baltimore. 1972. 33 Department of Social and Preventative Medicine in collaboration with the Ministry of Health and Environmental Control and Supported by the International in Deoeloping

Hopkins

235

Development Research Centre, U.W.I. An Assessment of the Community Health Aide Programme in Jamaica, 1978-79. DSPM, UWI, 1979. 34. Marchione T. J. Child nutrition and dietary diversity within the family: a view from the Caribbean. Fd Nutr. Bull. 312, 10, 1981. 35. Marchione T. J. Food and nutrition in self-reliant national development: the impact on child nutrition of Jamaican Government Policy. Med. Anfhrop. 1, 58-79, 1977. 36. Nutrition Unit, Ministry of Health and Environmental

Control and the Caribbean Food and Nutrition Institute, Draft Report of a Survey in Jamaica on the Nutritional Status of Vulnerable Groups in 1978 (mimeograph) 1978. 37. Alderman M. H. and Minott 0. D. Reduction of young child malnutrition and mortality in rural Jamaica. Trap. Pediat. Envir. Child Hlth 7, 1978. 38. Data on Western Parishes from 1971-l 978 provided by

Mr Chambers, Jamaican Government Child Feeding Service, 8 August, 1975. 39. Desai P. Infant mortality rate in three parishes of Western Jamaica, 1980. Department of Social and Preventative Medicine, University of the West Indies (mimeographed) 1982. 40. Marchione T. J. and Pryor F. The dynamics of malnutrition in Jamaica. In Social and Biological Predictors of Nutritional Status, Physical Growth and Neurological Development (Edited by Green and Johnson). Academic

Press, New York, 1980. 41. Marchione T. J. Factors associated with malnutrition in the children of Western Jamaica. In Nutritional Anthropology (Edited by Jerome N., Pelto G., and Kandel R.)

Redgrave Press, New York, 1980. 42. Erb F. and Kalak V. Beyond Dependency: The Developing World Speaks Out. Overseas Development Coun-

cil, Washington,

DC 1975.

43. Ul Haq M. The Poverty Curtain: Choices for the Third World. Columbia University Press, New York, 1976. 44. Sinha P., Diloreto A. and Rojas-Aleta I. Primary Health Care in Jamaica (Assessment Report). Pan

American Health Organization/WHO

1981.

45. Jamaican National Planning Agency. Economic and Social Survey, January-June 1981, Government Printer,

Kingston, Jamaica, 1981. 46. Stone C. Electoral Behaviour and Public Opinion in Jamaica. Institute of Social and Economic Research,

University of the West Indies, Kingston,

1974.

47. Foner N. Status and Power in Rural Jamaica: A Study of Educational and Political Change. Teachers College

Press, New York, 1973. 48. Jamaican Governor’s Commission of Enquiry. Report of Commission of Enquiry into the Award of Contracts, the Grant of Work Permits and Licenses and Other Matters. Government Printer, Kingston, 1973. 49. Ennever O., March M. and Standard K. E. A Community Health Aide Training Programme. Wesr Indian med. J. 18, 193-201. 50. Garrett, E. J., Jumar A. K. and Standard K. E.

Approaches to primary health care in the commonwealth Caribbean. Educ. med. salud 15, 232-248, 1981. 51. Felzer M. Draft project for training programme of Community Health Aides. Unpublished Document. PAHO, Kingston. Mimeographed, 1971. 52. Palmer R. W. A decade of West Indian migration to the United States, 1962-72: an economic analysis. Sot. Econ. Stud. 23, December, 1974.