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GOOD INTENTIONS, UNFORTUNATE CONSEQUENCES
1334 GOOD
INTENTIONS, UNFORTUNATE CONSEQUENCES
SIR,-In 1978, at a conference in Alma Ata, United Nations member states accepted a policy on primary health care (PHC) that was
remarkable both for its universal acceptance and for the scale of
change proposed. In developing countries, this meant a move away from hospital and technology based services towards access to basic preventive and curative services for everyone. Despite this international consensus on PHC some international agencies, including UNICEF and the World Bank, have adopted a different approach that seeks to reduce child mortality quickly by the use of selective health interventions. This approach is known as GOBI (growth charts, oral rehydration, breast feeding, immunisation). Although GOBI is often presented as complementary to PHC, in practice they often conflict. In most developing countries PHC means the extension of services through the training of village level workers to provide basic curative care such as oral rehydration and preventive activities such as improved sanitation. It is perhaps less widely appreciated that PHC also provides a link between the community and "conventional" services from government health staff, and that this link can improve the efficiency with which more complex services are provided. Immunisation coverage is much easier to achieve when there is an organised link with a population, and there is considerable potential, for the first time in most poor countries, to address hitherto intractable problems such as tuberculosis, which require high levels of contact and compliance. PHC is developed with community involvement and support, which in many places means that the community pay, in cash or kind, for the services received. The introduction of charges, such as the sale of low-cost generic drugs through conventional services, raises the possibility that health services in the developing countries can be substantially financed locally and become less dependent on international assistance.
RESPONSIBILITY AND ILLNESS
Sir,-Dr Skrabanek (Nov 21, p 1180), in a book review, asserts that Health for All by the Year 2000 implies that those who do not achieve health by this date will be held responsible for their fate. Everything published about this programme seems to me to take the very dlfferent view that the health of individuals is largely determined by public policies and that individuals might be healthier if they had a larger say in shaping those policies. Department of Epidemiology and Social Oncology, University of Manchester, Christie Hospital & Holt Radium Institute, Manchester M20 9QL
ALWYN SMITH
ARE CHILD SURVEILLANCE CLINICS WORTHWHILE?
SIR,-lt
has
been claimed that
developmental
climes are
beneficial for the early detection of remedial abnormalities, reassurance of parents, and a means for answering parents’ questions.! There is concern, however, about the clinics’ effectiveness.2 A retrospective audit of 349 records of attendances for paediatric health-checks done by a general practitioner with a trainee over one year was made. These well-attended examinations at six weeks, seven months, and one, two and a half, and four years revealed 38 suspected abnormalities (an abnormality was defined as that sufficient to require another appointment for treatment or followup) (table). Other minor abnormalities have been ignored. 3 children had two abnormalities each with hearing loss and speech delay and 1 had both Down syndrome and a pathological heart murmur. 8 children with suspected abnormalities are still under surveillance awaiting final allocation. SUSPECTED ABNORMALITIES FOUND DURING
349 ATTENDANCES
FOR PAEDIATRIC HEALTH-CHECKS
Clear measures of the impact of PHC on health are still lacking. However, a regular, reliable, and sustained contact between a health service and its population must surely be a precondition for success. In contrast, the GOBI approach seeks to secure the maximum impact on health in the minimum of time. GOBI is promulgated by use of the mass media to promote ORS and other health education messages and by national immunisation campaigns, which seek to achieve the maximum coverage in a short time. In the
the
countries, these campaigns are heavily dependent upon imported funds, material, and personnel. Although there are common areas between PHC and GOBI (eg, some health education activities), there is, in the underlying philosophy and practice, a direct conflict. If PHC is a method by which people, both directly and through their national services, can improve their own health and sustain that improvement, then GOBI is its opposite. GOBI is dependent upon large foreign inputs which cannot be replaced locally, and the technology is essentially imposed on the population concerned. Worse, given the reluctance of most international aid donors to consider long-term financial support, any impact on health will be transitory. For example, poorer
immunisation coverage in Lesotho in 1986 was 65 %-an impressive coverage built up over many years of consistent service
development. An accelerated programme is being implemented by UNICEF ; this may well raise coverage but will inevitably create increased recurrent costs which the government is ill placed to support. The poorer developing countries, especially those in Africa, are highly dependent on international aid and can hardly refuse offers of assistance. In many of them health policy is in effect formed by the major aid donors. We find it surprising that this fundamental conflict of policy, which has consumed enormous sums of public money and which is widely discussed privately, has attracted so little public and professional debate. Save the Children, Mary Datchelor House, 17 Grove Lane, London SE5 8RD
JOHN SEAMAN PETER POORE
This study suggests that although few diagnoses were missed, an important proportion (4%) were incorrect, with attendant parental anxiety. This is a heavy price to pay for mis-diagnoses, which might have been ascertained anyway in the normal course of clinical work. More appraisal is necessary before general practitioners and their patients should be asked to spend so much time and resources in unselected developmental surveillance. We thank Dr A. M. W. Porter for
Upper Gordon Road, Camberley, Surrey GU15 2HJ
37
1
2
help and encouragement. C. B. DEL MAR I. S. MILLER
Polnay L, Hull D, eds Community paediatrics, London Churchill Livingstone, 1985, 3: 22-32. Hendrickse W. How effective are our child health clinics? Br Med J 1982,284:575-77.
SOCIOLOGY AND MEDICINE
SIR,-Professor Rose, in a book review (Nov 14, p 1120), states that there are few situations at which doctors and sociologists meet and that when they do the exchange is "not very fruitful". He cites meetings of the Society for Social Medicine as an example of these
INTENTIONS, UNFORTUNATE CONSEQUENCES
SIR,-In 1978, at a conference in Alma Ata, United Nations member states accepted a policy on primary health care (PHC) that was
remarkable both for its universal acceptance and for the scale of
change proposed. In developing countries, this meant a move away from hospital and technology based services towards access to basic preventive and curative services for everyone. Despite this international consensus on PHC some international agencies, including UNICEF and the World Bank, have adopted a different approach that seeks to reduce child mortality quickly by the use of selective health interventions. This approach is known as GOBI (growth charts, oral rehydration, breast feeding, immunisation). Although GOBI is often presented as complementary to PHC, in practice they often conflict. In most developing countries PHC means the extension of services through the training of village level workers to provide basic curative care such as oral rehydration and preventive activities such as improved sanitation. It is perhaps less widely appreciated that PHC also provides a link between the community and "conventional" services from government health staff, and that this link can improve the efficiency with which more complex services are provided. Immunisation coverage is much easier to achieve when there is an organised link with a population, and there is considerable potential, for the first time in most poor countries, to address hitherto intractable problems such as tuberculosis, which require high levels of contact and compliance. PHC is developed with community involvement and support, which in many places means that the community pay, in cash or kind, for the services received. The introduction of charges, such as the sale of low-cost generic drugs through conventional services, raises the possibility that health services in the developing countries can be substantially financed locally and become less dependent on international assistance.
RESPONSIBILITY AND ILLNESS
Sir,-Dr Skrabanek (Nov 21, p 1180), in a book review, asserts that Health for All by the Year 2000 implies that those who do not achieve health by this date will be held responsible for their fate. Everything published about this programme seems to me to take the very dlfferent view that the health of individuals is largely determined by public policies and that individuals might be healthier if they had a larger say in shaping those policies. Department of Epidemiology and Social Oncology, University of Manchester, Christie Hospital & Holt Radium Institute, Manchester M20 9QL
ALWYN SMITH
ARE CHILD SURVEILLANCE CLINICS WORTHWHILE?
SIR,-lt
has
been claimed that
developmental
climes are
beneficial for the early detection of remedial abnormalities, reassurance of parents, and a means for answering parents’ questions.! There is concern, however, about the clinics’ effectiveness.2 A retrospective audit of 349 records of attendances for paediatric health-checks done by a general practitioner with a trainee over one year was made. These well-attended examinations at six weeks, seven months, and one, two and a half, and four years revealed 38 suspected abnormalities (an abnormality was defined as that sufficient to require another appointment for treatment or followup) (table). Other minor abnormalities have been ignored. 3 children had two abnormalities each with hearing loss and speech delay and 1 had both Down syndrome and a pathological heart murmur. 8 children with suspected abnormalities are still under surveillance awaiting final allocation. SUSPECTED ABNORMALITIES FOUND DURING
349 ATTENDANCES
FOR PAEDIATRIC HEALTH-CHECKS
Clear measures of the impact of PHC on health are still lacking. However, a regular, reliable, and sustained contact between a health service and its population must surely be a precondition for success. In contrast, the GOBI approach seeks to secure the maximum impact on health in the minimum of time. GOBI is promulgated by use of the mass media to promote ORS and other health education messages and by national immunisation campaigns, which seek to achieve the maximum coverage in a short time. In the
the
countries, these campaigns are heavily dependent upon imported funds, material, and personnel. Although there are common areas between PHC and GOBI (eg, some health education activities), there is, in the underlying philosophy and practice, a direct conflict. If PHC is a method by which people, both directly and through their national services, can improve their own health and sustain that improvement, then GOBI is its opposite. GOBI is dependent upon large foreign inputs which cannot be replaced locally, and the technology is essentially imposed on the population concerned. Worse, given the reluctance of most international aid donors to consider long-term financial support, any impact on health will be transitory. For example, poorer
immunisation coverage in Lesotho in 1986 was 65 %-an impressive coverage built up over many years of consistent service
development. An accelerated programme is being implemented by UNICEF ; this may well raise coverage but will inevitably create increased recurrent costs which the government is ill placed to support. The poorer developing countries, especially those in Africa, are highly dependent on international aid and can hardly refuse offers of assistance. In many of them health policy is in effect formed by the major aid donors. We find it surprising that this fundamental conflict of policy, which has consumed enormous sums of public money and which is widely discussed privately, has attracted so little public and professional debate. Save the Children, Mary Datchelor House, 17 Grove Lane, London SE5 8RD
JOHN SEAMAN PETER POORE
This study suggests that although few diagnoses were missed, an important proportion (4%) were incorrect, with attendant parental anxiety. This is a heavy price to pay for mis-diagnoses, which might have been ascertained anyway in the normal course of clinical work. More appraisal is necessary before general practitioners and their patients should be asked to spend so much time and resources in unselected developmental surveillance. We thank Dr A. M. W. Porter for
Upper Gordon Road, Camberley, Surrey GU15 2HJ
37
1
2
help and encouragement. C. B. DEL MAR I. S. MILLER
Polnay L, Hull D, eds Community paediatrics, London Churchill Livingstone, 1985, 3: 22-32. Hendrickse W. How effective are our child health clinics? Br Med J 1982,284:575-77.
SOCIOLOGY AND MEDICINE
SIR,-Professor Rose, in a book review (Nov 14, p 1120), states that there are few situations at which doctors and sociologists meet and that when they do the exchange is "not very fruitful". He cites meetings of the Society for Social Medicine as an example of these