Primary health care and developing countries

Sac. Sci. & Med.. VoL 13A. pp. 505 to 514 Pergamon Press Ltd 1979. Printed in Great Britain

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PRIMARY HEALTH CARE A N D D E V E L O P I N G COUNTRIES F. J. BENNETr Department of Community Health, Faculty of Medicine, University of Nairobi Abstract--Primary Health Care has been firmly established as the avenue which most developing c6untries will explore in the next twenty years, in order to improve the quality of life and health of every individual in every community. This commitment is largely the result of the Alma-Ata Conference which clarified many of the political, technical, social, administrative and educational aspects of Primary Health Care. This paper summarizes this process of consolidation of the concept, gives some examples of national plans, and then deals with types of support that facilitate community participation. Because PHC involves people rather than merely technology, the role of social scientists is one which needs greater emphasis. Primary Health Care, since 1975, has been a subject which has been discussed in innumerable seminars, workshops and conferences in every continent and has thus already generated a very large literature. The Alma-Ata Conference in September 1978 with 134 nations deliberating on the subject for one week was probably the largest single-theme conference ever held. Without a computer-aided search of the literature it is therefore, beyond the scope of this paper to review such a voluminoustopic comprehensively. Consequently this paper will merely give a personal view (medical more than sociological), a few examples of primary health care in some selected developing countries, and will indicate those facets of Primary Health Care that are at present of great interest. The well-known seven principles of primary health care were set out by the Director-General of the World Health Organization in his Report to the 28th • World Health Assembly in 1975 [1] and this model was again brought to the attention of social scientists in a position paper on Primary Health Care prepared for the Fifth International Conference on Social Science and Medicine I-2]. In that paper, Victor and Ruth Sidel gave evidence that "only in countries in which there has been a fundamental shift of wealth and power to those who previously had least and in which there has been an exercise of that power for the strengthening of equity and community is the model of primary care approached". Others have also stressed the fact that the creation of barefoot doctors was a political act to change patterns of control over health care [3]. Many subsequent reports and conferences have emphasized that Primary Health Care should result from a firm national resolve and decision [4, 5]. The Alrea-Ata Conference Joint Report for WHO and UNICEF [6] defines Primary Health Care as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families i n the community through their full' participation and at a cost that the community and country can afford, to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system of which it is the central function and

main focus of the overall social and economic development of the community: It is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process". This concept is further amplified to describe the essential services required, the participation of the community, and the need for support from the other levels of the national health system and coordination with other sectors is stressed. The Conference went on to adopt a 10-point Declaration and made 22 specific recommendations [7]. The need for Primary Health Care (PHC) is no longer debated, as all previously tried systems of delivery have failed to reach more than a fraction of any country's population. The state of health care in Developing Countries and the emerging responses in the form of PHC have been ably summarized by Benyousseff and Christian [8]. The very term "delivery of health services" is no longer strictly correct, as it implies something delivered to people from above or centrally, whereas the concept gaining acceptance is of health services generated within the periphery and linking up with a referral system. The focal point is thus the community and the perspective has been reversed, being no longer the former one of viewing the high-cost technology teaching hospital as the centre of the medical universe. This change in thought has been largely due to the impact of Alma-Ata and the joint W H O - U N I C E F declaration adopted by so many nations. Equity of distribution of health care has now become the yardstick by which nations will be measured. Primary Health Care has become a recognized field where International Funding Agencies now want to put their money and more projects can be expected in future. The reports of the six WHO Regional Directors presented at the AlmaAta Conference are reviewed in the WHO Chronicle [9] and show what remarkable progress has been made in all continents. There are of course some individuals and even countries who regard PHC as a policy which will undermine the high scientific standards of medicine and there are others who regard it as a new form of political rhetoric, or as just a new name for Com-

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munity Development. There are yet others who give lip service to PHC but continue to put up large hospitals which will permanently skew the distribution of the health budget towards tertiary care for the urban elite minority. The developing world can now be divided up into those countries where Primary Health Care is a natural outcome of their political ideology and is a normal part of their programme of social development, those where Primary Health Care is part of a national health plan and has been recently added on to a restructured "colonial" type health service, those where Primary Health Care is still at a pilot project phase (either a single nationally sponsored project or multiple experiments by a variety of agencies), those where it is said to be contemplated in the next few years, and lastly those who have as yet little interest in Primary Health Care. This paper will give a few selected examples of Primary Health Care and in addition it will attempt to describe to what extent some of the examples can answer Dr Mahter's questions which he posed at the Alma-Ata Conference [10]. These questions are important as they summarize the criteria by which a national health plan can be judged. 1. Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have nots" and to adopt concrete measures to reduce it'? 2. Are you ready to ensure the proper planning and implementation of primary health care in coordinated effort with other relevant sectors, in order to promote health as an indispensible contribution to the improvement of the quality of life of every individual, family and community as part of overall socioeconomic development? 3. Are you ready to make preferential allocation of health resources to the social periphery as an absolute priority'? 4. Are you ready to mobilize a n d enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management, and their contribution to its application'? 5. Are you ready to introduce the reforms required to ensure the availability of relevant manpower and technology sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford'? 6. Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority'? 7. Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care'? 8. Are you ready to make unequivocal political commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?" SOME EXAMPLES OF PRIMARY HEALTH CARE

In this section, four examples of Primary Health Care will be given and special emphasis will be placed

on National plans, the type of workers and their job descriptions andthe relationship between the different levels of health care. Some of these examples (Sudan, Tanzania and India) have been given before by Benyoussef [8] but it is hoped that the details quoted here will add to his previous descriptions. Example I: Primary Health Care in the Sudan The Democratic Republic of the Sudan in 1975 finalized its National Health Programmes for the period 1977-84 and this had eight specific programmes in health and rural development with special emphasis on a Primary Health Care Programme. Two very detailed documents have been published, one a plan for the Southern region [11], and the other for the rest of Sudan including areas with nomadic populations 1-12], and in addition a summary report [13] has also been produced in Sudan, as well as one in the WHO Chronicle [14]. The reports emphasize that "Primary Health Care is the only feasible strategy with respect to the economic resources of the Sudan at present and it is socially and politically acceptable". The Sudan aims at achieving maximum coverage of the whole rural and nomadic population by the year 1984. It will achieve this through community health workers. In rural areas these workers will be based at a Primary Health Care Unit covering a population of about 4000 and five such units will be supervised by a Medical Auxiliary in a dispensary which will also cover 4000 people. It is intended that these PHC Units will cover a radius of about 16 km. In nomadic communities (described in greater detail by Benyoussef [8]) another category of Nomad Community Health Workers will be trained having responsibility for 1500 people--they will have no static base but move with their community. The report for the Southern Region, where there are 3 linguistic groups, mentions the need to integrate and coordinate the political, administrative and medical machinery for the rural health services. The first level of Health Care will be at a dressing station, the second at a dispensary, the third at a Health Centre (which has beds and a maternal and child health unit) and the fourth at a Rural and District Hospital. A new cadre of workers will be trained called the Community Health Worker (CHW) who "is an indigenous member of the community selected by that community and paid by the Rural Council to provide primary health care services to a population of approximately 4000". This worker will be supervised technically by the Medical Assistant at the Dispensary and administratively and politically by the community through the Village Development Committee (of which there are several hundred in the Southern Region), the Village Council and the Sudanese Socialist Union basic Unit committee. These are responsible for his discipline and can recommend dismissal. These committees are also the ones which do the selection of the CHW who are then trained for 9 months at CHW training centres where the tutors are medical assistants. The other members of the team at Dispensary Level--viz. Medical Assistant, Nurse, Village Midwife and Sanitary overseer--will also receive reorientation training. (An interesting comment is that in future Medical Assist-

Primary health care and developing countries ants for rural health services will be recruited from CHWs.) The job description of the CHW states that he must maintain contact with community members, leaders and other workers and participate in community projects. He also has preventive and promotive activities and is to provide ambulatory tre~itment, preventive advice, and referral when necessary for a list oT 12 common conditions (e.g. malaria and diarrhoea). Another list of diseases for referral to the dispensary has also been established (e.g: leprosy, bilharzia). He has responsibility for keeping records and drugs and recording births and deaths. This plan for the Southern Region also goes on to describe in detail the job description of the more highly trained staff in the Dispensary and the exact nature of the technical supervision by professional staff at higher levels. Community control is also mentioned. Besides manpower and administration, the types of buildings, supply system for drugs, the record system, details Of community participation, and the place of External cooperation and assistance are included. Careful costing was done separately for the five regions of Sudan and capital and recurrent expenditure are shown on a yearly basis. A programme such as this with careful attention to all aspects has every possibility of achieving inexpensive maximum coverage of the rural population. It was developed by a Sudanese committee assisted by WHO and in addition to the Ministry of Health there were representatives from the Ministry of Finance, Planning and National Economy, Agriculture, Food and Natural Resources, Communications and Transport and the Department of Rural Development. Unfortunately there are as yet no readily available evaluations of the achievements of these plans.

Example 2: The United Republic of Tanzania Tanzania first came into prominence as a country with a structured primary health care programme in 1975, when its measures for meeting basic health needs in rural areas were described in the book Health by the People [15]. The very title of the book has in fact become one of the passwords for admitting a member to the evergrowing company of countries with a national policy of PHC. The paper submitted by Tanzania [16] to the Alma-Ata Conference goes much further in clarifying the progress made. It starts by making the point that Primary Health Care is Personal Care. This is stated to counteract widely held misconceptions that the type of individualized personal medical care found in the doctor-patient relationship of the developed world cannot be replicated in the auxiliary-in-thecommunity relationship of primary health care. This paper also emphasizes that all doctors have to work for 2 years in rural areas after qualifying and that they are being produced at present in approximately the ratio of one to every four Medical Assist~ints and to eight Rural Medical Aides. An admirable feature of the Tanzanian manpower development is that every grade of worker has the possibility of being upgraded to a higher grade by selection by the party, testing, further training and examination. A Village

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Medical Helper could thus become a Rural Medical Aide and so on up the scale. Tanzania has been moving towards having its population regrouped in villages (8000 at present) and is aiming at having 80~ of its population shortly within 10 km of some dispensary or health centre (see also reference [8]). The primary health care workers are called Village Medical Helpers (VMH) and two (one male and one female) are selected by each village--they have full primary education and have a 6-month training course. After that, they work in people's homes and instead of a salary their work is regarded as a contribution to the communal effort of the village. Travel expenses are met by the village and refil of drugs by the district. While away on training, the VMH have their plots maintained by the village. At the Health Centre level in Tanzania, there are 14 staff including a Medical Assistant, a Nurse, Midwife and Nursing assistants, a Maternal and Child Health Aide and an Environmental Health Assistant. At the next smaller unit, the Rural Dis~pensary, there are only four staff, viz. a Rural Medical Aide, an MCH Aide, an Environmental Health Assistant and a Nursing Assistant. The parallel voluntary village workers are the Village Medical Helper, the Village Sanitary Helper and the Village Birth Attendant [17, 18]. Mobile clinics are not now part of the National policy in Tanzania, as they have proved too costly with heavy recurrent expenditure on vehicles which prove difficult to maintain in rural areas. Traditional healers also have not proved to fit in well into the scheme, as they expect fees or gratuity and often have insufficient education to keep records--however there is a programme of research in local herbs. The Tanzania PHC programme fits in well with the national ideology and it is accepted by the doctors of Tanzania. Nevertheless there is apparently room in Tanzania for further more intensive projects in primary health care. In Hanang District [19] there is a mission-hospital sponsored project which covers 100 villages with each subdivided into units of 30 households as a health unit. This scheme has objectives worked out in behavioural terms and will evaluate progress in terms of both capability of community and homes, and of utilization. Certain indicators are used, e.g. beans for nutrition, latrines for sanitation, water for hygiene and vaccines for clinics and communicable disease. The village health workers have a training of alternating month blocks in the classroom and the field for about 6 months. The information system is designed to give answers for the various levels of decision maker, viz. village, ward, party, district and region and all these decision makers are involved in deciding what information they need.

Example 3: Republic of Ghana Ghana, in 1978, produced a revised national plan entitled "A Primary Health Care Strategy for Ghana" [20]. The preamble states that it is based on the premise that health service activities are part of a total social and economic development with involvement of the community, and that by 1990 it is aimed to reach 80~ of the population of Ghana and to prevent and treat the disease problems contributing 80~o

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of unnecessary sickness, disability and death. The justification for initiating primary health care is that with a system based on passive service delivery points, only 30% of Ghanaians could use the health system and the health of the nation had not improved; in fact some communicable diseases had increased. A 3-tier system is planned with level A (for communities of 200-5000 people) being provided -by community health workers selected and paid by the community but supervised technically and trained by the Ministry for primary, promotive, preventive and curative measures. Three types of workers are envisaged: a re-trained traditional birth attendant [21, 22], a household family health worker and a local environment and development worker. Level B would have broadly trained community health nurse/midwives and environment development officers who would supervise level A by visits every 2 weeks, give immunization and see referred cases. They would also have a radio-link with District Headquarters. Level C would manage the system and consist of District Health Management Team (Medical Officer, Public Health Nurse, Health Inspector and Administrator) and District Executive Officer to ensure an integrated approach to development. The training of this level would also be reorientated. The disease problems of Ghana have been ranked in order of impact on health status and days of healthy life lost and the whole programme will be orientated to achieving the maximum reduction in healthy days of life lost by using specific measures. Areas identified as needing extensive inputs and careful attention are training and logistic support, and initially these would be the areas probably requiring external aid. The greatest cost to the primary health care sytem will in fact be the large number of vehicles' and bicycles required. By keeping vaccines at District level and delivering them to the primary level on supervisory visits once a quarter, it will not be necessary to have refrigerators at community level. Acceptance and initiation of the programme is in'sured by a series of workshops and re-training and re-development of professional staff. A head for the Primary Health Care Programme has also been appointed to carry though the phased timetable of implementation. Example 4: India and S. E. Asia The East is almost the home of Primary Health Care because with enormous populations and slender resources, many countries were forced to explore new methods and to rely on their own greatest resource-the people in communities. The example of The Peoples Republic of China is too well-known to repeat and there is a vast literature available [23, 24]. Perhaps less well-known is the example of India which had the now familiar triad of no visible improvement in the health of the nation, inadequate coverage of the population with inadequate services, and a marked imbalance between the rural and urban facilities and health expenditure. Projects in PHC in India have already been described [8] and the Jamkhed Project in 1970 included agriculture, water supply and housing as the villagers saw them as of greater priority than health. In 1977 however, the

Ministry of Health and Family Welfare [25] published a plan for PHC in India, which has an enormous rural population living in village communities and having village committees. The definition of Primary Health Care in India follows the W H O concept. Their definition of a community is that it is an identifiable group with a known social organization, shared cultural, economic and political patterns, common interests, aspirations and problems (including health) and usually a spatial identity. The ability to define a community is in fact very crucial to a Primary Health Care system if it is to be set in motion. Community participation involves a course of action which that community and the health personnel have decided jointly. The original health services of India were based on Health Centres and Rural hospitals, but there was an inadequately bridged gap between service and population, not only of distance, but also of failure of identification of the staff with the villagers' problems. Vertical unipurpose programmes were also prominent with no coordination between workers. In 1975 a 3-tiered plan for health with community health workers was evolved and medical education was reorientated to put an emphasis on community care rather than expensive hospital care. In 1977 the new rural health scheme was commenced with community health workers selected by the villagers (about 1000 population)and trained at the Primary Health Centres. Collaboration was obtained between Health. Social Welfare, Rural Development and Agriculture. A group of about 20 Community Health Workers were trained together and received a stipend while training, They receive a medical kit which is replenished quarterly and includes remedies from any locally accepted traditional system. They also get a loose-leaf manual of health practice in English and the local language. The criteria for selection of the community health workers are acceptability to the community, motivation, leadership qualities, basic education (grade VIVII1) and permanency of residence--females are preferred. The selection is by the community but with guidance from the doctor and health centre staff. The training is essentially practical and job-oriented and is given by paramedicals rather than the doctor. The total of 3 months training is split up over 1 year with alternating periods at headquarters and in the field with multipurpose workers on the job. Training is also given in indigenous medicine by a local practitioner who selects simple treatment considered to be most useful and most liked by the community, The Community Health Worker essentially functions as a liaison between the people and the health system and there are certain things he does not do, viz. give injections, give illness certificates, treat patients for more than 2 days if there is no response, prescribe drugs outside his limited list, pay home visits, or treat patients outside the room specially constructed for the purpose. The proposed functions of the CHW have been defined: communicable disease treatment and control (especially malaria and education about and assistance in immunization), environmental sanitation, maternal and child health, recording births and deaths, nutrition, first aid, treatment of 14 minor ail-

Primary health care and developing countries ments which are specified, and recognition and referral of mental illness. Details of each of these are given, for example, for malaria the worker must be able to identify fever, make blood slides and take them to the laboratory, give treatment, keep records, inform the health centre of the names and addresses of cases, assist the health workers in spraying and larviciding and they must educate the community on prevention, In the reports assembled in Seminars preceding the Alma-Ata Conference [5], there were very positive accounts of PHC in numerous communities and South East Asia. Most of these stressed the inadequacies and iniquities of the previous systems of health care and looked to PHC as the method holding out most hope of reaching all people by the turn of the century. Intersectional collaboration is stressed and some additional Ministries included are Irrigation, Animal Husbandry, and Energy and Power. Appropriate technology and the logistics of supply, support, supervision and referral are considered. In Indonesia where Primary Health Care has been very successful, this has been attributed to a concrete policy and national will, an existing mutual self-help concept, training involvement of communities and their willingness to accept change if these lead to improvement in the quality of life, decision making through discussion, adequate professional guidance and supervision and the involvement of the traditional health personnel. In a project in Thailand, three primary health care workers are used: a Health Post Volunteer (per 500 people), a Traditional Birth Attendant (per 1000 people) and a 10-house "Health Communicator". Evaluation is by the performance of the personnel and the operation of the system, the consumer accessibility and acceptance, the changes in health targets from the established baseline and ultimately the financial, social and administrative feasibility of replication of the project on a larger scale.

IMPORTANT ASPECTS OF PRIMARY HEALTH CARE

From these examples and from the current literature on Primary Health Care certain aspects have become prominent and received a lot of attention. These will now be highlighted and some pertinent references given. In fact most of them did come under scrutiny at the 5th International Conference on Social Science and Medicine held in Nairobi in 1977 [26].

Community initiation and participation, administration and management In 1974 a joint W H O / U N I C E F study [27] of novel approaches in developing countries discovered that what they had in common was, that they started from where people lived and that there was active participation of community selected health workers. Another U N I C E F / W H O study analysed how community members participate and what factors led to success [28]. A decentralized administrative system is required which gives responsibility to the local level and this implies the development of managerial and administrative capacities at that level. Any com-

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munity will usually recognize that health status is affected by factors not falling directly within the health service orbit and if the initiation of health development comes from the community, then it is more likely to be broad in concept and involve sectors such as agriculture, education etc. Manzoor Ahmed [29] in his analysis of the major dimensions of community participation, listed the following: • the organization of services on a community basis, e t h e contribution by the community to the operation and maintenance of the services, e t h e participation of the community in the planning and management of the services, e a community input into the overall strategies, policies, and workplan of the programme, • and the overcoming of factionalism and interest conflicts. He goes on to analyse patterns discernible in programmes which are effective and also to discuss obstacles to community participation, such as diversity of interests and priorities due to social divisions within the community, resistance by the administration to decentralization, failure of reorientation of the health service and inadequate budgeting for support of Primary Health Care. Some communities pose difficulties if they tack local organization or government structure, but others have been able to organize very effective village health committees [30]. One of the mechanisms to stimulate community participation is "self-diagnosis". This is a process of involvement of the community in surveying its own problems--the extent of, for example, lack of latrines and the percentage of the people using unprotected water supplies. This has been tried in Kenya where medical students have participated with community members in doing a "community diagnosis" survey and they have then fed the results back to the community for interpretation and for planning action. Communities are now much more educated and the population more mobile with a consequent broadening of horizons, so that the advantages of initiating schemes to improve the environment are much more apparent to the community than they were 20 years ago. Previous attempts at Community Development often failed because of lack of involvement of the community and because the Community Development Workers came from outside, and were paid from outside. The collective ability of the groups within the community was not mobilized to decide, to act, to pay and to supervise. This whole area of community involvement is a most fruitful field for the collaboration between social scientists and the health workers and the community. The very identification of what is the most suitable community unit for Primary Health Care is difficult and could benefit from greater study.

The types of workers, their trainin9 and incentives It would appear that most countries now utilize the services of several workers--the most usual spectrum being a retrained traditional birth attendant, a worker specializing in environmental improvement

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and a worker who deals especially with prevention and treatment of specific diseases. Training appears to vary between 3 and 9 months, but all countries realize the need for periodic refresher courses or additional training. This training is usually done by the Ministry of Health at Health Centre level or at District Level. The most suitable tutors appear not to be doctors but rather a team of specially trained auxiliaries who have little social distance from their trainees. In Kenya, medical students have trained community health workers and both seem to have gained considerable insight into community problems. Incentives vary considerably but in many countries the PHC workers do receive some payment usually by the community, local councils or by a "family health insurance" scheme, or even in kind. There is no single pattern however, and many described projects or services have not been in operation long enough to judge their permanence. It seems that in some countries there is a high rate of attrition of trained PHC workers. Few of the aspects of training and motivation have really been studied properly and described in detail nor have many cost effectiveness studies been done.

National commitment, country health plans

allocation of resources and

If equity and social justice is to be achieved, then most developing countries have to make a very definite commitment to redistribute health funds to the rural periphery. National planning can also help to coordinate various programmes and to secure adequate funds for promotive and preventive health measures. Primary Health Care is not an inferior foreign body tacked onto the National Health Service, but it should be the essential basis of the system for improvement of health towards which other levels of care are oriented. The Ghanaian Primary Health Care country plan [20] has a very striking diagram of two juxtaposed pyramids, one showing expenditure by level of care and the other showing population served by each level. These pyramids should both be orientated the same way instead of an upside down relationship with most money spent on the few. Unfortunately health economists do not appear as yet to have become greatly involved in PHC in developmg countries.

The role of the national administration and support for the health system by the medical profession Mere allocation of resources to a system of Primary Health Care would be meaningless without a total reorientation of the administrative system. This usually requires a series of workshops and of even closer dialogues between professionally-trained staff and primary care workersl Far from feeling that they have no role or that their technical skills are no longer needed, doctors properly involved in the development of primary health care become enthusiastic. They now see what a challenge it is to use their knowledge and skills with all the new possibilities of actually reaching everyone. For example, prophylactic drugs for malaria is no longer a theoretical issue: the doctor must now make the correct ,decision about drug and dosage, as with PHC it is possible to reach every child and not merely 20°o on occasion as pre-

viously. Parker [31] has discussed this problem of Health Technology and PHC and outlined the steps and processes involved in deciding where and how the smallest expenditure will have the greatest possible effect. He also discusses how to make choices between alternative technologies to ensure a balance of clinical efficacy with factors of cost, acceptability and feasibility which will result in actual effectiveness. This whole process of sifting through and modifying technologies requires planning by the national administration, involvement of the health professions, and active involvement of the community. The "package concept" however has to be used with care as it implies often detailed protocols, equipment, drugs, etc. all decided and worked out by someone remote from the commuoity--it may well be a good "package" but the community did not go through the learning experience of making the decisions and adaptations.

The content and scope of Primary Health Care (comprehensive hut with an emphasis on High Risk groups) Many publications have dealt with possible content and scope of PHC [32,33]. Maternal and Child Health [34] is the priority, Family Planning is being included in most programmes, Nutrition [35], Communicable Disease Control, Health Education, Environmental improvement and the treatment of simple common complaints [36] are the usual headings under which content is listed. Priorities however vary, so there are programmes which have stressed the prevention of blindness by Vitamin A distribution, the follow-up of leprosy and tuberculosis, the treatment of families with trachoma, the reporting of Vital Events, epidemiological surveillance of particular disease problems, and the maintenance of Family Health Folders. In some countries, a blend of traditional and scientific medicine has been achieved. Primary Health Care seems to hold out most hopes for the control of endemic disease which require a multifaceted approach through environmental control, personal education and treatment. With health workers really close to the community, it is possible to know which children are immunized and which ones are not and to educate parents and to arrange well-attended immunization sessions for visiting health centre staff~ High risk groups or individuals within the community can be identified by looking for simple indicators, e.g. the young unmarried mother under 150 cm in height, the child from a large family with repeated episodes of diarrhoea. When identified as "Highrisk", antenatal women or children or families can be given special attention or referral to the next level of care. However an evaluation of this "High Risk" approach is needed.

Primary Health Care and the training of doctors and proJ'essional staff There can be few developing countries which have planned the training of doctors, nurses and other health professions with a view to their role in Primary Health Care. Many have a legacy of colonial type services with the doctor as a hospital-based and sickness-orientated individual who investigates and treats at great cost the small proportion of rural people who manage to get referred to him, or the larger majority

Primary health care and developing countries of wealthy urban patients who see him with relative ease. Obviously a completely new type of training programme is required if this system is not to be perpetuated and channelled into the rising spiral of exorbitant superspecialized technology. Many countries, e.g. Ghana, Tanzania, Kenya, India, Indonesia, the Phillipines have programmes that involve medical students in primary health care--all facets including the training of community workers, and also dealing with cases referred to health centre level. Sometimes nursing training lags behind, but categories such as Community Nurses with training primarily in rural areas rather than in teaching hospitals are now beingturned out in greater numbers in many countries, and are being trained to supervise and work with PHC workers.

Supervision The community can take responsibility for many aspects of supervision including discipline of the Community Health Workers, and the extent of Coverage. The national health service usually has to supervise the technical aspects such as quality of care, use of drugs, the content of health education, the accuracy of records, and ongoing education. Most PHC programmes rely on the health centre staff for supervision as they are the ones in closest relation to the PHC workers. Supervision will be inadequate or inappropriate if the health centre staff have not been trained for this role, or do not accept it as part of their duties. Another aspect of supervision is stimulation and motivation of the worker and this can be increased by adequate feedback on referred cases. The best national health plans are very detailed on these aspects of supervision as they are crucial to the success of any programme, but there are no readily available accounts of the success of or problems related to supervision.

Environmental improvement Although improvement of the environment is always mentioned as one component in Primary Health Care, it is seldom given the emphasis it needs. In the past this disinterest in environment was perhaps due to the fact that it was often considered as "Community Development" rather than "Health". In PHC there is no such dichotomy. There is in this field a very real challenge to those concerned with appropriate technology because it is especially in the areas of housing, water supplies, excreta and household waste disposal that new cheap effective and locally available materials and methods are required [37-39]. Improvement of the environment also requires extensive health education programmes and coordination of different sectors at all Ievels of planning. One of the essential factors common to successful programmes has been detailed planning based on a priori assessment of needs. The execution of projects requires professional support and usually also some government financial support to eomplemeht community contribution of cash and labour. Careful site selection, detailed estimates of supplies, adequate drawings, simple design and rapid execution of a project are also characteristic of those which have been successful. Continued operation depends on an edu-

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cated public, maintenance and repairs with available spares, assumption of responsibility for management by the community, training of operating personnel and reasonable renumeration. Payment of rates by the consumers can assure funds for operation and maintenance. The health benefits of environmental projects are sometimes indirect and difficult to measure, e.g. improved water quality can lead to fewer episodes of diarrhoeal disease and this in turn can lead to less malnutrition, or improved quantity of water can also lead to improved personal and food hygiene and fewer episodes of diarrhoea. When water is brought near the homes, the women have more time and use less energy and this can have effects o n child care. Many studies have already been done on rural water supplies and sanitation in less-developed countries [40, 41].

Appropriate technology "Appropriate technology" [42-44] has passed through the phase of being a catchphrase and has become an established art, although often still practised mostly by demonstration centres and one or two enthusiasts. But there are many partly solved or unsolved problems--the expensive baby weighing scales that break, the pumps for which there are no spare parts, the out-of-action refigerators. The ingenuity of local artisans has yet to be tapped--looking round the markets of undeveloped countries one is always amazed at the tremendous use of recycled material-shoes made from tyres, lamps from Chloroquine tins, bangles from bullet cases. Such inventiveness if properly channelled can surely still produce local answers to technical problems in health.

Use of traditional health services The range of traditional practitioners available in a community varies--in Nigeria there are many categories, but usually there are at least herbalists, "diviners", birth attendants and bone-setters. The birth attendants have been trained as village midwives [45, 46], the herbalists remedies have been incorporated into the armamentarium of PHC workers and the traditional healer's methods have sometimes been used by psychiatrists. Traditional healers are not restricted by anatomical and pathological boundaries in making their diagnoses of a sickness but usually include social, interpersonal, emotional, economic and cultural areas in the process. The primary health care worker being close to the community can well be aware of these aspects and can make use of it and include this information in his referrals. The bone-setters methods of splinting and physiotherapy are often excellent, but his skills are seldom exploited. The full use of the whole range of traditional healers has hardly been used in Africa, although many types of healers and types of system have been successfully incorporated into PHC in the East. The Peoples Republic of China [47] have certainly saved vast sums of money by using well-known and highly appreciated local remedies in their PHC. It is interesting to see the increased attention shown by anthopologists, sociologists and psychologists to traditional healing but there has been less concrete adaptation of this knowledge into PHC.

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Essential drugs and problems of distribution and cost The presence of someone with knowledge and a small supply of drugs in a village is a great source of satisfaction to most communities familar with frequent illness and death of children. Chloroquine can be lifesaving, benzyl benzoate can give relief to the intolerable itching of scabies, piperazine by eliminating roundworms can indirectly improve nutrition and tetracycline eye ointment can save sight. Such drugs are obviously useful and cheap but are difficult to distribute and it is even more difficult to keep up supplies. The cost can often be covered by small payments, by patients or village committee. In the Cameroons .[-48] small pharmacies are started by government and financed by the councils but they are run by nurses--this was started to meet the chronic drug shortages in Health Centres. Carl Taylor [49] has pointed out that drugs and supplies must hold up well under storage, have a high safety factor and produce minimal side effects. So the doctors can identify the correct drugs for PHC, but it appears that administrators are needed to work out the methods of attaining a constant supply.

The information system Records are necessary for individual families and the different levels of administration also require records for evaluation of the community situation. The main problem has always been to simplify these to the point where they can easily be completed regularly and yet where they still give the required information. Lay reporting [50] has long been a topic of interest and it can now be adapted for Primary Health Care. The minimum set of records required to make a PHC system function needs to be worked out in different situations.

Logistic support and.facilities The importance of logistic support cannot be underestimated and in developing countries might well be one of the most crucial aspects--if there are no vehicles or no fuel or no spare parts for vehicles then supervision is difficult, refresher courses are difficult, the provision of drugs and supplies are jeopardized, referral is often impossible, and adequate coverage for effective immunization is sometimes difficult to achieve. Bicycles might help if women are prepared to use them and the terrain is flat. Telephone or radio communication would obviously decrease the amount of physical movement necessary. Some countries or projects provide a small building, room or shelter for the Primary Health Care worker but others use the house of the worker or rely on home visiting. When a special building is provided then it is usually put up by selfhelp. Buildings however are often a secondary consideration and tend to localize activities in one place not necessarily accessible to all in the community. An advantage of some focus is however, that it can be used for many activities---committee meetings, youth clubs, storage, a base for a visiting immunization team, etc. The community have to make these decisions but there are at present few guidelines to offer them and many poorly sited buildings are underutilized.

The interrelationship of health and development and coordination between different sectors Health is part of development and some economists have even considered that the nutritional status of children might be one of the more valid indices of development. Some communities are struggling at such a low level of health and life expectancy that there is little energy or will left for cooperative efforts to improve a neighbourhood. In such communities, adequate nutrition and water are basic to health and their effects on a community are far reaching; both more energy and more time are available if they are adequate. Communication obviously leads to development as is shown in the rapid changes that ensue along any road that is opened up in a developing country. But this type of development might in itself bring health problems e.g. increasing sexually transmitted disease and migration of men with repercussions on the agriculture. Primary Health Care involves all sectors in a coordinated effort to improve the quality and length of life in a community. At village level this implies the working together of health workers, agricultural workers, community development staff, etc. who should all be involved in village meetings, and committees and also the political organization. A development programme starting in one specific sector has often proved to be the entry point for a more comprehensive programme. Unfortunately Health workers continue to see only health aspects and if left to do the evaluation of PHC, they will continue to use only indices such as morbidity rates, and mortality rates whereas the broader aspects of development need to be evaluated. Teamwork in evaluation is required and a sociologist, agriculturalist, economist and nutritionist could give a community more comprehensive guidelines for measuring their progress.

Research and the place of projects Some developing countries have many projects experimenting with different approaches to primary health care. Kenya has for example, about 12 such projects and it is difficult to get to know about them as they are often very local and not made known by the sponsoring agencies. There is a spectrum of types of project from ones where a few family health workers have been trained by a mission hospital or church organization, through ones with international funding and a more specific orientation (e.g. family planning) to larger ones which truly constitute a National Pilot Project, as for example the Kenya National Pilot Project in Primary Health Care initiated by Dr Were of the Department of Community Health, Nairobi with U N I C E F aid. This project links up with the National Health Service and the lines of supervision and referral are designed to be reproducible elsewhere in the country. Although the essence of PHC is that it is rooted in a local community and therefore a variety of types of programme may be needed in any one country, nevertheless a single pilot project can give essential experience in the development of community structures for PHC. as has been shown in Kenya.

Primary health care and developing countries Some very famous research projects, e.g. the Danfa Project in G h a n a went on to become examples of PHC [21] with the training of volunteer health workers and traditional midwives [51, 52, 53]. Such research projects have proved very useful for in-depth studies of particular facets of PHC, e.g. the evaluation of different ways of training volunteers, the most useful content of training, the value and reliability of demographic work. Unfortunately, there tends to be underreporting of failed projects and in many projects evaluation is inadequate. Suchman [-54] has classified demonstration projects into pilot projects which can operate by trial and error and where rigorous design is not necessary, model projects based on pilot projects and where control and evaluation are required and prototype projects where there is the application of project results and an emphasis on providing services. An analysis of "the state of the art of delivery of low cost health services in developing countries" [55] analysed 180 health projects and found that only half were designed to be replicated and that half used volunteers. Two thirds made innovations most of which were in health manpower training and it was usually the newer projects which tend to use most innovations. International aid versus self-reliance

Many International agencies are interested in PHC as it presents the first real opportunity for aid to reach all the rural population rather than just the urban elite. Some see it as a way to getting their own particular objectives furthered, e.g. family planning. There has thus been a proliferation of projects many with ad hoe planning and little attempt at ensuring permanence or replication. The value of outside money used in this way is questionnable and rather than stimulating self-reliance, it might well diminish it. The most appropriate channels are probably to increase local planning capacity at a higher level and p e r h a p s to assist with specific items such as setting up a local drug manufacturing and distributing network, to assist with communication and transport or spare parts for vehicles, and perhaps with technical aid which is requested and directed by communities, e.g. water schemes.

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