TECHNICAL PAPER # 21
UNDERSTANDING PRIMARY HEALTH CARE
FOR A RURAL POPULATION
James E. Herrington, Jr., M.P.H.
Helen R. Hamilton
1600 Wilson Boulevard, Suite 500
Arlington, Virginia 22209 USA
Tel: 203/276-1800 * Fax:
Understanding Primary Health Care for a
1985, Volunteers in Technical Assistance
This paper is one of a series published by Volunteers in
Assistance to provide an introduction to specific
technologies of interest to people in developing countries.
The papers are intended to be used as guidelines to help
people choose technologies that are suitable to their
They are not intended to provide construction or
details. People are
urged to contact VITA or a similar organization
for further information and technical assistance if they
find that a particular technology seems to meet their needs.
The papers in the series were written, reviewed, and
almost entirely by VITA Volunteer technical experts on a
Some 500 volunteers were involved in the production
of the first 100 titles issued, contributing approximately
5,000 hours of their time.
VITA staff included Maria Giannuzzi
and Leslie Gottschalk as editors, Julie Berman handling
and layout, and Margaret Crouch as project manager.
James E. Herrington, Jr., M.P.H., the author of this paper,
worked over the past six years with the Senegal Sine-Saloum
Health Project, a model primary health care program; as a
Corps Volunteer; as Public Health Advisor with the U.S.
for International Development; and as a short-term
program and management issues.
He received a B.S. from Texas A&M
University and a M.P.H. from the University of North
Chapel Hill. VITA
Volunteer Herrington is currently Health Promotion
Specialist and Assistant Administrator for the Western
Group, a nonprofit rural primary health care organization in
North Carolina. The
reviewer of this paper, Helen R. Hamilton,
is also a VITA Volunteer.
She has been an Assistant Librarian for
the International Health Project of the American Public
Association (APHA) and a cataloger for the Clearinghouse on
Infant Feeding and Maternal Nutrition, APHA.
VITA is a private, nonprofit organization that supports
working on technical problems in developing countries.
information and assistance aimed at helping individuals and
groups to select and implement technologies appropriate to
maintains an international Inquiry Service, a
specialized documentation center, and a computerized roster
volunteer technical consultants; manages long-term field projects;
and publishes a variety of technical manuals and papers.
PRIMARY HEALTH CARE FOR A RURAL POPULATION
VITA Volunteer James E. Herrington, Jr., MPH
On January 1, 2000, the World Health Organization's goal of
"Health for All" is supposed to become a
reality. Will the
world's six billion people truly have access to essential
and medical care by this target date?
At present, a majority of
the world's rural inhabitants do not have access to
health care, cannot afford the limited health care that may
available, and usually have little, if any, control over the
health care system of their country.
A lot has to be accomplished
if basic health and medical care services are to be extended
all the world's rural poor.
Nevertheless, since the declaration
of the World Health Organization's "Health for
All" goal in 1978,
progress has been made in increasing the numbers of rural
who have access to essential health care services.
Much of this
progress is due to the establishment of primary health care
systems in many developing countries.
Simply stated, primary health care is
health care made universally accessible to
families in the community by means acceptable
to them through
their full participation and at a cost
that the community
and country can afford. It forms an
integral part both
of the country's health system of which
it is the nucleus
and of the overall social and economic
development of the
As the above definition indicates, the PHC system is not
aimed at helping the rural poor lead better physical,
social lives, but also at encouraging their participation in
decision-making process of achieving overall well-being and
just treating the diseases or ailments that afflict them.
(*) World Health Organization, Primary Health Care:
A Joint Report
by the Director General of the World Health Organization and
Executive Director of the United Nations Children's Fund
York, New York:
World Health Organization, 1978).
NEEDS SERVED BY THE PHC SYSTEM
The PHC system aims to fulfill four basic needs.
strives to reduce the high rate of morbidity and mortality
and death) among rural people.
In many developing countries,
50 percent of the children die before their fifth birthday
from three diseases--diarrhea, malnutrition, and
their associated complications.
The PHC system is an effective
means of preventing these childhood killers and other less
Second, the PHC system attempts to make essential health
accessible and affordable to rural people, who usually have
meager incomes. In
many developing countries, the nearest health
care facility to a rural village may be several, if not
kilometers away. A
sick family member who is transported at
substantial time and financial cost to the nearest health
may find long waiting lines and an exhausted supply of basic
drugs and medical material.
If the health facility runs out of
medicine, the patient's family may have to purchase it at a
private pharmacy, where the cost may be five times greater
at the health facility.
Because the PHC system attempts to bring
health care closer to more people, it reduces the enormous
amounts of money, time, and energy that rural people often
under their present health care system.
Third, the PHC system promotes local self-reliance and
by encouraging a rural community to fully participate
in the planning, organizing, and managing of the PHC system.
The health problems of a community are more effectively
if members of the community are educated and understand how
attack the problems themselves rather than depending on
outside the community to do it for them.
Outsiders, though well-intentioned,
may make poor or unwise decisions for a community
simply because they may not know the dynamics of that
A community's best resource is often its own members.
system encourages the community to rely on itself and to set
realistic goals and objectives toward meeting its needs.
Fourth, the PHC system is not an isolated program.
forms an integral part of the social and economic
a community and country.
The PHC system strives to improve the
health of people not only through the provision of essential
medical care and active participation in decision making at
local level, but also through linkages with other sectors
the community that make an impact on a community's social
Establishing links with the agriculture
sector ensures production of nutritious food for families;
links with the water and sanitation sector promotes
plentiful supplies of clean water and safe disposal of human
waste; establishing links with the housing sector fosters
construction of houses that protect people against
animals and insects and foul weather; establishing links
the educational sector helps communities understand and
their health problems as well as encouraging health
activities in the schools.
Finally, establishing links with the
public works and communication sectors ensures better roads
rural populations can have greater access to urban and other
rural areas, thereby promoting increased social interaction,
communication of information, and accessibility to medical
In sum, primary health care is not an isolated activity but
rather a system that encourages integration and linkage of
health sector with other sectors.
As a result, PHC fosters the
social and economic development of a community and country
addition to reducing disease or disability through medical
THE BASIC THEORY OF THE PHC SYSTEM
The primary health care system is founded on the principle
health is a fundamental human right to be enjoyed by all
rich or poor, in all countries, industrialized or
Because health is more than just the delivery of medical
the PHC system attempts to address people's "health
through an integrated approach utilizing other sectors such
agriculture, education, housing, and social services, in
to medical services.
This integrated approach encourages active,
horizontal relationships between people and their local
as opposed to the traditional top-down or vertical
where people are simply recipients, passively participating
The PHC system employs the concepts of a "village
and "community health workers."
A village health committee
is usually composed of local residents, chosen without
political affiliation, sex, age, or religion.
The committee actively
participates in planning, organizing, and managing the
primary health care system serving their village.
the village as an organized and collective voice of the
before the government, the committee can assist in ensuring
the national health care service actively supports its
health workers. The
village health committee is an important
vehicle not only for promoting better physical health for
members, but also for improving their overall social and
Fundamental to the PHC system is the realization that the
killer diseases in rural communities in the Third World are
preventable and that the majority of victims of these
are children under five years of age.
Illnesses such as diarrhea,
malnutrition, pneumonia, measles, diptheria, tetanus, and
which strike children, can be prevented through relatively
effective and low-cost methods.
The PHC system advocates, for
example, immunization against measles and
(DPT) for children and tetanus toxoid immunization for
women in their childbearing years (15 to 44); breast feeding
the use of oral rehydration therapy (ORT)(*), and the
of children (use of antimalarial drugs) on a regular basis
in areas where malaria is a problem.
Thus, preventive medicine is
the major emphasis of the PHC system.
Since childhood killer diseases most severely affect
living in rural locations, the PHC system encourages
shift their national health care strategy emphasis from
rural areas. In
developing countries, the majority of health care
services often are based in large urban centers and serve
small percentage of the country's total population.
usually experience great difficulty in reaching urban-based
health care facilities.
The cost of getting to an urban center
may exceed a family's or individual's ability to pay.
As a result,
a child's opportunity to be immunized or a minor illness
may not receive medical attention until the child becomes so
that the child's parents are forced to seek emergency care
regard to cost. Even
so, the child may become permanently
disabled or die because medical treatment was obtained too
if at all. The PHC
system is based on the premise that when
preventive medicine is taken to the rural areas, childhood
can be dramatically reduced at low cost to the community
(*) Oral rehydration therapy (ORT) is a simple solution of
sodium (salt), glucose (sugar), and bicarbonate of soda that
be made at home and given as a drink to a child with severe
diarrhea in order to replace important body fluids lost due
dehydration associated with this disease.
For more information on
the proper proportions for the oral rehydration solution,
American Health Organization, Oral Rehydration
Annotated Bibliography, 2nd edition, Washington,
D.C.: Pan American
Health Organization, 1983; and World Health
Organization, The Management of Diarrhoea and Use of Oral
Therapy, a Joint WHO/UNICEF Statement, Geneva, Switzerland:
A key factor in the delivery of preventive medicine through
PHC system is the use of "community health
health workers are local individuals who may also be the
healer or midwife in the village.
They receive training
from national health personnel, who themselves have received
instruction on training techniques, and have an intimate
of the PHC system.
The community-health worker training
program lasts from two weeks to three months, depending on
needs and skills.
The community health workers work on a part-time,
or sometimes voluntary, basis to address basic health needs
identified by the village with technical assistance from
The PHC system recognizes that local people with little or
formal education can be trained to:
(1) deliver high-quality
basic first-aid; (2) recognize signs and symptoms of more
conditions; (3) deliver babies under more hygenic
(4) educate their fellow villagers in understanding the
processes in their community.
HOW THE PHC SYSTEM IS APPLIED
The application of the primary health care system to a
country or a specific community depends largely on the
conditions and the sociocultural characteristics of the
and the community.
The PHC system is flexible as well as highly
dependent on active support from the community.
Thus, two communities
may differ in their approach to primary health care, yet
both may achieve positive results.
In other words, the PHC system
does not adhere to one strict set of methods or ways of
However, a PHC system should include eight essential
promotion of better nutrition;
clean water and improved sanitation;
promotion of maternal and child health;
disease prevention and control;
treatment of common diseases and injuries;
provision of essential drugs.
Ideally, all eight elements should be a part of the PHC
although some may be phased into the system at various times
to local community priorities and economic and sociocultural
community should strive to include as many of
these elements as possible in their PHC system, but should
recognize its limitations and take one step at a time.
Wolof (a language of Senegal, West Africa) proverb says,
slowly one catches the monkey in the forest."
The PHC system should include health education, which is
than just mass media campaigns, though these are
education helps people to consistently, freely, and
change their personal and social behaviors to prevent and
health workers can give advice on health
matters to community members while treating illnesses in the
village health hut, in addition to providing home health
and community group education.
It is important to bear in
mind that the advice of a community health worker who is
and respected in the village will more likely be followed
than that of a community health worker who is inexperienced
Promotion of Better Nutrition
Promoting better nutrition involves helping people learn how
improve the family food supply and child-feeding practices
prevent nutritional illnesses.
For example, breast feeding should
be strongly encouraged over formula or bottle feeding since
breast milk contains nutritious vitamins essential to a
growth and strong antibodies which fight disease in a baby's
body. A baby's
growth can be watched by the mother when the
community health worker regularly weighs and measures the
Use of fresh vegetables in the family's meals should also be
encouraged to help children and mothers of childbearing age
strong, healthy, and less likely to become seriously ill
minor diseases like colds.
Clean Water and Improved Sanitation
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A basic, fundamental need of all people is a safe and
supply of drinking water.
Use of hand-dug wells (usually 3 meters
in diameter), which are covered to protect against dirt,
and animals, and regular cleaning of household water
(jugs, canaries, etc.) are important ways of preventing
sanitation facilities such as latrines and
garbage pits are significant means for containing disease
Promoting community and personal hygiene is also
Promotion of Maternal and Child Health
Promoting the health of mothers and children involves
care, safe and hygenic deliveries, postnatal care, child
and family planning.
The community health worker, who may also be
the traditional midwife, can improve health care for mothers
their children at home and within the community.
worker can watch for signs of anemia, i.e., lack of iron in
(for example, a pale mucuous membrane of the eye), in
women, practice clean and sanitary birthing procedures, and
women to space their births through family planning
methods so that children already in the family can receive
nutrition and care.
Immunization of infants and children under five can prevent
from contracting major killer diseases such as diptheria,
poliomyelitis, tetanus, tuberculosis, whooping cough, and
Community health workers can assist in organizing
the village to participate in immunization activities and
village leaders understand that the village children will be
protected from certain illnesses by being regularly
Disease Prevention and Control
Community health workers can help in wiping out
flies, rats, water snails, and mosquitoes.
chloroquine to young children and mothers on a regular basis
during the peak malaria season(s), community health workers
help reduce and prevent severe disability and death due to
They can also help to prevent the spread of infectious
diseases by advising villagers to wash their hands often and
isolate infectious individuals from the community until they
recover from the infectious disease.
Treatment of Common Disease and Injuries
Recognizing and treating diseases and injuries is an
means of protecting children from disability and death.
instance, almost all children under five years of age in
countries experience diarrheal disease and risk becoming
severely dehydrated due to a loss of body fluids.
earlier, the use of oral rehydration therapy is a simple,
home-prepared method of replacing lost body fluids in
health workers can teach mothers how to
recognize signs of severe dehydration (e.g., loose,
skin, sunken eyes, lethargy) and how to prepare the oral
and bandaging wounds, stabilizing broken
limbs, and recognizing signs and symptoms of more serious
and injuries are some examples of how community health
workers can treat disease and injury within the PHC system.
Provision of Essential Drugs
The regular availability of basic drugs for people living in
rural areas is an important aspect of the PHC system.
health workers of the Sine-Saloum region of Senegal, West
Africa, use the following basic drugs to treat illnesses in
aspirin (for pain, fever);
chloroquine (for malaria);
piperazine (for worms);
aureomycine 1% (for eye infections);
aureomycine 3% (for skin infections);
ferrous sulfate (iron for anemia);
alcohol (for cleansing equipment and swabbing
oral rehydration powder (for dehydration due
Obviously, the above list is not intended to be
Yet the Sine-Saloum community health workers' drug supply is
regularly available at an affordable cost due to the list
short and simple.
The Senegalese government's efforts to decentralize
their drug distribution system from the national to the
village level aids in providing a local source of affordable
The eight essential elements of the PHC system can be
at the local level by using locally-selected community
workers may receive technical training and supervision
from government health personnel but are ultimately responsible
to the community they serve.
Since most local residents know their own community's needs
strengths best, it is quite reasonable that local villagers
be trained to deliver some, if not all, of the eight
essential to the PHC system described above.
HISTORY AND DEVELOPMENT OF THE PHC SYSTEM
For centuries most communities have relied on some type of
healer and/or midwife for their health problems.
the advent of industrialization and greater medical
a scarcity of physicians in the rural areas of many
nations still exists today.
Traditional midwives and healers
still play a prominent role in the delivery of medical care
to many rural people.
A traditional healer is often consulted
first by sick individuals and their families.
Western or industrialized
medical care is often sought only when the traditional
remedy has not worked satisfactorily.
In some developing countries, the scarcity of doctors in
areas has made it necessary to train medical assistants
called auxiliaries) such as medecins africains (francophone
the barefoot doctors of China, the feldshers in the USSR,
and the licentiate (people who are licensed to practice
in India and Pakistan, to name a few examples.
personnel function essentially as doctors in rural areas
there are no physicians.
The World Health Organization (WHO),
shortly after its establishment in 1946, promoted the
medical auxiliaries as a means of meeting the health needs
WHO has been instrumental in providing organization,
research, and information on medical auxiliaries as primary
health care workers and promoting the development and use of
trained non-physicians and traditional practitioners to meet
rural people's health needs.
Other organizations, such as UNICEF
and Catholic Relief Services, have also promoted the use of
medical auxiliaries and community health workers in areas
physicians are not available.
During the past two decades, the interdependence of health,
education, and other sectors that have a direct impact
on rural people's lives has received increasing recognition.
Health care has become linked to the economic and social
of a country.
Providing more primary health care services to
rural people helps to foster the economic development of a
for example, because it reduces the number of productive
workdays lost due to illness during peak agricultural
The development of stable vaccines against measles, polio
smallpox, and the use of local personnel to administer them
led to the greater use of vaccines as part of primary health
at the local level.
The adoption of simple, primary health care
measures has substantially reduced the number of deaths of
under age five from diarrhea, malnutrition, and pneumonia.
By and large, primary health care has been and continues to
viewed as the most effective and least costly means for
In 1978, WHO sponsored a conference in
Alma Ata, USSR, for practitioners and researchers to discuss
primary health care and formulate recommendations for its
Since that time, many developing countries have adopted
and are attempting to implement a national primary health
strategy, with the goal in mind of "health for all by
II. ALTERNATIVES TO
THE PHC SYSTEM
There are basically four alternatives to the PHC system:
comprehensive hospital-based medical care;
semi-comprehensive nonhospital-based medical
transmissible and environmental disease
COMPREHENSIVE HOSPITAL-BASED MEDICAL CARE
Modeled after Western health care systems, the comprehensive
hospital-based medical care system provides primary through
services in one central location at the national and
Primary services treat immediate and usually
minor cases of illness, and frequently include maternity
services involve short-term hospitalization and
minor surgery such as repair of lacerations, circumcisions,
incisions and drainage of infections.
Tertiary services treat
patients with chronic or severe illnesses, such as tuberculosis
and cancer, that require a longer period and more
personnel and equipment for treatment.
The hospital may hold between 100 and 500 beds, use high
and sophisticated medical equipment, and require substantial
amounts of financial and personnel support.
offered might include complete laboratory analysis,
surgical capabilities, labor and delivery facilities, and
nuclear medicine, chemotherapy, immunotherapy,
and computerized axial tomography (CAT) scanning
capabilities are becoming more prevalent services offered in
hospital-based medical care systems.
Staff required for this type of health care system are
highly trained, skilled professionals.
Such individuals are
needed to operate the sophisticated equipment, perform the
of lab tests, diagnose and treat difficult and complicated
illnesses, and provide skilled nursing care.
A large administrative
staff is usually needed to coordinate the inputs of
supplies, and personnel required for optimum performance of
the facility. Large
amounts of energy are needed to run the
hospital facility and operate its high-tech equipment.
Hospital efficiency is sometimes measured by the percentage
beds occupied to the total number of beds available.
percentage of occupied beds supposedly indicates that the
facility is operating with greater efficiency.
Capital investments in hospitals are substantial.
operating costs are also very high due to the sophisticated
equipment used, the large amounts of resources required, and
highly skilled nursing care needed for tertiary and
Personnel costs are also high since the medical
staff of a hospital facility would usually include several
obstetricians, general surgeons, pediatricians, and various
specialists and subspecialists.
Table 1 lists the advantages and disadvantages of using
hospital-based care to provide health services to rural
populations in developing countries.
SEMI-COMPREHENSIVE NONHOSPITAL-BASED MEDICAL CARE
Semi-comprehensive nonhospital-based medical care facilities
usually located in small urban centers at the regional and
levels in developing countries.
These facilities are sometimes
called health centers, dispensaries, or health posts.
offer primary and secondary medical care following a
model of hospital-based care.
One of these facilities may have
between 10 and 25 beds, and may serve within its
area between 40,000 and 200,000 people, depending on the
to which the national health care system extends into the
The health center differs from a hospital facility in that
uses less sophisticated equipment and technology and
only moderate amounts of financial and personnel
typically offered might include diagnosis and treatment for
primary and secondary illnesses, small laboratory services,
screening capabilties, immunizations, limited nursing care,
minor surgery. This
type of facility would be staffed by one
physician with two to five medical auxiliaries, nurses,
and/or sanitation aides.
The physician and medical auxiliary or
nurse would perform the administrative duties.
In some countries
with a scarcity of physicians, a nurse or medical auxiliary
serve as the administrator, medical director, and trainer of
Advantages and Disadvantages of a Comprehensive
Hospital-Based Medical Care System
All care facilities are under
Does not significantly reduce
one roof or within close
high rates of infant mortality
proximity to one another.
Wide range of illnesses
Very expensive to build and
maintain; can drain the national
budget very quickly; rarely
Gives the appearance that the
cost effective, especially where
country is "well developed" due
third-party payment (insurance)
to sophistication of facility.
is not common.
Urban populations have easier
Caters to small portion of
access to high-quality primary,
secondary, and tertiary care.
urban residents; rural people
have little or no access
Places greater importance on
secondary and tertiary care,
less importance on primary
Basically, curative care or
The community plays no role in
the development or day-to-day
operation of the hospital
Health centers emphasize curative rather than preventive
They serve the surrounding urban population and rural
that are nearby. Due
to limited staff and facilities, long waiting
times may be normal and medicines and medical material may
in short supply or depleted.
The farther a facility is from major
cities, the longer will be its supply lines and the greater
amount of time required to fill its drug and material
This is especially true where transportation systems are
to inadequate roads, lack of fuel, and harsh geographic and
Similar to a hospital, the greater the
distance the facility is from rural communities, the more
and money it will cost people living in rural areas to use
Table 2 lists the advantages and disadvantages of adopting
nonhospital-based medical care systems to provide
health services to rural populations in developing
Table 2. Advantages
and Disadvantages of a Semi-Comprehensive
Nonhospital-Based Medical Care System
Extends health care coverage
Principally offers curative
of nation to smaller urban
centers and some rural
communities near facility.
Caters only to urban population
and rural communities located
Can treat primary and
nearby (within 10 kilometers).
Will not always have medicines
Provides nursing care
or materials if isolated from
for acutely ill.
major supply centers.
Offers more hygienic and
Offers little in the way of
skilled birthing care.
Can offer minor surgery if
Does not significantly reduce
skilled personnel are
high rates of infant mortality
Less costly than
Community participation plays
little or no role in decisions
made concerning care offered
at the health facility.
TRANSMISSIBLE AND ENVIRONMENTAL DISEASE CONTROL
In many developing countries, efforts to control the
that carry human disease, such as mosquitoes and snails,
been very effective.
For example, outbreaks of malaria, yellow
fever, and dengue fever can be controlled through regular
of insecticides to kill the particular mosquitoes that act
carriers of these diseases.
Programs to control onchocerciasis
(*) A vector is an agent, such as an insect, capable of
or biologically transferring a pathogen from one organism to
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(river blindness) are being carried out in the Volta River
in West Africa over a 20-year period.
Vector control is a long-term
problem that is often compounded by the fact that some of
the disease carriers and pathogens become resistant to the
Water and sanitation programs are also effective in
waterborne and fecal-oral diseases when properly carried out
activities consist of developing clean water
sources and sanitary disposal of human waste, which often
the regular maintenance of equipment (such as water pumps)
and persuading the target population to use new water
waste disposal sites.
Vector control is an attractive health care strategy because
requires minimal personnel and equipment.
This effort, however,
is usually carried out through mobile teams and therefore
reliable transportation, the cost of which can increase
sharply depending on the costs of fuel and maintenance.
Unlike vector control, water and sanitation efforts require
more equipment (e.g, drilling rigs, pumps, maintenance
tools), and more personnel to train the local population in
upkeep of water pumps, for instance.
Yet the greatest labor
requirement is in educating and motivating the target
to change its habits in order to obtain maximum benefit from
new water sites and waste disposal facilities.
Vector control and water and sanitation efforts can be very
effective and efficient strategies for controlling disease
personnel are well trained and affordable equipment and
parts are regularly available.
Disease levels can be reduced
dramatically over the long term if these efforts are carried
regularly and consistently.
However, the increasing resistance of
organisms to pesticides requires the continual development
toxic substances and alternative methods for organism
Moreover, if replacement parts and locally-trained personnel
not available to repair pumps or disposal sites when they
down, these control efforts will fail since people will
their previous, less hygenic methods of water gathering and
Vector control is comparatively inexpensive but must be
over indefinite periods of time or until the vector has
Water and sanitation programs, are, on the other
hand, quite expensive since installation of community water
requires a substantial investment in equipment, material,
and skilled labor.
Tables 3 and 4, respectively, list the advantages
and disadvantages of vector control and water and sanitation
programs in developing countries.
Table 3. Advantages
and Disadvantages of Vector Control Programs
Must be continued indefinitely.
Can effectively reduce
Insects and mollusks or the
death and disease rates
pathogenic organisms become
with regular spraying
resistant to pesticides.
over the long term.
Does not involve much
Is rarely an intersectorial
effort (involving education,
agriculture, or social services).
4. Advantages and Disadvantages of
and Sanitation Programs
Can produce dramatic reduction
Very expensive in capital
in waterborne disease rates if
and maintenance costs.
water supplies are installed
within the house.
Public water faucets do not
always bring about reductions in
waterborne disease rates since
water may be stored in unclean
containers in the house.
Extremely difficult to change
people's personal and social
Does not usually involve active
such as education, agriculture,
and social services.
Nutrition supplementation programs typically distribute food
as grains, powdered milk, and canned meats to mothers with
in an attempt to supplement their daily caloric and protein
intake. In addition,
these programs often bring together women
with children for baby weighings, lectures on nutrition, and
demonstrations, as part of the food distribution
as an efficient and effective method to reduce childhood
malnutrition, food supplementation may be necessary but by
is rarely sufficient.
Food products for these programs are often supplied through
agencies such as the U.S. Agency for International
"Food for Peace" program and through private
such as Catholic Relief Services.
The food products are
often transported to social service or health care centers
the country and distributed as part of their regular
A social service worker or medical assistant would be
the responsibility of organizing baby weighings and health
at which time food is distributed to the mothers attending
active community participation is required.
mothers and children are passive recipients.
There is little evidence to suggest that nutrition
programs alone can reduce childhood morbidity and mortality
rates. Moreover, an
adverse dependency on outside food donations
is created with these types of programs--rather than
self-reliance and self-sufficiency through home gardens,
drying and preservation, and better eating habits.
supplementation programs often find their donations sold to
cash incomes or eaten by family members other than the
targeted infants and mothers.
In some instances, food supplements
may be diluted to last longer and thereby diminish their
not eaten when first opened, canned
meats may be improperly preserved and cause food poisoning.
The cost of nutrition supplementation programs is relatively
expensive due to the long logistical supply lines and
and storage costs involved in getting the food from the
donor source to the field.
In countries where transportation
systems are poor and the rural population is isolated, costs
be greatly magnified.
The relative advantages and disadvantages of using nutrition
supplementation programs to improve the health status of
populations in developing countries are listed in Table 5.
5. Advantages and Disadvantages of
Some mothers and children will
Creates psychological dependency
benefit from the nutritional
on outside donations
value of the donated food.
Relatively easy to implement.
Food is often diverted for cash
income needs rather than going
Essential in famine areas where
to women and children.
little or no food is available.
Alone, nutrition supplementation
has no significant effect
on decreasing childhood
morbidity and mortality.
Costly due to transportation
and storage requirements.
Involves little or no
III. DESIGNING THE
PHC SYSTEM RIGHT FOR YOUR NEEDS
PHC SYSTEM VERSUS ALTERNATIVE HEALTH CARE SYSTEMS
None of the alternatives to the PHC system described above
an emphasis on actively involving the target community in
its own health status.
Most of the alternative health care
systems are top-down approaches and concentrate on curative
rather than preventive medicine.
Unlike PHC, these systems may
not significantly reduce the high rates of infant mortality
morbidity due to their inaccessibility to rural people, high
costs, other medical priorities, or long-term implementation
Unique to the PHC system is the use of local resources, in
of personnel and experience, to address local health
training one or two local residents (who may also be the
healer or midwife) as community health workers in simple
first-aid, preventive health, birthing, and sanitation
and supplying them with a simple array of essential
drugs, materials, and supervisory support, a community can
reduce its high death and disease rates, particularly
those for children less than five years old.
Through the use of
community health workers, the health care coverage of a
can be dramatically increased.
Self-reliance and self-determination are significant
of the PHC system that are lacking in the alternative
the PHC system, health is seen from a much broader
than simply the elimination of disease or infirmity.
and economic development of a community and country is
related to primary health care efforts.
Health care is linked to
other sectors such as agriculture and education, all of
mutually benefit from collaborative efforts.
POSSIBLE PROBLEMS TO CONSIDER IN DESIGNING A PHC SYSTEM
In designing a PHC system it is important to avoid the
to copy or emulate a successful PHC system from elsewhere
critically assessing the needs and strengths of the targeted
health care is not only a right but a responsibility,
community support and participation are essential in all
phases of PHC planning, organization, and management.
with health planners in a collaborative relationship,
leaders can provide a wealth of information and support
for an effective and successful PHC system.
It is important to diagnose the community in terms of not
what it lacks but also where its strengths lie.
In this initial
stage of PHC development, the community should participate
answering questions such as these:
Where do people go for medical care?
How much does medical care cost?
What illnesses are afflicting the entire
Where is drinking water obtained and what is
How do people dispose of human and other
Who are the influential people in the
How are important decisions made?
Who do people go to for counsel?
How are children educated about health?
What is the degree of control villagers feel
In selecting community health workers, it is important to
the need to employ respected individuals who have their
roots in the community and are not likely to use their
for political or religious gain.
The ability to read and write is
not essential; however, community health workers should be
listeners and learners.
Young people who have received some
formal education are mistakenly viewed as better equipped to
health worker. They
often become discouraged, however, since the
position usually is part-time and pays little.
Village health committees should also be composed of
individuals from the local community without regard to age,
education, or religious or political affiliation.
Health is the
concern of everybody and exclusive to no one.
In designing the best PHC system for a specific community,
leaders and local health personnel should consider the
eight essential PHC elements described earlier, bearing in
the specific sociocultural characteristics of the community.
Above all, the PHC system should be tailored to local needs,
emphasize local strengths and resources, and work with other
sectors involved in the community.
IV. THE FUTURE OF
THE PHC SYSTEM
The future of the PHC system depends largely on the degree
which it is successful in raising the health status of rural
there are numerous factors, such as drought
and famine, that can influence the health of a community,
are beyond the control of anyone.
Yet the aspects of a PHC system,
including greater emphasis on community participation, use
of community health workers and village health committees,
intersectorial approach, as well as the eight essential
of a PHC system discussed earlier, need to be tested and
under field conditions to determine their usefulness in
the health status of rural populations.
The development of more
effective training methods and materials, improved drug
schemes, and realistic financing requirements and methods
are some examples of areas within the PHC system that need
Only through intensive field-based research, analysis, and
of findings on actual PHC systems will decision makers
and governments be able to modify their primary health care
such efforts, the goal of "health for all by
the year 2000" is more likely to become a reality,
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and the Developing World. Ithaca, New
University Press, 1969.
"The Principles and Practice of Primary Health Care."
Special Series No. 1. St. Albens, Harts,
Teaching Aid at
Low Cost, April 1979.
"Community Health Care in Developing Countries."
Development. 17 (1980):
Harrison, Paul. The
Third World Tomorrow. New York, New
Hetzel, B.S., ed.
Basic Health Care in Developing Countries.
England: Oxford University Press, 1978.
Johns Hopkins University.
The Functional Analysis of Health Needs
Services. New York, New York:
Asia Publishing House,
Medical Care in Developing Countries.
Oxford University Press, 1966.
Paediatric Priorities in the Developing World.
England: Butterworth, 1973.
Pan American Health Organization.
Oral Rehydration Therapy:
Bibliography. 2nd Edition.
"Community Health Education."
A Practice of Social
E. & S. Livingstone, Ltd.,
Uphoff, N.T.; Cohen, J.M.; and Goldsmith, A.A.
Care Programs." Feasibility and
Development Participation. Ithaca, New
Werner, David. Where
There Is No Doctor. Palo Alto,
World Health Organization.
Health--A Time for Justice:
Care. Geneva, Switzerland:
World Health Organization,
World Health Organization.
Primary Health Care: A Joint
Director-General of the World Health Organization and
Executive-Director of the United Nations Children's Fund.
New York, New
York: World Health Organization, 1978.
World Health Organization.
The Management of Diarrhoea and Use of
Therapy. A Joint WHO/UNICEF Statement.
Switzerland: WHO, 1983.
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