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                            TECHNICAL PAPER # 21
                           FOR A RURAL POPULATION
                       James E. Herrington, Jr., M.P.H.
                             Technical Reviewer
                              Helen R. Hamilton
                        1600 Wilson Boulevard, Suite 500
                         Arlington, Virginia  22209 USA
                     Tel:  203/276-1800 * Fax:   703/243-1865
                    Understanding Primary Health Care for a
                               Rural Population
                             ISBN:   0-86619-221-1
                  [C] 1985, Volunteers in Technical Assistance
This paper is one of a series published by Volunteers in Technical
Assistance to provide an introduction to specific state-of-the-art
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 situations.
They are not intended to provide construction or implementation
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 illustrated
almost entirely by VITA Volunteer technical experts on a purely
voluntary basis.  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 typesetting
and layout, and Margaret Crouch as project manager.
James E. Herrington, Jr., M.P.H., the author of this paper, has
worked over the past six years with the Senegal Sine-Saloum Rural
Health Project, a model primary health care program; as a Peace
Corps Volunteer; as Public Health Advisor with the U.S. Agency
for International Development; and as a short-term consultant for
program and management issues.   He received a B.S. from Texas A&M
University and a M.P.H. from the University of North Carolina at
Chapel Hill.  VITA Volunteer Herrington is currently Health Promotion
Specialist and Assistant Administrator for the Western Medical
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 Health
Association (APHA) and a cataloger for the Clearinghouse on
Infant Feeding and Maternal Nutrition, APHA.
VITA is a private, nonprofit organization that supports people
working on technical problems in developing countries.   VITA offers
information and assistance aimed at helping individuals and
groups to select and implement technologies appropriate to their
situations.  VITA maintains an international Inquiry Service, a
specialized documentation center, and a computerized roster of
volunteer technical consultants; manages long-term field projects;
and publishes a variety of technical manuals and papers.
                By 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 health
and medical care by this target date?   At present, a majority of
the world's rural inhabitants do not have access to essential
health care, cannot afford the limited health care that may be
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 to
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 people
who have access to essential health care services.   Much of this
progress is due to the establishment of primary health care (PHC)
systems in many developing countries.
Simply stated, primary health care is
  .... essential health care made universally accessible to
  individuals and 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 community.(*)
As the above definition indicates, the PHC system is not only
aimed at helping the rural poor lead better physical, mental, and
social lives, but also at encouraging their participation in the
decision-making process of achieving overall well-being and not
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 the
Executive Director of the United Nations Children's Fund (New
York, New York:  World Health Organization, 1978).
The PHC system aims to fulfill four basic needs.   First, it
strives to reduce the high rate of morbidity and mortality (disease
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 pneumonia--and
their associated complications.   The PHC system is an effective
means of preventing these childhood killers and other less severe
Second, the PHC system attempts to make essential health care
accessible and affordable to rural people, who usually have very
meager incomes.  In many developing countries, the nearest health
care facility to a rural village may be several, if not many,
kilometers away.  A sick family member who is transported at
substantial time and financial cost to the nearest health facility
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 than
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 spend
under their present health care system.
Third, the PHC system promotes local self-reliance and self-determination
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 addressed
if members of the community are educated and understand how to
attack the problems themselves rather than depending on people
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 community.
A community's best resource is often its own members.   The PHC
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.   Rather, it
forms an integral part of the social and economic development of
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 the
local level, but also through linkages with other sectors within
the community that make an impact on a community's social and
economic well-being.  Establishing links with the agriculture
sector ensures production of nutritious food for families; establishing
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 the
construction of houses that protect people against disease-carrying
animals and insects and foul weather; establishing links with
the educational sector helps communities understand and address
their health problems as well as encouraging health education
activities in the schools.  Finally, establishing links with the
public works and communication sectors ensures better roads so
rural populations can have greater access to urban and other
rural areas, thereby promoting increased social interaction,
communication of information, and accessibility to medical facilities
and supplies.
In sum, primary health care is not an isolated activity but
rather a system that encourages integration and linkage of the
health sector with other sectors.   As a result, PHC fosters the
social and economic development of a community and country in
addition to reducing disease or disability through medical intervention.
The primary health care system is founded on the principle that
health is a fundamental human right to be enjoyed by all people,
rich or poor, in all countries, industrialized or developing.
Because health is more than just the delivery of medical services,
the PHC system attempts to address people's "health needs"
through an integrated approach utilizing other sectors such as
agriculture, education, housing, and social services, in addition
to medical services.  This integrated approach encourages active,
horizontal relationships between people and their local services
as opposed to the traditional top-down or vertical relationships
where people are simply recipients, passively participating in a
health program.
The PHC system employs the concepts of a "village health committee"
and "community health workers."   A village health committee
is usually composed of local residents, chosen without regard to
political affiliation, sex, age, or religion.   The committee actively
participates in planning, organizing, and managing the
primary health care system serving their village.   By representing
the village as an organized and collective voice of the community
before the government, the committee can assist in ensuring that
the national health care service actively supports its community
health workers.  The village health committee is an important
vehicle not only for promoting better physical health for community
members, but also for improving their overall social and
economic health.
Fundamental to the PHC system is the realization that the major
killer diseases in rural communities in the Third World are
preventable and that the majority of victims of these diseases
are children under five years of age.   Illnesses such as diarrhea,
malnutrition, pneumonia, measles, diptheria, tetanus, and malaria,
which strike children, can be prevented through relatively
effective and low-cost methods.   The PHC system advocates, for
example, immunization against measles and diptheria-pertussistetanus
(DPT) for children and tetanus toxoid immunization for
women in their childbearing years (15 to 44); breast feeding and
the use of oral rehydration therapy (ORT)(*), and the chloroquinization
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 children
living in rural locations, the PHC system encourages countries to
shift their national health care strategy emphasis from urban to
rural areas.  In developing countries, the majority of health care
services often are based in large urban centers and serve only a
small percentage of the country's total population.   Rural people
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 ill
that the child's parents are forced to seek emergency care without
regard to cost.  Even so, the child may become permanently
disabled or die because medical treatment was obtained too late,
if at all.  The PHC system is based on the premise that when
preventive medicine is taken to the rural areas, childhood diseases
can be dramatically reduced at low cost to the community
and country.
(*) Oral rehydration therapy (ORT) is a simple solution of water,
sodium (salt), glucose (sugar), and bicarbonate of soda that can
be made at home and given as a drink to a child with severe
diarrhea in order to replace important body fluids lost due to
dehydration associated with this disease.   For more information on
the proper proportions for the oral rehydration solution, please
consult:  Pan American Health Organization, Oral Rehydration
Therapy:  An Annotated Bibliography, 2nd edition, Washington,
D.C.:  Pan American Health Organization, 1983; and World Health
Organization, The Management of Diarrhoea and Use of Oral Rehydration
Therapy, a Joint WHO/UNICEF Statement, Geneva, Switzerland:
WHO, 1983.
A key factor in the delivery of preventive medicine through the
PHC system is the use of "community health workers."  Community
health workers are local individuals who may also be the traditional
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 understanding
of the PHC system.  The community-health worker training
program lasts from two weeks to three months, depending on local
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 national
health personnel.
The PHC system recognizes that local people with little or no
formal education can be trained to:   (1) deliver high-quality
basic first-aid; (2) recognize signs and symptoms of more serious
conditions; (3) deliver babies under more hygenic conditions; and
(4) educate their fellow villagers in understanding the disease
processes in their community.
The application of the primary health care system to a particular
country or a specific community depends largely on the economic
conditions and the sociocultural characteristics of the country
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 operating.
However, a PHC system should include eight essential elements:
  1.   health education;
  2.   promotion of better nutrition;
  3.   clean water and improved sanitation;
  4.   promotion of maternal and child health;
  5.   immunization;
  6.   disease prevention and control;
  7.   treatment of common diseases and injuries; and
  8.   provision of essential drugs.
Ideally, all eight elements should be a part of the PHC system,
although some may be phased into the system at various times due
to local community priorities and economic and sociocultural
constraints.  A community should strive to include as many of
these elements as possible in their PHC system, but should also
recognize its limitations and take one step at a time.   As the
Wolof (a language of Senegal, West Africa) proverb says, "Slowly,
slowly one catches the monkey in the forest."
Health Education
The PHC system should include health education, which is more
than just mass media campaigns, though these are useful.  Health
education helps people to consistently, freely, and rationally
change their personal and social behaviors to prevent and control
illnesses.  Community 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 counseling
and community group education.   It is important to bear in
mind that the advice of a community health worker who is experienced
and respected in the village will more likely be followed
than that of a community health worker who is inexperienced and
not respected.
Promotion of Better Nutrition
Promoting better nutrition involves helping people learn how to
improve the family food supply and child-feeding practices to
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 baby's
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 baby.
Use of fresh vegetables in the family's meals should also be
encouraged to help children and mothers of childbearing age stay
strong, healthy, and less likely to become seriously ill from
minor diseases like colds.
Clean Water and Improved Sanitation
A basic, fundamental need of all people is a safe and adequate
supply of drinking water.  Use of hand-dug wells (usually 3 meters
in diameter), which are covered to protect against dirt, insects,
and animals, and regular cleaning of household water containers
(jugs, canaries, etc.) are important ways of preventing waterborne
diseases.  Basic sanitation facilities such as latrines and
garbage pits are significant means for containing disease away
from people.  Promoting community and personal hygiene is also
Promotion of Maternal and Child Health
Promoting the health of mothers and children involves prenatal
care, safe and hygenic deliveries, postnatal care, child care,
and family planning.  The community health worker, who may also be
the traditional midwife, can improve health care for mothers and
their children at home and within the community.   The health
worker can watch for signs of anemia, i.e., lack of iron in blood
(for example, a pale mucuous membrane of the eye), in pregnant
women, practice clean and sanitary birthing procedures, and encourage
women to space their births through family planning
methods so that children already in the family can receive adequate
nutrition and care.
Immunization of infants and children under five can prevent them
from contracting major killer diseases such as diptheria, measles,
poliomyelitis, tetanus, tuberculosis, whooping cough, and
yellow fever.  Community health workers can assist in organizing
the village to participate in immunization activities and help
village leaders understand that the village children will be
protected from certain illnesses by being regularly vaccinated.
Disease Prevention and Control
Community health workers can help in wiping out disease-carrying
flies, rats, water snails, and mosquitoes.   By administering
chloroquine to young children and mothers on a regular basis
during the peak malaria season(s), community health workers can
help reduce and prevent severe disability and death due to malaria.
They can also help to prevent the spread of infectious
diseases by advising villagers to wash their hands often and to
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 important
means of protecting children from disability and death.   For
instance, almost all children under five years of age in developing
countries experience diarrheal disease and risk becoming
severely dehydrated due to a loss of body fluids.   As mentioned
earlier, the use of oral rehydration therapy is a simple, low-cost,
home-prepared method of replacing lost body fluids in
children.  Community health workers can teach mothers how to
recognize signs of severe dehydration (e.g., loose, nonelastic
skin, sunken eyes, lethargy) and how to prepare the oral rehydration
solution.  Cleansing and bandaging wounds, stabilizing broken
limbs, and recognizing signs and symptoms of more serious illnesses
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.   The community
health workers of the Sine-Saloum region of Senegal, West
Africa, use the following basic drugs to treat illnesses in their
  o   aspirin (for pain, fever);
  o   chloroquine (for malaria);
  o   piperazine (for worms);
  o   aureomycine 1% (for eye infections);
  o   aureomycine 3% (for skin infections);
  o   ferrous sulfate (iron for anemia);
  o   alcohol (for cleansing equipment and swabbing around
     infected skin areas; and
  o   oral rehydration powder (for dehydration due to diarrhea).
Obviously, the above list is not intended to be comprehensive.
Yet the Sine-Saloum community health workers' drug supply is
regularly available at an affordable cost due to the list being
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 carried out
at the local level by using locally-selected community health
workers.  Health 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 and
strengths best, it is quite reasonable that local villagers can
be trained to deliver some, if not all, of the eight elements
essential to the PHC system described above.
For centuries most communities have relied on some type of traditional
healer and/or midwife for their health problems.   Even with
the advent of industrialization and greater medical sophistication,
a scarcity of physicians in the rural areas of many developing
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 rural
areas has made it necessary to train medical assistants (often
called auxiliaries) such as medecins africains (francophone Africa),
the barefoot doctors of China, the feldshers in the USSR,
and the licentiate (people who are licensed to practice medicine)
in India and Pakistan, to name a few examples.   These health
personnel function essentially as doctors in rural areas where
there are no physicians.  The World Health Organization (WHO),
shortly after its establishment in 1946, promoted the training of
medical auxiliaries as a means of meeting the health needs of
rural populations.  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 where
physicians are not available.
During the past two decades, the interdependence of health, agriculture,
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 development
of a country.  Providing more primary health care services to
rural people helps to foster the economic development of a country,
for example, because it reduces the number of productive
workdays lost due to illness during peak agricultural periods.
The development of stable vaccines against measles, polio and
smallpox, and the use of local personnel to administer them has
led to the greater use of vaccines as part of primary health care
at the local level.  The adoption of simple, primary health care
measures has substantially reduced the number of deaths of children
under age five from diarrhea, malnutrition, and pneumonia.
By and large, primary health care has been and continues to be
viewed as the most effective and least costly means for combatting
childhood diseases.  In 1978, WHO sponsored a conference in
Alma Ata, USSR, for practitioners and researchers to discuss
primary health care and formulate recommendations for its implementation.
Since that time, many developing countries have adopted
and are attempting to implement a national primary health care
strategy, with the goal in mind of "health for all by the year
There are basically four alternatives to the PHC system:
  1.   comprehensive hospital-based medical care;
  2.   semi-comprehensive nonhospital-based medical care;
  3.   transmissible and environmental disease control; and
  4.   nutrition supplementation.
Modeled after Western health care systems, the comprehensive
hospital-based medical care system provides primary through tertiary
services in one central location at the national and sometimes
regional levels.  Primary services treat immediate and usually
minor cases of illness, and frequently include maternity
care.  Secondary services involve short-term hospitalization and
minor surgery such as repair of lacerations, circumcisions, and
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 sophisticated
personnel and equipment for treatment.
The hospital may hold between 100 and 500 beds, use high technologies
and sophisticated medical equipment, and require substantial
amounts of financial and personnel support.   Typical services
offered might include complete laboratory analysis, radiology,
surgical capabilities, labor and delivery facilities, and emergency
treatment.  Moreover, 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 usually
highly trained, skilled professionals.   Such individuals are
needed to operate the sophisticated equipment, perform the multitude
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 equipment,
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 of
beds occupied to the total number of beds available.   A high
percentage of occupied beds supposedly indicates that the hospital
facility is operating with greater efficiency.
Capital investments in hospitals are substantial.   Maintenance and
operating costs are also very high due to the sophisticated
equipment used, the large amounts of resources required, and the
highly skilled nursing care needed for tertiary and intensive
care patients.  Personnel costs are also high since the medical
staff of a hospital facility would usually include several physicians,
obstetricians, general surgeons, pediatricians, and various
specialists and subspecialists.
Table 1 lists the advantages and disadvantages of using comprehensive
hospital-based care to provide health services to rural
populations in developing countries.
Semi-comprehensive nonhospital-based medical care facilities are
usually located in small urban centers at the regional and district
levels in developing countries.   These facilities are sometimes
called health centers, dispensaries, or health posts.   They
offer primary and secondary medical care following a scaled-down
model of hospital-based care.   One of these facilities may have
between 10 and 25 beds, and may serve within its geographical
area between 40,000 and 200,000 people, depending on the degree
to which the national health care system extends into the rural
The health center differs from a hospital facility in that it
uses less sophisticated equipment and technology and requires
only moderate amounts of financial and personnel support.  Services
typically offered might include diagnosis and treatment for
primary and secondary illnesses, small laboratory services,
screening capabilties, immunizations, limited nursing care, and
minor surgery.  This type of facility would be staffed by one
physician with two to five medical auxiliaries, nurses, midwives,
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 may
serve as the administrator, medical director, and trainer of the
health center.
    Table 1.   Advantages and Disadvantages of a Comprehensive
              Hospital-Based Medical Care System
Advantages                                Disadvantages
All care facilities are under        Does not significantly reduce
one roof or within close             high rates of infant mortality
proximity to one another.            and morbidity.
Wide range of illnesses              Very expensive to build and
are treated.                         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,      country's population--usually
secondary, and tertiary care.        urban residents; rural people
                                    have little or no access
                                    to facility.
                                    Places greater importance on
                                    secondary and tertiary care,
                                    less importance on primary care.
                                    Basically, curative care or intervention,
                                    not preventive care.
                                    The community plays no role in
                                    the development or day-to-day
                                    operation of the hospital
Health centers emphasize curative rather than preventive care.
They serve the surrounding urban population and rural communities
that are nearby.  Due to limited staff and facilities, long waiting
times may be normal and medicines and medical material may be
in short supply or depleted.   The farther a facility is from major
cities, the longer will be its supply lines and the greater the
amount of time required to fill its drug and material stocks.
This is especially true where transportation systems are poor due
to inadequate roads, lack of fuel, and harsh geographic and
climatic conditions.  Similar to a hospital, the greater the
distance the facility is from rural communities, the more time
and money it will cost people living in rural areas to use the
Table 2 lists the advantages and disadvantages of adopting semi-comprehensive
nonhospital-based medical care systems to provide
health services to rural populations in developing countries.
Table 2.  Advantages and Disadvantages of a Semi-Comprehensive
          Nonhospital-Based Medical Care System
Advantages                                Disadvantages
Extends health care coverage       Principally offers curative
of nation to smaller urban         care.
centers and some rural
communities near facility.         Caters only to urban population
                                  and rural communities located
Can treat primary and              nearby (within 10 kilometers).
secondary illnesses.
                                  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.            preventive medicine.
Can offer minor surgery if         Does not significantly reduce
skilled personnel are              high rates of infant mortality
present.                           and morbidity.
Less costly than                   Community participation plays
hospital care.                     little or no role in decisions
                                  made concerning care offered
                                  at the health facility.
In many developing countries, efforts to control the vectors(*)
that carry human disease, such as mosquitoes and snails, have
been very effective.  For example, outbreaks of malaria, yellow
fever, and dengue fever can be controlled through regular spraying
of insecticides to kill the particular mosquitoes that act as
carriers of these diseases.  Programs to control onchocerciasis
(*) A vector is an agent, such as an insect, capable of mechanically
or biologically transferring a pathogen from one organism to
(river blindness) are being carried out in the Volta River basin
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 insecticides.
Water and sanitation programs are also effective in preventing
waterborne and fecal-oral diseases when properly carried out and
maintained.  These activities consist of developing clean water
sources and sanitary disposal of human waste, which often requires
the regular maintenance of equipment (such as water pumps)
and persuading the target population to use new water sources and
waste disposal sites.
Vector control is an attractive health care strategy because it
requires minimal personnel and equipment.   This effort, however,
is usually carried out through mobile teams and therefore requires
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 substantially
more equipment (e.g, drilling rigs, pumps, maintenance
tools), and more personnel to train the local population in the
upkeep of water pumps, for instance.   Yet the greatest labor
requirement is in educating and motivating the target population
to change its habits in order to obtain maximum benefit from the
new water sites and waste disposal facilities.
Vector control and water and sanitation efforts can be very
effective and efficient strategies for controlling disease if
personnel are well trained and affordable equipment and replacement
parts are regularly available.   Disease levels can be reduced
dramatically over the long term if these efforts are carried out
regularly and consistently.  However, the increasing resistance of
organisms to pesticides requires the continual development of new
toxic substances and alternative methods for organism control.
Moreover, if replacement parts and locally-trained personnel are
not available to repair pumps or disposal sites when they break
down, these control efforts will fail since people will revert to
their previous, less hygenic methods of water gathering and waste
Vector control is comparatively inexpensive but must be administered
over indefinite periods of time or until the vector has
been eliminated.  Water and sanitation programs, are, on the other
hand, quite expensive since installation of community water systems
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
Advantages                                Disadvantages
Relatively inexpensive.            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
                                  community participation.
                                  Is rarely an intersectorial
                                  effort (involving education,
                                  agriculture, or social services).
           Table 4.  Advantages and Disadvantages of Water
                     and Sanitation Programs
Advantages                                Disadvantages
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
                                  community participation.
                                  Rarely involves other sectors
                                  such as education, agriculture,
                                  and social services.
Nutrition supplementation programs typically distribute food such
as grains, powdered milk, and canned meats to mothers with infants
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 strategy.  Advocated
as an efficient and effective method to reduce childhood
malnutrition, food supplementation may be necessary but by itself
is rarely sufficient.
Food products for these programs are often supplied through donor
agencies such as the U.S. Agency for International Development
"Food for Peace" program and through private voluntary organizations
such as Catholic Relief Services.   The food products are
often transported to social service or health care centers within
the country and distributed as part of their regular activities.
A social service worker or medical assistant would be assigned
the responsibility of organizing baby weighings and health talks
at which time food is distributed to the mothers attending the
sessions.  Little active community participation is required.  Most
mothers and children are passive recipients.
There is little evidence to suggest that nutrition supplementation
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 encouraging
self-reliance and self-sufficiency through home gardens, food
drying and preservation, and better eating habits.   Nutrition
supplementation programs often find their donations sold to supplement
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 nutritional
effectiveness.  If 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 transportation
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 will
be greatly magnified.
The relative advantages and disadvantages of using nutrition
supplementation programs to improve the health status of rural
populations in developing countries are listed in Table 5.
          Table 5.  Advantages and Disadvantages of Nutrition
                    Supplementation Programs
Advantages                                Disadvantages
Some mothers and children will       Creates psychological dependency
benefit from the nutritional         on outside donations
value of the donated food.           ("handout syndrome").
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
                                    community participation.
None of the alternatives to the PHC system described above places
an emphasis on actively involving the target community in improving
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 and
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 terms
of personnel and experience, to address local health problems.  By
training one or two local residents (who may also be the traditional
healer or midwife) as community health workers in simple
first-aid, preventive health, birthing, and sanitation techniques,
and supplying them with a simple array of essential
drugs, materials, and supervisory support, a community can potentially
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 country
can be dramatically increased.
Self-reliance and self-determination are significant components
of the PHC system that are lacking in the alternative systems.  In
the PHC system, health is seen from a much broader perspective
than simply the elimination of disease or infirmity.   The social
and economic development of a community and country is strongly
related to primary health care efforts.   Health care is linked to
other sectors such as agriculture and education, all of which can
mutually benefit from collaborative efforts.
In designing a PHC system it is important to avoid the temptation
to copy or emulate a successful PHC system from elsewhere without
critically assessing the needs and strengths of the targeted
community.  Given 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.   Joining
with health planners in a collaborative relationship, community
leaders can provide a wealth of information and support necessary
for an effective and successful PHC system.
It is important to diagnose the community in terms of not only
what it lacks but also where its strengths lie.   In this initial
stage of PHC development, the community should participate in
answering questions such as these:
     o   Where do people go for medical care?
     o   How much does medical care cost?
     o   What illnesses are afflicting the entire population,
        especially children?
     o   Where is drinking water obtained and what is its quality?
     o   How do people dispose of human and other wastes?
     o   Who are the influential people in the community?
     o   How are important decisions made?
     o   Who do people go to for counsel?
     o   How are children educated about health?
     o   What is the degree of control villagers feel they have
        over their own health?
In selecting community health workers, it is important to emphasize
the need to employ respected individuals who have their
roots in the community and are not likely to use their positions
for political or religious gain.   The ability to read and write is
not essential; however, community health workers should be keen
listeners and learners.  Young people who have received some
formal education are mistakenly viewed as better equipped to be a
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 respected
individuals from the local community without regard to age, sex,
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, community
leaders and local health personnel should consider the
eight essential PHC elements described earlier, bearing in mind
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.
The future of the PHC system depends largely on the degree to
which it is successful in raising the health status of rural
people.  Certainly, there are numerous factors, such as drought
and famine, that can influence the health of a community, which
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, the
intersectorial approach, as well as the eight essential elements
of a PHC system discussed earlier, need to be tested and analyzed
under field conditions to determine their usefulness in raising
the health status of rural populations.   The development of more
effective training methods and materials, improved drug distribution
schemes, and realistic financing requirements and methods
are some examples of areas within the PHC system that need further
Only through intensive field-based research, analysis, and dissemination
of findings on actual PHC systems will decision makers
and governments be able to modify their primary health care
strategies.  Through such efforts, the goal of "health for all by
the year 2000" is more likely to become a reality, especially for
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