Chapter 3: Primary Health Care in Theory

The Preacher says that there is nothing new under the sun. (Ecclesiastes 1:9) As you might expect, Primary Health Care (PHC) is not really a new concept at all. It is a set of ideas which have been around for a long time in germinal form, but have been coming to the forefront over the past 50 years. Worldwide attention has been given to PHC since September, 1978, when the Alma-Ata Conference on PHC released its Declaration.

In order to understand the essence of PHC, it is useful to go beyond technical jargon and delve into its origins. Although medical missions and others have been practicing some aspects of PHC for decades, the first written principles appeared in 1946 in a "Report of the Health Survey and Development Committee" chaired by Sir Joseph Bhore in India. This report was written one year before India received its formal independence.

The Bhore Report enunciated the following principles:

1. No individual should fail to secure adequate medical care because of inability to pay for it.

2. Health services should provide, when fully developed, all the consultant, laboratory and institutional facilities necessary for proper diagnosis and treatment.

3. The health program must, from the beginning, lay special emphasis on preventive work.

4. The need is urgent for providing as much medical relief and preventive health care as possible to the vast rural population of the country. The time has come to redress the neglect which has hitherto been the lot of the rural service.

5. The health services should be placed as close to the people as possible.

6. It is essential to secure the active cooperation of the people in the developments of the health programs. The idea must be inculcated that, ultimately, the health of the individual is his own responsibility and, in attempting to do so, the most effective means would seem to be to stimulate his health consciousness by providing health education on the widest possible basis as well as opportunities for his active participation in local health programs.

7. Health development should be entrusted to Ministers of Health who enjoy the confidence of the people and are able to secure their cooperation. (Ashish Bose et all 983:27)

Two years later, the Indian National Planning Committee, under the chairmanship of Jawaharial Nehru, formulated a policy of utilizing village health workers.

As an immediate step, in order to meet special conditions prevailing in India, we recommend the training of large numbers of health workers. These health workers should be given elementary training in practical, community and personal hygiene, first aid, and simple medical treatment, stress being laid on the social aspects and implications of medical and public health work. There should be one health worker for every thousand of the population, and this number should be attained within five years. (Ashish Bose et al 1983:26)

Ironically, while the Indians clearly formulated and planned this PHC approach, they failed to implement it. China, on the other hand, beginning in 1949, moved forward and launched a two-prong attack on their health problems. First, they trained large numbers of paramedical workers commonly known as "barefoot doctors." These health aides were part of the community they served and brought the delivery of health care services close to the people in both cities and rural areas. The second prong was the development of "centers of excellence" where physicians and nurses could be trained and medical research be carried out. Between 1949 and 1965, China trained 100,000 new physicians and 170,000 physician assistants. (Victor and Ruth Sidel 1974:20)

In 1980, the infant mortality rate in India was 120 per 1000 live births. For China, it was 39. The life expectancy of a baby born in India in 1982 was 52 years. In China, it was 67. Yet, both nations are equally poor, with the Gross National Product per capita in India being $250/year (1982) and in China $310. (U.N.l.C.E.F. 1984:112) The difference in the health status of the two countries is that one has successfully implemented its PHC program, while the other has not.

The PHC approach to health care is innovative, if not revolutionary, because its relies on the people themselves in the community to become active and responsible for their own health. It is quite the opposite of a socialized, hospital-based system of health care. Essentially, it

turns around the definition of health resources from one which requires massive capital to one which sees potential in every human being. It is the rationalized version of the ancient model of the self-help organization. (J. M. Janzen 1980:22)

For evangelical Christians, the idea of people being the most important resource in any community, and the idea that people are responsible, under God, for their environment and their health, should strike a responsive chord.

People should be treated with dignity as equals before God. Paternalism is anathema to the PHC theme. As stated by Dr. Ron Pust, former medical missionary to Papua New Guinea who is now on the faculty of the Department of Family and Community Medicine at the University of Arizona, "the most important issue in PHC is the transition from being the boss to being a partner-servant." (Ron Pust 1984)

One goal of the PHC approach is for the people of any community to own and control their own health care services. The PHC program is not brought to the people from the outside, but is developed right from the first step in concert with the desires and input of local people. The beauty of this approach is that the people not only own the program, but also they learn something valuable about the process of problem-solving and the power of collective community action.

The PHC approach does not cancel the need for curative care, but seeks to integrate curative care with preventive and promotive medical care. What do these terms mean? Basically, curative care treats the individual after he has a disease. Preventive care treats the individual before he has the disease. Promotive medicine treats the community so that no one will be exposed to the disease. The following table, prepared by Dr. Franklin C. Baer, a Christian physician working with U.S.A.I.D. in Zaire, helps to illustrate the differences.

Curative Preventive Promotive fire fighting fire prevention fire proofing filling cavities brushing teeth regulating diet treating diarrhea boiling water protecting water source Curative medicine meets a felt need and provides a good income for the health care worker. However, it is expensive for the community and has little overall effect on the level of health. Promotive medicine, at the other extreme, is less expensive but generates almost no income for the health worker, and a lot of community participation is required. When there is no immediate felt need, community participation is difficult to achieve. Why should everyone in this village build and use a latrine?

The challenge of PHC is to emphasize preventive and promotive health care while doing the necessary curative health care, utilizing local resources and personnel. Curative care is an appropriate response to the felt need of the people, but only preventive and promotive health care improves the general level of health of the community.

Please note again that PHC does not cancel the need for curative medicine. Rather, it calls for the integration of all three important aspects of medicine. "People in the village will not believe in the efficacy of oral rehydration therapy unless they are able to see a dehydrated infant resuscitated by intravenous fluids." (P. J. Andrew 1984) But the work of the hospital will be limited to referred medical and surgical cases, not minor cases or persons with diseases which have been prevented. More than half of outpatient visits to mission hospitals could be treated by village health workers in the patient's own village, and two-thirds of the deaths among children in hospitals in the Two-Third 5 World could be prevented if PHC were implemented.

PHC does not mean primary medical care. The focus is not on disease, drugs and doctors, but on teaching people how to maintain good health. By emphasizing health rather than medicine, it is also implied that non-medical factors are important. In the preceding chapter, it was shown that the level of health is more related to general socio-economic progress than to advances in medical science.

The term Primary Health Care is used because the Village Health Worker (VHW) is the first contact the patient has with the health care system. The VHW lives right in the same village, and is able to make an assessment of the health problem near to the patient's home. Problems beyond the scope of the VHW are quickly referred to the next level of health care services available. In this way, secondary (clinics and dispensaries) and tertiary (hospitals) health centers can actually concentrate on the specific work they were designed to do. And the patient will receive the level of care needed to address his particular problem.

Thus, Primary Health Care is clearly not a

level of medical care that is elementary, rudimentary, primitive even, with no scientific basis, using crude technology, and provided by non-professionals with little training. Nor is it a second or third class vertical programme operating parallel with and independent of the conventional health care system. It is not a campaign separate or isolated from the health sector, which by means of a set of simplified activities...is directed paternalistically at the rural inhabitants or the urban poor as some form of charity to relieve some of their misery. Far from it. (David A. Tejado-de-Rivero 1984)

PHC is also quite different from the mere extension of hospital services into the surrounding community. A hospital can send out immunization teams into the countryside, but this is not really PHC. Far too often, these programs are not community based. They are more tied up with "pills, preaching and per-diems" than with "people, prevention and problem-solving." (Roy Shaffer 1984:3)

The ideal PHC program involves the people who will be receiving the health services right from the beginning. The people must be involved with the initial planning, the initial health surveys, and the selection of priority health needs of the community. As the local people make contributions of time, advice, and physical help to ward the PHC program, they identify with it and begin to own it. It can become a means whereby people are enabled to identify and solve their own problems, in their own way, at their own speed, and with their own resources. Hospitals tend to do things for people, while PHC is aimed at allowing people to handle most health problems themselves.

The key ingredient in the PHC scheme is the local health care worker, such as the barefoot doctor in China or the Village Health Worker in most other parts of the world. VHW's learn how to communicate to their fellow citizens the basics of hygiene, sanitation, nutrition, and simple health concepts. They are also taught how to diagnose and treat the common ailments found in their area. Usually they are taught how to properly dispense a limited number (7-10) of essential drugs. For example, in tropical Africa they would learn how to dispense chloroquine for the treatment of malaria and worm medicines for the common infestations.

It is not within the scope of this monograph to cover the details of how to set up or manage a PHC project. One should be referred to the excellent series of papers called Contact, published by the Christian Medical Commission (see Address Appendix), or the MAP International reference library which has an excellent bibliography available on PHC (see Address Appendix). Included with the MAP bibliography are two monographs published by MAP. The first is by David Hilton, veteran medical missionary from Nigeria, which explains the value of story-telling in health education. The 0ther is a study guide written in July, 1982, for Christian health care ministries put together by a team of evangelicals interested in helping mission agencies think through the new directions and new opportunities presented by PHC.

The PHC approach is flexible enough that it should be adapted, not adopted, for each area. There are many different types of communities, and the same methodology will not work in all. (C. P. MacCormack 1983:51)

PHC works in urban communities and suburban areas, as well as in rural villages. With more than 50% of the world's population living in urban areas by the year 2000, it is important to know that PHC principles can be applied in cities. The methodology of implementing a PHC program in an urban setting will be different than in a rural area, but the principles work in either. The documentation on the experience in urban PHC work is sparse, however, and additional information is needed.

The budget of a PHC program in an urban or rural area is not cheap. Although there is a lot of community voluntary effort, any program which involves training, transportation, drugs, and adequate supervision and follow-up will incur expenses. (George Cumper 1984:19) "Extending primary health care to all of the world's people would cost an additional $10 billion annually. . ." (William U. Chandler 1984:10) Universal PHC could easily prevent the majority of the 40,000 deaths per day of children in the Two-Thirds World. The ten-billion-dollar price tag is but a fraction of what is spent on cigarettes annually. (William U. Chandler 1984:11)

PHC is not a panacea for all of the world's health problems. If implemented, however, it could dramatically improve the health status of several billion people. The implementation of national PHC programs by the 160 member nations of the W.H.O. has been far from optimal. A commitment by governments to health care services as a basic right and a political ideology which facilitates a national approach to health care seem essential for success. (J. Patrick Vaughan and Gill Walt 1984:108)

The concept of PHC, as with any innovative idea, requires time to sink in and take root. It took over 50 years for the idea of kindergarten to be adopted by U. S. public schools. The time is now ripe for the idea of PHC to permeate medical mission thinking and planning.

For the past decade, MAP International has been running PHC workshops for medical missionaries and mission executives. To date, more than 700 have participated. (Jeannie Thiessen 1986) The graduates of these workshops, plus others, have been promoting the concept and practice of PHC within their various missions. As a result, several missions have revised their overall strategy plans, incorporating the concepts of PHC.

The importance of having a well-thought-out strategy within a mission is illustrated by the comment of one medical missionary from Pakistan. "The main lesson we learned in experimenting with various PHC projects is that we should have developed an overall Mission Health Care Ministries policy first." (Ed Rasmussen 1984)

An example of such a strategy is the one devised by The Evangelical Alliance Mission (TEAM) during a health ministries consultation in October, 1984. Under strategic objectives, it reads:

When there is a demonstrable need, and where God so leads, we will seek to develop and maintain health care ministries which should include curative, preventive, and promotional components in a balance which is appropriate to the local situation. Our objectives with these ministries shall be:

1) To demonstrate compassion;
2) To alleviate physical suffering;
3) To assist people in the practice of basic health standards;
4) To proclaim Jesus Christ as Lord and Saviour;
5) To assist those who profess faith in Christ to grow in their relationship with Him, and to form local fellowships. (TEAM Health Ministries Consultation 1984:6)

Continuing under Strategic Priorities, the TEAM document says under PHC:

TEAM fields, especially in third world countries, are encouraged to explore the possibilities of recruiting and training primary health care workers. Gratifying examples of such programs are already operative on several TEAM fields. Health care workers should be trained to teach preventive measures, to recognize common health problems, and to use appropriate curative measures including essential drugs. TEAM's primary health care programs should aim for access, effectiveness, and efficiency. This care should be directed most where the needs are greatest so that increasingly all people will enjoy God's gift of health. (TEAM Health Ministries Consultation 1984:7)

In concluding this chapter, it can be truthfully said that the theory of PHC is not difficult to understand. The General Secretary of the Christian Medical Fellowship of Great Britain and a medical missionary statesman, Dr. R. K. M. Sanders, has written:

PHC is so simple most educated communities don't realize they practice daily what we want to be taught in third world nations, e.g., potty training of their children. PHC, like the Gospel, is simple, but has profound life changing consequences. It is too simple for most doctors and nurses. We are long past the basic nursing teaching of Florence Nightingale who said the objective of nursing care is to only do for the patients what the patients cannot do for themselves. PHC needs to be applied at every level of society, not only to primitive women in the bush. In Nepal it may be sanitation and hygiene. In the U.K. it is moral and social health needs which are primary. (R. Keith Sanders 1984B)

With this introduction to the theory of PHC, the next chapter reviews the experience of a few PHC programs in medical missions.

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