Chapter 4: Primary Health Care in Practice

Primary Health Care (PHC) can be thought of in various ways, including a philosophy, a strategy, a level of health care, and a set of activities.

In its philosophy, PHC is based on the principles of social justice, equity and self-reliance. As a strategy, it is based on individual and community need embracing the concepts of accessibility, acceptability, affordability and community participation. As to level of health care, it is the level that is closest to the people. As a set of activities, PHC includes health promotion, prevention of disease, nutrition, basic sanitation, health in the workplace, and first-line medical care. (W.H.O. Symposium 1982:12)

How, exactly, does all this theory work out in practice? This chapter gives examples of PHC programs, some secular and some done by missions, which will flesh out the concept. In addition, advice will be culled from the writings of medical missionaries who have had experience in PHC. Finally, the relationship between the mission hospital and PHC will be explored.

I. Examples of PHC Programs

A. Haiti, 1968-1972

A pilot PHC program was established among nearly 9,000 rural Haitians. (W. L. Berggren et al 1981) Haiti is the poorest nation in the Western hemisphere. Its infant mortality rate is estimated at 150 deaths per 1,000 births annually; life expectancy at birth is only 47.5 years; the annual birth rate is 37 per 1,000 population.

The nucleus of the project geographically was the Albert Schweitzer Hospital, a 140-bed general medical facility supported by private philanthropy. The target area of 28 square kilometers, encompassing 23 villages and 8, 820 residents, was first surveyed. This health surveillance was conducted by local volunteers who were trained, each volunteer surveying approximately 100 families. The results of this survey were analyzed, in addition to data on recent causes of death within the area, and used to map out a strategy to combat the biggest killers. Eight categories of disease were selected for intensive intervention at many points: malnutrition, diarrhea, tuberculosis, tetanus, pertussis, diphtheria, measles and poliomyelitis.

Every three months, a health rally was held at specially designated locations where 1,000 to 1,500 people could attend. At these rallies, the local volunteers, assisted by a doctor or nurse plus five to ten health auxiliaries, would give 15-minute health talks in the vernacular of the people. Eight specific preventive services were offered to the people at these health rallies, including the weighing of the children and plotting their weights on a Road to Health Card, provision of supplemental feeding, instruction in the use of Oral Rehydration Solutions, screening for TB, deworming, immunizations, and support of the traditional birth attendants.

The hospital base had its usual staff of ten doctors, 30 registered nurses, 60 auxiliary nurses, and the many other personnel necessary to run the various departments of a hospital. The Community Health Program staff included a rural sanitation officer, two nurses, three doctors, 30 full-time auxiliaries, and 60 community volunteers. The volunteers were not paid, except for their participation during rally days and for time spent working on the annual census.

After five years, the results of the PHC program were gratifying. Mortality rates fell progressively in each age group to levels only one-fourth as high as the national average. It was calculated that 495 years of expected life were saved for each 1,000 people in the target population. The life expectancy at birth in the area increased to 66.5 years by the fifth year of the program, 19 years higher than the national average.

For the eight categories of disease specially singled out for attack, it was expected statistically that there would be 41 deaths among the target population during 1972, the fifth year of the program. Instead, there were only 19 deaths, a saving of 22 lives who were expected to live an additional 1,064 years.

In 1967, before the PHC program began, there were 64 admissions to the hospital with neonatal tetanus per 1,000 infants born, with half of these babies dying. Through proper immunization and education of the 1raditional birth attendants and the mothers, during the years 1969-1972 there were no deaths from neonatal tetanus.

How much did this program cost? The average annual cost was only $1.60 per inhabitant. This is for the PHC program, including its program development costs and the initial training costs. It does not include the $5.65 per capita which the government spends on curative services for the people of Haiti.

B. Zaire, 1961-1986

In 1961, the American Baptist Mission Hospital in Vanga, Zaire, consisted of a small rural hospital and two isolated dispensaries. Today, Vanga is a 200-bed, five-doctor referral hospital which functions as the main backup facility for a network of 50 PHC rural centers covering an area of 4,000 square kilometers and serving over 200,000 people. How did this happen?

This transformation occurred because medical missionaries had a commitment to the people and to the principles of PHC, and were willing to put them into practice. The philosophy at Vanga is clearly spelled out in the words of Dan Fountain, the Medical Director:

The purpose of health care is the health of the people. This cannot be something people passively receive from paternalistic do-gooders, but involves personal participation and involvement of the people willing to work at solving their own problems. (Dan Fountain 1984)

It was recognized that as long as missionaries themselves were delivering all of the health care services, genuine progress toward self-reliance of the people would be retarded. So, in 1962 a nurses training program was started. This accredited secondary level school now feeds graduate Zairian nurses into the hospital or one of the 50 PHC rural centers. In 1971, a health auxiliaries training program began, using a six-month course. A five-week training program for paramedics began in 1974.

The government of Zaire and its officials were consulted and involved in every stage of development at Vanga. The close working relationship which evolved has resulted in young Zairian graduates of the medical school in Kinshasa being able to elect a two-year internship in rural health care at Vanga.

The network of 50 PHC rural centers did not develop overnight. There were years of communication and cooperation between the people, the government, the church and the hospital. Each PHC center serves four to twelve villages with 100 to 1,500 people within an eight to ten kilometer radius. The goal in site selection of the PHC centers was that no villager would have to walk longer than two hours to reach one. Each PHC rural center engages in curative, preventive and promotive health activities.

Each receives a regular supply of drugs and material plus adequate professional supervision. This is no mean accomplishment in a poor nation with rugged terrain and great distances involved. A health supervisor visits at least monthly, and a physician every three months. A 30-minute film on one of these PHC centers run entirely by Zairian staff is available through American Baptist Films (see Address Appendix).

From experience, the health workers at Vanga have found it extremely advantageous to have a PHC rural center located close to a Christian church, whenever possible. A dynamic and cooperative pastor is an invaluable asset in promoting the cause of health in the village. The community participation and support of the PHC center is much stronger when affiliated with a local church.

In order to qualify as a PHC center site, a village must show its intent by constructing a building which is suitable. Often these are made out of mud bricks with thatched roofs. Later, as villages see the obvious improvement in the health status of their people, they often convert these structures into permanent cement block buildings.

The local people legally and emotionally own their PHC center. Villages which are farthest from Vanga have not only built facilities for their PHC centers, but have cleared out and maintained 600-meter long landing strips for the Missionary Aviation Fellowship planes. In this way, the PHC center can receive supplies and supervision regularly.

As of 1985, over 400 villages in the area covered by the Vanga project have functioning village development committees. Each committee is composed of three to ten individuals, men and women, who meet monthly to discuss and solve problems of health and development in their village.

Some objective results of the Vanga program are available in its 1985 annual report. A total of 11,605 measles immunizations were given, thus preventing roughly 11,000 cases of measles. With a 10% mortality rate from measles in Vanga, this should result in a saving of nearly 1,100 lives. In addition, 4,439 infants were immunized against polio, and 6,703 against diphtheria, pertussis and tetanus. The total cost of the vaccination program was $1,415. The vaccines were donated free by the government of Zaire who received them from U.N.l.C.E.F. The cost effectiveness is obvious, with nearly one life saved for each dollar spent!

While the PHC program at Vanga is going well now, it has not come about easily. Dr. Fountain, who has been there from the beginning, says: "Without a long-term commitment to the people and an absolute commitment to Jesus Christ, no one would have the necessary motivation or source of strength to stick it out. One would become frustrated and give up." (Dan Fountain 1984)

The next goal of the Vanga PHC program is to completely indigenize. They are working on developing young Christian Zairian physicians, administrators and medics to be able to carry on the program independent of the missionaries. One Zairian physician is now at Tulane University obtaining a master's degree in public health.

C. India, 1970-1986

Drs. Rajanikant and Mabelle Arole met while they were both medical students at the Christian Medical College and Hospital in Vellore, India. They had much in common as believers in Jesus Christ and in being excellent students (they were ranked number one and number two in their class). They married in 1960, worked in a rural hospital in central India, did post-graduate medical work in Ohio, and in 1970, obtained a master's degree in public health from The Johns Hopkins University.

In contemplating their life's work, they looked at the situation in their homeland. There were 621 mission hospitals providing nearly 15% of all the health services in India. Over 95% of the Christian health dollars were being spent for curative services. Yet, from their previous experience in a rural Indian hospital, they were convinced that 70% of the illnesses they saw were preventable. They dreamed of devising an approach which could meet the basic health care requirements of a rural India population. Their study for the master's degree in public health was entitled "Comprehensive Health Care in Rural India" (submitted February 16,1970). The Aroles returned to India that year to begin to implement their plan. However, they found that it was not until they altered their Westernized approach and put in their own concepts, which took into account the local culture, that progress really took place.

They selected the area of Jamkhed in Maharashtra state, some 400 kilometers southeast of Bombay. Here, 40,000 rural poor people were living in 30 villages. The area had no Christian church, few natural resources, and had suffered three consecutive years of drought.

From the outset, the Aroles knew that to promote health, they had to assist in meeting the other needs of people. Agriculture was the major occupation, so the Aroles obtained a tractor which farmers could rent to use on their farms. They assisted in the formation of Young Farmers Clubs. Through Oxfam and other Christian organizations, they were able to get 42 wells placed. Not only did this cut down drastically on the incidence of diarrhea, but 2,000 acres of farm land were irrigated.

The Aroles succeeded in combining community development with a comprehensive approach to rural health care. They have stressed adequate food, water supplies, education, family planning and agricultural development. Every day over 5,000 children are given food supplementation provided by the villagers in PHC centers, and the children and their mothers are taught informally while eating at the centers.

Through the PHC programs the Aroles have established, 47 villages now receive comprehensive health care services, and over 1,000 people have obtained a job in the process.

The infant mortality rate in the area dropped from 150 deaths in the first year of life per 1,000 births to less than 30. The percentage of malnourished children in the area decreased from 30 to five.

The Aroles have been asked by the government of India to serve on several high-level national advisory boards. In 1981, due to a continual problem with leprosy, the state government of Maharashtra asked the Aroles to become responsible for leprosy control in the Jamkhed and Karlot blocks, comprising 200 villages and 300,000 people. They agreed, on the condition that they could introduce comprehensive health care to this larger area in addition to leprosy control measures.

The government agreed. In 1982, 9,000 families in the new area were surveyed. The health survey teams also handled the case finding and referral for treatment of all leprosy cases. Within twelve months, 130 Village Health Workers had been trained for the leprosy control program and were back in their villages. There were 187 new cases of leprosy in 1982 out of 1,536 patients under treatment. Nearly all of the new cases were patients in the early stages of leprosy without deformities. Health education in the villages about leprosy and other health matters is being done utilizing skits, puppet shows and various audio-visual helps.

The Aroles obviously cannot do all of this work alone, and the key to success has been their ability to facilitate community involvement. The Aroles themselves are busy doing administration, supervision, training and the day-to-day medical affairs at the hospital in Jamkhed. They keep to a strict schedule, allowing themselves the following distribution of their professional time: 30% curative services; 30% public health services; 20% supervision; 10% training; and 10% for self-education.

In a similar fashion, they have ordered the budget for the Jamkhed program: 30% to curative services; 60% to preventive and promotive services; 10% to administrative and training activities.

The key person in the community is the Village Health Worker. Initially, the Aroles ask the village to find local women who would be interested in joining the health team. Usually, women with little or no household responsibilities volunteer for such work. They come to the health center at Jamkhed on Saturdays and Sundays, and are given regular classes on various health topics. The women are mostly illiterate, so the teaching is done with stories, drama, pictures and flash cards. (This method of teaching VHW's has been promoted by Dr. David Hilton whose monograph on the subject is available free from MAP International.) Each session begins with a review of last week's lesson and a discussion of the practical application of the knowledge gained.

Thus, the Village Health Worker learns how to promote health and to do health teaching in her own community. She acts as a liaison officer between the community and the nurse or other health worker. Delegation of each task to the least trained member of the team capable of performing the task satisfactorily is one of the ways of overcoming the problem of inadequate manpower and limited financial resources. The Aroles have been bright lights for Jesus in a dark place. While there are no evangelists or chaplains on their staff, they themselves pray openly and conduct worship services on Sunday. They think of their work as "pre-evangelism," aiming to demolish prejudices against Christians. They are busy building friendships and relationships of trust, while enabling poor people in rural India to develop economically and physically.

II. Advice from Medical Missionaries Involved with PHC Projects

The majority of the following responses came from a questionnaire sent out in April, 1984, by Dr. Howard Searle, who was then the Director for Community Health Programs at MAP International. Note that some of the following comments will give advice that conflicts with others. Views expressed in this section are those of the specific contributor, and do not necessarily represent those of the author of this monograph.

A. Advice concerning finances

1. "The VHW should be selected, supervised, and paid for by the village health/development committee. The entire PHC program should be self-financed, the village paying for drugs, travel and buildings." (Robert P. Morris, Kagando, Uganda, Africa Inland Mission:1984)

2. "Villages cannot be expected to take on the entire financial responsibility for health care. They just do not have the necessary resources. (Cecile de Sweemer, Baltimore)

3. "Start small and keep a low budget." (David Sorley, Uganda, Southern Baptist: 1984)

4. "PHC in the USA often takes the form of a Health Maintenance Organization (HMO). These models are too expensive for third world consideration." (Evvy Hay, Sierra Leone, Wesleyan Church:1984)

5. "Cost is often the critical factor, though lack of commitment and administrative ineptitude are also important. Costs of supervisors' salaries, supplies--drugs, tools and paper--and transport are considerable. The slogan that prevention is cheaper than cure overlooks the fact that neglect is cheaper still! The real costs of primary health care programmes are only fairly recently becoming appreciated." (Christopher Wood:1981)

6. "The only caution is that as Western churches promote PHC, they may be perceived as withdrawing resources in medical care that third world churches think they need--and rightly do deserve if Western nations truly shared their abundance. If PHC is seen as a subterfuge for financial disengagement in a world that is already unequal in resources, it could backfire--unless the theology of development is developed mutually with our third world partners." (Ronald E. Pust:1985)

B. Skills needed to do PHC work

1. "You must be a people person, able to teach and to be an encourager. Not one prone to giving answers, but one who helps people discover answers themselves." (Andea Propst, Uganda, Africa Inland Mission:1984)

2. "Pioneering spirit; innovative cross-cultural understanding; a love to work." (Andrew K. C. Ng, Niger, SIM lnternational:1984)

3. "Be able to think in new ways about health." (James E. Kipp, Nigeria, Church of the Brethren:1984)

4. "Be committed, not necessarily charismatic. One needs managerial, anthropological and economic skills. If one needs four years of intense training to do surgery on a person's body, why do we think we can work on a community's health with less?" (Prem Chandran John, India:1984)

5. "Ability to nurture people. We have been amazed at how readily village people can grasp a new health concept and respond appropriately. The innate ability to survive, to adapt, to want to improve, is present in most villages." (Rex and Jeanne Blumhagen, Afghanistan, MAP International:1974)

6. "The number one skill is to be able to motivate people to change. (Chavannes Jeune, Haiti, Worldteam: 1984)

7. "Obtain at least some formal training in public health." (David J. Drake, Zimbabwe, TEAM: 1984)

8. "Be a good non-formal teacher; have a love for people; have a knowledge of the culture, customs and language of the people; have a good knowledge of the Bible." (Martha Craymer, Ecuador, HCJB: 1984)

9. "Spiritual strength, robust health, patience--and be willing to live in a village for weeks at a time." (Steve Befus, Liberia, SIM lnternational:1984)

C. The strategy or approach of PHC

1. "The key to PHC is to move slowly and with patience. It's the opposite of a tertiary care center." (Hubert K. Morquette, Haiti, Worldteam:1984)

2. "PHC and literacy programs can work synergistically. The principles of PHC and SIL are remarkably similar. In addition, PHC allows Christians to be seen as equals working together rather than condescending in our hospital compassion." (Stephen A. Lynip, Philippines, Wycliff: 1984)

3. "PHC in South India involves a TEAM approach: Training, Education, Agriculture and Medicine." (Daleep S. Mukarji:1976)

4. "Doctors must be consultants to PHC programs only. They need to continue to do curative medicine. . .as physicians need to continue to practice and maintain their skills." (P. J. Andrew, Jos, Nigeria, SIM lnternational:1984)

5. "Our weekly visits to Barrio Clinics include a team comprised of a doctor, nurse, aide, church planter, Filipino Bible study leader, local midwife and some local church members. Each person plays an important part to the entire ministry of the team." (J. Paul Seale, Philippines, Southern Baptist: 1984B)

6. Often PHC implementation breaks down at the middle supervisory level. Obstacles include lack of transport, commitment, time and necessary supplies. It is also important not to push PHC as a package deal. It is community more than it is medicine. Learn the culture. Maybe forming committees is not an effective way to get things done." (Allison Howell, Ghana, SIM International: 1984)

7. "Missions should not feel that they must control the PHC program. Cooperation with Catholics, the World Bank, and the host government is possible for evangelical missions. For example, in Bombali, Sierra Leone, in 1980, the World Bank funded a government PHC project, but they lacked an accountable administrator. Our mission was asked to supply one, and now four chiefdoms with 67,000 people have midwives, VHW's and basic drugs for the first time." (Evvy Hay, Sierra Leone, Wesleyan Church:1984)

8. "Don't start a PHC program unless the curative care people in your mission are financially, emotionally, physically and prayerfully behind it." (Martha Craymer, Quito, Ecuador, HCJB:1984)

9. "The emphasis should be on the community, not on health. Our 'help' is often destructive. Mission leaders and medical administrators need an introduction into the concepts of PHC." (Gary and Metzi Barker, Haiti, Worldteam: 1984)

10. "Since teaching/learning strategies and communication skills are vital to the success of PHC programs, one must ask the question--Is the time appropriate that mission agencies begin to recruit and use community health educators as part of their medical programs? It would seem to me that the answer to this question must be a positive one." (Dean F. Miller, Toledo:1978)

III. Mission Hospitals and PHC Programs

If PHC as an approach to health/development problems has validity, how should it relate to existing mission hospitals?

Obviously, no one is suggesting that the idea of mission hospitals is "ready for a decent burial. The Declaration of Alma-Ata never intended to establish a completely new order. All it meant to do was to integrate what was already in place with a new approach." (John Lautenschlager:1984)

The question is whether existing mission hospitals can be integrated into a wider health care program. Some answer this question in the negative. It's easier to start a new PHC program than to add PHC to an existing hospital." (Gary and Metzi Barker, Haiti, Worldteam:1984)

An even stronger statement on the negative side comes from India. "PHC should be done by itself, not tied to or started by an existing curative hospital. This often leads to 'step-motherly' support. I'd rather see Christian money set up PHC programs, referring patients who need a doctor to the nearest government facility." (Prem Chandran John, India:1984)

W. Henry Mosely, a Christian physician with a wide experience in international health, thinks of PHC as "new wine" and of existing mission hospitals as "old wineskins." (W. Henry Mosely 1985A: 14) He states that this new wine cannot be poured into the old wineskins without a rupture occurring. Since the solutions to health problems range far beyond the field of medicine, and since PHC can address these health/development problems, he suggests that PHC needs its own wineskins.

Affirmative answers to the question can also be heard. Some argue that mission hospitals not only can do PHC (as demonstrated in the second of the three examples in this chapter), but should play a leading role in its promotion. If the people who administer and staff mission hospitals catch a vision of the broader perspective of health development, they can be prepared to play a cooperative and supportive role in PHC programs.

A proper courtship must take place, however, before the marriage can be accomplished. First, the PHC program must be thoroughly PHC, emphasizing preventive and promotional health, and not merely be an extension of the hospital's curative services. "We did not experience much success with PHC while our PHC centers were really tiny satellite curative centers. Now we have taught oral rehydration therapy and no longer see deyhdrated babies. Simple lacerations are now clean, not infected, as a result of teaching hygiene." (Marilyn Hunter, Haiti, Wesleyan Church :8/13/85)

Second, "in setting up a PHC program, the hospital-based health worker should not be allowed to feel less important. PHC field workers should feel that they are referring patients to 'their' hospital. Hospital-based workers should feel like they are receiving a patient from 'their' PHC team. Workers in each area should be assigned times in the other area." (Stephen J. Nelson, Ecuador, HCJB: 1984)

Third, the concepts of PHC which nudge people toward self-reliance should pervade all the work of the mission. "PHC must be total health care, even on the wards of the hospital and village huts." (R. Keith Sanders, London, Christian Medical Fellowship: 1984B)

The sum of this discussion is that PHC programs and existing mission hospitals need to be seen as complementary and interdependent components of the overall health care program. This is possible if significant educational and attitudinal barriers are overcome on the part of expatriate missionaries and national health care workers, as well as among those whom we serve.

In order to promote changes in attitudes and understanding within existing mission hospitals, one medical missionary suggests that each answer the following questions:

1. Whom are you treating?

2. What diseases are being reduced?

3. Has there been any measurable health improvement in your area?

4. Are the people in your area becoming more knowledgeable about health care matters?

5. Is the community involved in decisions? (David J. Drake, Zimbabwe, TEAM:1984)

The answers to these types of questions may be surprising. It is possible that a frank discussion of these and similar questions will lead to a better understanding of what the church and missions are doing today in health care compared to what they should be doing. Reflection on the history of missions is revealing. Perhaps there was a more wholistic approach to missions in the past than today!

Again, to quote Dr. Mosely:

Historically, in my limited reading it seemed clear that mission programs in many societies were aiming for a social and economic transformation as a means of improving the life and health of the people rather than focusing on one element like providing sophisticated curative services. For example, typically many mission stations established schools, brought in modern agricultural practices, and developed local leadership in the church and the community. Medical services were only one part of that and in many cases because of the limited resources available the focus was, indeed, primarily on preventive measures. Thus in the past, many mission programs were, in fact, achieving all of the goals of PHC. I think when we are looking for the new wineskins we should study our own history and see what has been lost in recent years and how this transformation from a more holistic approach in the past to the technological approach of the present actually occurred. (W. Henry Mosely: 1985C)

The current technological approach of many mission hospitals is all too obvious. After making a survey trip through Africa and Asia for two months in 1972, Dr. Carroll Behrhorst, medical missionary in Guatemala, wrote:

Speaking generally, the Presbyterian and related mission hospitals we visited on this trip are doing a fine job within the compound walls--and an equally poor job outside those walls.

It is as if we had a score of S.S. Hopes, clean, efficient, merciful and radiant, sailing wide oceans in which millions of plague-ridden swimmers slip beneath the waves and disappear for want of life rafts. (Carroll Behrhorst:1972)

That hospitals can do PHC successfully and creatively has been shown in a study of 400 hospitals around the world. (Rufino L. Macagba:1984) He personally visited a representative sampling of these hospitals, and his report details how fourteen different hospitals in various geographical and cultural settings have established successful PHC programs. Conclusion

The concepts of PHC are not only exciting on paper, but effective in practice. The modern mission family is only at the beginning of the enabling phase of health care work, no one having more than three decades of experience. The few success stories that are coming to light are a real encouragement to those who want men and women everywhere to be able to experience life more abundantly. In the final analysis, "A health care system, whether operated by physicians or non-physicians or both, should be judged by one criterion: the health of the population." (W. Henry Mosely 1983)

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