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Chapter: Medical Forum
Author # Title:  Click to visit article
David R Phillips
1 Excerpts from 'Chapter 1: Health, development and health care' in "Health and Health Care in the Third World", Longman Scientific & Technical, page 1.
David R Phillips
2 Excerpts from 'Chapter 5: Primary health care' in "Health and Health Care in the Third World", Longman Scientific & Technical, page 150.
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1. Excerpts from 'Chapter 1: Health, development and health care'; in "Health and Health Care in the Third World", Longman Scientific & Technical, page 1.
Definition of health:
A technocratic view of health is "the absence of disease" (generally organic but possibly also mental), This definition implies that medical intervention can often restore health and places emphasis on medical diagnosis, treatment and cure along standardized lines ... The World Health Organization (WHO) indicates that health encompasses 'a state of complete physical, mental and social well-being, not merely the absence of infirmity' in an individual. Clearly much more than the absence of diagnosed disease is involved; 'basic human needs' will, by implication, be satisfied in a healthy individual. Thus, it is today widely agreed that the concept of health as a technical measure - the absence of diagnosed illness - is insufficient for most purposes. Rather more useful, perhaps, is the objective of basic needs approaches to provide for a 'full life' in which healthy individuals live in caring, well-provided and intellectually stimulating communities. This is a more comprehensive perspective but its achievement will obviously require involvement of far more than the medical sector alone.

... Even in the use of apparently simple statistics such as birth or death rates, major problems arise in the quantitative expression of 'health' in many Third World individuals and communities, because of the lack of reliable data. Many births and deaths go unrecorded or are registered without any detail. Nevertheless, some attempts at quantification are important and the different conceptions of health noted above are of relevance in so far as they influence the 'nature' of restorative or promotive activities embarked upon ... involving the improvement and upgrading of the social and physical environment as well as of bodies and minds. This demands a much greater total involvement than medical intervention alone. Such a realization has great implications for the nature of nations' health care as to whether 'top-down' intervention and programs are imposed, whether 'total packages' are adopted or whether selective medical care is sought. This will also partly determine the extent to which people can become involved in, and take responsibility for, their own health and welfare.

Health and Development:
There appears to be a reciprocal relationship between 'development', broadly defined and health, equally broadly defined. Traditionally, a healthy population and workforce have been assumed to favor economic development, whilst an unhealthy population has been associated with poverty and underdevelopment ... Today, it is recognized that there is not a simple one-way relationship between 'health' and development. Whilst development generally brings improved diets, housing, social change and reductions in infectious diseases, it is also usually associated with rises in degenerative diseases, mainly apparently of non-infectious aetiology [inquiry into the origin or causes of disease: Essem] (often called 'Western' diseases).

One problem of analyzing relationships between health and development is that development is a rather vague notion. Some organizations are reasonably content to identify development in terms of changes in certain economic or socio-economic indicators. For example, an increase in per capita income is taken by some as a proxy for development. 'Orthodox' development is assumed to be along Western lines, usually involving industrialization, often on increasing scales, and associated with economic growth measured via increased GNP. However, others are less happy with this rather narrow view of development ... In addition to the economic productivity aspects of development, broader issues may involve national development that enhances the power and independence of nation-states - relating to improved distribution or to increased economic efficiency of industrialization, but the necessity for Western-styled industrialization is often questioned.

It is important to realize, from the standpoint of health, that modernization theory initially did not consider adequately or explicitly the possible detrimental effects of Western innovation or the widespread emergence of Western diseases. Whilst it appears that many 'Western' diseases actually did exist in traditional societies, modernization with increased life expectation has brought epidemiological change and such conditions are growing in importance. Health-care needs change and new health resource problems both replace and stand alongside the old.

In conceptual and practical terms, populist and 'small is beautiful' ideologies have their counterparts in health care as well in economic development. Enormous improvements in health can and should be gained without the use of high technology. However, a broader based development for health demands considerable intersectoral collaboration, which is often difficult to achieve. Globally, there has been something of a shift in philosophy - if not always in practice - from favoring large-scale, top-down (vertical), technology-oriented development projects to smaller-scale, bottom-up or 'grass-roots' approaches to development and provision of human services such as health care. Nevertheless, top-down vertical approaches remain commonplace in health care provision, particularly in selective disease-oriented programs, even if broader-based, horizontal, 'community' approaches in Primary Health Care (PHC) have for some years been gaining prominence. Basic needs provision and a basic needs approach to development have become widely appreciated. Small-scale approaches to development are frequently regarded as more human, more satisfactory, less externally imposed and generally less prone to many of the adverse side-effects that have often accompanied large-scale modernization projects. For probably the majority of poorer Third World residents, the benefits of many neo-modernization strategies have been elusive and the measures possibly even counter-productive. Certainly, the effects of large-scale, expensive strategies in terms of health and quality of life have been often ambiguous at best and lethal at worst, as the environmental degradation and dangers to health in places such as Cubatao in Brazil and Bhopal in India sadly illustrate. Large-scale, largely uncontrolled modernization along Western lines may be highly damaging to health in the Third World.

... Today, the debate has moved on. In the 1970s and early 1980s, ideas of dependency had come to the fore, particularly with the suggestion that Third World development was being prevented and underdevelopment even being exacerbated by dependent relations with industrial countries. The publication in 1980 of the Brandt Report argued the need for common action at a global scale based on the recognition of mutual interests. Whilst this is still widely accepted, the means of achieving common goals are now questioned. In simple terms, there has been a theoretical and political shift in the debate, in which conviction is growing among some that market liberalization can mutually benefit the Third World and First World and bring about development. The debate tends to be between dependency and and free-market thinkers. Whilst this juxtaposition of two schools of thought inevitably oversimplifies a deep and complex issue, it is nevertheless important, since, if the free marketeers come to the fore, it will have major implications for health and health provision in much of the Third World (in particular, for the future perception of state responsibility for health care and, perhaps, how this might be minimized).
 

Major characteristics of health care in the Third World:
Many people see 'planning without people' as a major danger for the implementation of specific, selective interventions (such as immunization or malaria control); the converse risk, of course, is a broad level of popular participation but with little practical progress.

It has often been felt that there is little direct relationship between conventional medical inputs and traditionally defined health outputs. It appears that prevention of disease by social improvements and environmental management is a more promising avenue for enhancing health than merely increasing expenditure on medical technology. Indeed, it is often argued that the principal determinants of health in any society are basically nutritional status and environment.

There is something of a tendency in the Third World to regard health care in a rather narrow, technical light. The provision of comprehensive PHC has become an important thrust in the 1980s in Third World health care and this will no doubt continue in the 1990s. However, it is not difficult to reduce even theoretically comprehensive PHC itself to a technocratic strategy that ignores the wide role of the state (in distribution of resources, for example), and regards 'health' as something determined by (or created by) the delivery of health services rather than by overall development. An imbalance in the use of resources available for health care can therefore be perpetuated and a neglect of social-environmental management can occur, which may remain the poor relation of 'high-tech' medicine. The interest of many institutions, training systems and technology and pharmaceutical companies continues to be served by the 'Asclepian cult', favoring medical intervention. Collier (1989) attributes the the excessive use of medication and multiplication of useless drugs to the extensive influence of multinational pharmaceutical companies. Others seek to explain health more abstractly as being largely a function of rational living and personal lifestyles. Clearly, some balance needs to be achieved.
 

Some specific features of health care in the Third World:

Availability and accessibility:

  • Health facilities, especially Western facilities, are often geographically inaccessible to the majority of populations. Women and children in particular may experience difficulties in reaching a source of care;
  • Urban and rural differences and inequalities frequently persist in health and health care;
  • The availability of services and treatment (such as drugs or X-ray) is often erratic, not only in rural areas but also in some parts of towns;
  • Official health facilities sometimes fail to provide the necessary medicines, whereas the private black market may do so;
  • Economic as well as physical barriers exclude many people from formal health services, transport costs and time lost from work may prove too great for poor people to be able to use services;
  • Imbalances therefore characterize health care; imbalances between individuals and communities (rich versus poor; favored versus unfavored), between regions, between urban and rural areas, and between countries.
Systematic factors and training:
  • Curative medicine is often emphasized, whilst prevention and early treatment, which need an effective system, are frequently neglected;
  • Related to this, hospital facilities are often excessive in relation to primary and community provision; they are also often accessible only to a small proportion of national populations;
  • The 'cost explosion' in health care often has disproportionately serious effects for Third World countries, which have limited financial resources and, frequently, debt burdens.
  • Education of physicians is rarely geared to conditions in the country;
  • Common health problems are often neglected, as are appropriate technologies, whilst relatively unusual diseases and high-technology equipment may be emphasized in professional training and facility provision;
  • By contrast, an extensive 'appropriate' system of traditional medicine often coexists with the modern, but its degree of integration, official recognition or support is extremely varied;
  • Health workers, especially in rural areas, are frequently inadequately trained, supported and supervised;
  • There is often heavy, sometimes excessive, reliance on paramedics or community workers without wholesale community participation.
Intersectoral and coordination features:
  • Referral and advisory support systems are often weak or non-existent;
  • Community participation in health is sometimes weak, and intersectoral integration of health (with housing, education and infrastructure) is often underdeveloped;
  • Integrated approaches are increasingly recognized as a major vehicle for improving health at the wider level, but political jealousies and intersectoral rivalries have frequently hindered effective coordination.
Political and social importance:
  • Considerable political importance is often attached to health development although practical activity and assistance is often inadequate. Unattainable statements of intent can be promulgated: 'slogan-led' health care is frequently apparent;
  • The state often assumes responsibility for health care but it is rarely equal to the task. This can be particularly true in the poorest countries and/or revolutionary regimes where conditions are unstable;
  • Development of selective health care programs (with limited objectives) is sometimes promoted whilst citizens remain exposed to other, continuing hazards;
  • Social security systems are at best partial and at worst non-existent, so families and individuals are often reliant on their own financial resources to support care.
Environmental conditions:
  • The socioeconomic environment is often injurious to health; housing, working and travel conditions may pose hazards and create extra health burdens. This may be exacerbated by a lack of environmental controls, and weak industrial or labor legislation;
  • Natural environmental disasters such as flooding, drought, hurricanes and fires may drain financial and other resources, as well as creating greater pressures on existing health provision.

Intersectoral action for health: integrated components?
Recently, a major concern has become the health and well being of communities as a whole, as opposed to simply the technical cure of varieties of sickness; so too has the focus of action shifted to integrated development among many inseparable sectors impinging on health. Agencies, ministries and organizations responsible for health and health care have increasingly recognized that these topics cannot be solely a responsibility of one group of professionals. The intersectoral strategy recognizes that the improvement of health will require contributions from many sectors of the economy and society.

To enhance the chances of success of integrated actions at the local level, it is imperative that high-level blessing is given and the avenues and mechanisms for intersectoral collaboration are established ... It is hardly novel to recognize the significance of the linkages between the major sectors of health, agriculture, education and environment.

In agriculture, output, production, land ownership, technology and decision-making have crucial health impacts. For example, the choice of whether to grow cash crops as opposed to staple foods can influence food availability, costs and access for vulnerable groups. Sen's (1981) discussion of the concept of food entitlement is relevant. The income from cash-crop sales rarely accrues in sufficient proportions to those growing and tending crops ... Changes in land holdings and lack of access to credit can reduce small-scale farmers to landless labourers. This group is often identified as most at risk, and its members are sometimes seen as victims of Green Revolution strategies. At a macro-scale, economic policies that influence food prices, distribution and availability can have immense impact on the nutritional status of the population, with concomitant correlations with health levels.

Education can have a similar critical role in health improvement. Formal education is generally felt to be decisive in improving health and reducing mortality (especially among infants) in developing countries. A few years basic schooling can make a crucial difference to an individual's ability to cope with the living environment and use services effectively, and to his or her awareness of nutrition and hygiene requirements. Universal primary education is intrinsically linked to the 'health for all' goal, and basic education is the foundation for heath education. The health sector therefore has great interest in promoting equity-oriented education policies that allocate priority to primary education and especially to the health-related needs of women. Reduction of female illiteracy rates is regarded as particularly important, as women so often play the major role in child rearing, the determination of family size, nutrition, and health care utilization.

Other, but by no means less important, sectors that should be involved in collaboration are those of water, sanitation and housing development. The linkages between water, sanitation, housing and health are many. Frequently, water and sanitation projects do not give sufficient attention to socioeconomic and socio-cultural conditions of the communities served. Basic personal hygiene, for example, needs to be maintained even with improved sanitation. The message of boiling drinking water is now widely accepted, but boiled water is often reinfected on storage by the use of dirty receptacles and by dipping unclean hands into it, negating the benefits of boiling. A by-product of this apparent failure of the relatively expensive boiling to prevent infections may be to make people skeptical of other health-promotion messages.
 

'Health byproducts' of industrialization:
A rapid and often poorly planned industrialization process can expose many folks to new hazards that require a different set of intersectoral activities to safeguard them. Unorganized labor is often only poorly protected from industrial and pollution hazards, and casual workers, garbage pickers and others in informal activities are constantly exposed to many health hazards. Little advice, guidance or safety equipment is currently available to help these workers. Many Third World industries also pose dangers to the community as a whole. Whilst examples of industrial pollution can be seen today in developed countries, severe industrial pollution disasters, such as the leak of toxic chemicals from the plant at Bhopal in India in 1985, seem to be more frequent occurrences in the Third World, where environmental legislation may be weak and maintenance of equipment sometimes lax. Toxic pollutants often affect much broader areas than their locality. Traffic fumes, vehicles, noise, and other factors all impinge on the wider environment. However, to encourage investment and economic growth, many of the poorer and middle-income Third World countries are ignoring (or are unaware of) health hazards from numerous industrial or related processes. By contrast, the first wave of NICs [
newly industrializing countries], especially those in South-east and East Asia such as Hong Kong, Singapore and Korea, have been developing environmental controls and considerable industrial health legislation over the past decade. Ironically, their effect may only be to encourage polluting or dangerous industrial processes to relocate in countries where controls are laxer.

Intersectoral action at an official level is increasingly crucial for the rapidly growing urban populations of the Third World. Never before have such large numbers of people in so many settings been exposed to and potentially at risk from the direct and indirect effects of industrialization. The health sector should be strengthened so that a dialogue can grow about health-related aspects of other activities. Importantly, knowledgeable and authoritative health workers at all levels will need to be trained to contribute to the fostering of major intersectoral linkages with health. Community medicine, industrial medicine and environmental health will all have to be enhanced or, more usually, initiated in many Third World countries, so that the healthpromotion (and health-damaging) aspects of the activities of other sectors can be identified, regulated and improved.

[Reminder from Essem: This abridged presentation is only an extract. Please read the full article for a more comprehensive understanding of the authors' presentational niceties and subject.]
Links to related subjects:
Excerpts from "More than just a bad moon rising" ; Copy of article appearing in 'Perspective'; The Statesman, dated October 3, 1998 : page 9.
Education and economic growth: The three Rs as levers of change' by Amartya Sen; first appeared in The Statesman on Wednesday, 26 August 1964, and reprinted in 'Perspective' dated October 19, 1998; page 9.
DISCUSSIONS:
Comment # 1: Received from
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2. Excerpts from 'Chapter 1: Primary health care' by David R Phillips; in "Health and Health Care in the Third World", Longman Scientific & Technical, page 150.
Primary health care (PHC) has emerged as the dominant approach to health problems in most Third World countries. Its development has stemmed from 
  • the realization that the existing hierarchical systems have failed the vast majority of people, and
  • an acceptance of the proposition that health services should try to serve the bulk of people rather than a favoured few, and
  • a practical recognition that highly facility-oriented, high-tech health care is neither appropriate for the majority of health and development needs of most Third World countries, nor generally affordable.
Definitions of PHC:
Primary health care integrates two main streams of activities and processes. One relates to growth and extension of basic health services; the other involves development of the local community in terms of infrastructure, education, initiatives and resources. PHC was defined in the 1978 Alma Ata conference as :
    essential health care made universally accessible to individuals and families in the communty 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 of the country's health system, of which it is the nucleus, and of the overall social and economic development in the community.
It is viewed as being a mixture of curative, preventive and promotive activities of a basic nature, involving many segments of economy and society that have a bearing on health and welfare, not solely (primary) medical care. More recently, selective PHC (SPHC) has been suggested to target and confront specific health problems in given areas.

PHC philosophy has often become health care policy, involving first-contact services and front-line workers within a framework of eight activities and five basic principles:

  1. education about diseases, health problems and their control
  2. safe water and basic sanitation
  3. Maternal and Child Health (MCH), including Family Planning (FP)
  4. immunization against major infectious diseases
  5. appropriate treatment of common diseases and injuries
  6. provision of essential drugs.
Whatever the range of cover, a basic tenet of the PHC approach should remain that services are not exclusively technocratic and provided by highly trained, technologically oriented professionals. At different levels, auxiliaries community workers and, where appropriate, traditional practitioners will be involved within the broad orbit of health services. A referral network should exist to give mutual support at all levels, and especially to provide care not available locally. Hospitals should become involved in the overall health of communities in which they are located and participate directly in PHC activities. PHC should thus be broad-based essential care, but not totally divorced from higher levels of the health care hierarchy. Figure 5.1 shows diagrammatically the components of the PHC approach.

The intersectoral collaboration and community involvement at all levels provide the totality of the PHC approach.

Doubts about PHC:
There are growing doubts as to the real long-term potential of PHCs. These relate to fundamental explanations of the existing patterns of inequality in health and access to health resources, involving the 'development of underdevelopment' debate, and many lay the blame on previous colonial systems, which undervalued the health of the masses (by neglect and exploitation) whilst catering for the elite. Improved health is not simply, or even mainly, a matter of medical systems. Rather, a much more complex question of the relationship between health and underdevelopment, the nature of underdevelopment, and the local and international reasons for its perpetuation, is involved.

Personnel involved in PHC:
Several types of primary health workers with greater or lesser degrees of formal training have been identified. A common theme is that all need a "wider social outlook" than the purely clinical or bureaucratic; this certainly applies to hospital staff who might become involved in PHC or its support. A crucial issue concerns the relevance of professional medical and nursing training to the needs of localities in which the PHC is set. Often a wide understanding of public health and local ecologies, and considerable skill in communication with people in their own home settings, are required.

Selective PHC:
Whilst the comprehensive approach of PHC is laudable and arguably "ideal", its very scope and breadth often make it unattainable because of the bottlenecks and shortages in finance, personnel and, perhaps, goodwill. Faced with a vast number of health problems of varying severity, proponents of SPHC argue that these cannot be tackled simultaneously; some priorities must be assigned to various tasks for reasons of practicality, cost and effective use of resources.

SPHC typically focusses on paediatric conditions, such as measles, whooping cough, neonatal tetanus and diarrhoeal diseases (see Table 5.1).

Table 5.1: Selective PHC - some identified priorities for disease control in the developing world (from Walsh and Warren, 1979)
Priority Group
Reasons for assignment to this category
1. High
Diarrhoeal diseases
Measles
Malaria
Whooping Cough
Schistosomiasis
Neonatal tetanus
High prevalence, high mortality or high morbidity, effective control
2. Medium
Respiratory infections
Poliomyelitis
Tuberculosis
Onchocerciasis
Meningitis
Typhoid
Hookworm
Malnutrition
.
High prevalence, high mortality, no effective control
High prevalence, low mortality, effective control
High prevalence, high mortality, control difficult
Medium prevalence, high morbidity, low mortality, control difficult
Medium prevalence, high mortality, control difficult
Medium prevalence, high mortality, control difficult
High prevalence, low mortality, control difficult
High prevalence, high morbidity, control complex
3. Low
S. American trypanosomiasis (Chagas' disease)
African trypanosomiasis
Leprosy
Ascariasis
Diphtheria
Amoebiasis
Leishmaniasis
Giardiasis
Filariasis
Dengue
.
Control difficult

Low prevalence, control difficult
Control difficult
Low mortality, low morbidity, control difficult
Low mortality, low morbidity
Control difficult
Control difficult
Control difficult
Control difficult
Control difficult

It has the effect of reducing priorities to those conditions which can be treated or averted at the least cost, and so, cynically, it may be argued that ot merely places relative costs on human lives. The typical SPHC targets, measles and whooping cough for example, have effective vaccines; neonatal tetanus is vaccinable and preventable with sterile practice; diarrhoeal diseases likewise have preventive measures, and Oral Rehydration Therapy (ORT) is known and available in many places. A lower priority is usually accorded to conditions such as polio, typhoid, respiratory infections. meningitis and malnutrition, a varied group of which only polio can effectively be controlled by medical intervention. The lowest priority in SPHC terms are accorded to diseases such as dengue, filariasis and amoebiasis, as their control id difficult, largely environmental and hence costly and needing continued efforts.

SPHC approaches do not tackle many of the numerous basic health problems. The most sustained argument against SPHC and all selective approaches comes from the philosophical objection to the technocratic intervention by the West, which denies local initiative. Comprehensive PHC represents, at least symbolically, the opportunities for promotion of self-help and democratization of health services. "Vested interests have struck back by glorifying the work of Walsh and Warren" (Banerji, 1988) and, by use of political and economic strength, have imposed selective, Western-determined programs on the Third World. This criticism, though of course justified, is countered by reference to the need for judicious use of scarce resources.

Hospitals and urban PHC:
In rural areas, facilities such as rural health units, district hospitals, health aid posts and the like can all provide foci for PHC. In urban areas, however, whilst hospitals may sometimes consume over half of the national health budgets (and sometimes as much as 80%), in many instances these have little interest in, or connection with, PHC. This is related to the weakness of social, preventive or community medicine (in its various guises) in many Third World countries and the relatively low status often attached professionally to PHC (it may be viewed as amenable for community workers, rural peasantry and the like).

Nevertheless, increasingly, PHC strategies will be essential to enhance the serious health and environmental situations of many Third World urban neighborhoods. Housing, sanitation, availability of potable water, nutrition and effective access to health care are frequently worse in poor urban neighborhoods - especially in slum and shanty areas - than in corresponding rural sites. There are instances where attempts to provide PHC in urban settings have been made, but these projects are often piecemeal and fragmented, clinics poorly staffed and lacking medicines and equipment. Therefore, PHC clinics are frequently bypassed in favor of hospitals, which are often crowded  ut perceived as being the only loci at which any chance of health care is likely to be available.

Community involvement has long been recognized as a major, often essential, ingredient for successful PHC, by which local communities participate in planning, implementation and use of health activities, taking responsibility for, and benefiting from, improved health and health care.

Infrastructure projects, sites-and-services schemes, low-cost housing upgrading and comprehensive redevelopment schemes all involve considerable multisectoral action. They can become entry points for PHC initiatives in low-income areas and could certainly be used for more broadly based urban environmental upgrading, including health targets.

Urban PHC projects should not be "one-off" actions, but should be steps in a strategy for continuing, large-scale coverage for all those whose health needs have previously been ignored. However, to date, few PHC initiatives in poor urban areas have been successful, hindered by:

  • financial and human constraints
  • "step-motherly", negative attitudes of government officials or health professionals
  • lack of community or government involvement.
Before attempting to extend the coverage of urban PHC initiatives, it is necessary to evaluate the effectiveness and desirability of elements within one-off projects, and to identify their wider applicability. Little work of this sort has yet been achieved.
[Reminder from Essem: This abridged presentation is only an extract. Please read the full article for a more comprehensive understanding of the authors' presentational niceties and subject.]
DISCUSSIONS:
Comment # 1: Received from
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