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CRE - CREATIVE LEARNING EXERCISE

AGL - PRIMARY HEALTH CARE IN DEVELOPING

COUNTRIESDraft for publication – 2012

Dr. Bob Boland & Team MD, MPH, DBA, ITP (Harvard)

1. Planning2. Priorities3. Management4. Evaluation

Source: JHSPHAudios: freely available on www.crelearning.comHelp: [email protected]: ER/RGAB 2012

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http://www.crelearning.com/

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TABLE OF CONTENTS

Section age No.

1. Introduction 3 2. Work Pack 4

3. Diary & Glossary 111

4 Guide & Quiz 133

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1. INTRODUCTION

3

2. WORK PACK

4

CONTENTS

Item Page Number

1. Abbreviations And Protections 1

2. Introduction 5

3. Part A: PHC Priorities 8

4. Part B: PHC Planning 26

5. Part C: PHC Management 43

6. Part D: PHC Evaluation 53

7. Mini Cases Problems for A Consultant 64

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AGL 21 – PHS HEALTH CARE IN DEVELOPING COUNTRIES

EXHIBET A

1.0 ABBREVIATIONS

JHSH&PH – Johns Hopkins School of Hygiene and Public Health

AGL – Autonomous Group Learning

IND – Individual

SC – Small Group

CSG – Combined small group

MG – Main group

LP – Learning Point

PHC – Primary Health Care

LDC – Less Developed Country

IMR – Infant Mortality Rate

MM – Maternal Mortality

LE – Life Expectancy

CBR – Crude Birth Rate

CDR – Crude Death Rate

GNP – Gross National Product

OR – Oral Rehydration

PAR – Population at Risk

MCH – Maternal Child Health

CDB – Community Development Block

PFD – Provision for Disaster

WHO – World Health Organization

TBA – Traditional Birth Attendant

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AGL 21 – PHC IN DEVELOPING COUNTRIES

1.0 PROGRAM

Starting DurationActivity Mode Time (Minutes)

Day I1. Introduction MG 8:30 30

2. Quiz IND 9:00 30

3. Part A- PHC Priorities MG/SG 9:30 60

4. Break - 10:30 15

5. Case – West Primary Health Care SGCSGMG/SG

10:4511:4512:15

603030

6. Lunch - 12:45 45

7. Part B – PHC –Planning MS/SG(new) 1:30 60

8. Case – Asian Island Project SG 2:30 45

9. Break - 3:15 15

10. Case – Asian Island Project(cont’d)

CSG 3:30 30

MG/SG 4:00 30

11. Review and homework assignment MG/SG 4:30 30

Total 510

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AGL 21- PHC IN DEVELOPING COUNTRIES

1.0 PROGRAM cont’d

Starting DurationActivity Mode Time (Minutes)

Day II1. Review and Minicasas(1-16) SG(new) 8:30 45

2. Part C – PHC – Management NG/SG 9:15 45

3. Case – PHC Food Project SG 10:00 45

4. Break - 10:45 15

5. Case – PHC Food Project (cont’d) CSGMG/SG

11:0011:30

3030

6. Minicasas (7-12) MG/SG 12:00 45

7. Lunch - 12:45 45

8. Part D – PHC Evalution SG (new) 1:30 30

9. Case - Rally Health Care SGCSG

2:002:30

3030

10. Break - 3:00 15

11. Case –Rally Health Care (cont’d) MS/SG 3:15 30

12. Quiz IND 3:45 45

13. Review and feedback MG/SG 4:30 30

Total 510

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2.0 INTRODUCTION

2.1 PROGRAM OBJECTIVES

The Program is developed for Doctors directly and indirectly involved in the management of Primary Health Care (PHC) activities in developing countries. Specific learning objectives are:

a. To use the language and concepts of PHC

b. To develop skills in managing in terms of : priorities, planning, management and evaluation.

c. To recongnize the constraints of PHC : political, financial, administrative, social, cultural, medical, etc.

d. To motivate further study in the future.

2.2 MATERIALS

a. Retained by participants:

1. Textbook – to be decided

2. Work pack – including lecture notes, learning points, simplified glossary, references, worksheets, etc. Common abbreviations are given in Exhibit A.

3. Learning Recall Tape – cassette for future study summarizing each step in the learning process (to follow)

b. Not retained by participants:

1. Case Guide – case studies, questions on the cases, case solutions, learning patterns, quizzes, exercises, etc.

2.3 TRAINING METHOD

a. The AGL (Training Method) for this material was developed in 1969 for international management training programs. It is a way of learning in groups without formal instruction. Participants use the materials and group resources to develop answer to all the cases and questions arising from the learning experience.

b. The work will be done in various modes: IND – individually, PAIRS – in pairs, SG – in small groups, CSG – in combined small groups, and MG –in main group.

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2.0 INTRODUCTION (con’t)

2.3 TRAINING METHOD (cont’d)

c. Groups will be changed to enables participants to work with a variety of course members.

d. The Group Organizer assists the participants and groups to solve all the problems and thus achieve rapid individual learning in the limited time available.

e. Work quickly to cover all the materials in the time allowed. Use the SG’s to help you clarify difficult points and questions. Use your notebook to continually record key learning points. Use the Glossary for new technical word definitions. Appont a SG member “timekeeper”.

f. After the program use the LRT (Learning Recall Tape) for about one hour weekly for a month. This should improve the quality of your learning and convert short-term into long-term learning.

2.4 ACKNOWLEDGEMENTS

Acknowledgement is made to Professor Carl Taylor and the staff of the Department of International Health of the Johns Hopkins School of Hygiene and Public Health who have provided some help and encouragement for preparing this program.

However, the authors take responsibility for all material and opinions which do not represent the official views of any organization.

2.5 GROUP STUDY

a. In MG (main group) – follow the lecture notes

b. In SG (small groups) – read the lecture together as follows (A,B,C,D):

1. A Reads the first sections to the SG2. B Summarizes what A has said and reads the seconds section 3. C summarizes what B has said and reads the third section4. The process is repeated by D, and the cycle is continued until the lecture

is covered completely.

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2.0 INTRODUCTINS (cont’d)

c. In SG – summarize the key points of the lecture on one sheet of the flip chart. Use your manual as a worksheet. Mark key points. Write in questions.

d. Work quickely to complete all the work in the time allowed. Key points will be repeated many times during the program

2.6 REFERENCES FOR FUTURE STUDY

1. Management of Health Systems in Developing Countries R, O’ Connor, D.C. Health, Toronto, 1980

2. Health Problems and Policies in Developing Countries World Bank Staff working Paper No. 412, Washington, 1980

3. Primary Health CareWHO, Geneva, 1979

4. The Primary Health Care WorkerWHO, Geneva, 1980

5. Primary Health Care for Pediatrics Parts I and IIM. King, Pergammon, London, 1979

6. Health – Sectional Policy PaperWorld Bank, Washington, 1980

7. Manpower Planning for Primary Health CareR.A Smith, Hawaii University, 1978

8. Training and Use of Auxillary Health Workers: Lessons from Developing Countries

D.M Storms, APHA, Washington, 1979

9. Functional Analysis – Department of International Health JHSH&PH Asia Publishing House, New York, 1976.

NOTE: Now complete the Program Registration Form and introduce your background to the members of your SG.

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3.0 PART A: PHC PRIORITES

3.1 STRUCTURE OF THE PROGRAM

a. Primary Health Care (PHC) seeks to achieve health for all at affordable cost. It may be divided into four areas: priorities, planning, management and evalution.

b. Priorities – Analysis of environment and resources to generate health priorities and population at risk. This data may be coverted to health objectives, appropriate health service targets and specific health Indicators.

c. Planning – Given priorities, health objectives and health service targets, plan manpower, facilities, logistics and organization to achieve objectives.

d. Management – mobilizing resources to achieve objectives involving: input (msnpower, facilities,logistics, finance), process (health services), output (access, coverage, utilization, quality of care) and outcome (health status improvement).

e. Evalution – Input, proce, output and outcome in terms of efficiency and effectiveness.

3.2 HEALTH CARE PRIOR TO 1978 (Alma-Ata) –H/2000

a. 1946 formation of WHO, UNICEF, WDP, UN, WFP as international organizations fully or partly involved with World Health.

b. Vertical programs for immunizations, disease control (small pox eradicated; malaria and yellow fever partially controlled). Horizontal programs for general PHC (FSCSP-Brazil; a national system

c. Mulitiple short term projects exposing western medicine to developing countries generally failed to achieve more than 10% coverage. Over 200 international,bilateral or voluntary agencies active in Health care but western medical care available only to 20% of the world population in 1978.

3.3 DEFICIENCES OF A PURELY MEDICAL APPROCH TO PHC

a. Developing country GNP per capita $500 (or less) not adequare for PHC. See comparison of indicators (Exhibt A).

b. Maldistribution of physicians with western care inaccessible to rural areas. Medical preference for “no care” rather than “inferior care”. Traditional practitioners and healers fill the gap.

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AGL 21- PHC IN DEVELOPING COUNTRIES

3.0 PART A : STUDY PRIORITIES (Cont’d)

3.3 DEFICIENCIES OF A PURELY MEDICAL APPROACH TO PHC (Cont’d)

c. Recognition of nutrition and poverty as more significant than medical care in improving health status.

3.4 ALMA-ATA-1978

a. Health defined as physical, mental and social well-being, not merely the absence of disease. Universal human right of access to PHC.

b. PHC eight functions defined: maternal and child care, nutrition, water and sanitation, environmental control of communicable disease, extended program of immunization, family planning, health eduction, and basic curative care.

c. PHC recognized as requiring political change toward social equity and social justice for all by income redistribution, but political impracticality of such change by the year 2,000.

d. Trade off between “individusl freedom” (inappropriate health lifestyles - smoking, drinking, eating, exercises, etc.) and “healthy life style” generally ignored. Health not the first personal priority.

3.5 ROUTINE FOR SETTING PRIORITIES

a. Determine priority diseases and health problems and define specific populations at risk. (Exhibit B).

b. Assess the importance of priority diseases in terms of: incidence, prevalence, fatality, social effects, technical vulnerability, cost/benefit of treatment, political factors, logistics,and resources feasibility; recognize the conflict between community demand and professional need assessment.

c. Set health objectives and target populations. (Exhibit C)

d. Set health service targets in terms of coverage, utilization, access, availability, quality, cost, etc. (Exhibit C).

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AGL – PHC IN DEVELOPING COUNTRIES

2.0 PART A: STUDY PRIORITIES (cont’d)

3.6. HEALTH INDICATORS

a. Basic health indicators relate to economic indicators (Exhibit A). Some basic indicators are:

1. IMR (infant mortality rate) – not more than 20/1000

2. LE (life expectancy)- not less than 60 years

3. MM (maternal mortality) – not more than 3/1000

4. Population growth – not more than 2%

5. CBR (crude birth rate) – not more than 30/1000

6. CDR (crude death rate) – not more than 15/1000

b. From surveys or analysis of hospital and clinic records determine indicators for prevalence and incidence of disease in relation to specific populations. Particular attention to communicable and endemic disease (malaria, parasites, trachoma, leishmania, trypanosomiasis, schistosomiasis, etc.). (Exhiit D).

c. Survey data better than published annual statistics due to poor reporting, late and incomplete registration, political influence, lack of data on rural areas, etc.

d. A systematic approach to PHC practices and planning in the “Functional Analysis” technique discussed later in this program.

3.7 UNDERSTANDING THE ENVIRONMENT

a. Need to understand disease: morbidity and mortality, technical and logistic feasibility, political and public priorities, and resource availability.

b. This involves analysis of existing health systems and national health planning (reality or shopping list?), analysis of existing and past PHC projects, basic environment analysis of the: social, political, cultural, economic and medical framework to determine the strengths and constraints.

c. Household surveys or special community studies to determine the patterns of health, illness, work, nutrition, etc. and to understand the values, beliefs, customs, and attitudes to sickness, health, death, religion, etc. of the community, including traditional healers: numbers, type, activity, coverage ,etc.

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3.0 PART A: PHC PRIORITIES (cont’d)

3.8 POLITICAL FEASIBILITY

a. Distinguish political rhetoric from reality by examination of past actions not words. Health is seldom the first government priority. Political power uses technical and scientific reports for political objectives. Political power has a limited time horizon which affects its priorities (the Minister of Health may only be in office for 3 years).

b. The “very poor” may have little political voice even in community participation projects. Avoid limiting the benefits to the “less poor” only, since communities have political power systems even under relative poverty conditions.

c. Recognize that voluntary organizations cannot affect along term generalized health status improvement without government support evidenced by a political will and capacity.

3.9 THE RANGE OF PHC ALTERNATIVES

a. Curative or preventive care.

b. Horizontal or vertical services.

c. Comprehensive or limited (selective) PHC.

d. Reinforce existing activity or start a new activity ororganization.

e. Passive care at clinic versus active outreach in thecommunity.

f. Local or international staff.

g. Start now or later

h. Use existing data or delay to gain more data (date will never be adequate for all purposes).

i. Geographical access easy or difficult.

j. Coverage urban or rural, total or partial.

k. Cost. Locally or internationally financed; short term orlong term.

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3.0 PART A: PHC PRIORITIES (cont’d)

3.10 PRIORITY SETTING TECHNIQUES

a. In the final analysis all PHC priorities are political(recognize the hidden agendas of all parties to PHC).

b. Theoretical techniques have been applied: Delphi, Delbeque,Nominal Group Process, etc.

c. The national health planning and community surveys should identify priorities. Recognize that community demand may not be the same as professional assessment of health needs.

3.11 EXHIBITS

a. Health/Development indicators.

b. Populations at risk.

c. Objectives and targets.

d. Priority diseases in developing countries.

e. Contrast of Professional/Community priorities for PHC.

f. Health priority computation.

g. Optional study note questions.

IMPORTANT NOTE: Despite years of political rhetoric, many developing countries place low cultural priorities on “time and efficiency” as compared with human and social values. In this environment the priorities, planning, management and evaluation of PHC must be consistent with these values while still providing for the very different values of the western donors of funds for international health projects.

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT APart A – PHC – Priorities

Health/Development IndicatorsIndex Range

Indicators 0 10 20 30 40 50 60 70 80 90 1001. Crude birth rate 48 46 44 44 43 40 35 27 20 17 162. Crude death rate 22 19 17 16 13 10 9 8 9 11 113. Population growth rate 2.6 2.7 2.7 2.8 2.9 2.9 2.5 1.8 1.1 0.5 0.44. Infant mortality rate 161 148 135 125 106 86 64 45 32 21 135. Life expectancy 41 44 47 48 52 57 62 66 69 71 726. Animal protein onsumption per capita

per day 9 11 11 12 14 18 24 35 45 53 63

7. Percent literate, ages 15+ 23 32 37 39 47 60 72 85 92 97 1018. Percent aged 5-19 enrolled in primary

and secondary school 23 26 31 35 43 50 56 63 69 75 80

9. Percent of dwellings with electricity23 27 33 37 38 46 58 78 93 98 99

10. Newspaper circulation per 1,000 population 4 7 11 17 32 55 83 133 208 290 356

11. Telephones per 100,000 population136 205 348 607 1,058 2,011 3,768 6,768 12,193 22,482 41,192

12. Automobiles per 1,000 population 1 3 4 7 8 13 23 46 92 166 29913. Males in agriculture as percent of

total male labor force 91 81 71 64 57 52 42 29 20 13 8

14. Steel consumption per capita (kg.) 3 5 8 14 26 43 73 143 275 442 57115. Energy consumption per capita (kg.)

37 73 118 201 351 524 871 1,600 2,837 4,389 6,608

16. Percent GDP from manufacturing 9 10 10 11 14 17 19 22 27 30 3317. GNP per capita (US $) 72 90 117 163 230 304 464 727 1,081 1,675 2,500

Source : United Nations Institute for Social Development (1980)- 13 -

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT B3.0 Part A: PHC – Priorities

POPULATIONS AT RISK

A. Children Under Five: B. Women of Childbearing Age:

Poverty Poverty

Low level of maternal education Pregnancy at age < 18 years

Birth internal of < 24 months Anemia

Maternal weight gain > 7 kg Malaria

Birth weight < 2500 gms Undernutrition

Neonatal tatanus Abortion

Pertussis Short interbirth interval

Undernutrition < 80% weight/height Previous delivery complication

Diarrhea & Dehydration High parity

Respiratory Infection Associated disease

Malaria (Hypertension, Tuberculosis, Diabetes)

MeaslesInadequate antenatal care

Source: JHSH&PH

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT C3.0 Part A: PHC Priorities

OBJECTIVES AND TARGETS

Objectives relate to general health status or to specific causes of morbidity or mortality. They are specific goals for change in health status. They must be understandable, quantitative, and time limited, with current and the desired quantitative levels.

Targets are levels of program activity for coverage, utilization, access and availability to attain objectives. Listed below are objectives and four targets for program activities for each of two health programs.

PROGRAM I

Objective:

Health Status:

To reduce neonatal tetanus from 25/1000 live births to 10/1000 live births through immunization of pregnant women.

Targets

1. Coverage:

Immunize 70% of pregnant women with 2 doses of tetanus toxoid by 8th month of pregnancy.

2. Utilization:

Provide 6000 injections of tetanus toxoid to pregnant women per year.

3. Access:

Provide access within 5km to a tetanus toxoid delivery point to 80% of pregnant women.

4. Availability:

Provide one midwife with tetanus toxoid per 10,000 population.

PROGRAM II

Objective:

Health Status:

To reduce malaria mortality in children under 5 from 20/1000 children to 5/1000 children per year through provision of chemoprophylaxis.

Targets

1. Coverage:

Maintain malaria chemoprophylaxis in 80% of children less than five.

2. Utilization:

Provide 5000 monthly cycles of malaria chempprophylaxis to children under five.

3. Access:

Provide depot source of malaria chemoprophylactic drugs to 95% of families within a distance of 2km.

4. Availability:

Provide one village health worker with drugs for malaria chemoprophylaxis per 1000 population.

Source: JHSH&PH

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT D3.0 Part A: PHC Priorities

PRIORITY DISEASES IN DEVELOPING COUNTRIES

CHAD: Malaria, intestinal amoebiasis, intestinal parasitic diseases, gastroenteritis, acute bronchopulmonary diseases,eye diseases, tetanus, tubercolusis, vesical schistosomiasis.

EQUITORIAL Leprosy, trypanosomiasis, onchocerciasis, filariasis,GUINEA: yaws, venereal diseases, intestinal parasites, nutritional diseases.

ETHIOPIA: Venereal disease, helminthiasis, bacillary and amoebic dysentery, gastroenteritis, leprosy, malaria, tuberculosis,schistosomiasis, trachoma, influenza, filariasis.

MADAGASCAR: Tuberculosis, diarrheal and parasitic diseases, measles, schistosomiasis, malaria, leprosy, venereal disease, plague, typhoid fever, paratyphoid, polio, diphtheria and rabies.

UNITED Trypanosomiasis, malaria (prevalence 100%), leprosy,REPUBLIC OF measles, venereal disease, cerebral meningitis.CAMEROON:

BAHAMAS: Influenza, gonococcal infections, gastroenteritis, streptococcal infections (throat), measles.

BOLIVIA: Most important causes of morbidity for the following age groups:

1-4 years Gastrointestinal and respiratory diseases accidents, assaults, diseases of the digestive system.

5-15 years Respiratory diseases, gastrointestinal diseases, tuberculosis

15+ years Complications of childbirth, complications of pregnancy, diseases of the digestive system, accidents, assaults, tuberculosis, measles, pertussis, polio.

NICARAGUA: Enteritis, parasitic diseases

Source: JHSH&PH

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT E3.0 Part A: PHC Priorities

CONTRAST OF PROFESSIONAL/COMMUNITYPRIORITIES FOR PHC

PROFESSIONAL CRITERIA COMMUNITY CRITERIA

(1) Expected benefits commensurate (1) Expected benefitswith commensurate with- frequency and severity of - perception of

disease incidence, prevalence or severity

- social impact of disease - social impact- technical feasibility of - perceived causation preventaion or cure (Physical/supernatural

/other)- acceptability and

credibility ofprevention or cure

(2) EXPECTED COSTS (2) EXPECTED COSTS

- manpower - direct costs ofservices, medicines,diets, transport

- technology: investment,maintenance, training - opportunity costs

- logistics relating to

a) population distributionand nucleation, preexisting (3) ALTERNATIVESexisting communication

- private practitionersb) timing of services: balance

between a planned or randomly - traditional healersoccurring need

- drug stores

- self care

Source: JHSH&PH

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT F3.0 Part A: PHC Priorities

HEALTH PRIORITY COMPUTAION

PROBLEM DISEASES INCIDENCE PREVALENCE

FATALITY SEQUELAE

SOCIAL IMPORTANCE

TECHNICAL VULNERBILITY

BENEFIT COSTRATIO

POLITICAL IMPORT

TOTAL

1. MALNUTRITION

2. ANAEMIA

3. DIARRHEA

4. POLIOMYELITIS

5. TETANUS

6. PERTUSSIS

7. MEASLES

8. PNEUMONIA

9. SKIN INFECTIONS

10. EYE INFECTIONS

11. EAR INFECTIONS

12. OBSTRETICAL COMPLICATIONS

13. INJURIES

14. VENERAL DISEASES

15. TUBERCULOSIS

16. LEPROSY

17. MENTAL DISEASES

18. MALARIA/ BILHARZIA

19. INTESTINAL PARASITES

20. TRYPANOSOMIASIS/FILARIASIS

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AGL 21 – PHC IN DEVELOPING COUNTRIES EXHIBIT G3.0 Part A: PHC Priorities

OPTIONAL STUDY NOTE QUESTIONS

1. How have the international health organizations changed since 1946?

2. Should Alma-Ata H/2000 have been “Health Care for All by 2000”? What is the hidden agenda?

3. Why is research into cultural values of poverty environments so vital in setting PHC priorities?

4. Should any PHC be started in a country that cannot support it long term from local or national funds?

5. Are traditional medical systems related to important values about the meaning of life? Could PHC with western standards harm a society?

6. What are the key constraints to PHC?

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AGL 21 – PHC IN DEVELOPING COUNTRIES3.0 Part A – Case: West Primary Health Care

QUESTIONS ON THE CASE

1. Outline the key facts from the story of the case.

2. What were the important characteristics of the environment: geographical, political, economic, social etc. What was the “target population?

3. Were health priority objectives and health service targets properly determined? To what extent has a Functional Analysis been completed? Why was the project not extended from 24,000 to 120,000 population?

4. Discuss the alternatives that are now available.

5. Decide and justify your decision.

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AGL21 – PHC in Developing Countries3.0 Part A – Case: West Primary Health Care

INTRODUCTION

In March 1985 Dr. David Hall had been three months in his new appointment as Head of the Department of Community Health at the West hospital located on a Caribbean Island. The Department was formed to improve the health of the 120,000 people in the hospital district by:

a) identifying the health problems;b) identifying populations at risk; and,c) providing out-reach health services to the populations at risk.

Dr. Hall had just received from the chairman of the hospital governing board a copy of the World Bank Health Sector Report dated December 1984 and he noted the Bank’s view on health problems in developing countries and the constraints upon a purely medical approach to health care (Exhibit A). He was now considering what should be done with regard to health care particularly in terms of health priorities objectives and health services targets.

BACKGROUND

The Caribbean Island was governed by a black political dictator for the 30 years and was stable. According to government statistics the population was about 5 million with a GNP of $ 380 per capita in 1984; there was a high prevalence of chronic malnutrition and IMR was 157/1,000 LE 45 years, CBR 37/1,000. About 80% of the population lived in rural areas deriving their living from agriculture which was constantly threatened by erosion and droughts, and hampered by primitive methods. The other key industry was tourism. The population was essentially christian but susceptible to voodoo and black medicine and there were established traditional healers and witchdoctors in most of the villages. The government health service was minimal in that it had several hospitals and a system of health centers which were generally under-supplied with drugs and staff, and not active.

The West Hospital was founded with government consent in 1978 and financed by international donors to serve a rural population of 120,000 persons in a district of 400,000 square kilometers. It had 120 general hospital beds and provided annually 2,000 admissions, 50,000 patient days of hospital care and 60,000 outpatient consultations. Nominal fees only were charged and the major portion of the hospital’s budget was financed by international funds. Although the out-patient load was mainly curative the hospital had been trying to give preventive care such as: screening for TB and malnutrition, immunization against tetanus, diphtheria, pertusis and tuberculosis, health education, etc.

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AGL 21 – PHC in Developing Countries3.0. Part A – Case: West Primary Health Care (Continued)

BACKGROUND (Continued)

In view of the general lack of response to preventive medicine it was decided to form a Department of Community Health to provide out-reach preventive services in the villages. This was all with the tacit approval of the government but without their direct involvement.

WORK TO DATE

In 1984 preventive work had already been started in a limited area of 20 square kilometers surrounding the Hospital. Voluntary community collaborators had been selected for each 100 families in the villages to conduct a census of all members of the 8,000 population and to improve data on births and deaths so that rates could be calculated. This was the beginning of a health surveillance system but could only be applied to a small area until development of the Department of Community Health.

WORK OF THE COMMUNITY HEALTH DEPARTMENT

To assess the need for health services from available morbidity information, hospital records had been analyzed and showed that:

a) Tetanus was the most common cause for admission [15%]b) Malnutrition accounted for most hospital days [23%]c) Tuberculosis [25%] and diarrhea [20%] were most important in terms of

out-patient services.

However, no data was available on the incidence/prevalence of specific diseases in the hospital district since no general surveys had ever been done.

In terms of priority health problems it seemed to Dr. Hall that the data on morbidity and mortality, the contacts with community leaders, the health surveillance and the hospital records, all indicated so far that malnutrition, diarrhea, tuberculosis and tetanus were target diseases for preventive services. Malaria was not among the target diseases because there was already a national malaria eradication service and no cases were diagnosed in the previous two years. No data was available on the extent to which people preferred western to traditional health care.

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AGL 21 – PHC in Developing Countries3.0 Part A – Case: West primary Health Care (Continued)

DR. HALL’S ALTERNATIVES

Dr. Hall recognized that “priority diseases” depended not only on incidence and prevalence but also; fatality, social effects, technical vulnerability, cost/benefit of treatment and political factors. However, he was more concerned with deciding about the target population for health services, and was considering at least four alternatives:

a) Plan full PHC (8 functions} for a limited 8,000 population near the hospital.

b) Plan Selective PHC (Nutrition and EPI) for the 8,000 population nearest the hospital and gradually expand at low cost to cover the full 120,000 population.

c) Plan Selective PHC for the whole 120,000 population at a cost that would be locally self-supporting long term in this chronic poverty environment.

d) Do nothing until he could complete Functional Analysis (including a house-hold survey) of the whole population and use that delay to persuade the government to cooperate in a joint venture for out-reach PHC.

Source : Developed from articles in the NEJM and other data.

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EXHIBIT AAGL 21 – PHC IN DEVELOPING COUNTRIES3.0 Part A – Case: West Primary Health Care

IMPROVING HEALTH CONDITIONS IN THE DEVELOPING COUNTRIES

Despite the large expenditures on health, and the technical feasibility of dealing with many of the most common health problems, efforts to improve health have had modest impact on the health of the vast majority of the population in most developing countries. This is commonly attributed to two main reasons.

First, health activities have typically overemphasized sophisticated, hospital-based care, while neglecting preventive public health programs and simple primary care provided at conveniently located facilities.

Second, even where health facilities have been geographically and economically accessible to the poor, deficiencies in logistics, inadequate training of staff, poor supervision, inappropriate services, and lack of social acceptability have often compromised the quality of the care they offer and limited their usefulness.

Though not present in all developing countries, the following problems are frequently encountered:

1. Health facilities are geographically inaccessible to the majority of people. Women with children are most likely to experience difficulties in reaching a source of care.

2. Economic barriers exclude many people. Even where users are not charged for service, the costs of transportation and time away from work can be prohibitive for the poor, particularly those who live in urban areas.

3. Curative care is emphasized while prevention and early treatment are neglected.

4. Hospital facilities built are excessive relative to primary health care facilities.

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AGL 21 – PHC IN DEVELOPING COUNTRIES3.0 Part A – Case: West Primary Health Care EXHIBIT A

5. Education of physicians is often not geared to the condition in the country; it neglects common local health problems and appropriate technologies, while emphasizing rare diseases and the use of costly equipment.

6. Health workers, particularly those in rural health position, frequently are not sufficiently trained, supported, or supervised.

7. The availability of services is erratic, particularly in more remote areas, because of unreliable delivery of drugs, pesticides, and other essential supplies.

8. The services provided are sometimes not socially acceptable or not rerceived to be efficacious by their intended beneficiaries.

9. Community participation and integration with other sectors is underdeveloped.

The most persistent problems in improving health do not result from the complexity of medical technology, and only partially from the scarcity of financial resources; rather, they derive principally from problems in the design and implementation of policy, management, and logistics. The obstacles most frequently encountered by the Bank in its lending for health components are:

1. Lack of sound, long-term planning, particularly for the financing of recurrent cost, and for the co-ordination of program elements.

2. Limited capacity for implementing new programs.

3. Inconsistencies between new health programs (especially for training paramedical workers) and existing laws and regulations.

4. Inadequate methods of procurement, distribution, and control of drugs and pesticides.

5. Insufficient and poorly managed transport.

6. Inadequate technical supervision and personnel administration.

7. Poorly designed curricula for training health manpower and insufficiently prepared procedures for clinical care.

Source: World Bank Reports

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4.0 PART B: PHC PLANNNING

4.1 PLANNING FUNCTION

a. The planning function clarifies the health priority objectives and health system targets in relation to the environment and resources available; it organizes activity to achieve objectives in terms of: input, processes, outputs, and outcome.

b. Initial priorities may require substantial revision in response to the realities of the environment.

c. Planning is a “vulnerable function” and thus not a popular management specialty. It is best done not by planning staff alone but in close collaboration with the actual operating managers.

d. The key factors for planning to be feasible area: leadership and management skills, long term resource availability, political will and capacity, government support and community acceptance, appropriate environment, integrated support and alternative plans depending on environmental changes.

4.2. THE SEARCH FOR ALTERNATIVES

a. Planners must find a broad range of alternatives before becoming “emotionally involved” in more obvious solutions.

b. Small group “brain-storming” develops a wide range of alternatives, which are then restricted for detailed analysis.

4.3 TARGET POPULATION ANALYSIS AND COMMUNITY INVOLVEMENT

a. Study of the target population must include social, political, economic and cultural background preferably by living with the community. There is a need to understand both community demand and the professional health needs.

b. Health surveillance is a technique for continuous monitoring of a community’s morbidity, births, deaths needs, etc. using health volunteers (1/100 people) and a baseline census and mapping of the areas.

c. Community involvement (passive) is a poor substitute for active community participation and decision making.

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4.0 PART B: PHC PLANNING (cont’d)

4.4 FUNCTIONAL ANALYSIS

a. Systematic collection of data used for:

1. Setting priorities

2. Planning

3. Evaluation

b. Three major areas:

1. Records information: analysis of health service reports

2. Community information:

A. Regional village assessments

B. Village leader opinions

C. Household surveys

3. Activity and service information:

A. Health center sampling

B. Field work sampling

C. Patient flow analysis

c. Such data collection may require 150-300 work days of effort but it will provide essential baseline and comparative data for planning of PHC in terms of the: technical, social, cultural and political costs (Exhibit A).

4.5 MANPOWER PLANNING

a. Inventory existing sources.

b. Calculate requirements by types and quantities over time. (Exhibit B)

c. Recruitment and training programs including development of materials, protocols, etc.

d. Scheduling activities in terms of: what, when, who, with verifiable achievement indicators, etc.

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3.0 PART B: STUDY PLANNING (cont’d)

4.5 MANPOWER PLANNING (cont’d)e. Coordination with existing local, national, international, activities (trying not to

create classifications that will not fit with the legal and medical system of the country).

4.6. FACILITY AND LOGISTIC PLANNING

a. Inventory existing facilities and logistical systems.

b. Calculate need for facilities and logistics.

c. Decide about adapting old or constructing new facilities/logistic systems. (Exhibit C)

d. Schedule activities by: what, when, who, with verifiable achievement indicators.

e. Define constraints and PFD (provision for disaster).

4.7 FINANCIAL PLANNING

a. Inventory existing resources.

b. Calculation of requirements distinguishing costs: capital, direct, fixed, marginal, opportunity, replacement, standard, unit, output, true, average, etc.

c. Consider local, national and international sources of finance short term and long term.

d. Decide about long term financial planning so that “nothing is started that cannot be continued long term with local funds”.

4.8 THE PLANNING PROCESS

a. Analyze given health priority objectives and health service targets.

b. Analyze the target population, manpower, facilities, and logistics.

c. Analyze financial requirements in relation to potential resources.

d. Redefine objectives and targets, inputs (manpower, facilities, logistics), processes (health service activities), outputs (access, coverage, quality, cost) and outcome (health status improvement). Develop overall operational plan.

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4.0 PART B: STUDY PLANNING (cont’d)

4.9 OVERALL OPERATIONAL PLAN

a. A typical plan for a donor agency includes the following:

1. Detailed program and activities. (EXHIBIT D)

2. Organizational and administrative arrangements.

3. Projected staff.

4. Physical inputs and process.

5. Quantifiable output targets.

6. Built-in evaluation.

7. Baseline Summary data for subsequent comparisons.

b. Recognize diverse objectives of different parties to PHC project and the implied hidden agendas.

c. Integrate plans with government and other organizations for best long-term survival. High quality PHC is not generally consistant with long term poverty.

d. Extensive local management and planning increases the practicality of the plans in satisfying local demand as apart from professionally designated health needs.

e. PFD (provision for disaster) as integral part of all planning to enable consideration of alternative assumptions and plans to deal with changing environments.

4.10 EXHIBITS

a. Streamlined functional analysis.

b. Staff allocation of service time by function.

c. Service locations of PHC

d. Project design summary – logical framework

e. Optional study questions.

Important Note :

When “time” and “efficiency” are of lower priority than social norms, then planning targets must recognize this reality.

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT A4.0 Part B: PHC Planning

STREAMLINED FUNCTIONAL ANALYSIS

PROCEDURE DESCRIPTION ESTIMATED MAN-DAYS REQUIRED BASIC DESIGN EXTENDED DESIGN

A. Records Information

1. Health Services Record Review

One year of data from the health facilities

12 20

B. Community Information

2. Regional and Village Assessment

4 CDBs*, 300 villages 4 4

3. Village Leaders Opinions 36 Villages in 4 CDBs 18 18

4. Household Surveys 400 households in 36 villages of the 4 CDBs

40 60

C. Activity and ServicesInformation

5. Health Center Work Sampling

7,200 observations at 4 health centers for 10 days each

40 40

6. Field Work Sampling 7,200 observations at 4 health centers for 10 days each (doubled in extended design)

40 80

7. Patient Flow Analysis 1,200 patients at 4 health centers for 5 days each (extended design only)

0 100

TOTAL 154 322

Months Required Using a Team of 5 Investigators at 20 Days Per Month 1.5 3.2

* CDB = Community Development BlockSource: JHSH&PH

35

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT B4.0 Part B: PHC Planning

STAFF ALLOCATION OF SERVICE TIME BY FUNCTION

Percentage Distribution

Staff CategoryMed.Relief MCH

FamilyPlanning CDC

Env.San. Total

HEALTH CENTER

Doctor 86 2 12 - - 100

Nurse 82 7 11 - - 100

Pharmacist 95 - 5 - - 100

Dresser 97 - 3 - - 100

Lab Technician 7 - 13 80 - 100

Total Health Center 64 1 13 22 0 100

FIELD

Doctor 14 9 29 48 - 100

Lady Health Visitor 16 29 47 8 - 100

Aux. Nurse Midwife 33 35 26 6 - 100

Trained Dai 40 32 26 2 - 100

Health Inspector 6 2 8 69 15 100

Block Ext. Educator 1 2 92 4 1 100

Fam. Plan. Worker 2 1 95 2 - 100

Basic Health Worker - - 2 97 1 100

Total Field 12 12 22 53 1 100

GRAND TOTAL 23 10 20 46 1 100

Source: JHSH&PH

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AGL 21- BASICS OF FRIMARY HEALTH CARE IN DEVELOPING COUNTRIES – EXHIBIT C4.0 Part B: PHC Planning

SERVICE LOCATIONS OF PHC

LOCATION OF SERVICES

PROGRAM COMONENTS PHC

COMMUNITY

Sickness care MedicalSurgical/dressingPhysical/orthopedicGynecologicalMental

XXXXX

SurveillanceSurveillanceSurveillanceSurveillanceSurveillance

Maternal Care Prenatal careLabor and deliveryPostpartumFamily Planning

Care during lactation

XXXX

X

Surveillance

NoFamily-planning

motivation programNo

Child Care Growth and developmentImmunizations

School eye and hearing Testing

Xx

Surveillance ProgramCommunity Immunization ProgramSchool health program

Communicabledisease Control

Malaria smearsTuberculosis smearsMalaria surveillanceTuberculosis surveillance and defaulter controlTrachomaImmunizations

XX

Surveillance ProgramNoSurveillance ProgramSpecial-Care Program

Surveillance ProgramCommunity immunization Program

Environmental health Safe waterSafe latrineWaste disposalPublic facilities Inspection

Safe-water programSafe-latrine ProgramWaste-disposal ProgramInspection Program

Health education To PatientsTo groups at PHCTo SchoolsTo community groups

XX

School health programHealth education program

Food distribution ChildrenWomen

XX None

Source: Management of Health Systems in Developing Countries (O’Conner 1980)

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AGL 21 PHC IN DEVELOPING COUNTRIES – EXHIBIT D40 Part B: PHC Planning

PROJECT DESIGN SUMMARY: LOGICAL FRAMEWORK Phase I - 18months

Project Title: Medical Education and HealthServicesArea – Phase I

NARRATIVE SUMMARY OBJECTIVELY VERIFIABLE INDICATORS MEANS OF VERIFICATION IMPORTANT ASSUMPTIONS

Program Sector Goal: The broader objective to which this project contributes:

To improve the quality of life by making basic health services, particularly those related to primary care including MCH, nutrition and family Planning available and accessible to the majority of the population

Measure of final achievement1. The increase in proportion of

the population with access to the appropriate primary care services

2. Thechange in the relevance of health programs to meet regional health problems

3. The increased efficiency of utilization of all health resources.

1. Infant and maternal mortality statistics school and industrial attendance records.

2. Community health Nutrition and population surveys.

3. WHO and LDC communicable disease statistic reports.

4. WHo Demographic and Statistics yearbood

5. Special Surveys and reports.

Assumptions for achieving goal targets:1. Local & National Government

interested in improving the health status of the population.

2. Assistance in the health sector will improve health status.

3. That the efficient utilization of trained manpower is a priority.

4. An excensive training program is necessary

Project Purpose:a. Integration of the medical education

and health services.b. Education and training of primary

care physicians as direct providers and health team managers to work effectively within resource constraints.

Conditions that will indicate purpose has been achieved.a. Faculty of Medicine has

begun operations – 6yr. Curriculum development and educational methods. Management system developed. Architectural Plans developed.

Reports by the contractor a. On-site visits to assess the

extent to which the new education system has begun to function]

b. Reports from the Faculty of Medicine.

1. The ministry and University are willing to work together & make necessary changes in order to accomplish project purpose.

2. Primary responsibility for achieving project purpose rests with

Outputs:1. Curriculum Development

Curriculum developed for first 1 ½ years

Magnitude of outputs:

At end of 18 month period, all courses for year 1 and year 2 semester one completed

Course materials including specification of optimal physician performance and competency-based objectives available.

Assumptions for achieving outputs:

Curriculum is needed to teach.

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Exhibit D

NARATIVE SUMMARY OBJECTIVE IDENTIFIABLE INDICATORS MEANS OF VERIFICATION IMPORTANT ASSUMPTIONS

1. Curriculum development(cont’d) Six year curriculum Projection

Staff and faculty members trained in curriculum development and skills

Library plans developed/books purchased

2. Clinical Training sitesDesignate

Renovating rural health units

3. Primary Care Group practice planInitial actions

4. Design & Renovation – Building 29 Renovation Plans

Equipment list

1 Set of materials

60-80 staff and faculty trained

One 1ibrary plan detailing equipment space requirements as well as specification of reference and learning material (4-5,000 Volumes)

10-15

4-6 renovations in progress

Feasibility study completed and proposals made

Architectural plans, building renovation plans equipment list

Six year planning document

Semi – annual report

Library Plan/site visit

reports/site visits

Reports/site visits

Semi-annual report

Site visits, inspection of plans

Faculty of Medicine will open 1980 or 1981 Overall Planning document is needed

Curriculum developmentSkills will help faculty develop and teach own curriculum

A Carefully planned library is needed by the U

Clinical traing sites are needed for training medical students

Substantially full-time faculty and limitation of solo private practice are necessary to success of the school

Building # 29 will provide adequate space for faculty and students Building can be renovated.

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Exhibit D

NARRATIVE SUMMARY OBJECTIVE VERIFIABLE INDICATIORS MEANS OF VERIFICATION IMPORTANT ASSUMPTIONS

Outputs (continued):5. Continuing Education

Plan Developed for faculty and MOH staff

6. Management SystemDeveloped for faculty of Medicine

Data set on clinical facilities to be used at teaching sites developed

Management and evaluation plan for Medical School developed

7. Planning for phase IIEvaluation of emergency medical services(EMS)

Plan for phase II

Magnitude of outputs:

One Plan

One SystemOne data Set

One Plan

2-4 man weeks of technical assistance supplied

One plan completed

Semi-annual reports

Semi-annual reports

Semi-annual report

Semi-annual reports

Semi-annual report

Assumptions for achieving outputs:

CME will strengthen faculty and staff

Availability of data will improve planning and implementation of training

Management and evaluation Plan will be useful in working toward project goals

EMS service requires evaluation

A 3½ year project continuation is necessary

Inputs: 1. Technical Expertise –

a) Primary careb) Curriculum Developmentc) Health Managementd) Public Healthe) Facility design & Health Planning

2. Faculty of Medicine and MOH staff3. Selected Support & Construction materials4. Project support in Boston & Egypt

SalariesFringe benefitsConsultantsGoods & services purchased International and domestic travel

Total Direct CostsIndirect CostsExternal Evaluation

Project expenditureRecords & input

Assumptions for providing inputs:1. The contractor has the

unique experience and special capability. Necessary to carry out the project.

2. Egyptian side will provide trainees, facilities, and other support.

Source: AID Project Proposal,1981- 35 -

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AGL 21- BASICS OF FRIMARY HEALTH CARE IN DEVELOPING COUNTRIES – EXHIBIT E4.0 Part B: PHC Planning


1. Does working with community leaders ensure that the “very poor” and the “traditional healers” are represented?

2. What is the advantage and the handicaps of formal planning? What is “emotional investment”?

3. Distinguish functional analysis from task analysis.

4. Why do donors advocate new organizations and facilities? Why do they normally insist that some international staff be present?

5. Why is long term financial planning the key to effective PHC?

6. Why do operational plans tend to seek quantifiable health and target indicators? Are quantitative factors more important than non-quantifiable factors?

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AGL21 – PHC IN DEVELOPING COUNTRIES4.0 Part B – Case: Asian Island Project


1. What were the key factors in the story of the case?

2. What are the key environmental factors and the achievements of the project?

3. Were the priorities and the health service targets properly established?

4. Trace the steps in the planning process after setting priorities and justify the key decisions regarding: access, coverage, quality, integration, financing and target population. Has improved health status reduced the basic poverty of the area?

5. Is this a pilot project which could be extended to the whole island or country? What are the planning alternatives for the future? What are the criteria for deciding among the alternatives? How can the demand/ needs of the community be determined?

6. As the donor organization decide on plans for the activity for 1982-7 and justify your decision.

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AGL21 – PHC in Developing Countries4.0 Part B – Case: Asian Island Project

INTRODUCTION

The PHC project began in 1975 on an island off the coast of a small Asian country as a demonstration project for community health. The work was initiated by a surgeon with “experience in the futility of solving Asian health problems in a hospital setting” and was funded through various church and international organizations. Although the whole island population of 400,000 was the target population, the project had never expanded from its initial objective of 24,000 people in two townships and fifty villages.

In June 1985 a team from APHA was appointed as part of the planning for the next five years to evaluate the project’s planning of health services in terms of: target population, access, coverage, quality of care, integration and long term financing. Although the project had been uniquely successful in achieving improved health status there was some doubt in the minds of the governing body as to whether this had been appropriate to the total environment.

BACKGROUND

During 1971-85 the government of the country was by military dictatorship with some attempts at democratization but only limited success. Many international bodies participated in the improvement of the economy which was developing rapidly except for remote areas like the island.

The government had established a network of health centers throughout the country but these were generally under-staffed and little utilized with the result that most people still relied on traditional healers or self-medication. Because of the inaccessibility of medical care, pharmacists were allowed to dispense nearly all medication without prescriptions.

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AGL21-PHC in Developing Countries4.0 Part B – Case: Asian Island Project (Continued)

PLANNING AND DEVELOPMENT OF THE PHC PROJECT 1971-85

The Project was preceded by a demographic and sociological study by a major Asian university which reported a typical rural situation with poverty, large families, little access to modern health care, stoical acceptance of the environment and little motivation to change.

This study was followed by intensive international staff Visits to local villages and meetings with community leaders. A local board of directors was chosen from village leaders; at that time there was little understanding of the culture or political power structure in the village, but this was considered less important than the obvious local health problems. The board served as volunteers and with their assistance a group of employees was hired including: a business manager, clerical personnel, laborers, drivers, nurse-midwife and fourteen high school graduates to be trained as PHC workers.

Each PHC worker was assigned to 1-3 villages [about1,000 people] and was required to establish a census of everyone living in the area. A numbering system was installed to facilitate identification because of name similarities. From this central file a PHC center was setup to control operations within a 5 kilometer limit for the whole population. Maps were drawn of each of the villages, roads, buildings and there was a complete record of families in each village.

During this preliminary work an intensive course on the basics of health care was given by the international staff and the local midwife including: basics of nutrition, prenatal care, immunization, epidemiology of diseases as TB, typhoid, etc.

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AGL21 – PHC in Developing Countries 4.0 Part B – Case: Asian Island Project (Continued)

THE PHC IN ACTION

The PHC workers made systematic visits to villages to get to know the people and gain their confidence. This was helped by the fact that they all lived in the area. They sought out village volunteers to represent each village who were usually housewives of good reputation and interest in the health of the village. Such Village volunteers were the liaison between the village and the PHC center.

Although most of the volunteers had little education, they were gradually introduced to the basics of health care in monthly meeting which emphasized health promotion and the prevention of the spread of disease, family planning and nutrition. The volunteers served to identify local health problems and call them to the attention of the PHC workers. Medical records of the villages were kept in the homes of the village volunteers which were the location of health activities as the PHC workers spent at least one day in each village.

In addition to health education the PHC worker provided free care: immunization, prenatal clinics, well baby clinics and simple curative treatments with antibiotics, vitamins and iron, simple antiparasitic medications, etc. This was done on protocols devised by the international staff. Any medical problems outside the competence of the PHC worker were referred to the PHC center where the physician was located. His work was supported by a simple laboratory, X-ray facilities, pharmacy, and a few in-patient beds.

The work of the PHC workers and village volunteers was supervised by the nurse midwife who made frequent visits to all Villages. In addition to individual medical records of the people, the village volunteers also kept lists of births, deaths and patients with chronic diseases such as hypertension and tuberculosis, monthly weights and immunization of children, records of pregnant women and reports of their prenatal visits. Records of family planning were also kept and updated every three months.

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AGL21 – PHC in Developing Countries4.0 Part B – Case: Asian Island Project (Continued)

RESULTS OF PHC ACTIVITY

The results of this PHC activity were felt to be good in that after 1983 there were no cases of polio or tetanus reported and the severe reduction of tuberculosis. Typhoid became extremely rare. Health status statistics showed:

Rates / 1000

TargetPopulation Whole

24,000) Country U.S.A.

I.M.R. 16 35 15

Neonatal Mortality 11 20 11

Crude Death Rate 6 7 9

Birth Rate 15 24 15

Furthermore the eight functional areas of primary health care had all been made available to the community of 24,000 over this 10 year period and the international staff have been replaced by national physicians so that the project was locally in the hands of national personnel although still financially supported from abroad.

PLANNING FOR THE NEXT FIVE YEAR’S

In the evaluation of work the APHA team was impressed with the health status results but had many questions such as:

a) Why was coverage limited to 24,000 and not extended to the whole island?

b) Why was the quality of care so high in relation to the rest of the country?

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AGL21 – PHC in Developing Countries3.0 Part B – Care: Asian Island Project (Continued)

PLANNING FOR THE NEXT FIVE YEARS (Continued)

c) At what cost had this care been achieved? To what extent would this be supportable locally or by the government?

d) To what extent did the community participate as apart from merely accept free health services?

e) Should traditional healers be part of the medical system and should some charge be made for medical care?

f) Was this a pilot project that really could be transferred to other areas in the island or to the country or just a “Hawthorne” effect?

g) Was success due to western control of management systems which long-term would be inappropriate for the country environment?

It was felt among the evaluation team that it was easy to criticize than to get practical results and here was a case of a project which had achieved, if only for a limited area a very significant health improvement. The question arose as to whether such Projects were appropriate use of resources and what should be done for the next five years in terms of priorities and planning?

Source: Developed from articles in the “Tropical Doctor” and other data.

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5.0 PART C: PHC MANAGEMENT

5.1 MANAGEMENT ROLE, STYLE AND VALUES

a. Management creates the environment to motivate staff to achieve objectives. Classically it involves: planning, controlling, coordinating, and motivating.

b. Management style differs, according to environment and culture and may be: “Napoleonic”, participative, committee, “KITA”, etc. Distinguish “starters” from “runners” in choosing managers for new organizations.

c. Western management tends to value highly: “time, resources, and efficiency”, and to put low value on: “family, culture, history, and relationships”. Need to understand the local culture and not impose inappropriate western management value.

5.2 ORGANIZATION AND ACTIVITY SCHEDULING

a. Job descriptions may describe responsibility and authority of the formal organizational structure. Organic development over time distinguishes the formal from the informal reality (which is how the organization really works).

b. Schedule new major activities using Gant charts or PERT charts to show: when, what, who, how for each new major activity.

c. Scheduling may be conceived as: inputs (manpower, facilities, logistics and finance), processes (health services), and outputs (access, coverage, quality, utilization, cost).

5.3 AUTHORITY AND SUPERVISION

a. Although authority from job descriptions appears to come from above it is in reality given by subordinates. Responsibility and authority are not always related.

b. Supervision should help staff to achieve objectives and support their long term motivation. Supervisory styles include: personal interaction, committees, conferances, field studies, education, training, performance assessments, etc.

c. Need to plan long term for financial and other rewards not merely for volunteer labor.

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5.4 CONTROL OF OPERATIONS

a. Procedure manuals and protocols are useful in training and setting up new organizations but soon become outdated without special attention. Paperwork must be useful and limited.

b. Development of organizational structure is a significant investment of resources; better to adapt old organizations than to always start new ones.

c. Personal supervision required at every level continually to insure performance and motivations.

d. Records and reports for long term continuity should be of some value to the recorder as well as the supervisor. Records should be minimized and continually reviewed and audited if they are to be reliable.

e. PHC worker logistical support and continued training and supervision is vital for long term efficiency and effectiveness.

f. PHC does not have to be comprehensive to be effective. Need to emphasize the “high pay-off” functions for the particular environment.

g. Set time and cost standards for each input, process and output. Measure actual against standard regularly to determine efficiency. Periodically review health status outcome to consider effectiveness and appropriateness of the PHC health service targets to the real environment.

5.5 FINANCIAL CONTROLS AND PLANNING

a. Budget should be flexible such that the accountant does not manage the PHC operation.

b. Investigate cost and cost reports carefully to determine the underlying assumptions. Cost data is not suitable for all purposes and must be relevant cost of a particular purpose.

c. Short term cash control is important but long term financial planning is vital for continuity of the operation (preferably from local resources).

d. Financial records are necessary not only for donors but also for efficient use of resources. Such financial records must be audited by independent professional staff before data can be accepted as valid.

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5.6 CHANGE OVER TIME

a. Leadership and long term finance are critical, for long term project continuity.

b. Environment changes over time due to: seasonal, social, economic, political and cultural changes and thus management must change both in function and style.

c. The manager is responsible not only for: planning, controlling, coordinating, and motivating the staff but also for defending them because they give him authority. Failure to defend them will result in withdrawal of all such authority from below.

d. Independent management of PHC without government, support cannot deal with the problem of long term poverty.

5.7 EXHIBITS

A. Management/administrative jobs in a well-developed PHC

B. Responsibilities of the auxiliary health worker.

C. Optional study note questions

Important Note

When time and efficiency are not of high priority, management must achieve objectives in ways that are culturally acceptable or achieve nothing!

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT A5.0 Part C: PHC Management

MANAGEMENT/ADMINISTRATIVE JOBS IN A WELL-DEVELOPED PHC

WORKER TYPE JOBSSKILLS NEEDED TO PERFORM

EFFICTIVELY

Doctor Scheduling Planning individual services targetsPlanning hours of operation for individual servicesAllocating work among staff for individual programs

Quality control for individual services programs

Performance-evaluation skills for medical-care activities, basic teaching and communications skills, motivational skills

Community health program

Overall management of community public health programs

Public-health subject matter, basic planning skills, advanced operations-management skills (all aspects), evaluation skills

Logistics specialists

Managing use of supplies and equipment

Ordering and inventory control for medical and public health equipment

Program supervisors

Controlling the quality of work Performance evaluation for public-health activities, basic teaching and communication skills, motivational skills.

Administrator Managing the support systems Personnel management, financial management, information system management, physical plant management

Source: Management of Health Systems in Developing Countries (O’Connor)

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT B5.0 Part C: PHC Management

RESPONSIBILITIES OF THE AUXILIARY HEALTH WORKER

1. PROVIDES PROMOTIVE AND PREVENTIVE HEALTH SERVICES

a. Plans, organizes, implements, and evaluates health education programs for the control and prevention of diseases and for the promotion of health in the community.

b. Organizes and carries out environmental health programs.c. Investigates outbreaks of communicable diseases and carries out control and

prevention programs.d. Provides community health nursing services in family planning and in maternal and

child health programs.e. Participates in a community nutrition program.f. Organizes and carries out a school health program.g. Participates in community development program in relation to the health needs of the

community.

2. PROVIDES MEDICAL, SURGICAL, AND NURSING AND REHABILITATION SERVICES

a. Carries out simple diagnostic or screening procedures and provides treatment for common medical problems.

b. Dispenses drugs, mixtures, ointments, and solutions from the Health Post stocks of pharmaceutical and medical supplies.

c. Performs simple laboratory procedures for the detection of diseases and for diagnostic purposes.

d. Performs first aid measures for accidents or emergency cases.

3. CARRIES OUT ORGANIZATION, ADMINISTRATIVE, AND SUPERVISORY FUNCTIONS OF THE HEALTH POST

a. Participates in the routine administrative activities of the Health Post.b. Carries out supervisory and training activities.c. Participates in the activities of the statutory health programs of the Ministry of Health

and the Department of Health Services.d. Promotes integrated and coordinated health services in the Health Post District.

4. MAINTAINS PROFESSIONAL RESPONSIBILITIES

a. Performs work with minimum supervision and guidance.b. Participates in professional development activities.c. Maintains high standard of professional practice and discipline in the Health Post

Service.

QUESTION: While useful for PHC project planning it may be less appropriate for illiterate PHC workers in poverty environments

54

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AGL 21 – PHC IN DEVELOPING COUNTRIES-EXHIBIT C5.0 Part C – Case: PHC Management


1. In management why do “starters” make poor “runners”? What do we need for new PHC projects?

2. Do all organizations have formal and informal systems? Do job descriptions and organization charts, etc. prevent the development of informal systems?

3. How can task analysis be helpful and sometimes harmful in supervision, training and management? Does it affect motivation?

4. What feedback is needed about PHC activity in terms of: access, coverage, quality and cost? Can workers be expected to continue to achieve standards without supervision?

5. How do you decide how much personal supervision is appropriate?

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AGL 21 – PHC IN DEVELOPING COUNTRIES5.0 Part C – Case: PHC Food Project


1. What are the key factors from the story of the case?

2. What were the priorities of the government, the UN body and the PHC project team?

3. How well was the project planned and managed?

4. What results did the project achieve?

5. Identify the local, national and international causes of the management problems?

6. Decide and justify what the project team should do about:

a. this project?

b. future similar projects?

STOP

STOP

STOP

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AGL21 – PHC in Developing Countries 5.0 Part C – Case: PHC Food Project

PRIORITIES

In 1974 the government of a Moslem country with a population of 50 millions and the usual problems of rural poverty, malnutrition and low health status agreed to an AID financed international team for a PHC project which it hoped would provide a model for generalized application in the country. After the team had been working for two years a UN body in 1981 offered a substantial quantity of food for improvement of general nutrition. There were several separate projects, one of which was targeted via the PHC activity.

This project to aid the PHC activity was providing priority calorie and dietary supplement to a target population of pregnant and lactating women and to chronically ill young children. It was indirectly designed to increase motivation for mothers to regularly attend the maternal child health clinics at the PHC centers.

PLANNING

The plan was wholly integrated using a small administrative unit in the Ministry of Health with a junior officer appointed as responsible for the project with access to senior officials of the ministry or even to the minister himself. A separate Ministry of Rural Development was responsible for logistics of food distribution. A Central Administrative Unit was responsible for actual deliveries since several World Food programs were involved and transport economics could be achieved by coordination of delivery arrangements. Finally the PHC centers were responsible for the actual food distribution.

The project promised enormous benefits at nominal cost to the national government which was aware that malnutrition was a basic cause of low health status in the country.

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AGL21 – PHC in Developing Countries 5.0 Part C – Case: PHC Food Project (Continued)

PRODUCTION

From February 1985 the free food induced so many mothers to attend the PHC clinics, that the maternal child centers were overwhelmed by the volume of activity. With crowds of free food seekers, little health service could be delivered and frequently the staff had only time to sign food coupon cards, providing little or no medical service at all. Examination of children was rare and for pregnant women practically non-existent.

In the Ministry of Health, the project required a considerable time of senior officials and even the minister, since the project manager refused to take responsibility himself and constantly sought authority for decisions to be made.

There was no direct evidence that the food distributed improved nutritional status of the intended target population. However much of the food distributed appeared to be consumed by other family members especially adult males, or made its way on agricultural economics and the motivation of farmers in the various regions of the country.

PROGRESS

In March, April and May, 1985 the international PHC project team made extensive efforts to improve the management of food distribution with only minor success. Of 20 suggestions to the Ministry of Health, the only 3 which were adopted. These concerned forms designed for food distribution and the use of volumetric measurement methods. They were matters for which the PHC project team were actually operational in carrying out the work for themselves and required no action by other ministry officials.

PROGRAM REVIEW

Finally a project review in July 1985 brought the officials of the Ministry of Health, the Ministry of Rural Development, the Central Administrative Unit, the PHC project team and the UN body together for the first time in a group problem solving session. For several hours the problems were outlined in great detail and toward the end of the session the UN body representative was asked if he felt changes were merited. To everyone’s surprise and in the face of two hours of evidence to the contrary he announced: “The program has not only been a great success but we anticipate doubling it next year in its current form.”

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AGL21 – PHC in Developing Countries 5.0 Part C – Care: PHC Food Project (Continued)

DIVERSE OBJECTIVES

The PHC Project team was demoralized by the situation and was privately blaming the UN body and the national government for failure to manage the project effectively. However they realized that the government and the UN body did not see the problem in the same way as the PHC team. The government was reluctant to refuse any international aid, especially food, since this would directly effect its ability to achieve more aid in the future. Furthermore the UN body with willing donors was keen to move available food to malnourished populations quickly even if this meant some inefficiencies in the process. They wondered too whether the PHC project team was also partly responsible?

Source: Developed from material in “Management of Health Systems in Developing Countries” (O’Connor) and other data.

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6.0 PART D: PHC EVALUATION

6.1 EVALUATION OBJECTIVES

a. PHC may be evaluated before, during or after a project.

b. Evaluation objectives vary according to the parties: PHC management team, community, traditional healers, local or national government, international donors, etc.

c. Alternative decisions from evaluation include: project continuity, change, reduction, increase, termination, extension, etc.

d. Project “success” for many diverse reasons: efficiency, effectiveness, survival, political or social change, foreign currency earnings, building of structures or organizations, etc., dependent upon the stated and hidden agendas of the parties.

6.2 TRADITIONAL EVALUATION METHODS

a. Input evaluation – measuring the inputs of manpower, facilities, logistics against a target or standard.

b. Process – measuring activity of the input against standard.

c. Output evaluation – measuring health service outputs (access, coverage, quality, costs) against a target or standard. Measure efficient use of resources and avoidance of waste.

d. Outcome evaluation – measuring health outcomes by: IMR, LE, MM, mortality and morbidity statistics, etc., against target or standard. Measure effectiveness of the resource utilization in achieving appropriate health change in a target population.

e. Difficult to measure outcome and even output without difficult assumptions that could be questioned. Thus simple measures of: cost/output, cost/benefit, years of life saved, years of earnings saved can only be considered if the underlying assumptions are disclosed and validated.

f. Evaluative input, process, output and outcome sequentially; thus unless there is input, there will be no process. Without process there can be no output.

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6.0 PART D: STUDY EVALUATION

6.3 OTHER EVALUATION METHODS

a. Recognize that comparison of actual cost with budget may not indicate either waste of useful achievement in a project.

b. Consider evaluation as “quantitative” (Q) and “non-quantitative” (NQ) (i.e., not easily quantifiable without difficult assumptions or investment).

c. Use multiple evaluation methods:

1. Cost efficiency – actual cost against budget or standard with detailed accounts to provide analysis by type of costs and also by fixed or variable cost. Comparison of similar projects may reveal a measure of efficiency in terms of unit costs. Mainly Q with some NQ.

2. Appropriateness – does project focus on the health priorities of the target population? Is the PHC service long term locally supportable? Does it harm the population in cultural terms? Was the target population well chosen? Mainly NQ with some Q.

3. Adequacy – what coverage and utilization was achieved? What effects on morbidity and mortality? How has it affected the traditional healers? Does it really serve the whole population? Is it a free service? Q and NQ.

4. Acceptability – to the target population, local and national government, donors, etc. Cultural sensitivity and effect of the human values of the population? Mainly NQ.

5. Access – availability to the population in terms of: geography, time, communication, social factors, finance, time lost from work as evidenced by analysis of the persons coming and those not coming for PHC services. Q and NQ.

6. Community involvement – influence of different parts of the community on making key decisions, setting priorities, planning, production, and progress. Active as a part from passive acceptance. Are the very poor really involved? Mainly NQ.

7. Flexibility – ability to change the location, staff, service, time of PHC work to changes in community needs and demands and changes in the environment. Mainly NQ.

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6.3 OTHER EVALUATION METHODS

c. Use multiple evaluation methods: (Cont’d)

8. Integration – separate independent work or integrated part of the long term government health system? Working in cooperation with other organizations? Related to development and community independence? Mainly NQ.

9. Financing – short and long term financial planning to determine locally financed viability. Independence from donors planned and practicable for the community within the planning period? Q and NQ.

6.4 EVALUATION CONSTRAINTS

a. Time – Several years are necessary for change in health status and in this interval the environment may have changed, thus the cause/effect of total PHC or even one part of the PHC cannot be distinguished from other factors (like education?). Thus there is not any scientific proof available.

b. Bias – Every evaluator has bias of a sort; even professional “peer review” tends to conform to an almost medical etiquette of “no direct criticism” except among professionals, thus rigorous evaluation is seldom published.

c. Failure – There is no payoff from reporting either to the donor, PHC management, receiving country or target population, thus these factors tend to be quickly passed over in favor of new more promising projects or efforts.

d. Data – published data on international health is notoriously unreliable due to underreporting of rural morbidity and thus country-wide data is not reliably available for comparison. Thus good results from one project of PHC may have no significant overall country effect.

e. Finance – Any project can be effected to improve health status in a limited target population over time with large amounts or resources and active leadership, but this is no indication of the nationwide PHC needs or methods for large LDC’s.

f. Audit – There is no acceptable body or process for management audit of PHC locally and nationally by independent and professional staff, such that results could be verified and published so that mistakes and achievements could be learning experiences for all. The political influences are too strong.

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6.5 HEALTH INDICATORS

a. General indicators of health status include: IMR, LE, MM, morbidity and mortality statistics of disease and treatment.

b. Criteria for selecting indicators (Exhibit A) include: availability, coverage, quality, calculation acceptance, specificity, sensitivity, reproducibility, validity, cost, etc.

c. Sources include: disease and household surveys, nutritional surveys, analysis of health records (clinics, hospitals), published statistics, etc. Surveys normally better than routine data. Emphasis on disease or treatment normally leads to increased diagnosis and thus “humps” in incidence short term.

d. Publication of health data by WHO does not improve its reliability since the data is poor for 50% of the world, due to: poor recording in rural areas, poor communication, poor auditing of results, lack of resources to set up effective reporting systems.

6.6 PROGRESS OVER TIMEa. Comparison of baseline “before” with “after” PHC studies may be false if

improvement of the baseline was possible in another way without PHC i.e. funds given for nutrition or drugs may be as effective as eight functions of PHC in some situations.

b. Best evaluation is continual supervision and good management with occasional surveys to get feedback from the “market” i.e. the target population.

c. Post project evaluation of actual against original plan is normally irrelevant since the plans must change during the project as the needs of the environment change. Need to compare actual against some revised plan which is more appropriate.

6.7 PROFESSIONAL STNDARDS

a. Need to standardize the planning and recording of PHC activity to facilitate international and national comparison.

b. Need standards of PHC in terms of time, manpower and cost which can be audited. No cost data should be accepted without audit because of the technical complexity of using the data (i.e. need to disclose all cost components including “free” services provided by local, national, or international bodies before even a simple rate of $2.00 per capita can be accepted as the cost of providing the care of PHC project;

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6.7 PROFESSIONAL STANDARDS (Cont’d)

need also to verify the “population” since if this is in fact not 100% coverage and utilization, then the per capita figure is invalid). (Exhibit B)

c. Need to report on the total PHC within each country not merely the internationally supported project which may not be providing significant overall coverage of the total population.

6.8 EXHIBITS

A. Criteria for selecting indicators.

B. Potential errors in PHC costs per capita pre annum

C. Optional study questions

Important Note

Political and social costs are a more significant PHC constraint than economic costs. Some “trade off” of “individual freedom” for “health” maybe an unpopular necessity.

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT A 6.0 Part D: PHC Evaluation

CRITERIA FOR SELECTING INDICATORS

1. AVAILABILITY – It should be possible to obtain the data required without complex special investigations.

2. COMPLETENESS OF COVERAGE – The index should be derived from data covering the entire population of a country or that part of it to which the index is intended to relate.

3. QUALITY – The national data should not vary in time and place in such a way as to have any substantial effect on the index.

4. UNIVERSALITY - The index should, as far as possible, be the expression of a group of factors that determine and affect the level of health.

5. CALCULATION – The index should be calculated in as simple a manner as possible and the calculation should not be costly in terms of the resources required.

6. ACCEPTANCE – The index should be widely accepted and used and no doubts should exist as to the methods employed for developing the index or for interpreting it.

7. REPRODUCIBILITY – When the index is used by different specialists under different conditions at different times the results should be identical.

8. SPECIFICITY – The index should reflect changes only in those phenomena of which it is the expression.

9. SENSITIVITY – The index should be sensitive to changes in the phenomena concerned. Allowance should be made for the effect of inflation on the index.

10. VALIDITY – The index should be a true expression of the factors of which it is supposed to be a measure. Some form of independent or external evidence for this should be provided.

Note – Health indicators should be:

- output-oriented rather than input-oriented;- simple and readily understandable;- comprehensive enough to take into account all the significant consequences

associated with health;- based on information that is readily, quickly and cheaply available;- separable into geographically localized components;- able to reveal the intensity, as well as the extensiveness of shortfalls from health

objectives;- capable of revealing the differential effects of given trends on different groups within

the population.

Source: WHO

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT B6.0 Part D: PHC Evaluation

POTENTIAL ERRORS IN PHC COSTS PER CAPITA PER ANNUM

Example

Population: 10,000

Costs: Paid local manpower $10,000Paid Local Supplies 10,000

TOTAL $20,000

Crude Cost of primary health care per capita: $20,000 / 10,000

Per Capita$ 2.00

Total$ 2,000

Types of ErrorsA. Ignores the opportunity cost of “free” labor,

supplies, and food ($30,000) $ 3.00 $ 30,000B. Ignores the cost of supervision, logistics

reorganization, water, sanitation, communications, etc. which tend to become continuous ($20,000)

2.00 20,000C. Ignores the cost of depreciation of equipment and

facilities ($10,000) 1.00 10,000D. Ignores the cost of “free” overseas staff, with their

head office overhead, travel, etc. ($10,000) 1.00 10,000E. Ignores the “start-up” costs and the training, which

also tend to become continuous ($10,000) 1.00 10,000SUBTOTAL

$ 10.00 $ 100,000F. Per capita computation based on the total

population rather than on the actual population which used the primary health care services (50% of 10,000 population)

x 2 -------ADJUSTED TOTAL COST OF PRIMARY HEALTH CARE:

$100,00/5,000 $ 20,00 $ 100,000

*The allocation of such joint costs which affect both health and general development is a difficult technical decision for which the assumptions need to be clearly defined. This is similar to the cost analysis problem of the oil industry which seeks to determine the “cost” of different products which come out of a “barrel of oil.”

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AGL 21 – PHC IN DEVELOPING COUNTRIES – EXHIBIT C6 Part D: PHC Evaluation


1. Why should PHC be evaluated?

2. What are the Advantages and disadvantages of the traditional evaluation methods? Can the results be manipulated?

3. Can all evaluation measures by quantified? Does this make them more useful?

4. What are the constraints to evaluation?

5. What health indicators are appropriate to LDC’s?

6. How rigorous can professional standards be in evaluation?

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AGL 21 – Basics of Primary Health Care6 Part D – Case: Rally health Care


1. What are the key facts from the story on the case?

2. What PHC services were provided by the project?

3. How do you evaluate the project in terms of: process, output, outcome, cost? Does your evaluation apply to the whole population of the hospital area or the country? Can the data be generalized to the country?

4. Why should health surveillance and a selective PHC produce improvement of health status? Can you accept the data without independent verification?

5. Does the project prove that health surveillance and selective PHC is better than comprehensive PHC?

6. Decide and justify how you would improve the evaluation of this project?

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AGL 21 – PHC in Developing Countries6.0 Part D – Case: Rally Health Care Case

INTRODUCTION

In 1960 with international support a hospital was set up in a French speaking country in Africa with a population of 5,000,000 and GNP of only $200 per capita, IMR 174/1000, LE 46 years and child mortality 36/1000. There was severe morbidity from malnutrition, tetanus, diarrhea and TB with the usual rural poverty. The hospital had 140 beds and a small European staff for a target population of 100,000 in a catchment of 400 square kilometers.

After 10 years of hospital based services it was decided in 1970 to begin an outreach program of PHC with a limited range of services at “rally points” in the hospital catchment area, with key emphasis on “Health Surveillance.” The program started with the 8,000 population in the immediate hospital vicinity and slowly expanded over the years to the whole target population of 100,000.

In 1980 an evaluation was carried out to determine whether such limited PHC could be generalized to the whole country.

THE PHC PROJECT

The project was run by limited staff of 3 physicians, 1 sanitary officer, 3 nurses, 30 full time auxiliaries and 60 voluntary community volunteers. The health auxiliaries were recruited from local farmers with sufficient literary skills to keep records. Many worked as community volunteers and progressed to become health auxiliaries.

The training of a health auxiliary consisted of working for 3 months on a daily hire basis to get on the job training [census taking, weighing, measuring, recording, vaccination, etc.]. Each task was maximally experienced and mastered before their going to the next. By the time the volunteer became full time staff his dedication to community health was adequately demonstrated although it must be admitted that alternative employment opportunities were rare in that area. The better auxiliaries developed to become trainers.

By contrast community volunteers were paid only for the two days of work at the health rallies and for the time of the annual census.

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AGL 21 – PHC in Developing Countries 6.0 Part D – Case: Rally Health Care Case (Continued)

PHC HEALTH RALLIES

PHC’s health rallies were held quarterly at neighborhood locations for up to 1,000 inhabitants personally invited by community volunteers and close to the home of each participant. On rally days a physician, nurse and 10 auxiliaries delivered the health services. A few requiring curative care were treated on the spot or referred to the hospital.

The health services were:

a) Lessons on health and nutrition: in groups of 30, with 15 minute presentations in the local dialect. Topics covered were disposal of excreta, breast feeding, child feeding, family planning, etc.

b) Targetted supplemental feeding: all children under six were examined at each rally with rates recorded on the Road to Health cards kept by the parents.

Children with third degree malnutrition or negative weight increments received immediate supplementary food and were referred to a mother’s feeding center for food packages of skimmed milk, oil, sugar and protein. The children were followed weekly in the hospital. The 15% who failed to attend were followed up by volunteers and auxiliaries. Supplies were given twice weekly until children regained appropriate weight for age.

c) Demonstration education: mothers of malnourished children were given food and cooking demonstrations in local homes.

d) Oral rehydration: parents were shown how to prepare rehydration solution from locally available salt, sugar and boiled water.

e) Deworming: children 6 months to 3 years were treated to reduce the burden of Ascaris worms; this helped to maintain parental interest in rally attendance.

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AGL 21 – PHC in Developing Countries 6.0 Part D – Case: Rally Health Care Case (Continued)

f) Immunization: children from 3 months to 4 years were given vaccinations including: diphtheria, pertusis, tetanus, polio and measles.

g) Maternal child care: since 90% of the mothers delivered their babies at home with traditional birth attendants, the latter were supplied with sterile kits including razor blades, cord ties and umbilical dressings. They also attended training sessions given by the hospital staff to demonstrate their ability to use their materials correctly.

EVALUATION

The health of the target population of 100,000 was protected by easy access to the hospital and free preventive and curative care coordinated in “Health Surveillance” by the PHC workers and community volunteers. However statistics were available for the 10 year period 1970-80 only for the original 8,000 inhabitants in the immediate hospital vicinity. These showed reduction of the IMR from 174/1000 to 34/1000, improvement of life expectancy from 46 years to 65 years, reduction of child mortality from 36/1000 to 6/1000. Deaths due to malnutrition, tetanus and diarrhea declined by 50% and 5 of the target diseases show no mortality at all. Immunizations for tetanus increased form 35% to 86%.

No data was available on socio-economic changes during that period except that there was little change in housing, sewerage or water facilities or employment opportunities. GNP remained low, and less than half the population had access to protected water supply.

The project manager estimated that the PHC cost was about $2.00 per annum per capita (low because of voluntary labor which might not be available indefinitely). It had taken 10 years to expand from 8,000 to 100,000 people but similar programs in the country tended to show that access to hospital services did not add to the preventive PHC effects. Health Surveillance he argued enabled concentration of resources on the most frequent and seriously preventable diseases in the population. Voluntary workers provided coverage at low cost and alerted the PHC personnel to priorities. Thus Health Surveillance was the key to effective low cost PHC.”

Source: Developed from articles in the NEJM and other data.

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AGL 21 – PHC in Developing Countries 7.0 Exercise – Minicases

Problems for a Consultant

1. An Asian country with one physician for 50,000 population has sudden international publicity which brings offers from six government and 40 voluntary organizations for PHC projects. Many teams are prospecting for projects. Should the government accept all free projects? What criteria should they use to decide?

2. A church clinic in a rural African setting is so successful in providing PHC that the local government clinic and small hospital are generally not used. The government has severe financial problems. Should the church suggest that the government clinic be closed down to save money?

3. In the Middle East a voluntary organization set up a PHC program, with six paramedics and 15 community health workers one year ago. Now it is proposed to accept a grant from an international donor for a professional comprehensive evaluation including: Functional Analysis, Household Surveys, etc. to determine the health outcome of the project. Do you agree?

4. An Asian refugee camp with two hospitals and 15 out-patient departments for 140,000 refugees, successfully deals with malnutrition and war casualties over a four month period with VOLAG organizations loosely coordinated by UNHCR and ICRC. Health status improves substantially, and a neonatologist from Germany noticing that low birth weight infants (1 – 2.5 kg) mostly die, sets up a pediatric ICU with great success in saving lives. This uses most of the time of the nursing staff of two wards leading to considerable pressure on limited staff. Action?

5. An oil rich country seeks PHC of the highest quality of care. Due to lack of local doctors the system is 90% staffed by expatriates. PHC clinics see 600 patients daily mostly for minor illnesses (colds, diarrhea, etc.). Record Systems set up by international consultants for the clinic are unused due ‘lack of time.’ No vital signs are recorded on the charts or even taken unless the patient has a fever thus there is no preventive or long term care. Action?

6. PHC planning team financed by bilateral donor, has a tight time schedule to plan and produce PHC in an Asian country. Ministry of Health reports serious problems of logistics in the drug warehouse such that the warehouse can only issue to each PHC unit once a year. It also has problems in ordering, receiving, and storing drugs. Should the team stop its PHC work and deal with the warehousing problem?

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AGL 21 – PHC in Developing Countries7.0 Exercise – Minicases

Problems for a Consultant (Continued)

7. Voluntary Organization PHC system operating well in Africa for several years becomes aware of serious thefts of drugs and equipment on certain shifts. How to deal with this problem?

8. Great PHC training success in Asia with 500 paramedics trained and available for work in PHC centers suddenly blocked by the Medical Profession which feels that the ‘quality of care’ will suffer. The Medical Profession encourages application of an old law prohibiting such paramedics from treating patients? Cause? Action?

9. In Middle East PHC workers trained for one year in a medical school environment for rural health care are assigned to villages but limited in activity to preventive care without drugs. Doctors normally practice with excessive use of drugs. After three months the paramedics are largely ignored by the villagers. Cause? Action?

10. Asian project to train PHC workers was successful thus enabled to expand to a new village. PHC staff confronted by strike against them by the bullock cart drivers, carpenters, etc. A PHC worker is falsely accused of rape. Explanation? Action?

11. PHC services in a Caribbean Island limited to nutrition, supplementary feeding of ‘at risk’ populations, health surveillance, maternal child care, E.P.I. and health education, with basic curative care (rehydration and deworming, etc.) What results after nine years in IMR and LE?

12. An Asian country shows IMR 14/1000, attributes this to the result of PHC, late marriages and limited child families. A province in rural area reports LBW .5% compared with 6% in most developed countries. Explanation?

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AGL 21 – PHC in Developing Countries7.0 Exercise – Minicases

Problems for a Consultant (Continued)

13. South American PHC project planning uses WHO published statistics on morbidity and mortality indicating significant communicable diseases but almost no cancer especially in rural areas. Initial survey however reveals quite different data. Why?

14. During the smallpox eradication campaign, cases in Asia became increasingly rare and rewards for new cases were offered. Official written reports from one district were consistently negative despite verbal reports of cases. Why? Action?

15. Family planning project in SE Asia with National Youth Corps involvement showed significantly increased acceptors in one year and the program is publicly proclaimed as a success. Reports from the area however indicate no change in fertility rate. Comment?

16. PHC project financed by AID for six million dollars over several years for development of standardised systems for international application of PHC. Reports success but refuses to allow publication of its materials due to ‘possible misuse.’ Evaluation confirms progress but suggests project be scaled down. Why?

17. PHC project over two years is evaluated and reports large numbers of health posts set up, paramedics trained, patients treated and referrals to hospitals but demographic data reports little change in IMR or LE. Why?

18. A PHC proposal in Africa suggests a comprehensive PHC system in a limited area despite poverty and poor government support, because ‘there are no care facilities of any sort in this region.’ Voluntary organization prepared to go in and do it all with full international financing. There is no existing government health post available in this area. Should the government agree?

19. PHC in local Middle East community reported to have no money available for payment of curative or preventive services and suggested that international funding be permanently available. Cause?

Source: Developed from various written and verbal reports of PHC projects.

STOPSTOP

STOP

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MINICASES

1. Rural Nursing Careers

On a fact-finding mission to a rural area, 100 kms from the regional headquarters, an evaluation team noted a high turnover rate of qualified nurses. Remedial action?

2. Taking Charge

On his arrival at his new post, a rural health centre, the administrator (Mr. Brian) found that the moral and productivity of the health workers were low. In his interviews with the workers, he discovered that the employees were unhappy with what they considered a heavy workload. Immediate action by Mr. Brian?

3. Rural Church Clinic

A church clinic in a rural African setting is so successful in providing PHC that the local government clinic and small hospital are generally not used, and the staff only 25% active. The government has severe financial problems. Should the church suggest that to save money, the government clinic should be closed down and the staff transferred?

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4. The Missing sheets

Nursing staff complained that they were always short of sheets for beds at weekends. The output of the laundry had not changeed and there had been no change in nursing practice. Senior nurse requested more sheets be purchased, and the manager purchased 300 new sheets. The laundry manager asked for another staff members to process the increased load.

Three months later the nurses asgain complained about the shortage of sheets. A police investigation revealed no evidence of theft, but did produce tension between laundry and nursing staff. More sheets were purchased and in three months the problem again presented itself.

The manager ordered an investigation and discovered that the nurses were rejecting many clean sheets because they were torn. Diagnosis and action?

5. Negative response

The MOH justified rejection of proposals for change over the last twenty years for over thirty different reasons. From your own experiences can you list them?

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ANSWERS TO THE MINICASES

1. Rural Nursing Careers

Distinguish the symptom (staff turnover) from the possible underlying cause (poor induction management). Need for an investigation of the induction management procedures, to determine the underlying causes. Effective HMM should consider: selection, induction, training, deployment, logistic support, supervision, continuous development, salary scales etc.

2. Taking Charge

Action Research (interviews, work observations, research) should enable the administrator to decide on the workers’ complaints. If the workloads are too great, steps must be taken have to:

a. Spread the workload amnong the traditional health workers, support staff, and community workers

b. Identify and order tasks according to priorityc. Improve working conditionsd. Take measures attuned to the work environment that would increase

motivation.

3. Rural Church Clinic

No. Closure does not contribute to the long-term political objective of government health service. Need integrated PHC not a series of efficient but independent organizations. Suggest reorganization for cooperative services with the government and plan for long-term government control of the whole PHC service.

4. Missing sheetsDiagnosis –

a. Nurses probably put the torn sheets straight back into the dirty linen basket. The sheets were cleaned again, returned, rejected etc., such that perhaps 25% of the sheets were never used. The laundry supervisor probably would not take responsibility for torn sheet repair. The sewing room staff probably noticed a drop in workload for some months but made no comment.b. Communication failures and lack of performance controls; earlier diagnosis of the problem would have saved money. The sewing room supervisor failed to report a problem from the reduced workload. The obvious solution of buying more sheets was inappropriate.Decision - seperate bags in the wards for dirty sheets and for torn sheets for repair; define the roles of the laundry and the sewing room; get laundry staff to visit wards on a regular basis, so that they can check on level of service provided, and can catch new problems at an earlier stage.

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5. Negative response

You probably managed to get even more reasons than the ones listed below:

1. It was tried before2. Too early3. Too late4. Too expensive5. Not worth doing6. Too political7. Needs committee approval8. Needs further study9. Takes too long10. It will never work11. Too difficult12. Need a computer13. Government will never accept14. Unions will never accept it15. Patients will never accept it16. Needs experts17. No motivation18. Needs a trial19. No transport20. No finance21. No staff22. Not medically ethical23. Not legal24. Requires too much planning.25. Donors would not agree26. Requires external funds27 Equipment not available28. National problem29. Costs too much30. WHO would never agree.

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UNIT 4 - MINICASES

1. RESOURCEFUL MANAGEMENT (see page 4)

2. DOUBLE OR NOTHING?

The O & M team investigated and developed “processing standards” as to how many

documents should be processed by each clerk daily. It was found that if the normal output

was not doubled, the organization could not function efficiently.

The clerks were opposed to a plan of doubling the workload.

What can the management do to increase the processing?

3. WORKING TOGETHER

Due to union policies, the laboratory technicians did not work at night thus, blood

tests were not available for some hours in the morning. The policy resulted in less effective

health manpower.

What action should be taken by management?

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4. The Difficult Balance

An Asian refugee camp with two hospitals and 15 out-patient departments for

140,000 refugees, successfully deals with malnutrition and war casualties over a four

month period with VOLAG organizations loosely coordinated by UNHCR and ICRC.

Health status improves substantially, and a neonatologist from Germany noticing that

low birth weight infants (1 - 2.5 kg) mostly die, sets up a pediatric ICU with great

success in saving lives. This uses most of the time of the nursing staff of two wards

and leads to considerable pressure on limited staff.

What action should be taken by management?

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- 8 –

UNIT 4 - MINICASE ANSWERS

1. Resourceful Management (from Work Pack, page 4)

The shortage of facilities for the health centre can be overcome by searching for

resources among the community. This search could lead to sharing space in nearby

schools, raising a temporary, low-cost building, or using homes as the last resort.

2. Double or Nothing?

As the standards set by the O & M team are not negotiable, it is necessary for the

management to seek motivation factors for the workers. This may be done by providing pay

incentives (if resources permit), improve the work environment, or to initiate work

assessments that would result (on a satisfactory assessment) in job enrichment, that is:

additional training, diverse career paths, centre-sponsored field trips.

3. Working Together

Management could resolve the problem by negotiating with the union for

management options to hire part-time workers, offer incentives to the present staff for

increased day work testing, offer incentives to present staff to work night shifts. Negotiations

with the unions should be prefaced by Action Research on the laboratory workload.

4. The Difficult Balance

Poor planning and control of voluntary organizations. Must control the quality of care

that voluntary organizations are allowed to offer to ensure that it is appropriate to

environment, and long term feasibility. Difficult to stop an ICU for LBW infants once it has

started due to medical ethics and traditions. Scale it down slowly as the staff changes.

Recognize that surviving LBW infants may have serious retardation problems which cannot

be dealt with in this environment.

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MINI CASES (Cont’d)

1. See page 5

2. PHC planning team financed by bilateral donor, has a tight time schedule to plan and

produce PHC in an Asian country. Ministry of Health reports serious problems of

logistics in the drug warehouse such that the warehouse can only issue to each PHC

unit one a year. It also has problems in ordering, receiving, and storing drugs.

Should the team stop its PHC work and deal with the warehousing problem?

3. In the Middle-East a voluntary organization set up a PHC programme with six

paramedics and 15 community health workers one year ago. Now it is proposed to

accept a grant from an international donor for a professional comprehensive

evaluation including: Functional Analysis, Household Surveys, etc. to determine the

health outcome of the project. Do you agree?

4. An Asian country with one physician for 50,000 population has sudden international

publicity which brings offers from six government and 40 voluntary organizations for

PHC projects. Many teams are prospecting for projects. Should the government

accept all free projects? What criteria should they use to decide?

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- 10 -


1. Support System (South Asia) from work pack page 4.

PHC must use records for good preventive and curative care. Put in training staff to

start systems requiring recording of vital signs and at least a “SOAP” note for each

patient visit. Introduce health educators to improve preventive care and patient self

reliance, thus reducing the number of visits for trivial problems.

2. Yes. International staff must be recognized as working for the Ministry and not for

the donors. Stop the PHC project and work on the Ministry’s immediate warehousing

problem. Build cooperation and demonstrate the team’s ability to solve real local

problems efficiently.

3. No... Personal supervision by the management is presently adequate in this small-

scale situation. Do not expect improvement in outcome after only one year.

Measure process and output at this stage. Do not waste money on evaluation which

could be better spent on health care.

4. A developing country has only a limited capacity to absorb help. Must limit the

number of projects and different organizations to reduce the integrating problems.

Need to ensure that short-term projects have local long-term viability with local

resources. Foreign exchange is a temptation to be resisted because of the potential

harm of uncontrolled international aid. Must choose projects that can be controlled

by the national government.

3. DIARY 75 -

86

INTERNATIONAL LABOUR OFFICE

Draft materials for testing by ILO/WHO

PHC IN DEVELOPING COUNTRIES- A BASIC TWO/THREE DAY MANAGEMENT TRAINING COURSE

FOR DOCTORS

GLOSSARY AND REGISTRATION(Retained by participants)

Copyright: RGAB 2006/1Management Development Branch

Geneva

87

CONTENTS

ITEM PAGE NO

1 SIMPLIFIED GLOSSARY 2

2 REGISRATION FORM 12

3 QUIZ ANSWER SHEET 18

4 FEED BACK FORM 20

88

AGL 21 - Primary Health Care in Developing Countries

1.0: Simplified Glossary

Access - Ability of population to obtain or make use of health care; limited by: geography, finance, family/social constraints

Activities - A group of tasks with a common purpose

Activities Study - Analysis of work to measure efficiency and effectiveness

Acute disease - Disease having short and relatively severe course

Administration - See management

Ambulatory Care - Care of the patient not confined to bed; out- patient care

Amenorrhea - Absence of menses

Attributable risk - The proportion of a disease caused by a specific characteristic or etiological factor

Authority - The right to make decisions and enforce them; formally from above but informally from below

Auxiliary Personnel - Health personnel who are part of a health team, with short term training, often associated with specific tasks, working under supervision of more highly qualified staff

Barrier method - Any method of family planning where the sperm is prevented from entering the vagina by a barrier

Baseline Year - Pre-project or first year project data collected for subsequent evaluation purposes

Basic Health Care - See PHC

Basic Health Services - Health care to sustain life and prevent premature death

Benign Family Planning - Type of family planning program which offers services only

Bias - Influence on a study which invalidates results; may result from sample selection, design of study of staff involved

Birth Control - See family planning

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AGL 21 - Primary Health Care in Developing Countries8.0: Simplified Glossary (Continued)

Birth Rate - Crude Birth Rate; live births per thousand population

Budget - Plan in financial terms for program activity over a specified time period; may be a program budget (main accounting headings), activity budget (unit cost of service) or outcome budget (unit cost of output)

Capacity of Service Unit - Ability of a service unit to meet health care demands in quantity and quality

Case Control Study - See retrospective study

CDC - Center for Disease Control. Atlanta, Georgia

Centralization - Bring together operations of the same type for control by a central unit; contrast decentralization; a relative term

Change of Intensity - Change of strategic emphasis in setting priorities

Check list - A list of items used to routinize work; used as management tool to ensure all necessary work is completed

Child Mortality Rate - ‘Under 5’ mortality rate; number of deaths ‘under 5’ during a year per total population ‘under5’

Child Spacing - Service to women to space their pregnancies through family planning (condoms, IUD, pill, etc.)

Chronic Disease - Disease production incapacity which persists over time and modifies the patient’s life style

Community - A group in face-to-face contact with same common interests, aspirations, values and objectives; may have a wide range of subgroups and varying political power structure

Community Health Care - Activities and organized program needed to maintain or improve health in a community; public or private

Community Health Worker - All workers in a community health project including physicians, paramedics, nurses, community health workers, etc.

Comprehensive Care Unit - Health unit offering the full eight functions of primary health care; see primary health care

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Constraints - Limits to choosing alternatives; causes may relate to political, economic, social, cultural, administrative or technical factors

Cost - Resources expended to carry out an activity; various definitions

Cost-average - A cost achieved by dividing total cost by total volume of output; cannot be used for relevant cost analysis since it involves volume assumptions

Cost-capital - Capital expenditure for financing permanent, or semi-permanent facilities lasting one year or more

Cost-direct - Easily identified with an activity or product

Cost-fixed - A cost dependent on a passing of time and relatively unaffected by variation in volume

Cost-marginal - Increase in cost by changing volume by one unit

Cost-opportunity - Not a cost, but the value of alternative use of resources

Cost-output - Cost that tends to vary directly with the volume of the output

Cost-replacement - Cost of replacing a machine or a facility at a given time

Cost-standard - A predetermined efficiency cost; comparison against actual cost

Cost-true - Does not exist, each cost depends upon the purpose for which it is used and assumptions made in the calculation

Cost-unit - The cost of a single unit of output; assumes a particular volume

Cost Benefit Analysis - Evaluation measure comparing cost of a project with the value of benefits; alternative schemes may be compared using this technique to see which scheme contributes the most for a fixed investment; value of benefit difficult to assess without questionable assumptions

Cost Effectiveness - Evaluation measure comparing the cost of activity with years of life saved or other quantifiable advantages. Useful to compare alternative projects avoids the need to “value” the benefits

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Cost Efficiency - Evaluation measure comparing the cost of an operation with alternative methods of achieving the same result

Coverage - Number or percentage of persons reached by a health service; PHC coverage in most developing countries is often less than 30%

Cross Sectional Study - Data collected at one point in time from a sample to describe some larger population at that time; for description or determining prevalence of disease at the time of study

Crude Birth Rate - Number of live births per year per 1000 inhabitants

Crude Death Rate - Number of deaths per year per 1000 inhabitants; highly dependent on age structure of the population

Decentralization - Dispersion of the same type of work or activity with full executive power, away from the center and close to the initiating activity; contrast centralization

Degree of Cohesiveness - Relationship of peripheral unit to central authority

Delphi Method - A method of choosing priorities by weighting or indexing factors on the basis of a consensus or majority opinion of supposedly unprejudiced experts

Demand - The actual demand for health services as perceived by users; contrasted with the need for health services perceived by technical staff

Depovera - Injectable drug for Family Planning; used in some developing countries; side effects

Development Indicator - Economic and social indicators of ability of a country or community to affect its health status through change in poverty levels

Development Planning - Combination of sectoral plans for health, education, agriculture, industry, public safety, transportation, etc.

Disincentives - Type of family planning program in which you lose other services the more children you have

Edema - Swelling; excessive accumulation of fluid in the tissue space

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EEC (European Economic Community) - A Significant donor of health care for developing countries

Eclectic - Choice of an alternative according with environmental and organizational problems as they arise

Economic Indicators - Various economic statistics used to indicate the relative development and progress of a community; gross national product and gross national product per capita are useful indicators for ability of a country to provide finance for health care

Effectiveness - Evaluation measure; extent to which a plan, program or project achieves a purpose which is relevant to the community needs; considers whether the objectives of a project are appropriate

Efficiency - Evaluation measure; extent to which resources were used to achieve the given end, compared with alternative

Epidemiology - Study of distribution of disease and characteristics of that disease in a human population

Epidemiological Survey - A survey which may use sampling techniques to find out the prevalence, incidence or natural history of a disease through case finding

Evaluation Method - Progress measurement; evaluation of a project, program or process; may be evaluation of input, output (services) or outcome (change in health status); primary health care may require at least six years to change health status; and thus outcome evaluation relative to primary health care alone is very difficult, since other factors in the environment will change

Environmental Analysis - Analysis of the environment of primary health care in terms of political, social, cultural, economic and health factors; preliminary to setting health priorities, objectives and health targets

Extended Care - Care of patients not acutely ill over longer time periods

Expanded Program of Immunization (EPI) - Part of primary health care to provide immunization against six target diseases (diphtheria, pertussis, tetanus, measles, polio, TB) to all children of the world by 1990

Family Planning - Part of primary health care; range of methods to avoid unwanted pregnancy and spacing of children - planned conscious effort to plan the size of the family

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AGL 21 - Primary Health Care in developing Countries8.0: Simplified Glossary (Continued)

Fertility Rate - Number of live births per year per thousand women aged 15 - 44

Formal Organization Structure - Organization charts and job description which formalize the authorized position; and activity of different parts of the organization; may not correspond to reality where informal organizational activity and relationships are more important than formal structure

Function - Broad area of responsibility involving many activities

Functional Analysis - Systematic data collection for planning and evaluating PHC in terms of the technical, social, cultural, and economic cost. Three Phases:

1. Records information2. Community information3. Activity and service information

Goal - General term for objective or guideline

Growth - General term for expansion of activity or population

Gross National Product Per Capita - Economic indicator; total sum in a country of: personal expenditure on goods and services, government expenditure on goods and services, investment expenditure. This amount is divided by the total population to give GNP per capita; GNP per capita below $200 per annum (1980) makes comprehensive primary health care difficult to support on local resources

Harmonization - Organizational change without altered capacity of the health care system

Hawthorne Effect - Technical term related to Western Electric experiments in 1931; refers to improvement from project due to the attention paid to participants; invalidates cause or relationships in a project because the participants feel motivated purely by being chosen for the project; some primary health care projects have Hawthorne effect

Health - WHO definition of a state of complete physical, mental and social well-being not merely the absence of disease or infirmity; this definition has been criticized as impractical in relation to the world poverty

Health Care System - Inter-connected, and inter-dependent activities for health care

Health Education - Specific action to persuade people to adopt and sustain healthy life style practices

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Health Manpower Planning - Process of health planning and part of the national health plan involving a) analysis and projection of health needs and population demand for health services b) measurement of present available health manpower c) estimate of future manpower requirements and supply and d) formulation of policies to deal with the imbalance

Health Objective - Goals for change in health status related to causes of morbidity and mortality. Criteria are: understandable, quantitative, time limited, etc. with current and desired quantitative levels.]

Health Risk Analysis - System for determining the health age of an individual in relation to risk factors from environment, life style and genetic factors

Health Service Structure - Organized network of peripheral units providing basic health services using local resources for most urgent health needs

Health Service Target - Required level of program activity (coverage, utilization, access, availability) to attain objectives.

Health Status Indicator - A quantitative measure used to reflect health status of a community. Measure of the quality of health such as: life expectancy, functional ability or measure of disease or disorder, e.g. Neonatal Mortality Rate, Heart Disease Mortality Rate etc.

Health Strategy - Process of relating priorities to resources and environment to determine health objectives, health service targets and target populations.

Health Survey - Measure of general health of population, by obtaining range of health variables such as: demographic (age, sex, rural/urban), prevalence of acute and chronic disabilities, physical characteristics (HT , WT), etc. Survey methods are by interview, examination, canvas of the sources from which care is provided (hospital, clinic) etc.

Health System Indicator - Measure of the general characteristics of a health system such as: availability, accessibility, acceptability, quality, continuity and cost effectiveness.

Heuristic Approach - Problematic rather than theoretical approach to problems

High-Risk Pregnancy - Factors increasing susceptibility to problem pregnancy

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Holistic Care - Concept for care of the whole man

Horizontal Program - Health program which relies upon community support rather than direction from a central authority; contrast vertical program

Immunization - See Expanded Program on Immunization

Implant - A family planning method where a slow-acting contraceptive hormone is implanted beneath the skin of a woman

Incentives - Type of family planning program in which the family gains other services by not having children

Incidence - Epidemiological measure; number of new cases of disease in a given period for a given population; contrast with prevalence. A measure of the number of new cases of disease in a defined population during a specified time interval.

Incremental Risk - Epidemiological measure to determine the additional risk of some exposure of activity in terms of contracting disease

Infant Mortality Rate ( IMR) - Death under one year per thousand live births during that year; indicator of health differences within and between countries; range from 11 to 20 per 1000 live births in advanced industrial countries to 100 to 200 per 1000 in less developed countries

Infrastructure - The basic, underlying framework or features of an organization

Injectoles - type of family planning method where a slow-acting contraceptive hormone is injected into a woman

International Health Organizations - Organizations devoted to international health or some aspect of it financed by general international funding; includes World Health Organization, UNESCO, World Development Program, World Food Program, Food and Agricultural Organization, International Labor Office, etc.

Inter-sectoral Coordination - Coordination of activities between different ministries and ministry of health for general improvement of the environment and of health status

Intervention - Action applied to change the course of events

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IRC (International Rescue Committee) - International voluntary organization for relief of refugees in general, improvement of health status, PHC etc.

“J” Curves - Special graphs for measuring High Risk Pregnancy possibilities

Job Analysis - Scientific study of job content and modifying factors which surround it

Job Description - Description of job or activity including the procedures required, and qualifications and physical demands of the job

Kwashiorkor - African word which comes from Ghana. It means illness of the displaced child. By displaced we mean the child has been taken away from his mother’s breast, because she has become pregnant again. Edematous PCM (protein calorie malnutrition) severe protein deficiency - other signs - pale, skinny, swollen skin, anorexic (loss of appetite), apathetic.

Logistics - Problems of the supply inventory distribution and control of supplies and equipment including drugs and pesticides; a key problem in primary health care

Longitudinal Survey - Comprehensive review over a long period

Luteinizing hormone - Female hormone necessary for ovulation

Management - Administration - Planning, organizing, motivating and controlling staff to achieve objectives; alternatively; considered as the creation of environments for staff to achieve objectives

Malnutrition - State of nutritional deficiency. See Kwashiorkor and Marasmus

Marasmus - Non-edematous nutritional deficiency. Signs - starving, skin and bones, head appears large for body, monkey/aged faces - classically ravenous; commonly anorexic.

Maternal Mortality Rate - Number of maternal deaths from puerperal causes in a year per 100,000 live births

Medex - Specialized form of paramedic associated with the University of Hawaii international health operations

Methods Study - See work study

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AGL 21 - Primary Health Care in Developing Countries 8.0: Simplified Glossary (Continued)

Morbidity - Disease/illness in a defined population during a specified time interval

Morality - Epidemiological measure; number of deaths per thousand population during one year; developing countries have mortality rate exceeding 20 per thousand

Need and Demand for Health Care - A need for health care may be “felt” need recognized by the community or “real” need recognized by technical and professional staff; demand for health care is the actual demand for services which may not always correlate with the needs

Neo-natal - Newborn

NFP - Natural Family Planning. A System of family planning where a woman monitors her bodily changes

Nominal Group Process - Technique for selecting priorities using repetitive feedback of a small group system; derived from the Delphi system

Nutrition - Part of primary health care concerned with relationship between diet, health, and disease; improvement of health through prevention of nutritional disease

Nutritional Survey - Epidemiological technique; survey of a sample of population’s nutritional status; involves some judgmental factors, measures degree of relative malnutrition

Organizational Structure - Formal structure of an organization as defined by organizational chart and job definitions; informal structure relates to the real working or the organization

Operational Research - Formalized quantitative analysis to improve efficiency using mathematical techniques

Output - Health services produced by use of resources; i.e. access, coverage, quality, utilization, etc.

Outcome - Ultimate impact of the activity from use of resources on health status e.g. reduced mortality

Parity - In relation to pregnant women, the number of pregnancies carried to term

Peri-natal - Around the time of birth

Planning - Function of relating objectives to resources and environment to determine how they should be achieved

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Planning-Deductive - Policy and objectives established at a high level; detailed proposals for implementation downward

Planning-Indicative - Planning realized with the help of guidance and incentives

Planning-Inductive - Local experience and practice identified, coordinated and consolidated so as to be more widely available

Planning-Short Term - Planning to meet present needs as defined by present trends and using available resources

Planning-Medium Term - Planning to modify demand and recognize new needs and resources

Planning-Long Term - Planning to select a desired future in broad terms and design ways to achieve it; often involved with reorganization of social institutions

Planning-Normative - Based on norms or standards that have legal backing

Planning Curve - Curve showing the exponential increase in population growth

Population-at-Risk - Identifiable community with high risk for illness or disease

Pre-natal - Relating to events prior to birth

Prevalence - Measure of the number of all cases of disease existing in a defined population at a specific point in time or during a specified time interval. Used primarily for chronic diseases. Expressed as an absolute number per thousand of the population.

Preventive Medicine - Part of medicine concerned in particular with the promotion of health and prevention of illness

Primary Care - See PHC

Primary Health Care - See PHC

PHC - All activities influencing health made universally accessible to individual by acceptable means, at an affordable cost; key functions (8) of primary health care are: improved nutrition, adequate amounts of safe water, basic sanitation, maternal and child care including family planning, immunization, prevention and control of locally endemic diseases, education about local health problems, basic curative care

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Primary Health Care Center - Physical organization for delivering primary health care

Primary Prevention - means to avert the occurrence of disease

Priorities - Stage in planning process for setting guidelines to be implemented; involves balancing of objectives with variables such as: morbidity, morality, environment, availability of technical methods, social and political effects of a disease or health problem, etc. Provides health objectives and health services tasks

Production - Operational management of primary health care based upon priorities and planning

Progress - Evaluation of primary health care; see evaluation

Prolactin - Female hormone necessary for milk production

Quality of Life Index - Epidemiological measure for measuring life style; constructed from infant mortality rate, life expectancy, literacy rates; high income countries have index 97-98, middle income 70-80, low income 56-70

Quantitative Factor - Measure of achievement of PHC that can be easily expressed in “numbers” without significant assumptions. Often less important than “non-quantitative” factor (political, social, cultural, human effects) which cannot be adequately quantified. Q + NQ = Decision

Random Sampling - Selection process; Finite number individuals, cases or measurements chosen from a larger group in such a manner that each individual case of measurement has an equal and independent chance of being selected

Rate of Natural Increase - Increase of population per annum; crude birth rate less crude death rate

Regionalization - Decentralization of authority and responsibility for normalization of health care to regional centers

Relative Risk - Epidemiological measure; comparing incidence of disease in exposed to the risk factor to incidence of disease in those not exposed to the risk factor

Retrospective Study - People diagnosed as having a disease (cases) are compared with persons who do not have the disease (controls). The purpose is to determine if the two groups differ. Also called a case- control study

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Risk/Benefit - Approach for examining the value of family planning services by weighing the risk and benefits of a certain type of family planning with the risk/benefits of another type

“Road to Health” Chart - Recording progressive growth of child compared to expected growth

Rural Health Care - General term for PHC center in rural setting

Sample - A portion of a population for purpose of making estimates about the nature of the total population for which the sample has been taken

Sampling - Epidemiological concept for selection of a sample based on statistical methods

Sanitation - A part of primary health care; prevention of disease by eliminating or controlling environmental factors which link to transmission of disease e.g. collection and disposal of human excreta, and protection of water source from contaminant

Scabies - Contagious disorder of the skin characterized by multiform lesions with intense itching which occurs chiefly at night

Secondary Prevention - means to halt or slow the progression of a disease

Sepsis - Infection caused by unsanitary surroundings

Spacing - Amount of time between births

Supervision - See management

Support system - Source of emotional support including family, friends and others - such as medical people - to help a pregnant woman

Surveillance - Active monitoring of the occurrence and spread of a disease for effective control via collection and evaluation of morbidity and morality reports, investigation of epidemics or individual cases,

Systematic Sampling - Epidemiological concept; sampling systematically not by random numbers

TALC - Teaching Aids for Low Cost (London)

Target Population - That part of the population identified as being of high risk or appropriate for particular primary health care

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Task Analysis - Analysis of activity in terms of who, when and how to determine manpower requirements and qualifications; also used to determine how staff actually use their time

Time Motion Analysis - See work study; refers generally to analysis of a job in terms of time and motion in order to improve efficiency

Toxiod - Toxin detoxified by intense heat and chemical treatment but with antitoxic properties intact

Trimester of pregnancy - One third pregnancy term

UNICEF - United Nation Children’s Fund; emphasis on child health, education, nutrition, social welfare services

“Under Fives” Clinic - Clinic Specializing in Primary Health Care of children ages 0-5

UNDP - United Nation Development Program; involved with all types of development projects of developing countries

UNFPA - United Nations Family Planning Association; funds family planning projects internationally

UNWFP - United Nation World Food Program; organizes donors of food for distribution to developing countries

Volags - Voluntary agencies; nonprofit organizations supported by voluntary contributions; active in PHC

Vertical Programs - Specific limited health care directed from the center towards environmental control such as: water and sewage, communicable disease control, communities improvement, some health education; contrast with horizontal programs

WDP (World Development Program) - International organization concerned with economic and social development throughout the world; active also in international health

Weighting of Alternatives - System of decision making by allocating weights to alternative courses of action or priorities

WHO (World Health Organization) - International body concerned with various aspects of world health including: disease control/surveillance, health statistics, manpower development, biomedical research and technical cooperation among developing countries, etc.

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World Vision - International volunteer organization, provide emergency relief, supplies, and PHC in developing countries

Work Measurement - Application of work study techniques to improvement of efficiency; see time and motion study

Work Study - Includes methods study and work measurements; systematic recording, analysis and critical examination; of ways of doing work and development of more effective methods

Xeropthalmia - Dryness of the conjuctiva; conjunctivitis with atrophy and no liquid discharge producing an abnormally dry and lusterless condition of the eyeball; due to a vitamin A deficiency.

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REGISTRATION AND BACKGROUND DATA

COURSE DATE & LOCATION:

PARTICIPANT’S NAME:

TITLE:

ADDRESS:

PREVIOUS PHC EXPERIENCE:

QUIZ RESULTS:

DAY I ________ DAY II ___________ DAY II ________50 19 50

PERSONAL OBJECTIVES IN TAKING THE COURSE:

NOTE: COMPLETE ONE SHEET OF THE COURSE DIARY FOR EACH DAY INDICATING

1.) Key Points learned2.) Reactions to AGL3.) Questions which are not satisfactorily answered4.) Results of any quizzes given during the day.

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104

AGL 21 - PRIMARY HEALTH CARE IN DEVELOPING COUNTRIES

9.0 QUIZ ANSWER SHEET

1. (a) (b) (c) (d) 26. (a) (b) (c) (d)2. (a) (b) (c) (d) 27. (a) (b) (c) (d)3. (a) (b) (c) (d) 28. (a) (b) (c) (d)4. (a) (b) (c) (d) 29. (a) (b) (c) (d)5. (a) (b) (c) (d) 30. (a) (b) (c) (d)6. (a) (b) (c) (d) 31. (a) (b) (c) (d)7. (a) (b) (c) (d) 32. (a) (b) (c) (d)8. (a) (b) (c) (d) 33. (a) (b) (c) (d)9. (a) (b) (c) (d) 34. (a) (b) (c) (d)

10. (a) (b) (c) (d) 35. (a) (b) (c) (d)11. (a) (b) (c) (d) 36. (a) (b) (c) (d)12. (a) (b) (c) (d) 37. (a) (b) (c) (d)13. (a) (b) (c) (d) 38. (a) (b) (c) (d)14. (a) (b) (c) (d) 39. (a) (b) (c) (d)15. (a) (b) (c) (d) 40. (a) (b) (c) (d)16. (a) (b) (c) (d) 41. (a) (b) (c) (d)17. (a) (b) (c) (d) 42. (a) (b) (c) (d)18. (a) (b) (c) (d) 43. (a) (b) (c) (d)19. (a) (b) (c) (d) 44. (a) (b) (c) (d)20. (a) (b) (c) (d) 45. (a) (b) (c) (d)21. (a) (b) (c) (d) 46. (a) (b) (c) (d)22. (a) (b) (c) (d) 47. (a) (b) (c) (d)23. (a) (b) (c) (d) 48. (a) (b) (c) (d)24. (a) (b) (c) (d) 49. (a) (b) (c) (d)25. (a) (b) (c) (d) 50. (a) (b) (c) (d)

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AGL 21 - PRIMARY HEALTH CARE IN DEVELOPING COUNTRIES

9.0 QUIZ ANSWER SHEET

51. (a) (b) (c) (d) 76. (a) (b) (c) (d)52. (a) (b) (c) (d) 77. (a) (b) (c) (d)53. (a) (b) (c) (d) 78. (a) (b) (c) (d)54. (a) (b) (c) (d) 79. (a) (b) (c) (d)55. (a) (b) (c) (d) 80. (a) (b) (c) (d)56. (a) (b) (c) (d) 81. (a) (b) (c) (d)57. (a) (b) (c) (d) 82. (a) (b) (c) (d)58. (a) (b) (c) (d) 83. (a) (b) (c) (d)59. (a) (b) (c) (d) 84. (a) (b) (c) (d)60. (a) (b) (c) (d) 85. (a) (b) (c) (d)61. (a) (b) (c) (d) 86. (a) (b) (c) (d)62. (a) (b) (c) (d) 87. (a) (b) (c) (d)63. (a) (b) (c) (d) 88. (a) (b) (c) (d)64. (a) (b) (c) (d) 89. (a) (b) (c) (d)65. (a) (b) (c) (d) 90. (a) (b) (c) (d)66. (a) (b) (c) (d) 91. (a) (b) (c) (d)67. (a) (b) (c) (d) 92. (a) (b) (c) (d)68. (a) (b) (c) (d) 93. (a) (b) (c) (d)99. (a) (b) (c) (d) 94. (a) (b) (c) (d)70. (a) (b) (c) (d) 95. (a) (b) (c) (d)71. (a) (b) (c) (d) 96. (a) (b) (c) (d)72. (a) (b) (c) (d) 97. (a) (b) (c) (d)73. (a) (b) (c) (d) 98. (a) (b) (c) (d)74. (a) (b) (c) (d) 99. (a) (b) (c) (d)75. (a) (b) (c) (d) 100. (a) (b) (c) (d)

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FEEDBACK SUMMARY

1. NAME:

TITLE:

ADDRESS:

2. PREVIOUS PHC BACKGROUND:

3. QUIZ SCORES

DAY I DAY II DAY II_________ out of 50 _______ out of 19 ________ out of 50

4. DID THE PROGRAM COMPLETELY SATISFY YOUR PERSONAL OBJECTIVES?

5. WHAT SUGGESTIONS COULD YOU MAKE FOR IMPROVING THE PROGRAM?

6. WHAT OTHER AGL PROGRAMS COULD BE DEVISED WHICH WOULD BE USEFUL?

7. WHAT IS YOUR OVERALL EVALUATION OF THE COURSE IN TERMS OF:

Excellent1

Good2

Fair3

Poor3

Terrible5

Content

Presentation

Administration

Usefulness

Note: Mark the appropriate item with an X

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AGL 25 - MATERNAL/CHILD HEALTH IN DEVELOPING COUNTRIES

8.0 REGISTRATION AND BACKGROUND DATA

COURSE DATE & LOCATION:

PARTICIPANT’S NAME:

TITLE:

ADDRESS:

PREVIOUS EXPERIENCE:

QUIZ RESULTS:

DAY I ________ DAY II ___________ DAY II ________50 19 50

PERSONAL OBJECTIVES IN TAKING THE COURSE:

NOTE: COMPLETE ONE SHEET OF THE COURSE DIARY FOR EACH DAY INDICATING

1.) Key Points learned2.) Reactions to AGL3.) Questions which are not satisfactorily answered4.) Results of any quizzes given during the day.

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4. GUIDEINTERNATIONAL LABOUR OFFICE

Draft materials for testing by ILO/WHO

PHC IN DEVELOPING COUNTRIES- A BASIC TWO/THREE DAY MANAGEMENT TRAINING COURSE

FOR HEALTH STAFF

CASE GUIDE(Not retained by participants)

Copyright: RGAB 2006/1

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PHC IN DEVELOPING COUNTRIES

CASE GUIDE NOT RETAINED BY PARTICIPANTS

CONTENTS

Item Page Number

Part A: Case – West Primary Health Care 2

Part B: Case – Asian Island Project 6

Part C: Case – PHC Food Project 10

Part D: Rally Health Care Case 13

Mini Cases: Problems For A Consultant 17

Quiz 20

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart A – Case: West Primary Health Care

ANSWERS TO THE CASE

1 STORY OF THE CASE

a. Dr. Hall is head of a new Department of Community Health in the West Hospital founded in 1978 on Caribbean island with usual LDC problems.

b. Health surveillance program already started for 8,000 population in immediate hospital vicinity, out of total population of 120,000.

c. Hospital records analyzed for morbidity and mortality, limited community data available. Decision made to start some PHC.

d. Stated objectives: to identify health problems and populations at risk; to plan health services outreach. Implied objectives - start soon; costs to minimal level; start small.

e. What objectives and what health service targets? Is the data adequate?

2 CHARACTERISTICS OF ENVIRONMENT AND POPULATION

a. Geographical – semi-tropical island, Caribbean, poor agricultural land and primitive farming, periodic droughts and soil erosion.

b. Political – black dictatorship; health not high priority.c. Economic – GNP $380 p. c. with extensive unemployment; tourist industry.d. Social – no welfare programs.e. Cultural – multiple religions; primitive voodoo beliefs; traditional healers.f. Health Indicators – IMR 157/1000, CBR 37/1000, LE 45 years; 80% rural; key

diseases: high prevalence of malaria, TB, tetanus, malnutrition.g. Target Population hospital coverage 120,000 in 400 sq. km. but initial target only

8,000 in immediate hospital vicinity (comparable?).

3 HEALTH PRIORITIES AND HEALTH SERVICE TARGETS ADEQUATELY DETERMINED

a. Health objectives bases on census followed by health surveillance using voluntary workers; analysis of hospital inpatient and outpatient records; TB screening; some community contact; all of this data used together with intuitive medical local experience to determine health objectives.

b. Health service targets – malnutrition, diarrhea, parasites, TB, tetanus were chosen for attack without quantifiable targets.

c. Need additional data:1. Detailed study of community beliefs and attitudes towards: illness, life,

death and medical treatment.2. Study of traditional medical practices and extent to which preferred by the

community.3. Government plans for development and health services for possible

coordinated work. Relationship to national planning. Need a Comprehensive Functional Analysis and Household Survey for rigorous baseline data.

4. Better understanding of community demand/need/participation.

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ANSWERS TO THE CASE – cont’d

4 CRITERIA AND ALTERNATIVES AVAILABLE

a. Criteria

1. Demand/need – community key priorities to be met.

2. Cultural acceptability – related to cultural beliefs and patterns, with consideration for existing traditional medicine.

3. Cost – need to provide appropriate service that would be long term locally supportable.

4. Service type – preventive more effective than curative in LDC environments.

5. Government cooperation – provide mechanism for long term coordination with government system

6. Influence – need for a “successful” first project to establish opportunities for the future.

7. Management – difficulty related to the scale of the initial project.

b. Alternatives

1. Services – comprehensive or selective PHC; curative/preventive emphasis.

2. Staffing – physicians or paramedics, with paid or unpaid auxiliaries.

3. Integration – with or without the government health service or other bodies.

4. Population – 8,000 in immediate hospital vicinity or larger numbers in different locations.

5. Cost – locally supportable long term cost or higher; free or charged service.

6. Control – by the hospital expatriates or by the local community or government.

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5 DECISION AND JUSTIFICATION

a. General Decision – suggest Selective PHC to deal with: malnutrition, tetanus, parasites, and TB by culturally acceptable low cost methods. Use Health Surveillance to target health services to the population at risk.

b. Detailed Decisions

1. Access – choose population 8,000 closest to the hospital as first impact, to test the program; then expand to other areas.

2. Coverage – 75% coverage by making services easily available; recognize that some people will prefer traditional methods.

3. Quality of service – Selective PHC consistent with local culture; use group gatherings (“rallies”) in different locations; concentrate on nutritional support and maternal education for children at risk, with rehydration and de-worming; minimal curative care since hospital easily available for this population.

4. Cost – avoid free service; set small charge which is long term supportable and avoid long term international financing.

5. Standards – set standards for the time and cost of care; measure not only access/coverage but also cost against standard.

6. Community and government – work through the community for participation; not mere acceptance but active government support.

c. Justification – PHC should be appropriate to the culture (life/death/disease/beliefs are most important), economy, political climate and available resources; it should deal with priority health problems without creating dependence upon long term international aid.

Need to do something quickly on a small scale to satisfy the governing body and to gain influence with the community. Long term it must be a government-coordinated activity.

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6 LEARNING POINTS

a. Health priorities relate to the total environment (political, economic, social, cultural) not merely to medical problems.

b. Need for systematic Functional Analyses to determine priorities by development of baseline data.

c. Need for household surveys and study of the culture and beliefs of the community to understand community demand/need, and allow the community to decide priorities.

d. PHC need not be comprehensive to be effective; preventive care is often more effective than curative care provided the community cooperates (in return for some curative care..?).

e. Health surveillance with defined population by census and improved recording should enable continuous focus on populations at risk.

f. Need to know resources available to determine what is feasible but recognize that “adequate data” is never available. PHC must set up data gathering systems (Health Surveillance) as routine.

g. Relate PHC to: access, coverage, service, quality, cost, integration with government service, community participation.

h. A small initial target population enables early “influence” but the health services should be appropriate to the larger population.

i. Health care in poverty environments must be appropriate; do not create need and dependency that cannot be met long term from local/national resources.

j. The expatriate expert may not necessarily know what is best for a LDC community, but he sometimes may have to decide and to act.

k. Authoritarian government may facilitate program initiation but without development efforts by the government, health status improvement alone will not solve chronic poverty.

l. Recognize that sophisticated traditional health systems exist in all communities and that western type PHC care involves both benefits and social cost; this may explain “irrational local behaviour”.

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart B – Case: Asian Island Project

ANSWERS TO THE CASE

1 STORY OF THE CASE

a. In 1975, a PHC project was set up on an Asian island for a target population of 24,000 out of total island population of 400,000.

b. Planning was initially based on a population survey.c. Project provided free comprehensive (eight function) PHC with local staffing financed

by international donors.d. Presently doing ten year evaluation to determine appropriateness and future

planning.

2 ENVIRONMENTS AND ACHIEVEMENTS

a. Geographical – semi-tropical island; isolated; rural and urban population.b. Political – dictatorship with strong U.S. influence but without democracy.c. Economic – low GNP but no data; probably some development over ten years.d. Social – stoical community with cultural resistance to change; large families.e. Cultural – oriental; buddhist; probably a sophisticated traditional care system for the

relatively less poor.f. Health – government health posts poorly managed; traditional practitioners well

supported; no health status baseline data; tetanus, malnutrition, polio, probably malaria present.

g. Overall – change in the environment over ten years due to national economic development and probable communication improvement. Difficult to isolate the purely PHC effect.

h. Achievements – heath status improved to western standards; locally staffed with community involvement; health surveillance program for targeting population at risk; comprehensive PHC free service, externally funded.

3 ESTABLISHMENT OF PRIORITIES AND HEALTH SERVICE TARGETS

a. University survey before project but no quantified targets established.b. Health surveillance and census by auxiliaries provided continuous monitoring of

service and identification of demand/needs.c. Priorities – target influenced by the intuitive medical experience of the western staff

rather than a deep understanding of the culture and political power structure of the community.

d. Assumption made that eight function PHC was appropriate. No planning for long-term local financing; free service provided.

e. No systematic Functional Analysis available.

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AGL 21 – PHC IN DEVELOPING COUNTRIESCase: Asian Island Project


4 PLANNING PROCESS

a. Key decision as to health objectives and health service targets was to offer comprehensive PHC to achieve highest level of health care.1. Access – no financial or geographical constraints.2. Coverage – population within one area never expanded to the whole island.

Why?3. Quality of care – comprehensive PHC.4. Cost – free service financed externally.

b. Planning process –1. Facility and logistic planning – business manager appointed early to

organize logistics, transport, supplies etc. for one central PHC unit.2. Manpower – western staff supplied by donor; PHC workers recruited and

trained locally with early interaction with the community; first work involved census and records followed by health training; mixture of theory and practical work and a good health surveillance established.

3. Finance – donor financed for over ten years.4. Organization – PHC physical facility run with physician and staff as central

control unit for outreach PHC workers.

c. Justification of key 1971 decisions –1. Access – easy; avoids communication problems; central back-up available.2. Coverage – restricted to one original area; limits cost and management

problems.3. Quality of care – western standards probably not appropriate for one small

area only (could not be replicated?).4. Integration – no attempt at integration with the government system for long

term continuity.5. Finance – poor long term planning for local independence of this activity.6. Target population – easy alternative chosen; not difficult to achieve good

results with adequate finance, good management and a small target; however, such projects are not replicable for obvious reasons and do no prove anything.

d. Health Status and Poverty – poverty reduced by improvement of productive time (if work available); health services do not create development per se; No attempt to coordinate with the government long term development.

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AGL 21 – PHC IN DEVELOPING COUNTRIESCase: Asian Island Project


5 PILOT PROJECT EXTENSION AND ALTERNATIVES

a. Pilot project –1. No funds available for generalized free service.2. Hawthorne effect probably operating.3. Government cooperation vital for large scale operations; small scale

experience may not be relevant.4. No data on the total island community; no data on the real need for this PHC

in the light of possible local existing systems; need integrated planning for generalized PHC expansion.

5. Quality of care/cost probably not appropriate to the environment.b. Future planning alternatives –

1. Continue with external financing without change.2. Reduce the service to locally supportable levels – selective PHC.3. Expand to the full island population at appropriate service levels.4. Join with another organization or the government for integrated care.5. Localize the PHC operation such that the local community decides what is

appropriate and finances it.c. Criteria for decision –

1. for the community and the country.2. Priorities Health status objectives.3. Other objectives (hidden agendas).4. Long term cost feasibility – donor capacity to finance such projects

indefinitelyd. Demand/need should be determined by systematic Functional Analysis of the island

and the country as a whole in collaboration with the government.

6 DECISION AND JUSTIFICATION

a. Decision by the donor not to continue the PHC as internationally financed free service indefinitely but to merge it long term with local/national health care systems.

b. Discussion with:

1. Community (what they want to do?).2. Government (inclusion into the government service?)/3. Local traditional healers (possible cooperative efforts?).

c. Systematic Functional Analysis including: household survey, nutritional survey morbidity and mortality data on the limited target population and the whole island to set new priority health objectives and service targets.

d. Gradually change from free comprehensive PHC to selective PHC at a cost that is locally long term supportable.

e. Justification – comprehensive PHC to western standards for a limited population less appropriate than selective PHC increased coverage for the island total population at cost which could be independent of international aid.

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart B – Case: Asian Island Project


7 LEARNING POINTS

a. Given adequate management and finance, free comprehensive PHC can generally be achieved with high health status for a limited population.

b. All communities have resources and traditional medicine which must be understood before appropriate PHC intervention.

c. Pilot projects at high standard are not always appropriate due to cost, cultural, political and management problems.

d. Only integration with government systems ensures long term large scale continuity without international financing.

e. Comprehensive high level PHC is not appropriate to poverty environments without government support.

f. Recruitment of local auxiliaries for PHC work enables easier acceptance and training for establishment of health surveillance and PHC.

g. Recognize the hidden agendas of community, government and donors in PHC projects.

h. With international financing the community is never “in charge” of PHC.

i. Improvement of health status of part of the population does not necessarily indicate appropriate PHC planning.

j. Systematic Functional Analysis is necessary to provide the complex mix of data and quantifiable PHC targets.

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart C – Case: PHC Food Project

ANSWERS TO THE CASE

1. STORY OF THE CASE

a. PHC project financed by AID has been operating for two years in Asian LDC.b. UN body with multiple food projects offers a new PHC food project to target aid to a

population at risk (lactating and pregnant women and chronically sick children). This should improve PHC attendance, encourage MCH and reduce malnutrition.

c. Project organized among three Ministries with minimal controls and a junior project manager.

d. The volume of demand for free food destroys PHC normal functions. e. What should PHC do now?

2. PRIORITIES OF THE PARTIES

a. UN body – improve malnutrition with rapid volume food distribution by multiple projects.

b. Government – improve health through nutrition; provide free food (political benefit); get more aid in the future.

c. PHC – improve PHC and MCH coverage and target nutritional aid to the population with special risks.

3. PROJECT PLANNING AND MANAGMENT

a. Planning – junior staff in the Ministry of Health with responsibility but without authority.

b. Ministry of Rural Development-for logistics, and CAU for economic delivery arrangements.

c. Control Procedures – no anticipation of need for control, no training of manpower for new systems; no pilot projects.

d. Public Reaction – no anticipation or understanding of ten culture.e. Monitoring – no procedure for monitoring: input, process, output or outcome.

4. RESULTS ACHIEVED

a. Nutrition – probable improvement due to supplies delivered overall; no targeting to population at risk.

b. MCH – staff diverted to free food distribution; poor preventive and curative care.c. Logistics – possible dislocation of normal essential transport and agricultural

markets; diversion of supplies could have been anticipated; waste expected in large scale food programs

d. PHC Management – frustration and demoralization by the “success” of the project.

e. Government – political advantage from free distribution, possible long term dependence and disappointed expectations.

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5 CAUSES OF MANAGEMENT PROBLEMS

a. Local – cultural impact of free food not anticipated (cultural understanding?); failure to plan for volume and to organize to handle it; poor method for targeting a child/mother population in an LDC (need feeding center); failure to prevent local market diversion; little influence with the government.

b. National – ineffective organizational structure and procedures; manager without authority; poor information on outcome of the project as a possible dislocation of the agricultural and economic environment; emphasis on free food, short term only.

c. International – differing priorities; determination to move food and accept high level of “waste”; danger of actually doing more harm that good by the disruption of normal life patterns; transport probably limited and also distorted.

d. Overall – management must be able to anticipate future operations and have the resources and influence to plan (or reject) accordingly.

6 WHAT ACTION NOW BY THE PHC PROJECT ACTION TEAM?

a. Current Project – stop food distribution in PHC center immediately; set organization for supplemental feeding centers for the target population; start in one area and expand to others as techniques are proven; plan manpower to handle the volume of work and to maintain PHC objectives; concentrate on major issues (not forms design).

b. Future Projects – before any future project begins: coordinate priorities of the different organizations; ensure adequate organization and staffing to deal with anticipated volumes; consider effects on existing activity and environment; be prepared to fight for refusal of “inappropriate aid” which the country may be unable to absorb.

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7 LEARNING POINTS

a. The priorities of local, national and international organizations will be different despite common projects, management problems and obvious human problems.

b. Need to know the population well and to anticipate cultural reactions before projects begin, thus targeting aid appropriately to the population at risk.

c. A key management function is to anticipate the volume of activities and plan organization and manpower to meet demand.

d. The political advantage of “free projects” may make PHC and “management efficiency” low priority; such projects must be planned and managed carefully.

e. “Integrated” plans need special management procedures for control and coordination with access to high authority and influence.

f. Management of “free” supplies should anticipate ecological changes in the total environment; huge quantities of food may affect not only nutrition but also: agriculture, markets and fundamental patterns of behaviour.

g. Management must always look towards major problems and not be diverted to the minor ones which may be more easily controllable.

h. Do PFD (provision for disaster) as part of the planning process, and act quickly before programs get too big to change.

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart D – Case: Rally Health Care

ANSWERS TO THE CASE

1 STORY OF THE CASES

a. Ten years of outreach PHC in African country (with 5 million total population) covering 100,000 in area of 240 sq. km.

b. Hospital of 140 beds founded 20 years before (1960).c. Limited PHC services at low cost $2.00 P.C.P.A.d. PHC based on immediate hospital area show significant health status improvement

with “health surveillance and selective PHC”.e. Evaluation to determine if system could be generalized to whole country.

2 PHC SERIVICES PROVIDED

a. PHC delivered at quarterly rallies for 1,000 people. b. Selective PHC with only minimal curative service.c. Services: health education, targeted supplementary feeding, oral re-hydration,

deworming, immunization and TBA support.d. Firm base of health surveillance to the target population at risk to follow up PHC

care.

3 EVALUATION

a. Process – easy access and coverage for 8-100 thousand for limited PHC; staff recruited and trained locally; 30 full time auxiliaries and 60 community volunteers trained.

b. Output – delivery of health services (above); health surveillance with census, demographic reporting and follow up of PHC.

c. Out come – health status improved (IMR 174 to 34, LE 45 to 65, CMR 36 to 6, morbidity reduced from TB, tetanus, diarrhea).

d. Cost – estimated at $2.00 per capita for outreach in addition to curative costs at the hospital; free service internationally financed.

e. Date not available for 100,000 but only the initial 8,000. Not generalisable? Curative costs may be higher for distant populations.

f. Cost date must be audited before acceptance due to the complications as to what is relevant cost, “free cost”, start up cost etc. Will labor be free when alternative employment becomes available in the area: What are the “free” distributions provided by other international bodies that may have helped to keep costs low here?

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AGL 21 – PHC IN DEVELOPING COUNTRIESPart D – Case: Rally Health Care

ANSWERS TO THE CASE (cont’d)

4 GOOD RESULTS FROM SELECTIVE PHC

a. Health surveillance and volunteer/workers provided good targeting of population at risk.

b. Supplementary feeding, rehydration and education for population at risk should significantly improve health status.

c. Deworming used to encourage rally attendance; extensive program of EPI; PHC does not have to be comprehensive to be effective.

d. Hospital always available for emergency and curative care.e. Data for an immediate 8,000 not generalisable to a distant 100,000; cost data needs

verification.f. Need household survey to determine the real coverage of PHC compared with

traditional practitioners.g. Need Functional Analysis for proper evaluation.

5 HEALTH SURVEILLANCE AND PHC

a. No proof here. Need more data on the community and the totally 100,000 population. PHC does not have to be comprehensive to be effective.

b. Long term effects on remote populations not known. Is PHC used because it is “free” (traditional practitioners charge more)? Does it satisfy community demand/need in a culturally acceptable way? Rallies may be fine in times of unemployment but when work becomes available will people still come? Is this technique consistent with development?

c. Has the hospital activity been changed by the outreach development?d. Health surveillance seems to be an excellent technique for collaboration with the

community, targeting: population at risk and follow up of selective PHC.

6 EVALUATION IMPROVEMENT

a. Consider: cost, efficiency, appropriateness, accuracy, community involvement, flexibility, integration, long term financing, government policy etc.

b. Independent evaluation with freedom to publish results.c. Compare with baseline and latest health status statistics.

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