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close this bookTraining Manual in Combatting Childhood Communicable Diseases Part I (Peace Corps, 1985, 579 pages)
close this folderModule 2: Primary health care
close this folderSession 5: Primary health care
View the document(introductory text...)
View the documentHandout 5A: Shattuck lecture - Health care in the developing world: Problems of scarcity and choice
View the documentHandout 5B: Water supply and health in developing countries: Selective primary health care revisited
View the documentHandout 5C: Selective primary health care

(introductory text...)

TOTAL TIME: 2 hours

OVERVIEW

A thorough understanding of Primary Health Care is important for Peace Corps Volunteers involved in health activities such as CCCD activities. In this session participants critically review the WHO/UNICEF concept of primary health care as originally defined at the World Health Conference at Alma Ata, Russia in 1978. They focus on the emphasis of an integrated/multisectoral approach and community involvement. In small groups they develop charts illustrating primary health care which show the place of health education and their assigned programs. Through readings they learn about and discuss different approaches to primary health care.

OBJECTIVES

· To explain why primary health care is an appropriate means of protecting and promoting the health of all the people of the world. (Step 1)

· To describe the eight components of primary health care and give examples of primary health care activities in Africa. (Steps 2, 3)

· To describe the integrated/multisectoral design of health and development that characterizes primary health care and CCCD activities. (Steps 1, 3, 4)

· To identify at least two approaches to implementing primary health care. (Steps 3-5)

RESOURCES

Health: A Time for Justice

Handouts:

- 5A Health Care in The Developing World: Problems of Scarcity and Choice
- 5B Water Supply and Health in Developing Countries: Selective Primary Health Care Revisited
- 5C Selective Primary Health Care

MATERIALS

Projector and screen if movie is shown, newsprint, markers, the Film, "That Our Children Will Not Die" (Ford Foundation).

PROCEDURE

Trainer Note

By way of an introduction to primary health care, you might consider having the participants read Health: A Time for Justice (available through ICE Reference No. HEO79), the day before this session is to be presented. Also before this session you should critically read all the handouts so that you are prepared to facilitate discussions on the provocative concept of PHC. Viewing and discussing the film "That Our Children Will Not Die" is a suggested alternative to reading and discussing the articles. You may consider lengthening this session so that the readings and film can both be included.

Step 1 (15 min)
Understanding The Primary Health Care Approach

Introduce this step by reading and writing the following definition of Primary Health Care as stated at the International Conference on PHC in Alma Ata in 1978.

"Primary Health Care is a practical approach to making essential health care universally accessible to individuals and facilities in the community in an acceptable and affordable way and with their full participation".

"Health cannot be attained by the health sector alone. In developing countries in particular, economic development, anti-poverty measures, food protection, water, sanitation, housing, environmental protection, and education all contribute to health and have the same goal of human development".

Ask participants to look at this definition carefully and then using their knowledge of health care in the U.S. discuss aspects of the Alma Ata definition of PHC, and why some countries may find it a difficult or revolutionary concept to implement.

Trainer Note

Possible questions to facilitate this discussion might include:

- What is meant by essential health care?

- What aspects of health care have been essential to you?

- Is health care universally accessible in the U.S.?

- Are there more physicians and other health personnel and facilities in urban areas as compared to rural areas?

- What is meant by secondary and tertiary health care? How do these levels of care relate to Primary Health Care?

- Do you think that the health care system in the U.S. is acceptable to everyone? If not, why not?

- Do most Americans fully participate in the decisions that affect the kind of health care that is delivered in their area? If not, why not?

- What about the cost of health care? Is it affordable?

- What do you think about viewing health as an integrated part of the political, economic, social and environmental aspects of a country?


Step 2 (15 min)
Defining the Eight Components of Primary Health Care

Present the list of the eight components that the delegates from 134 governments and representatives from 67 United Nations' organizations and other specialized agencies have determined to be essential services provided by primary health care and ask the participants to briefly discuss why they think these areas have been stressed.

Trainer Note

Write the following list of the eight components of Primary Health Care on newsprint and present to the participants:

- Education concerning prevailing health problems and the methods of preventing and controlling them;
- Promotion of food supply and proper nutrition;
- Adequate supply of safe water, and basic sanitation;
- Maternal and child care, including family planning;
- Immunization against the major infectious diseases ;
- Prevention and control of locally endemic diseases;
- Provision of essential drugs;
- Appropriate treatment of common diseases and injuries.

This discussion should focus on:

- How these eight areas can help persons to lead a socially and economically productive life.
- The interrelationship between these eight areas.
- How an integrated approach to health care can most effectively deliver these services.

Conclude this discussion by stating that although most persons agree that primary health care should include these eight essential components, the ways of approaching the implementation of the PHC programs vary from one country and community to another and the following articles they will read and discuss present some of the different approaches/strategies.

Step 3 (20 min)
Examining Different Approaches to Primary Health Care

Have the participants form three groups and assign one of the articles found in Handouts 5A (Health Care in The Developing World: Problems of Scarcity and Choice), 5B (Water Supply and Health in Developing Countries: Selective Primary Health Care Revisited), and SC (Selective Primary Health Care) for reading and brief discussion by each group.

Trainer Note

Ask the participants to keep the basic principals of Primary Health Care in mind when they read these articles and to select one person in each group to prepare a 3-5 minute summary of the article that they have read to present to the large group reconvened for discussion in the next step (Step 4).

The attached articles were selected because they present three different approaches/strategies for the implementation of primary health care.

Step 4 (25 min)
Discussion of PHC Approaches

Reconvene the large group and ask the selected persons from each group to present a summary, not longer than 3-5 minutes, of their articles. Based on their understanding of the different approaches to PHC as presented in the summaries of the articles, have the group discuss and list on newsprint the pros and cons of the different approaches, and decide which ones they feel will be most effective in attaining "Health For All By The Year 2000".

Trainer Note

This discussion should be most provocative given the different approaches to PHC that they have just reviewed and shared in their brief presentations. In this 25 minute discussion the participants should direct their discussion to various aspects or approaches to PHC, some of which include questions concerning:

- What are the different approaches presented in these articles and an what key issues do they differ?

- Is there coordination of the health and health related sectors? (e.g. agriculture, education, finance)

- What are the social and economic determinants of health and ways PHC approaches affect these determinants?

- How is or how should PHC be supported within the national health system?

- What should be the focus of PHC programs?

- What are the constraints on implementing a complete PHC program?

- How should these constraints be addressed? (For example, should they concentrate an two or three particular PHC activities and worry about integrating other activities later when more funds are available?)

- What is or should be the role of International agencies in PHC?

- How does "political will" affect or impact an the PHC approach of providing health for all?

- How does or can strong management capabilities affect PHC programs?


Step 5 (15 min)
Summarizing Primary Health Care

Lead a short discussion on summarizing PHC. Focus this discussion around the following questions:

- From what we have seen and discussed thus far concerning primary health care, how would you explain the meaning of this concept to someone?

- What generalizations can we make about primary health care and its effectiveness as a means of promoting positive health and development?

- We have seen that a key concept in the primary health care approach is integration. Where do you think problems might arise in trying to integrate the various components of primary health care services?

- How will what you have learned during this session help you in promoting primary health care in your primary job assignment? Through secondary activities?

- What are the controversial issues surrounding primary health care?

Step 6 (20 min)
The Role of the Peace Corps Volunteer in Primary Health Care

Based on their understanding of Primary Health Care and the discussions in Session 1 and from other parts of their training on their roles as health educators, ask the group to discuss and develop a diagram for Primary Health Care, identifying where they think they as health care generalists/educators fit in.

Trainer Note


An example of a diagram that may be developed and used for discussion is the following

Alternate Step 3 (30 min)
"That Our Children Will Not Die"
Show the film "That Our Children Will Not Die".

Trainer Note

Ask a participant to set up the projector and run the film. Introduce this activity while one of the participants is setting up the projector. Explain that the film they are going to watch discusses a primary health care approach in a particular part of Africa. Advise them to watch the film, keeping in mind the eight basic principles of PHC that they have just discussed, and to identify ways in which they have been incorporated.

Alternate Step 4 (30 min)
Discussion of the PHC Approaches

After viewing the film, have the group engage in a discussion on how practical the PHC approach is in achieving the health care needs of an individual, family and community, and what some of the difficulties are in implementing this strategy.

Trainer Note

In this 30 minute discussion, the participants should direct their discussion to various aspects or approaches to PHC some of which include questions concerning:

- From what you saw in the film, what were the major health problems and needs of the people in the area where primary health care was practiced? Do these problems differ from what you might find in the U.S.? How?

- How were these problems and needs identified? Handled? Specifically, how did this primary health care approach solve health problems/meet health needs? Were the people involved in helping themselves? How?

- Of the key elements of primary health care outlined before the film, which ones were incorporated into the health care approach in the film? Was the health care accessible, acceptable, affordable? Were the elements integrated?

- What would you say were the essential components of the primary health care approach in the film? Food and nutrition? Sanitation? Maternal and child health? Family planning? Immunization?

- Do you see any ways in which a PC Health Worker might fit into a process/approach like the one illustrated in the film?


Handout 5A: Shattuck lecture - Health care in the developing world: Problems of scarcity and choice

JOHN R. EVANS, M.D., KAREN LASHMAN HALL, M.P.A., AND JEREMY WARFORD, PH.D.

From the population, Health and Nutrition Department, World Bank, 1818 H St., N.W., Washington, DC 20433, where reprint requests should be addressed to Dr. Evans.

Delivered before the Bicentennial Meeting of the Massachusetts Medical Society, Boston, October 31, 1981.

The views and interpretations in this article are those of the authors and should not be attributed to the World bank, its affiliated organizations, or anyone acting on their behalf.

THE World Health Organization (WHO) and UNICEF, together with representatives of 134 member governments, launched a campaign in 1978 to achieve "Health for All by the Year 2000" through primary health care.1,2 The objective of this campaign was to increase the political commitment of member countries to address the health needs of their people and particularly to improve the health status of the rural and urban poor in the Third World. Our presentation describes the difficulties of putting this objective into practice, and what may be possible on the very limited budget available for health in most developing countries.

WHO and UNICEF might well have found the text for their plan in the Report of the Sanitary Commission of Massachusetts, which Lemuel Shattuck presented to the Massachusetts state legislature in 1850.3 The report was based on a careful survey of the health status of the population of Massachusetts, and its recommendations embodied the essential elements of primary health care: immunization and communicable-disease control; promotion of child health; improved housing for the poor; environmental sanitation; training of community-oriented health manpower; public-health education; promotion of individual responsibility for one's own health; mobilization of community participation through sanitary associations; and creation of multidisciplinary boards of health to assess health needs and plan programs in response to sound epidemiologic evidence. Recognizing the importance of political commitment, Shattuck built a strong public-health constituency by highlighting both the major differences in life expectancy between rural areas and Boston and the deterioration of health status over a decade in major cities in the United States.

The conditions described by Shattuck in the United States in 1850 prevail today in most countries of the developing world (Table 1).4-6 In low-income countries, life expectancy at birth averages only 51 years, and in several it is less than 45 years. Mortality rates are 10 to 20 times higher for infants and for children aged one to four than in developed countries. Nearly half of all deaths occur in children under five years of age. The major causes are diarrhea! diseases, respiratory infections, tetanus, and childhood infectious diseases such as diphtheria, measles, and whooping cough, all of which can be effectively and cheaply controlled by measures used in developed countries. Malnutrition is important as an associated - and even primary - cause of death in young children, and short birth intervals adversely affect the survival of infants. For those who reach the age of five, life expectancy is only eight to nine years less than in developed countries. The commonest causes of death are similar to those in industrialized countries: cancer, cerebrovascular disease, heart disease, respiratory disease, and trauma. However, in developing countries, tuberculosis ranks among the most common causes of death. These nations are also plagued with endemic diseases such as malaria, schistosomiasis, trypanosomiasis, onchocerciasis, and leprosy, which are major causes of serious morbidity and mortality in adults and children, but for which effective control measures have not been available or have proved difficult to implement or maintain.

Table 1. Health-Related Indicators in Countries with Different Income Levels.6

INDICATOR

YEAR

LOW-INCOME COUNTRIES *

MIDDLE-INCOME COUNTRIES **

INDUSTRIALIZED COUNTRIES ***

Gross national product per capita ($)

1979

240

1420

9440

Crude birth rate (birth/1000 population)

1979

42

34

15

Crude death rate (death/1000 population)

1979

16

10

10

Life expectancy at birth (yr)

1979

51

61

74

Infant mortality rate (death/1000 live births) ~

1978

(49-237)

(12-157)

13

Child mortality rate (deaths/1000 children 1-4 yr old)

1979

18

10

1

Per cent of population with access to safe water

1975

25

58

~~

Daily per capita cal- vie supply (% of requirement) ||

1977

96

109

131

Adult literacy rate (%)

1976

43

72

99

*Thirty-four low income developing countries with a per capita income of $370 or less us 1979 (China and India are excluded from the low-income group in this table).

** Sixty middle income developing countries with a per capita income Or more than $370 in 1919

*** Eighteen industrial-market economies

~ Weight averages figures in parentheses denote the sample range

~~ Data not available but assumed to be close to 100 per cent

|| Requirements based on calories needed to sustain a person al normal levels of activity and health taking into account age and sex distributions, average body weights and environmental temperatures as estimated by the United Nations Food and Agriculture Organizations

Even in middle-income countries, more favorable national statistics in the aggregate disguise wide disparities between the conditions, on the one hand, of the rural and pert-urban poor that are typical of low-income countries and the conditions, on the other hand, of more affluent urban dwellers who are better educated and have better access to health services and whose health status closely resembles the profile in industrialized countries. Table 2 contrasts the high mortality rates for infectious and parasitic diseases in the less developed northeastern and frontier regions of Brazil with the high rates for cancer and cardiovascular diseases in the more affluent southeastern region of the country. As economic development proceeds, the more prosperous regions of the country have the advantages Of greater individual and collective wealth and greater political leverage. Consequently, national health policies give priority to their needs, and the limited resources of hospitals, equipment, drugs, physicians, and other health personnel are concentrated in the urban areas, widening the sap between urban and rural populations.7

In the push for development, particularly industrial and commercial development, protective measures for workers and the environment usually lag behind, as they did in the earlier stages of developed countries. These measures are often disregarded because they are initially expensive, and can generally be enforced only by firm legislation and inspection. Rapid development accelerates the appearance of new health problems such as traffic accidents, work accidents, accidental poisoning, and environmental pollution. Similarly, disruption of families and community, migration, and unemployment contribute to a variety of disorders of individual behavior - alcoholism, violence, promiscuity - each with attendant physical and mental risks, counterparts of those seen in industrialized countries.

Urban problems will increasingly dominate the health pattern of the developing world. According to United Nations projections, the urban population in developing countries will increase by 1.32 billion between 1975 and 2000; by 2000 it will average 43 per cent of the population of the less-developed regions overall, and 75 per cent of the population of countries in Latin America.8 The primary-health-care approach for rural health problems may need to be modified to address different problems arising from life styles and diets in the urban setting. For example, recent analyses indicate that in several countries there are large numbers of malnourished urban dwellers, and that their numbers are increasing more rapidly than those of the rural malnourished.9

Table 2. Regional variations in Cause-Specific Mortality in Brazil, 1970.*

CAUSE OF DEATH

REGION


NORTHEAST

FRONTIER

SOUTHEAST


per cent of all deaths

Infectious and parasitic diseases

24.5

26.6

11.2

Neoplasms and cardio-vascular diseases

21.1

19 1

42.1

* Adapted from de Carvalho AVW, de Moura Ribeiro E. Estudo da Mortalidade proporcional, segundo Grupos de Idade e Causas de Obito, em algunas Capitais Brasileiras, em 1970. Revista Brasileira de Estatistica. 1976; 37(148):475 (as reported in World Bank Brazil: Human Resources Special Report. Washington, D.C., October 1979).

STAGES IN THE EVOLUTION OF HEALTH SYSTEMS

The pattern of diseases in northern Europe and the United States evolved in stages over the past two centuries, and with each stage distinctive control measures were introduced.

The first stage, dominated by major and minor infectious diseases linked to poverty, malnutrition, and poor personal hygiene, responded slowly to improved food supply, housing, and literacy made possible by greater prosperity, and to public-health measures, particularly safe water supply, sanitation, and immunization campaigns. The steady decline in infant mortality (Table 3) and the reduction in child mortality as a percentage of all deaths (Table 4) may be attributed to these changes. As scientific advances provided a wide array of immunologic and therapeutic techniques to control acute bacterial and viral infections, life expectancy increased, and heart disease, cancer, and stroke replaced respiratory and gastrointestinal infections as the principal causes of death. For example, in the United States in 1900, the three leading causes of death (influenza and pneumonia, tuberculosis, and gastroenteritis)-accounted for over 30 per cent of all deaths, whereas heart disease, cancer, and strokes were responsible for 18 per cent of deaths. By 1975, only influenza and pneumonia (3 per cent) ranked in the top 10 causes of death, whereas heart diseases (38 per cent), cancer (20 per cent), and stroke (10 per cent) together accounted for over two thirds of all deaths.10

The second stage in the evolution has been dominated by chronic diseases, particularly cardiac and cerebrovascular diseases, cancer, diabetes, arthritis, and mental disorders. As the threat of infectious diseases receded, public-health measures were relegated to a regulatory role, and personal health services became the primary channel for prevention and treatment of health problems. The development of expensive and complicated technology for diagnosis and treatment has led to the transfer of care from doctors' offices to elaborate and expensive hospitals. Doctors and patients have looked to these curative techniques and facilities to provide striking improvements in health. Sadly, experience has shown that for many problems the benefits hoped for have not been realized. As Cochrane has noted, the massive public and private expenditures on health, now close to $1,000 per capita annually for capital and recurrent costs in the wealthier industrialized countries, have not produced commensurate improvement in the health status of the population.11 Only a small proportion of the interventions used are of proved effectiveness, and the benefits to be gained from the intensive services for terminal illnesses are at best marginal.

Table 3. Infant Mortality in Selected Countries. 1750-1975.*

PERIOD

COUNTRY


SWEDEN

FRANCE

UNITED STATES


no. of deaths/1000 live births

1751-1755

206

277

**

1851-1855

144

166

**

1901-1905

91

141

124

1971-1975

10

14

18

* Source - Arriaga E, Boulanger PM, Bourgeois-Pichat J, et al. La Mortalité des Enfants dans le Monde et dans l'Histoire. Liege, Belgium: Department de Demographie, Université Catholique de Louvrain, Ordina Editions, 1980: 147-9.

** Data not available.

A third stage of evolution can now be defined. It reflects a shift from preoccupation with intrinsic disorders of structure and function of the body, to an awareness of the health hazards arising from environmental exposure to an increasing number of chemicals, drugs, and other toxic substances and from changes in the social conditions of the family, community, and workplace that influence behavior and life style and are associated with absenteeism, violence and alcohol and drug abuse of epidemic proportions. The personal health-care system concentrates on the consequences of such processes. New approaches are needed to encourage the healthy to avoid patterns of behavior that lead to disease, and to identify and treat the social and environmental causes of disease that originate in the community. Industrialized countries have recently recognized the importance of this third stage and the need to adapt their health systems to give greater emphasis to health promotion and preventive measures at individual and community levels.12,13 This stage is not new. These concerns provided much of the impetus for reform of industrial and other health practices for well over a hundred years. The meaning of the third stage is a return to the recognition that responsibility for health should not be exclusively the prerogative of the health professions - that protective and preventive measures have to be the responsibility of the individual and the society.

Industrialized countries have evolved through the three stages over the course of more than a century (Table 3). In contrast, developing countries face the challenge of coping with all three stages simultaneously: the rural and pert-urban poor who constitute a majority of the population are in the first stage; the influential, more affluent urban dwellers are at the second stage; and manifestations of the third stage are already apparent because of environmental deterioration and the social disruption associated with massive urban growth and unemployment. Furthermore, developing countries must cope with just a fraction of the financial and human resources available to their industrialized counterparts. In any circumstances, but particularly in these, the strategy to improve health must be selective. Success will depend heavily on correctly identifying the most important problems in each population group, selecting the most cost-effective interventions, and managing the services efficiently. Uncritical acceptance of new and expensive high technology will not serve the purposes of developing countries. But developed countries do have much to offer through scientific and technical cooperation. Already, developing countries, by taking advantage of the innovations in the industrialized world (vaccines, microbiologic techniques, and antibiotics, for example) have achieved much faster rates of improvement in health status than those achieved in northern Europe and the United States. However, there are signs that this rate of progress is not being sustained. As Gwatkin and Brandel pointed out (unpublished data), life expectancy in the less-developed regions of the world, which had been rising by 0.64 year annually between 1950 and 1960, slowed to 0.40 year annually 15 years later. Several factors stand out as impediments to progress.

OBSTACLES TO PROGRESS

Uneven Distribution of Health Services

Access to health services is very uneven, and large segments of the rural population are not reached. Health facilities and personnel are concentrated in urban areas, and within the urban population the services are oriented to the middle-income and upper-income groups, neglecting the pert-urban poor. Political considerations may override all other priorities, and little progress can be expected unless there is a political commitment to apply resources where the need is greatest.

There is a shortage of skilled health personnel, particularly in the poorer countries. National averages for physician: population ratios are reported to be 1:17,000 in the least developed countries and 1:2700 in other developing countries, as compared with 1:520 in developed countries. The nurse: population ratios are 1:6500, 1:1500, and 1:220, respectively.5 These national averages disguise the fact that in some rural areas there may be only one doctor serving 40,000 to 200,000 people. Furthermore, the pyramid of health manpower is inverted, particularly in the least developed countries. Instead of a broad base of inexpensively trained, less skilled personnel working at the community level, priority has been given to expensive training programs for "conventional" doctors, who expect sophisticated facilities and equipment, gravitate to practice in the cities, and have a propensity to emigrate. To achieve effective coverage of the population, large numbers of less skilled personnel need to be trained, and these health workers need to be part of a system that will provide supervision, drugs and supplies, and the support services necessary for their practice. Otherwise dissatisfaction will lead to high turnover of health workers and low utilization of their services as patients bypass the first level of care in the community in favor of higher-level facilities, which properly should function as referral centers. Doctors are key participants in the referral and supervisory systems; if they operate as primary-care workers, their expensive training is wasted and the cost of their practice may outweigh the benefits. The supervisory and managerial role of the physician in the health system must be addressed more directly in the process of medical education and in the career development and rewards for the physician in practice.14

Table 4. Child Mortality in Belgium, 1880-1970.*

YEAR

AGE GROUP

TOTAL


< 1 YR

1-5 YR

(0-5 YR)


per cent of all deaths

1880

27.7

13.3

41.0

1900

27.4

9.0

36.4

1920

17.7

4.1

21.8

1950

7.5

1.0

8.5

1970

2.5

0.04

2.6

* Adapted from Arriaga E., Boulanger PM, Bourgeois-Pichat J., et al. La Mortalité des Enfants dans le Monde et dans l'Histoire. Liege, Belgium: Department de Demographie, Université Catholique de Louvain, Ordina Editions, 1980-127.

Lack of Appropriate Technology

A second obstacle to progress is the lack of appropriate technology to address Stage 2 and Stage 3 health problems and to cope with the serious endemic diseases prevalent in the developing world. For Stage 1 health problems, much of the technology needed is already available, and in the case of vaccines technologic advances that would reduce dependence on the cold chain are imminent. In contrast, for Stage 2 health problems, relatively few technologies for dealing with the serious diseases of the adult population are appropriate to the circumstances and financial resources of less developed countries. Most of the technologies that are being transferred from the developed world are expensive, and the equipment is often difficult to maintain. It is necessary to determine which interventions are effective and which yield large benefits at acceptable costs. The greater challenge is in the search for preventive measures to reduce the large burden of illness from cancer, hypertension, diabetes, respiratory, cardiac, and cerebrovascular disease. For Stage 3 health problems, we are still handicapped by inadequate understanding of behavior and the links between social and environmental hazards and specific diseases. We have much to learn about conveying health-education messages, motivating community participation, and using modern communications technology to circumvent the barrier of illiteracy.

The "tropical diseases" (e.g., malaria, schistosomiasis, filariasis, trypanosomiasis, and leprosy) are a particular problem for developing countries, in part because they generally have climates and ecologies conducive to disease vectors. Techniques for ecologic control of vectors or transmission routes are available but are expensive and require repeated application over wide areas. Treatment of patients is generally expensive, sometimes risky, and often delayed. Prophylactic measures such as vaccination are largely undeveloped. Knowledge of the biology of the diseases is far from complete. Research on these diseases has so far been largely neglected by the scientific community and the pharmaceutical industry, which have been preoccupied with cancer, cardiovascular disorders, and the other major diseases of the industrialized world. The Special Program for Research and Training in Tropical Diseases led by the WHO is an attempt to mobilize the health-science research community throughout the world to focus attention on these neglected tropical diseases in order to discover appropriate technologies for their control.

The scientific and development resources of the developing countries are limited, and their problems are difficult to solve. The most promising results will come from combining the scientific and technologic potential of the industrialized world with the local knowledge of scientists and professionals in developing countries who will have responsibility for applying the new technologies.

Pharmaceutical Policies

The most widely used technologies in health are drugs and vaccines. Shortages of supplies and failure to provide for the timely distribution of drugs and vaccines are serious problems that must be overcome for an effective health program. In looking to the future, however, the problems may be excessive and irrational use of drugs and unsustainable costs to the health system. Patients who consult health personnel expect to receive a prescription or, in some cultures, an injection. As access to health services broadens with the implementation of primary-health-care programs, a rapid increase in the consumption of drugs may be expected. Experience in less-developed countries supports this contention. In China, with nearly universal access to health care, curative medicine occupies 90 per cent of the time of "barefoot" doctors, and nearly all patients receive medication; there is evidence that drugs and traditional medicines account for two thirds of overall health expenditures. In countries with less complete coverage of the population, expenditures on drugs constitute about 40 to 60 per cent of the health budget (as compared with 15 to 20 per cent in developed countries15) and over half of private health expenditures. In most developing countries, the majority of drugs are imported, and these outlays are a considerable drain on foreign exchange.

The importance of drugs to the quality of health care, to the credibility of community health workers, to the development of iatrogenic disease (for exam pie, from toxicity or antibiotic-resistant microorganisms), and to the cost of health services makes it imperative that developing countries establish better mechanisms for assessing drug requirements and for purchasing, quality control, storage, and distribution of drugs. Experience in Tanzania and Ghana indicates that savings of up to 70 per cent of the budget for pharmaceuticals could be achieved by promoting generic alternatives and introduction of controls against over-prescription.16,17 The South Pacific Pharmaceutical Scheme projects cost savings of at least 25 per cent through limiting the availability of nonessential drugs and through bulk purchasing.18 Without policies for national formularies, procurement, prescription, and pricing, this powerful and ubiquitous health technology could become more of a liability than an asset to the health system.

Management of Health Resources

One of the most difficult and pervasive problems to solve in the establishment of effective health services in developing countries will be deficiencies in management. The health sector presents a formidable organizational challenge. Some of its objectives can be achieved only with the cooperation of other sectors such as water supply and sanitation, education, agriculture, and community development. The delivery of health services involves widely dispersed facilities, numerous categories of personnel, general and specialized hospitals, vertically organized programs to control individual diseases such as malaria, tuberculosis, leprosy, or venereal disease - each with its own personnel and support services, community health-care programs with multipurpose workers, and a system of indigenous medicine with traditional healers and birth attendants. The different elements need to be organized to reduce conflict and duplication between programs and to provide a coherent system to screen and treat patients according to the level of care required and to refer patients with difficult problems. Supervision and continuous in-service education of health workers, improved logistics and supply to maintain credible services, institution of personnel policies and rewards to maintain the quality, distribution, and morale of staff, and policies and financial arrangements that encourage rational use of the health resources by the public are essential corollaries to enhance sector performance.

The weakest links in the administrative chain of most developing countries are institutions at district and local levels, which are usually poorly staffed, have inadequate authority or control of resources, and are unable to provide the necessary support and supervision of field staff. The development of planning and administrative capability at the district level is of special importance, since this is normally the lowest tier of the health-services organization still communicating directly with central government but also in contact with the villages, aware of their needs, and in a position to encourage community participation. It is at this level that matching of health needs and resource allocation is most likely to occur.19 Community-based non-governmental organizations active in health care may make an important contribution to the process of devolution of administrative responsibility.

The management of a system of health services is much more than the management of its facilities and support systems. It involves decisions about priorities and resource allocation that are based on the health needs of the population to be served. This epidemiologic perspective is missing from the training of many of those in positions of responsibility, and the information system on which to base such management decisions is typically inadequate. Management also involves gaining the cooperation and compliance of highly independent professionals and specialists who have their own constituencies and political support.

The medical profession is of special importance because of the profound steering effect of individual clinical decisions on the demand for expensive facilities and the consumption of resources for diagnosis and treatment. Most practicing physicians give relatively little weight to consideration of the efficacy of these procedures and almost no attention to the real cost and foregone opportunities in terms of resources used. Abel Smith (personal communication) has estimated that the consequential costs generated by the average medical specialist in Great Britain are on the order of £500,000 per year; if eliminating unnecessary procedures reduced expenditures by 10 per cent, the savings nationwide would be enormous. In developing countries, the secondary-health-system costs generated by physicians are smaller, largely because of the absence of much of the high-cost diagnosis and treatment modes, but the same problem exists as in developed countries, and the implications are more serious because of the much more limited resources available for health. To give priority to medical education and to a reward system for physicians is to place clinical decisions about the individual patient in the context of the health needs of the population and to promote more discriminating use of scarce resources for diagnosis and treatment based on evaluation of the effectiveness and the cost of these procedures. These decisions involve difficult ethical judgments. The concepts behind these decisions have only recently been introduced into medical education and health-services administration in developed countries.14

Poverty

Money alone will not ensure good health. However, in the opinion of most development specialists, the overriding constraint to improving health status in the least developed countries is the extreme poverty of most of the population and the low level of the gross national product per capita (below $400). Health must compete with other pressing developmental needs for extremely limited public resources.

The problem is made worse by the rapid growth in population, which averages 2.4 per cent per year among developing countries as a group and reaches nearly 4 per cent per year in Kenya; at this rate, the population of Kenya will double in 17 years. At current average annual growth rates, half the population will be under 15 years of age; and demands for employment, housing, and all basic services will increase rapidly. Public expenditures on health will have to increase commensurately just to "hold the line" on current levels of quality and coverage of services. Since population is the critical denominator of all development activities, with such limited resources reduction of fertility will be a decisive factor in attempts to improve services such as health care. At the same time, wider coverage of the population with effective services for maternal and child health and family planning is a necessary part of any strategy to reduce population growth.

Given the extremely limited resources and the rapid growth in population, several basic questions need to be addressed. First of all, what are the prospects for increased public expenditures on health, and to what extent are improvements in health dependent on economic progress? What other sources of financial support might be mobilized? Secondly, can existing resources be used more effectively? And thirdly, within these constraints is "Health for All" through primary health care feasible?

Financing of Health Services

Analysis of health expenditures in developing countries is hampered by a lack of satisfactory financial information on programs operated by different levels of government and the private sector. The available data indicate striking differences in the levels of current total public expenditures on health for capital and operating purposes, with average figures of $2.60 per capita per year in the poorest countries (1.1 per cent of the gross national product), $19 in middle-income developing countries (1.2 per cent of the gross national product), and $469 in industrialized countries (4.4 per cent of the gross national product). The combined public and private health expenditures in the United States and several northern European countries are close to $1,000 per capita per year - more than 100 times the level in the poorest group of countries. At the other extreme, a few of the poorest countries - Bangladesh, Ethiopia, Indonesia, and Zaire - have annual public expenditures on health of only $1 per capita. Since recurrent expenditures are concentrated in urban areas where hospitals and specialized manpower are located, it may be concluded that the resources available to operate health services for the rural population are very limited and in the poorest group of countries average substantially less than $1 per capita.

During the decade 1980-1990 the average annual growth in gross national product per capita is estimated to be 2.1 to 2.3 per cent in middle-income oil-importing countries, and 0.7 to 1.8 per cent in low-income countries. Assuming that public expenditures for health remain at the same proportion of the gross national product as in 1977, the allocation for health in low-income countries may be expected to increase by only $0.40 to $0.80, to a level of $3 to $3.40 per capita per year by 1990; the increment will be only $0.20 to $0.50 in Asia and even lower in Africa, where a reduction in per capita income is possible in the sub-Saharan countries during the decade. Predictions for the year 2000 show little further improvement, particularly in the low-income countries, with the gap between rich and poor countries continuing to widen. A substantial increase in poor countries' public resources for health by 2000 is possible only if there is a shift in resources from other sectors. This seems unlikely, unless investing in health can be justified more convincingly to ministries of finance and planning, in terms of immediacy of benefit and return on investment.

To what extent are improvements in health dependent on economic progress? Preston's study of the contribution of economic factors to declines in mortality, which uses national income and mortality data from populations in 43 countries between 1938 and 1963, indicates that income is a critical but not major determinant of mortality level.20 In the aggregate, income growth accounted for only 16 per cent of the improvement in life expectancy in the countries studied. In the subgroup of countries with incomes below $400 per capita, there appeared to be a stronger correlation of income and mortality trends. Nevertheless, Sri Lanka and the state of Kerala in India21 and the People's Republic of China are examples of countries that have attained a life expectancy close to the level in the industrialized world, with income levels in the range of the least developed countries. The achievements may be explained in part by the public priority given to literacy, food, and health and by special features of social and political organization. Furthermore, as McDermott illustrated in the case of chemotherapy for tuberculosis in blacks in New York City and Maoris in New Zealand, advances in medical technology can be very effective in reducing mortality promptly without any preceding improvement in living standards.22 These examples are of great importance for the least developed countries, which have such gloomy economic prospects for the next two decades.

In view of the continuing scarcity of public resources, what opportunities exist to supplement a central government's capacity to finance health services by mobilizing support from other sources? The possibility of revenue sharing by local government for local services warrants further exploration, although the capacity of local government to generate tax revenues is limited. In two regions of Senegal 8 per cent of general rural taxes are set aside for health, and in Colombia 35 per cent of the state beer tax is earmarked for hospitals. If these taxes generate new public revenue, they could expand support for health; otherwise, the process is merely an exercise in allocation.

Social-security schemes based on contributions by employers, employees, and sometimes governments are an important financing mechanism in middle-income countries, particularly in Latin America. The services financed are predominantly curative, and since the benefits are restricted to employees, the schemes cannot be relied on to attain full coverage of low-income populations, many of whom are outside the wage economy. The equity of social-security systems has been questioned, since the public-sector contributions in effect serve to subsidize the better-off segment of the population, and employers may pass on their costs to consumers by raising prices. Private financing of health care has also been undertaken by productive sectors. One of the largest examples is the Colombia Coffee Growers' Association, which in 1978 alone contributed two fifths (41 per cent) of the total operating costs of the rural health-delivery system in that country.*

User fees and contributions in kind from the individual or the community are also important means to supplement financing from government. Many governments resist any form of user charges, for fear of excluding the poor or in the belief that users will not understand the value of the services. Paradoxically, imposition of user charges can have a positive impact on utilization of health services, by increasing the perceived value of services and therefore the demand for them over alternative "free" care. Mission clinics and hospitals have demonstrated the feasibility of recovering a considerable part of their operating costs for selected curative services when quality of care is acceptable. Institution of a pricing policy for selected curative health services has been attempted in several countries. The establishment of community pharmacies in the Philippines and of village drug cooperatives in Thailand and Senegal are examples of this approach. Traditional healers and birth attendants practice on a fee-for-service basis and enjoy a high level of community acceptance; with appropriate training, they could serve as a valuable extension of the health system financed by user fees. Village organizations and popular self-help movements such as Saemaul in Korea and Sarvodaya in Sri Lanka illustrate the value of community participation for mobilizing local labor and materials for health facilities and salary support of community health workers. However, local initiatives may lead to disillusionment if they are not supported by appropriate services within the public-health system. Multiple independent initiatives may complicate the evolution of a rational system unless they are developed within a general framework.

China, one of the few low-income countries with a broadly based health-care system, uses a variety of financing devices. In addition to central, provincial, and county-government appropriations and some user fees, health-insurance schemes are also employed. The "public-medical-expenses" scheme is similar to a social-security system covering government employees and students. The "labor-medical-insurance" scheme covers about 10 per cent of the population and is financed by 2 to 3 per cent of factory income before payment of salaries. The large rural population is covered by "cooperative medical services" financed by the participating communes through production "brigade revenue, " individual premiums equivalent on average to 1.5 per cent of the family's disposable income, and user fees.23 All expenditures for preventive health care are borne by the state.

Much work remains to be done in analyzing the effect of prices on the demand for health services in developing countries; the success of the private sector in this area is not necessarily a reliable guide to public-sector pricing policy. Even when a superior public service replaces a private one, the public cannot be assured of capability to collect the same level of charges, since it is less able to refuse services to those unwilling to pay, as has been shown in the case of public water supply. Nevertheless, since private spending is estimated to be three to four times greater than government expenditures on health in many developing countries,24 it is clearly one of the most important sources of financing to explore.

Mobilization of resources for health from the widest spectrum of alternative sources should be actively pursued, ensuring that these resources are a net addition to public funding rather than a substitute for it. They have the added benefits of reducing the uncertainty associated with total dependence on public funding and of increasing the participation of the individual, community, cooperative, or local government in planning and managing the health services.

In many countries the principal alternative to government financing has been official development assistance from bilateral and multilateral agencies and extensive local contributions by foreign nongovernmental organizations According to Howard, assistance for health from all external sources totaled $3 billion in 1978 - less than one quarter of the total estimated public and private expenditures on health in the 67 poorest developing countries (excluding China).24 The largest component, $1,008 million, came from 18 bilateral donors; they allocated approximately 10 per cent of their total concessional assistance to the health sector - a share only exceeded by agriculture, public utilities, and education.25 In view of the economic difficulties facing industrialized countries, it seems unrealistic for developing countries to rely on any appreciable increase in external assistance for health in real terms to compensate for a shortage in public expenditures. Furthermore, care must be taken to avoid capital expenditures financed by external assistance if the recurrent cost obligations that they create are not in keeping with the priorities for use of the limited public funds available for health.

The tendency of governments to discriminate in budget allocations against programs with high recurrent costs in favor of capital-intensive projects is aggravated by the policy of many external donors not to support operating costs. In general, recurrent costs generated per dollar of capital investment are substantially higher for health than for other major public sectors, such as agriculture or transportation, and the ratios are particularly high for primary-health-care programs and rural health centers,26,27 in which expenditures are mainly for manpower and drugs. This makes these programs very vulnerable to budget cutting by government. In addition, even when general operating expenditures have been met, neglect of maintenance expenses leads to further capital expenditures for rehabilitation or replacement of facilities and equipment - a much more costly approach to sector development. An important consideration in the success of primary health care will be the willingness of governments and external donors to place appropriate priority on the financing of recurrent costs.

EFFICIENCY AND EFFECTIVENESS OF THE USE OF RESOURCES

National capability to plan and implement strategies and programs that make the best use of scarce resources is seriously deficient in most developing countries. The coexistence of sub-populations with different health needs requires programs that are designed for these groups and not based on national averages. The need to select from among a broad range of possible interventions the most appropriate mix of personnel, facilities, and technologies requires information on relative cost effectiveness, trade-offs between capital investment and recurrent costs, and assessment of the political and administrative feasibility of implementation - for all of these, data are seriously deficient.

Health planning is under a cloud of skepticism because the substantial efforts to date have had little effect on resource-allocation decisions for the health sector in most countries. Much of the planning has been normative, based on international estimates of the number of personnel and hospital beds needed to establish or extend coverage of services rather than on the nature of the health problems of a given population and the most cost-effective methods of solving them. Almost all planning and management have been central, with inadequate understanding of the real constraints on implementation at the operating level.

Matching programs more closely with needs will depend on strengthening planning in several areas. Some initial definition of priorities for the sector is essential. This may be achieved by a review of estimates or epidemiologic measures of the disease profile of representative population groups, clarification of explicit health-sector objectives, and assessment of the technical, political, and administrative feasibility of dealing with the most important problems. From this general framework it should be possible to define population-specific objectives for health investments and to establish targets For reductions in critical sector-development indicators such as infant mortality, malnutrition, fertility, or disease prevalence. Setting targets provides a mechanism not only to assess the value of use of scarce resources but also to monitor and evaluate program performance. Alternative approaches to achieve the targets should be reviewed, and the most cost-effective solution selected, weighing not only technical and financial considerations but also cultural acceptability and feasibility of implementation. This exercise will raise difficult questions about trade-offs: whether to pursue inexpensive short-term symptomatic therapy or more expensive long-term measures to eliminate the cause of disease; the relative merits of interventions in health and in other sectors such as water supply and sanitation, and the choice between disease-specific, vertically organized health services and the multi-purpose, horizontal primary-health-care approach. Walsh and Warren reviewed published reports of infectious and parasitic diseases endemic in tropical countries and concluded that the strategy of intervention should be selective - based on evidence of the contribution of each disease to mortality and morbidity, the efficacy and cost of currently available control measures, and the feasibility of applying these measures.28 The extensive studies of Morrow and his co-workers in Ghana29 illustrate the potential value of cost-benefit analysis in sorting out priorities within the health sector and in justifying to the government the investments in health vis-à-vis other sectors. Application of this technique is limited by the difficulty in quantifying benefits in health, the inadequacy of the human-capital approach to life valuation, and the lack of suitable data for analysis in most developing countries.30,31 In the absence of cost-benefit analysis, unit costs of specific health improvements may be compared in order to identify the least-cost solution. To apply these epidemiologic and economic measurements when planning health programs requires much information and takes time. In many cases, detailed measurements cannot be made, but more vigorous review of available evidence on the health needs of different population groups and the consideration of cost effectiveness in selecting interventions offer the best hope for stretching limited resources to achieve maximum impact on health. In addition to encouraging better policies and practices in the health sector, this should enhance the acceptability of proposals by ministries of health to ministries of planning and finance.

The development of measurement capability for both planning and managing health services has a high priority for health administrators. physicians, and others with leadership responsibility in the health system. This can be best achieved by strengthening existing institutions through mid-career training of the staff, improving management information system and undertaking operational research on health services at central and peripheral levels of the health system.

FINANCIAL FEASIBILITY OF PRIMARY HEALTH CARE

Primary health care has been accepted by the member governments of the WHO as the key to achievement of universal access to health care by 2000. Assuming that the low-income countries will have no more than $3 to $4 per capita per year in public resources to devote to health by 2000, is it possible to achieve the goals envisaged in the primary-health-care approach with this financial constraint?

Evidence from six primary-health projects undertaken in the late 1960s and 1970s in developing countries indicates that marked health improvements can be demonstrated within five years through provision of basic services with annual operating costs ranging from about $0.50 to $3.50 per capita (Table 5).32,33 When corrected for inflation, these figures would be $1 to $7 per capita in 1981 prices. The results must be interpreted with caution since five of the projects were of a pilot nature; most involved very small populations; the cost data varied greatly. As a rule, they did not include capital investment, training, expenditures beyond the primary level of health care, or the value of expatriate and volunteer labor. The contribution of voluntary health workers is of special importance because they provide a large share of rural health services and because volunteerism may be difficult to sustain over the long term.34 Although there should be economies in scaling-up to national programs, in fact higher marginal costs would be expected with expansion of primary health care to more widely dispersed populations. Furthermore, political and administrative problems involved in scaling-up would add costs for management, supervision, and support systems. Nevertheless, the results of the pilot projects, adjusted for inflation, are of the same order as the estimates of $1 to $3 by Joseph and Russell35 and $5 by Patel (unpublished data) for per capita recurrent costs of primary-health-care programs.

An alternative approach to estimating the cost of primary health care is to price the individual components of a model program designed to treat the principal causes of mortality in children in low-income countries, as outlined in a recent WHO discussion paper.36 The model for a total population of 100,00.0 would try to provide basic care for children under five years of age (about 17,000), tetanus toxoid, iron and folic acid for pregnant women (about 4000), and contraceptive advice and supplies for fertile women (about 5100 at a 30 per cent level of coverage). On the basis of estimates of the need for immunization against common infectious diseases and for treatment of diarrhea, acute respiratory infections, malaria, and intestinal parasites, and assuming that all patients in need will be treated with the least expensive, effective treatment available, it is possible to calculate the annual cost of drugs and supplies for each condition. For example, to immunize the 4000 children under one year of age against measles, 3200 doses would be required to achieve 80 per cent coverage (recognized as sufficient to halt transmission), which at $0.17 a dose would cost $544 each year. The annual cost of all the drugs, vaccines, and supplies for the model program was $35,000, or $0.35 per capita, for the population as a whole to cover the selected target groups.

The cost of commodities is, of course, only one component. It is necessary to add the cost of salaries of health workers, training, transportation, and maintenance. If these additional costs are in the same proportion to total primary-health-care costs as drugs are in national health budgets (drugs account for 25 per cent according to a conservative estimate6), then the total annual recurrent costs for primary health care may be in the range of $1.40. Since annuitized capital costs for primary care are about one third of recurrent costs,26,27 $0.45 to $0.50 may be added to cover capital investments. The combined capital and recurrent costs of the primary-health-care program would be under $2 per capita per year, well within the financial reach of low-income countries.

Table 5. Impact and Cost of Selected Primary-Health-Care Projects.*

PROJECT

PERIOD MONITORED

ESTIMATED POPULATION COVERED

INFANT MORTALITY RATE

CHILD MORTALITY RATE

PROJECT COST PER CAPITA




BASE OF STUDY PERIOD

END OF STUDY PERIOD

PER CENT REDUCTION

BASE OF STUDY PERIOD

END OF STUDY PERIOD

PER CENT REDUCTION





deaths/100 live births


death/100 children 1-4 yr


$

Miraj, India

1974-77

23,000

68

23

66

**

**

**

0.50

Jamkhed, India

1971-76

80,000

97

39

60

**

**

**

1.25-1.50

Narangwal, India

1968-73

10,500

128 ***

70 ***

45

19 ***

11 ***

42

0.80-2.00

Hanover, Jamaica

1973-75

65,000

36

11

69

13-15 ||

5-6 ||

60

0.40

Deschapelles, Haiti

1968-72

9,600

55

34

38

11

6

45

1.60

Rural Guatemala

1969-72

3,000

150

55

63

28

6

79

3.50

* Sources - Faruqee R. Johnson E. Health, nutrition and family planning: a survey of experiments and special project in India. (unpublished data); World Bank Discussion Paper No. 81-14. Population and Human Resources Division); Gwatkin DR, Wilcox JR, Wray JD. Can health and nutrition interventions make a difference? (Monograph No. 13) Washington, D.C.: Overseas Development Council, 9180, and Berggren WL, Ewbank DC, Berggren GG. Reduction of morality in rural Haiti through a primary-health-care program. N Engl J Med. 1981; 304: 1324-30

** Data not available.

*** Comparison of average rates for 1970-73 in medical-care intervention and control areas. Child mortality reflects deaths in children 12 to 36 months of age per thousand children in that age group.

|| Child mortality reflects deaths in children 1 to 48 months of age per thousand children in that age group.

The fragility of the assumptions involved in multiplying the commodity costs is acknowledged. The model itself is relatively insensitive to changes in the assumptions about the commodities with the exception of the contraceptive prevalence rate. (Increasing contraceptive prevalence to half the women at risk would increase per capita costs of commodities from $0.35 to $0.43.) A more important factor is the assumption that the primary-health-care worker will provide early diagnosis and treatment. For example, if treatment of diarrhea were delayed so that 50 per cent of children rather than 10 per cent required intravenous fluids and antibiotics, the cost of commodities would be increased from $0.35 to $0.62 per capita. The model also assumes encouragement of breast-feeding and nutrition education of mothers and children at nominal cost, but if food supplements are added, the cost of the package of commodities would be substantially increased. Using data from Project Poshak in India37 on the cost of the basic food supplements, adjusted for inflation and an assumed 30 per cent prevalence of malnutrition, as reported in several national nutrition surveys, the added cost would be $0.71 per capita - twice the cost of supplies for the basic health and nutrition interventions. Provision of rural water supply, which might be proposed in addition to or as an alternative to primary health services, is estimated to cost $5 per capita, of which approximately half would be annuitized capital cost.38 (This estimate is based on a reported capital cost of $26 per capita in 197738 annuitized at a 10 per cent discount rate and including complementary operation, maintenance, and support costs.)

The value of the modeling exercise is limited by the pyramid of assumptions on which the calculations are based. More important than the results, however, is the process involved in developing the model, which illustrates the trade-offs that countries must consider in determining the balance of services to be provided to their population. The process of choosing the most cost-effective approaches to meeting health needs is the essence of the planning and decision-making process outlined above.

CONCLUSIONS

Developing countries face the challenge of coping with a heavy burden of illness that differs markedly in subgroups of the population at different stages of development. The greatest improvement in life expectancy from health investments can be expected in the rural and pert-urban poor through a program that provides maternal and child health services, including control of the major infectious and parasitic diseases of children under five. Effective technology for such a program is now available and affordable even within the financial constraints of the least developed countries. Two major problems remain: the first is the political will to allocate the necessary resources for the program, and the second is the management capability to organize and operate a system of services for the rural and pert-urban populations that use multi-purpose community-health workers.

No satisfactory strategy has been developed to meet the health needs of older children and adults within the financial means of most developing countries. There are relatively few simple, effective interventions to control the metabolic, vascular, degenerative, and malignant diseases of the adult population, and there is little understanding of the behavioral disorders. Without new technologies for control and prevention, it is unlikely that the poorer developing countries will be able to provide more than symptomatic care for most patients with these health problems. Furthermore, adoption of the expensive technologies now used for the diagnosis and treatment of these diseases in the industrialized world will divert the limited resources available for programs for the rural and pert-urban poor to sophisticated, hospital-based, urban services, which will have, at best, a marginal impact on health.

The search for health technology appropriate to the financial and organizational circumstances of developing countries must be seen as a high priority for the research and development community of the entire world. Existing technology must be critically evaluated, and new, simpler techniques developed for the control and prevention of common chronic diseases. Greater attention should be given to research and development on the "tropical" diseases, which are a major component of the disease burden of developing countries but have been largely neglected by the world's scientific community. Pharmaceuticals are of special importance since the timely supply of essential drugs is critical to the quality of health care and the credibility of community health workers. The dangers of excessive use or inappropriate choice of drugs necessitate the introduction of policies on procurement, prescription, pricing, and quality control to avoid health hazards and excessive costs.

Financial constraints will be an overriding consideration in the development of the health sector for the foreseeable future, particularly in the least developed countries. The poorest countries that now have public expenditures on health averaging only $2.60 per capita per year also have the least favorable economic prospects for the next decade. Greater efforts are required to mobilize resources for health from other sources, particularly the private sector, and to ensure that the limited resources available from all sources are used in the most cost-effective manner. Few developing countries have the institutional capability to select health interventions on the basis of expected health impact, least cost, and feasibility of implementation, and to integrate independent facilities, practitioners, and disease-specific programs into a more coherent, economical, multipurpose system. A high priority should be given to strengthening the capability of administrators, physicians, and other personnel in positions of leadership in the health system at central and local levels in order to develop a population perspective in the analysis of health problems, a cost-effectiveness attitude toward the use of resources, and management skills appropriate for a human-services organization. More efficient management of health services is only one aspect of the problem. It is equally important to mobilize communities and individuals to take a more active role in promoting health and in financing health services, rather than to rely passively on a government system.

Scarcity of money for health is a critical limitation on progress toward the goal of "Health for All by the Year 2000." More money alone, however, will not produce the desired outcome unless there is a political commitment to programs for those in greatest need, as well as the managerial capability to implement them. This is first and foremost a challenge for developing countries, but it is also a consideration in the investment policies of donor agencies. Progress toward the goal of "Health for All" can be accelerated if more external assistance can be provided for the areas of greatest need and if the unique scientific and technologic resources of the industrialized world can be made available to developing countries, to strengthen their institutions and to collaborate in the development of appropriate technology to meet their needs.

We are indebted to Mr. Ved Kumar for his helpful contributions and advice

REFERENCES

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16. Yudkin JS. The economics of pharmaceutical supply in Tanzania, Int J Health Serv. 1980, 10:455-77.

17. Barnett A, Creese AL, Ayivor ECK The economics of pharmaceutical policy in Ghana Int J Health Serv. 1980, 10:479-99.

18. Kumar V Report on the establishment of (he South Pacific Pharmaceutical Service. Manila: World Health Organization, Regional Office for the Western Pacific, (in press).

19. Kaprio LA. Primary health care in Europe. Copenhagen: World Health Organization Regional Office for Europe, 1979.

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21. Gwatkin DR. Food policy, nutrition planning and survival the cases of Kerala and Sri Lanka. Food Policy 1979; 4:245-58

22. McDermott W. Medicine: the public good and one's own. Perspect Biol Med. 1978; 21:167-87.

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24. Howard LM. What are the financial resources for "Health 2000"? World Health Forum. 1981; 2(1):23-9.

25. Idem. A new look at development cooperation for health a study of official donor policies, programmes, and perspectives in support of Health for All by the Year 2000 Geneva: World Health Organization. (in press)

26. Over AM. Five primary care projects in the Sahel and the issue of recurrent costs. Williamstown, Mass.: Williams College Department of Economics, 1981.

27. Heller P. The underfinancing of recurrent development costs. Finance and Development. March 1979:38-41.

28. Walsh JA, Warren KS. Selective primary health care: an interim strategy for disease control in developing countries. N Engl J Med. 1979; 30 1 :967-74.

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35. Joseph SC, Russell SS. Is primary care the wave of the future? Soc. Sci. Med. 1980; 14C:137-44.

36. Discussion paper: Selected primary health care interventions. Geneva. World Health Organization, 1980.

37. Gopaldas T, Srinivasan N, Varadarajan I, et al. Project Poshak. Vol. 1. New Delhi: CARE INDIA, 1975.

38. World Health Organization Community water supply and sanitation: strategies for development I Background document for United Nations Water Conference). London: Pergamon Press, 1977.

(From: The New England Journal of Medicine. Boston. Vol. 305, pp. 1117-27)

Handout 5B: Water supply and health in developing countries: Selective primary health care revisited

DR. JOHN BRISCOE
Assistant Professor
Department of Environmental Sciences and Engineering
School of Public Health
University of North Carolina
Chapel Hill, North Carolina

Primary health care (PHC) and selective primary health care (SPHC)

In the health delivery systems of most developing countries, the bulk of available resources are devoted to curative services delivered from urban hospitals (Stern, 1983). With the exception of a few vertical programs, such as smallpox and yaws programs, health services have remained largely curative and largely unavailable to poor urban and especially rural people. 2 There have, however, been some dramatic exceptions to this general pattern. Of particular importance is the health care delivery system developed in the world's most populous country, The People's Republic of China, 3 but equally striking successes have been achieved in Sri Lanka, India, Vietnam, and Cuba. 2,4,5,6

In the light of the failure of most countries to deliver health services to the majority of their people and the success of other countries with similar resource bases to reach this goal, the WHO, UNICEF, and other international agencies embarked on an ambitious effort to encourage more countries to adopt the principles which had proved so successful in the above-mentioned countries.

At the Alma Ata Conference in 1978, the characteristics of the successful systems were analyzed and the concept of PHC defined and endorsed by all participating countries. Of particular importance in this definition is the explicit recognition given to the multiple causes of poverty and the manifestation of these causes in ill health, with the strategy therefore being defined as a multifactorial approach rather than simply a set of medical activities. In particular, PHC was to include:

. . . education concerning prevailing health problems and the methods for preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning, immunization against the major infectious diseases, prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. 7

Shortly after Alma Ata, two biomedical scientists, Walsh and Warren, 8 published a critique of this PHC concept in the New England Journal of Medicine. This critique and the alternative "selective primary health care" (SPHC) concept advocated by Walsh and Warren have received widespread and generally favorable attention in the scientific and development communities.

The reasoning behind the concept of selective primary health care is simple. While the adherents to the idea profess sympathy to the concept of comprehensive PHC as expressed in the Alma Ata Declaration, they are acutely aware of limitations on the resources available to developing countries for implementing primary health care programs and argue that insufficient resources are available for implementation of all components of the original PHC program. What is necessary, then, is to examine each possible item in the overall program individually, to determine what the costs of implementing that item are, and what the effectiveness of the program is in reaching any particular objective, such as reducing infant mortality The items are then ranked in terms of cost-effectiveness, and the "selective primary health care" program is designed to include the most cost-effective items within the overall budgetary constraints pertaining in any particular circumstances.

The approach is thus presented as simply a minor modification of the original concept expressed in the Alma Ata Declaration, a modification which adheres to the principles of Alma Ata, but makes the concept of primary health care operational and implementable.

The SPHC package emerging from the cost-effectiveness calculations is almost exclusively medical, including measles and diptheria-pertussis-tetanus vaccinations, treatment for febrile malaria, oral rehydration for diarrhea in children, and tetanus toxoid in mothers. Biomedical research for the development of vaccines and therapies for major tropical diseases, too, are considered "cost-effective" More systemic non-medical activities, such as community water supply and sanitation and nutrition supplementation, are rejected as being "non cost-effective"

The rationale of the SPHC approach has been widely accepted by both the scientific community (a computer search turned up dozens of references to the original article, with virtually all the articles accepting the premises of the SPHC approach in toto) and by policymakers in many international agencies, with the recent USAID health sector policy 9 an outstanding example of the application of these principles.

The purpose of this payer is to examine the details of the cost-effectiveness calculations with respect to one of the components of PHC (viz., community water supply), the choice of the measures of effectiveness chosen, and the methodology followed in comparing activities which fulfill different objectives. The rationale behind SPHC is also examined in terms of the light which this rationale can shed on the experience of both successful and unsuccessful national and pilot projects. The article concludes with a consideration of the programmatic and political consequences of SPHC vis-a-vis PHC.

The details of the water supply and sanitation cost-effectiveness calculations

As indicated earlier, a computer search was carried out to identify articles in the scientific literature which referenced the original Walsh and Warren article. Many of these references referred to the original article only to reinforce a contention that a particular field of inquiry was important, but some of the articles present a criticism of the details of the cost-effectiveness calculations pertaining to a particular sector, the objective usually being to argue that the ranking of the specialty of the particular author should have been higher than indicated by Walsh and Warren.

In this spirit, a critique of the numbers used by Walsh and Warren in assessing the cost effectiveness of investments in water supply and sanitation is presented in this section.

The data used by Walsh and Warren for the capital costs of water supply and sanitation programs are based on recent and widely verified World Bank data, and, aside from noting that in certain circumstances (such as tubewells in rural Bangladesh 10 and latrines in Zimbabwe 11) the per capita costs may be an order of magnitude less than the costs used by Walsh and Warren, there is no basis for disagreement with the cost data used.

What is apparently not appreciated by Walsh and Warren, however, is that, whether or not there are additional investments in water supplies, people in many Third World settings (particularly in urban areas) pay substantial amounts of money for poor-quality water supplies. A well-documented, but by no means unique, case is that of poor people in Lima, Peru, 12 the results of which are summarized on Table 1 below.

Table 1: THE QUANTITIES OF WATER USED AND EXPENDITURES ON WATER IN LIMA, PERU

Quality of Service

Quantities used (l/cap/day)

Monthly Household Expenditures on Water (soles)

Poor (vendors)

23

105

Medium (standpipe)

78

22

Good (house connection)

152

35

Table 1 shows that improvements in the quality of water supply service in urban areas may be associated not with an increase, but a reduction in the monetary costs of the supply, a finding by no means unique to Lima. One of the most experienced water supply engineers in the world has found this phenomenon to be virtually universal in developing countries and has concluded that "if daily expenditures made to a water carrier were invested instead in a proper piped supply, far more economical and better water service could be provided". 13

In terms of a cost-effectiveness analysis of the sort used by Walsh and Warren, then, the economic cost of such water supply improvements may be much smaller than the overall cost of the project, since much or often all of the costs can be covered by "simply" redirecting expenditures which are already being made by the population for an inferior water supply service. Since the Third World is rapidly becoming as much an urban as a rural world, since similar willingness-to-pay is often demonstrated by rural inhabitants, 14 and since those urban dwellers paying high costs for poor water supplies are those urban dwellers with the highest incidences of disease, this phenomenon is of major importance in terms of improving health through the investment of relatively few outside resources. The rub, of course, is in the word "simple", for these poor urban residents are frequently not recognized as either legitimate or deserving by their governments, and the organizational and managerial implications of these changes are by no means trivial. A key issue, then, is political will and program management, themes to which attention is directed later in this paper.

Turning to the denominator in the cost-effectiveness factor, an assessment of the likely impact of a water supply and sanitation program on health is far more problematic than the assessment of the effects of other PHC programs which operate more directly on the causes of disease. Thus, while it is a relatively straightforward (although not trivial) task to calculate the effects of a tetanus or measles vaccine on death rates, a similar assessment of the effects of a water supply and sanitation program is fraught with problems, for the intervening steps linking the program inputs to health outputs are far more numerous and the necessary behavioral changes far more complex. In particular, the assumption that the water supply produces the quantity and quality of water for which it was designed is frequently incorrect, as is the assumption that the water supply is being used appropriately by the classes or age groups most affected by water-related diseases. 15

In light of these problems, it is appropriate to proceed with caution in attempting to assign a "typical value" in the effect of water supply and sanitation programs on health. 16 In their analysis, Walsh and Warren drew on only a small sample of the large number of available studies and reached universal conclusions which are not supported by a more comprehensive assessment. For instance, Walsh and Warren concluded that while water piped into the home might result in substantial reductions in diarrhea! diseases, water supplied through public standpipes would affect only a very small reduction (about 5%) in the incidence of diarrhea! diseases. While this was certainly the conclusion to be drawn from the couple of studies examined by Walsh and Warren, fundamental doubts have been raised about the results of one of the studies, 17 and a more complete analysis of methodologically sound, available studies would have indicated that where improved quantities of water of improved quality became available through standpipes, the expected reductions in diarrheal diseases would be an order of magnitude greater than the 5% assumed by Walsh and Warren. This is indicated on Table 2, which is abstracted from a recent comprehensive review of the health effects of water supply and sanitation programs.

Table 2 : THE EFFECT OF WATER SUPPLY AND PROGRAMS IN 24 NONINTERVENTION STUDIES 18

Parameter Affected

Number of Studies

Reduction in % Diarrheal Diseases (median)

Water quality

6

30%

Water availability
(mostly through standpipes)

11

34%

Quality and availability

4

40%

Excreta disposal

8

40%

There are reasons, then, to believe that the figures used by Walsh and Warren in both the denominator and numerator of the cost-effectiveness calculations for water supply and sanitation programs are seriously in error. Furthermore, since the approach taken by Walsh and Warren is one in which the cost-effectiveness of different components of PHC are compared, it is pertinent to note that there are also serious problems with the costs and effectivenesses used by Walsh and Warren for the more traditional medical components, which their analysis suggested were most appropriate in a "selective" approach. Specifically, in the examination of several small, nongovernmental health projects 19 which served as a basic source of data for the Walsh and Warren analysis, costs generally did not include capital investment, training, expenditures beyond the primary level of health care, or the value of expatriate and volunteer labor." 20 In scaling these projects to a national level, the costs would be substantially greater and the effectiveness of the programs substantially less due to "political and administrative problems." 20 Indeed, the generalizability of these findings has been questioned by many (including the Director General of the WHO 21), with the comments on the Indian project being typical: "It was the dedication of the team leaders, their total involvement in the community programs, and their special organizational abilities which made the program successful". 22

However, as will be detailed in the following sections, the "selective primary health care" analysis of Walsh and Warren is, in our opinion, flawed by fundamental conceptual problems which are much more serious than the problems of detail outlined above. For this reason it is not appropriate to attempt to present revised cost-effectiveness figures for water supply and sanitation programs and other components, or to suggest, on the basis of such revised estimates, an alternative hierarchy of programs for "selective primary health care"

The criteria used for assessing the effectiveness of health programs: what are the objectives and who decides on these?

Health is a multifaceted concept. At the most elementary level, it is possible to distinguish between severity of effect (infection, disease, disability, and death) and age group affected (infant, child, or adult). A fundamental difficulty in comparing different health programs is that, typically, different programs affect different facets of health. One program, for instance, may affect infant mortality only, while another might affect infection, disease, disability, and mortality in all age groups.

Decision theory offers only some simple concepts in suggesting how to analyze trade-offs between programs which affect different facets of health in this way in particular, with reference to Figure 1, decision theory tells us only that, if outcome 1 and outcome 2 are both desirable, and if the costs of the programs represented on the diagram are equal, then program B is always preferable to program A, and program C is always preferable to program A (a concept known as "Pareto optimality") Decision theory tells us explicitly that, if we are unable to reduce output one and output two to a common measure (such as dollars), then the only way of resolving whether program B is preferable to program C is to submit the choice to decision makers and have them tell us which program is preferable.

It is immediately apparent, then, that two questions are of fundamental importance in attempting to compare different health programs:

1. What are the health outcomes which will be considered?

2. Who will be the judges of the trade-offs between these outcomes?

A first concern with the procedure followed by Walsh and Warren is their choice of criteria and the consistency (or lack thereof) in applying these to the components of PHC which they analyze. For the most part, Walsh and Warren consider reductions in infant mortality to be the unique criterion of interest, thus comparing, for instance, the cost per infant death averted through water supply and sanitation programs, and expanded immunization and oral rehydration therapy programs. This lands them in a bind, of course, for such a procedure means that all programs which do not result primarily in reductions in infant mortality (one of these considered by Walsh and Warren is an onchocerciasis control program) will automatically be rejected. The procedure followed by Walsh and Warren, then, is to write down that onchocerciasis control programs "prevent few infant deaths," leaving the reader to assume, reasonably, that onchocerciasis control programs may be justified on grounds other than reductions in infant deaths.

So far so good. With respect to the example which is followed through the present analysis - water supply and sanitation - Walsh and Warren follow a quite different procedure. Since it is never argued that the only effect of a water supply and sanitation program is a reduction in infant mortality, the only consistent procedure would be to repeat the procedure followed in the onchocerciasis control program and make no comparison between a water supply and sanitation program with a program the unique effect of which is to reduce infant mortality. This Walsh and Warren do not do. Instead, they compare water supply and sanitation programs with programs aimed specifically at reducing infant mortality (such as oral rehydration therapy programs) and conclude, not surprisingly, that the programs which affect infant mortality only are more effective in this than a program which has multiple effects on all manifestations of disease in all age groups. If we imagine that "outcome 1" on Figure 1 represents reductions in infant mortality and outcome 2 some other desirable outcome (such as reduction in adult morbidity), then Walsh and Warren's procedure is equivalent to claiming that program B is superior to program C simply because B gives us more of outcome 1 than C (ignoring the fact that C gives us more of desirable outcome 2 than B). This procedure is obviously unsatisfactory.

As indicated earlier, trade-offs between different outcomes cannot be considered in isolation from the decision as to who will make such tradeoffs. While Walsh and Warren could almost certainly defend their choice of reduction in infant mortality as an important criterion, other scientists would claim that other criteria (such as morbidity in the adult population 23) are important, too. Where different criteria are used, of course, the cost-effectiveness of different programs will be quite different. For example, in the case of cholera, whereas rehydration therapy has been shown to be less costly and more effective in saving lives than immunization, if morbidity reduction becomes the objective, the results of a cost-effectiveness analysis would be reversed. 23

In the spirit of John Grant, however, who argued that primary health care and other development programs should follow "the principle of inherent need and interest, in which "projects in a village should grow out of its own needs and interests, and not be superimposed by some idealists," 24 we would argue that the trade-offs between the outputs of PHC programs be done in light of the expressed needs of the communities involved. From an examination of the actual health and nutrition practices of families in the developing world, it is clear that their de facto priorities do not agree with the assumption of Walsh and Warren that reductions in infant mortality are of unique concern. In particular, throughout the developing world the economic welfare of families is highly dependent upon the economic production of adults, 23 giving rise, for example, to discrimination in feeding among household members to protect the actual or potential breadwinner in subsistence settings. 25

In assessing actual practices, however, attention has to be given to the fact that families, like villages, are not division-free entities, and it is necessary to go one step further and ask whose interests in the family should be given greater weight.

From a variety of perspectives it seems clear that the group whose needs are most important, in terms of the health of the community in general and young children in particular, are mothers. First, virtually all components of PHC programs are based on the assumption that mothers will be the most important front-line providers of health care to children. 26 Second, of all the correlates of infant health, none is as strong or as consistent as mother's education, 27 implying that there are few better investments in health than those which meet the needs of women, particularly those which alleviate the constraints limiting the education of girls and women. Later in this paper it is argued that a particularly important constraint faced by women in undertaking, to use James Grant's term, 28 "discretionary activities," such as education and child care, is the enormous demands made on women for performing time consuming, repetitive tasks. Investments which relieve mothers of part of this burden will have an effect on child health which is as certain as it is impossible to quantify. 16 Indeed, many experienced investigators of the determinants of health in the Third World would concur with Latham, 29 who has argued that "attentions to women's rights and the emancipation of women may ultimately have more impact on nutrition and infection in developing countries than any of the (conventional nutrition and health) interventions"

Concerned, then, with the exhortation of the Director General of the WHO that mothers become the subject and not the object of health programs, the following sections of this paper assess some principal constraints aired by women in implementing PHC programs.

Women as the front-line health care workers: some constraints

A concept central to all PHC programs is that no lasting advances in child health can be made unless the mother is involved in these programs. Thus, most of the core elements of PHC programs - such as breastfeeding, supplementary feeding, oral rehydration therapy, and household hygiene - involve the mother as the front-line health worker. Indeed, the objective of PHC programs may be described as the improvement of "mothering, the poorly-defined but crucial interactions between mother and child that form the principle determinants of health, growth and development." 30

To carry out the complex and demanding task being set her by primary health care programs, the mother faces four principal constraints, namely, technology, knowledge, resources, and time. One way of visualizing PHC programs is that such programs are aimed at relieving the mother of one or more of these constraints so that she may become a more effective mother.

In their analysis of "selective primary health care," Walsh and Warren focus their attention almost exclusively on the first of these four constraints, technology, an approach common to the policy formulations of some development agencies, too. While there is no doubt that technological advances, such as improved expanded vaccination programs and oral rehydration therapy, open new vistas in terms of the potential for child health in developing countries, the provision of improved technology alone is insufficient, for usually the effective implementation of such technology requires simultaneous inputs of knowledge, resources, and time on the part of the mother. Let us consider a few examples.

Breastfeeding. Primary health care programs provide both information to the mother on the fundamental importance of breastfeeding for the health of her infant and technology in the form of programs designed to monitor the growth of her child. While such programs are essential, equally essential is the availability of time for the women to breastfeed their babies. Studies throughout the world have shown that where women work outside of the home, they do not have the time available to breastfeed their babies, with the result that the inputs of knowledge and technology provided by the PHC program cannot be translated into improved child-rearing practices. (A typical finding is that of a study in Malaysia, where women recently employed breastfed their children 33% less time than women in a control group who had not recently been employed. 31)

Oral rehydration therapy. ORT technology undoubtedly opens entirely new possibilities for the reduction of mortality in young children in developing countries. As in all other cases, however, the provision of the technology alone will have little impact unless the constraints faced by the mother in using the technology are addressed simultaneously. The constraints are many: in many areas of the world, the cost of rehydration packages is too great for poor families; 32 in almost all situations, traditional understanding of food and liquid withdrawal during diarrhea have to be changed, 33 and thus the ORT technology has to be accompanied by educational and informational inputs. Finally, since "continually giving a sick infant large volumes of liquid by spoon or cup is time-consuming tiring, and inconvenient for an overburdened mother with other children plus household and farm work to do, ORT may require the commitment of more time and energy than she can easily provide". 34

Clinic-based supplementary feeding and other programs. Perhaps the simplest of all programs, in principle, is one in which the mother comes to a clinic or distribution center to collect food for her child, to weigh her child, or to have her child immunized. Yet many studies have shown that attendance at a clinic drops off dramatically as the distance to a clinic increases 35 and that women in the labor force are frequently unable to avail themselves of such services because of the constraints on their time. 36

Food preparation and storage. Recent longitudinal studies in Bangladesh 37 and The Gambia 38 have documented the vital role of food contamination on the transmission of diarrheal diseases, an effect which becomes particularly marked when great demands are made on the time of the mother. In The Gambia, for instance, at the peak diarrheal transmission season, "feeding of small children is particularly haphazard . . . infants may be left in the compound in the care of young nursemaids with a supply of porridge or gruel for the next 8 or 9 hours, and food for the evening meal is sometimes stored over night . . ." 38

In sum, the great demands placed on the time of Third World mothers constitute a serious barrier to the implementation of PHC, with these constraints often being particularly acute at those times of the year when children have most need of additional health care 39 and in low-income families where the incidence of illness is greatest. 40

The overall effect of restrictions in the availability of time is evident in recent data from the Philippines, Although the children of working mothers received 5% more food than the children of a comparable group of mothers who were not working, the children of the working mothers weighed, on the average, 7% less than the children of the mothers who did not work, an effect attributed to the lack of time available to working mothers to translate increased resources and improved knowledge into improved health of their children. 41

Thus, although improved water supply and sanitation conditions affect PHC in several ways - by reducing the disease load (see Table 2) and thus the need for child care, by increasing available income through reducing payments for water (see Table 1), and by releasing the calories used in carrying water (12% of a woman's caloric intake in East Africa) 42 - most important of all effects may be increasing the time available to mothers for carrying out child care and other "discretionary activities

Time and mothers' needs in developing countries

A recent workshop in "Women in Poverty" examined the phenomenon of poverty among women in the Third World and analyzed how women might become actors in and beneficiaries of the development process.

Three conclusions of this workshop are of particular importance for PHC. First, time is the most important resource which poor women have available to them. 31 Second, studies in a variety of developing countries (Bangladesh, Bolivia, Indonesia, and the Philippines) have found that the rural mother engages in ten to eleven hours per day of active home and market production, 40 whereas women in industrialized countries typically work at and outside the home only six hours per day. 31 And third, poverty is concentrated in female-headed households, and the number of these households is large (typically between 15% and 35%) and increasing. 31 Thus, the workshop concluded that, for women in developing countries, "saving time is development, for time saved from humdrum tasks is time to invest in human capital," 31 and that priority should be given to "technologies that reduce the time women and children spend fetching wood and water and preparing food." 31

Time required for water collection

The impact of the installation of a convenient village water supply system on the time spent by women and children in carrying water has been documented throughout the world. 16 To give just a few of many examples: in the lowlands of Lesotho, 30% of families spend over 160 minutes per day collecting water; 43 as a result of improved water supplies in the Zaina scheme in Kenya, about 100 minutes per household per day are saved from the water-collecting activity; 44 in East Africa, rural families spend up to 264 minutes per day carrying water; 42 in East Nigeria, families spend up to 300 minutes per day collecting water. 43 Studies in Asia (for example, the Philippines 41 and Thailand 14), too, have documented the substantial amount of time spent in collecting water in many areas.

Felt needs of low-income women

It would thus appear that a major constraint on women's discretionary activities (including child care) in many developing countries is the enormous demand made on their time for the performance of repetitive, time-consuming tasks. It has further been documented that in many rural communities the fetching and carrying of water is one of the most important of these tedious tasks. What do the low-income women of the Third World have to say about this when they are asked directly, when they are treated, as Halfdan Mahler would have, as subjects and not just as objects in the development process?

In looking for answers to this question, it bears repeating that societies in general, and societies in developing countries in particular, are typically sharply divided along class and sex lines. Earlier in this paper it has been argued that particular attention should be paid to the concerns of poor women, yet determining the concerns of this largely disenfranchised group is not simple, for two main reasons. first, the sexual divisor of labor is universal, with the time-consuming tasks performed by women seldom, if ever, being performed by men; and, second, "the decision-makers or leaders in the agencies and in the target communities are usually men and they communicate with other men and not with the women." 45 Thus, as has been documented for Kenya, 45 the reduction in time-consuming tasks like fetching and carrying water is a high priority need for rural women, but is typically given low priority when the "village leaders" (men) are asked for their opinion.

Where surveys of community needs have been aware and taken account of such factors, throughout the developing world water supply has ranked high on the list of expressed priorities. 46 In a recent review of the findings of surveys of low-income women in developing countries, water supply improvements were found to "rank right alongside the most basic human need (adequate food) in many (such) surveys." 40

Cost effectiveness revisited

Returning to the decision model outlined earlier it is thus apparent that when, first, outcomes of programs are not arbitrarily restricted solely to reductions in infant mortality and, second, the trade-offs between outcomes are made by poor Third World women and not scientists, water supply programs routinely constitute an integral part of PHC programs in those (large) areas of the developing world in which access to adequate water supplies is restricted.

It is thus not surprising that, in all countries in which PHC has been successful, improvements in water supply and sanitation conditions have been an integral part of strategies for both improving health and improving the status of women. 47,48

Summary and conclusions

Six years after Alma Ata, what is the prospect for the PHC philosophy as outlined in the Alma Ata Declaration? On the one hand, the concept is clearly a viable one which has been implemented successfully in a number of large, low-income developing countries and with considerable, if only temporary, success in a number of pilot projects in developing countries which have made little progress at the national level. 19 The overwhelming reality, however, is that in those countries which had made little progress before Alma Ata, little progress in implementing PHC programs has been made since. 27 Simplifying a complex debate, there have been two main contending theses explaining this failure. On the one hand, many have seen the failure of PHC programs in most developing countries as a predictable consequence of a "lack of political will," while others have focused on technical factors, such as the scarcity of resources for implementing PHC programs and the necessity for making cost-effectiveness choices on components to be included in an overall PHC program.

For those who favor the technical interpretation of this experience, the "selective primary health care" approach of Walsh and Warren is an insightful and pragmatic tool to be used in making choices in the light of the "resource scarcity, about which interventions are "cost effective" This analysis, as has been shown in this paper, is fundamentally flawed. If the problem is a problem of "resource scarcity" how is it that several low-income countries have implemented strikingly successful PHC programs, while many other countries with higher GNPs per capita have failed completely? If the problem is the comprehensive nature of the Alma Ata formulation of PHC, then how is it that all of the successful national programs have taken such a comprehensive approach? And if water supply and sanitation programs are not "cost-effective, why is it that all of the countries in which PHC has been effective have made improvements in water supply and sanitation a cornerstone to their PHC approach? In summary, although the approach taken by Walsh and Warren and used as a basis for sector strategies by some international development agencies has a certain appeal to fundamental notions of rational planning, the approach fails totally to account for the experience which has been accumulated with PHC programs throughout the world. This being the case, then, there are several critical questions. Is there an alternative interpretation which explains the experience with PHC programs more satisfactorily? If so, what are the implications of this alternative interpretation for policy? And, finally, why has the obviously flawed "selective PHC" approach proved to be so compelling and attractive to some development agencies?

Even the technically focused analyses of the SPHC sort usually mention in passing the "importance of political will and management" in the implementation of PHC programs. An alternative explanation for the success of some national PHC programs and the failure of others considers this factor of political will to be fundamental rather than incidental. The importance of this commitment is evident from both longitudinal and cross-sectional observations. Thus, history shows that prior to World War II cogent blueprints for appropriate health services were drawn up for both China and India (in the form of the Bhore Commission Recommendations of 1943) To John Grant, who played a major role in this process in both countries and who recognized that "the use of medical knowledge . . . depends chiefly upon social organization," 24 subsequent developments could have been no surprise. Where the government made a fundamental commitment to meeting the health (and other) needs of all people, as in China, enormous progress was made in developing an appropriate health delivery system. Where no such commitment was made, as in India, health services changed little over the intervening forty years. 49 Similarly, a contemporary cross-sectional comparison of countries which have made marked progress in the development of health services for all, with those countries in which adequate services have been developed for only a small minority, shows that progress has been rapid only where "health and health care became a political goal and eventually came under political control as a part of overall development." 2

To the proponents of this alternative interpretation, the experience of the successful nongovernmental PHC health projects which are the object of so much attention in the cost-effectiveness analyses, too, is consistent with this theory on the centrality of political commitment. For what distinguishes these successful small projects from the unsuccessful national projects in the same countries is not the resources available nor the choice of technology, but that, through dedication and management, these programs have managed to overcome the problem of the lack of political will that characterized the national programs in these countries. 21,22,27

Thus, the concerns of the technical analysts with "resource constraints" and the use of "non cost-effective technologies" appear to be either false problems or second-order problems. The problem of "resource scarcity" is a problem wrongly named, for it is clear that this problem arises not because there are insufficient resources for the health sector but because the vast majority of these resources, both public and private, are devoted to an existing urban, hospital-based, capital-intensive health care system serviced by and meeting the needs of an elite minority. 1 The problem of appropriate technology is a real one, and there is no doubt that, where political commitment exists, PHC programs will become more effective through the use of ORT, expanded immunization programs, improved low-cost sanitation technologies, and other technological improvements. This does not imply, however that an enormous amount cannot be done with existing technologies. The successful experiences in China, Sri Lanka, Cuba, Vietnam, and India all demonstrate the progress that can be made without the technological advances which some international development agencies suggest to be the major impediment to improving health in developing countries. Indeed, what the experience of the successful national PHC programs shows is that the issue of appropriate technology is intimately related to the issue of political commitment, as is evident in the development and widespread use of innovative "appropriate" solutions to the problem of sanitation technology in both China50 and Vietnam51 and the imaginative incorporation of traditional medicine into a modern health care delivery system in China.27

Given these manifest shortcomings of the Walsh and Warren type of approach, why has it proved to be so attractive to certain development agencies and many developing country governments?

First, the only reasonable conclusion from the evidence is that credit for the success, or blame for the failure, of national PHC programs lies squarely with the government of the country concerned. Where PHC programs have failed, this is because the commitment of the government to "health for all" its people is little more than empty rhetoric

The implication for development agencies with a genuine concern for the health of all people has been stated by one of the pioneers of the PHC movement: "Where support is available, let it be selectively to those countries which already have, or are taking steps to develop, a form of decision-making and implementation which is likely to be effective."2 Since the support of some development agencies for certain countries has more to do with political imperatives than a true concern for the health of the people of that country, such agencies use analyses, such as that presented by Walsh and Warren, to deflect responsibility for death and illness from its true source, namely, the home governments and their international supporters, and to assign responsibility for such suffering to "neutral" causes, such as "resource shortages" and "the limitations of technology." In short, "selective primary health care" is not, as the authors would suggest, a practical modification of the PHC concept, but rather a negation of much that was positive in the PHC approach formulated at Alma Ata.


Figure 1: THE CHOICE OF PROGRAMS WITH DIFFERENT OUTPUTS

REFERENCES

1. Stern, E. Health and development. Paper presented at International Conference on Oral Rehydration Therapy, Washington, D.C., June 1983.

2. Newell, K. W. "Developing countries" in 1 Fry, ea., Primary Care, 196-218. London: 1980.

3. Hetzel, B. S. "Basic health care and the people" In B.S. Hetzel, ed., Basic Health Care in Developing Countries: A,' Epidemiological Perspective, 1-10 Oxford: Oxford University Press, 1980.

4. Ratcliffe, J. "Social justice and the demographic transition: Lessons from India's Kerala State" Int. J. Health Services 8(1) (1978):123-44

5. Djukanovic, K. "The Democratic Republic of North Vietnam" in B. S. Hetzel, ea., Basic Health Care in Developing Countries An Epidemiological Perspective. Oxford: Oxford University Press, 1980.

6. Navarro, V. "Health Services in Cuba: An initial appraisal ." N. Eng. J. Med. 287 (1972):954-59.

7. World Health Organization. Declaration of Alma Ata. Report on the International Conference on Primary Health Care, Alma Ata, USSR. Geneva: September 6-12, 1978.

8. Walsh, J. A. and Warren, K. S. "Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries" N.E.J. Med. 301 (1979):96774

9. United States Agency for International Development. AID Policy: Health Assistance. Eleven pages. Washington, D.C.: 1982.

10. United States Agency for International Development. AID Policy Paper Domestic Water and Sanitation. Sixteen pages. Washington, D.C.: 1982.

11. Morgan, P R. and Mara, D. D. Ventilated Improved Pit Latrines: Recent Developments in Zimbabwe. Thirty-eight pages. Washington, D.C.: World Bank Technical Paper Number 3, 1982.

12. Adrianza, B. T. and Graham, G. G. "The High Cost of Being Poor: Water" Arch. Environ Health 28 (1974):312-15.

13. Okun, D. A. "Review of Drawers of Water." Econ. Dev. and Cult. Change 23(3) (1975):580-83.

14. United States Agency for International Development. The Potable Water Project in Rural Thailand. Fourteen pages and annexes. Washington, D.C.: 1980.

15. Briscoe, J. "The role of water supply in improving health in poor countries (with special reference to Bangladesh)" Am., J. Chin. Nutr. 31 (1978):2100-13.

16. Saunders, R. J. and Warford, J. J. Village Water Supply: Economics and Policy in the Developing World. Two hundred and eighty pages. Johns Hopkins University Press, 1976.

17. Dworkin, D. and Dworkin, J. "Water supply and diarrhea: Guatemala revisited." Thirty-eight pages. Washington, D.C.: AID Evaluation Special Study No. 2.

18. Hughes, J. M. "Potential Impacts of Improved Water Supply and Excreta Disposal on Diarrheal Disease Morbidity: An Assessment Based on a Review of Published Studies." Draft manuscript for publication, thirty pages. Atlanta: CDC.

19. Gwatkin, D. R.; Wilcox, J. R.; Wray, J. D. Can Health and Nutrition Interventions Make a Difference? Seventy-six pages. Washington, D.C.: Overseas Development Council, 1980.

20. Evans, J. R.; Hall, K. L.; Warford, J. "Shattuck Lecture, Health Care in the Developing World: Problem of Scarcity and Choice." N.E.J. Med. 305 (1981):1117-27.

21. Mahler, H. "Preface." In Gwatkin, D. R., et al., Can Health and Nutrition Intervention Make a Difference?, vi-ix. Washington, D.C.: Overseas Development Council, 1980.

22. Sharma, R. and Chaturvedi, S. K. "India." In B. S. Hetzel, ed., Basic Health Care in Developing Countries: An Epidemiological Perspective, 87-101. Oxford: Oxford University Press, 1978.

23. Chen, L. C. "Control of diarrheal diseases morbidity and mortality: some strategic issues." Am., J. Clin. Nutr. 31(12) (1978):2284-91.

24. Grant, J. B. Health Care for tire Community, Selected Papers of Dr. John B. Grant. Baltimore: Johns Hopkins University Press, 1963.

25. Chernichovsky. D. "The economic theory of the household and the impact measurement of nutrition and related health programs." In R. E. Klein, ed., Evaluating the Impact of Nutrition and Health Programs. New Jersey: Plenum Press, 1979.

26. Cole-King, S. "Primary Health Care: A look at its current content." Eighteen pages. New York: UNICEF, 1981.

27. Mosely, W. H. "Will primary health care reduce infant and child mortality? A critique of some current strategies, with special reference to Africa and Asia" Forty-three pages. Paper presented at IUSSP Seminar on Social Policy, Health Policy and Mortality Prospects, Paris, 1983.

28. Grant, J. P. "The State of the World's Children, 1983-83 [sic]." Twelve pages. New York: UNICEF, 1982.

29. Latham, M. C. In G.T. Keusch, "Resume of the discussion on interventions: strategies for success." Am. J. Clin. Nutr. 31(12) (1978):2252-56

30. Rohde, J. E. "Preparing for the next round: Convalescent care after acute infection." Am. J. Clin. Nutr. 31(12) (1978):2258-68.

31. Birdsall, N. and Greevey, W. P. "The Second Sex in the Third World: is female poverty a development issue?" Thirty-six pages. Paper summarizing findings of Workshop on Women in Poverty, International Center for Research on Women, Washington, D.C., 1978.

32. Kielmann, A. A., and McCord, C "Home treatment of childhood diarrhea in Punjabi villages" Environ. Child Health 23 (4) (August 1977):197-201.

33. Academy for Educational Development. Results of Honduras Field Investigation. Forty-three pages. Washington, D. C: 1982.

34. Parker, JR. L.; Rinehart, W.; Piotrow, P.T.; Douchette, L. "Oral rehydration therapy for childhood diarrhea ." Population Reports L(2) (1980).

35. DeSweemer, C. In E.I. Koster, "Resume of the discussion on 'Health care interventions'." Am. J. Clin. Nutr. 31(12) (1978):2274-78.

36. Popkin, B. M. and Solon, F. S. "Income, time, the working mother and child nutriture." Env. Child Health (1976): 156-66.

37. Black, R. E.; Brown, K. H.; Becker, S.; Alim, ARMA; and Merson. M. H. "Contamination of weaning foods and transmission of enterotoxigenic E. coli diarrhea in children in rural Bangladesh." Trans. Roy Soc. Trop. Med. Hyg. 76 (1982):259-64.

38. Rowland, M. G. M. and McCollum, J. P. K. "Malnutrition and gastroenteritis in the Gambia." Trans. Roy. Soc. Trop. Med. Hyg. 71 (1977):199-203.

39. Chen, L. C.; Chowdhury, A. K. A., and Huffman, S. C. "Seasonal dimensions of energy protein malnutrition in rural Bangladesh : The role of agriculture, dietary practices, and infection." Ecology of Food and Nutrition 8 (1979):175-87.

40. Popkin, B. M. "Some economic aspects of planning health interventions among malnourished populations." Am. J. Chi. Nutr. 31(12):2314-23.

41. Popkin, B. M. "Tune allocation of the mother and child nutrition ." Ecol. of Food and Nutr. 9 (1980):1-14.

42. White, G. E; Bradley, D. J.; White, A. N. Drawers of Water Use in East Africa. Three hundred and six pages. Chicago: University of Chicago Press, 1972.

43. Feachem, R.; Bums, E. Cairncross, S.; Cronin, A.; Cross, P.; Curtis, D.; Khan, M. K.; Lamb, D.; Southall, H. Water Health and Development : An Interdisciplinary Evaluation. Two hundred and sixty-seven pages. London: Tri-Med, 1978.

44. Carruthers, I. D. Impact and Economics of Community Water Supply: A Study of Rural Water Investment in Kenya. One hundred and twenty pages. London: Agrarian Development Unit, Wye College, 1973.

45. Elmendorf, M. Women, Water and Waste: Beyond Access. Seventeen pages. Washington, D.C.: WASH Project, 1982.

46. White, A. N. "The role of the community in water supply and sanitation projects." In The Impact of Interventions in Water Supply and Sanitation in Developing Countries, 121-38. Washington, D.C.: USAID, 1981.

47. Hsiang-Kuan, JC. "China: The rural health service." In B. S. Hetzel, Ed., Basic Health Care in Developing Countries: An Epidemiological Perspective, 121-27. Oxford: Oxford University Press, 1980.

48. Van Tin, N. "Mass prophylaxis on a national scale." In Twenty Five Years of Health Work, 21-40. Hanoi: Vietnamese Studies, No. 25, 1970.

49. Banerji, D. "Social and cultural foundations of the health services systems of India." Inquiry Supplement to Vol XII (1975):70-85.

50. McGarry, M. G. and Stainforth, J. Compost Fertilizer and Biogas Production from Human and Farm Wastes in the People's Republic of China. Ninety-four pages. Ottawa: International Development Research Centre, 1978.

51. McMichael, J. "The double septic bin in Vietnam." A. Pacey, Sanitation in Developing Countries, 110-15. New York: Wiley, 1978.

(From: Proceedings of the International Conference on Oral Rehydration Therapy. Washington. June 7-10, 1983, pp. 141-150.)

Handout 5C: Selective primary health care

An Interim Strategy for Disease Control in Developing Countries

JULIA A. WALSH, M.D., AND KENNETH S. WARREN, M.D.

From the Rockefeller Foundation, 1133 Avenue of the Americas, New York, NY 10036, where reprint requests may be addressed to Dr. Warren.

Presented at a meeting on Health and Population in Developing Countries, cosponsored by the Ford Foundation, the International Development Research Center and the Rockefeller Foundation and lead at the Bellagio Study and Conference Center, Lake Como, Italy, April, 1979.

Abstract. Priorities among the infectious diseases affecting the three billion people in the less developed world have been based on prevalence, morbidity, mortality and feasibility of control. With these priorities in mind a program of selective primary health care is compared with other approaches and suggested as the most cost-effective form of medical intervention in the least developed countries. A flexible program delivered by either fixed or mobile units might include measles and diphtheria-pertussis-tetanus vaccination, treatment for febrile malaria and oral rehydration for diarrhea in children, and tetanus toxoid and encouragement of breast feeding in mothers. Other interventions might be added on the basis of regional needs and new developments. For major diseases for which control measures are inadequate, research is an inexpensive approach on the basis of cost per infected person per year. (N Engl J Med 301:967-974, 1979)

THE three billion people of the less developed world suffer from a plethora of infectious diseases. Because these infections tend to flourish at the poverty level, they are important indicators of a vast state of collective ill health. The concomitant disability has an adverse effect on agricultural and industrial development, and the infant and child mortality inhibits attempts to control population growth.

What can be done to help alleviate a nearly unbroken cycle of exposure, disability and death? The best solution, of course, is comprehensive primary health care, defined at the World Health Organization conference held at Alma Ata in 1978 as

the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition, an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.1

The goal set at Alma Ata is above reproach, yet its very scope makes it unattainable because of the cost and numbers of trained personnel required. Indeed, the World Bank has estimated that it would cost billions of dollars to provide minimal, basic (not comprehensive) health services by the year 2000 to all the poor in developing countries. The bank's president, Robert McNamara, offered this somber prognosis in his annual report in 1978:

Even if the projected - and optimistic - growth rates in the developing world are achieved, some 600 million individuals at the end of the century will remain trapped in absolute poverty. Absolute poverty is a condition of life so characterized by malnutrition, illiteracy, disease, high infant mortality and low life expectancy as to be beneath any reasonable definition of human decency.2

How then, in an age of diminishing resources, can the health and well-being of those "trapped at the bottom of the scale" be improved before the year 2000? A valid approach to this overwhelming problem can be based on the realization that the state of collective ill health in many of the less developed countries is not a single problem. Traditional indicators, such as infant mortality or life expectancy, do not permit a grasp of the issues involved, since they are actually composites of many different health problems and disorders. Each of the many diseases endemic to the less developed countries (Table 1) has its own unique cause and its own complex societal and scientific facets; there may be several points in the process for which interventions could be considered. 3-5

Thus, a rationally conceived, best-data-based, selective attack on the most severe public-health problems facing a region might maximize improvement of health and medical care in less developed countries. In the discussion that follows, we try to show the rationale and need for instituting selective primary health care directed at preventing or treating the few diseases that are responsible for the greatest mortality and morbidity in less developed areas and for which interventions of proved efficacy exist.

ESTABLISHING PRIORITIES FOR HEALTH CARE

Faced with the vast number of health problems of mankind, one immediately becomes aware that all of them cannot be attacked simultaneously. In many regions priorities for instituting control measures must be assigned, and measures that use the limited human and financial resources available most effectively and efficiently must be chosen. Health planning for the developing world thus requires two essential steps: selection of diseases for control and evaluation of different levels of medical intervention from the most comprehensive to the most selective.

Selecting Diseases for Control

In selecting the health problems that should receive the highest priorities for prevention and treatment, four factors should be assessed for each disease: prevalence, morbidity, mortality and feasibility of control (including efficacy and cost).

Table 2 incorporates these factors into an analysis of three representative illnesses of the less developed world. The newly discovered Lassa fever was associated with a 30 to 66 per cent mortality rate in the few limited outbreaks recorded in Nigeria, Liberia and Sierra Leone. Those who survived recovered fully after an illness lasting seven to 21 days. Although this fatality rate seems to suggest giving Lassa fever high priority in a major health program, the prevalence of overt disease appears to be low. Furthermore, the only treatment available is injections of serum from patients who have recovered. Since its mode of transmission is unknown and there is no vaccine, Lassa fever is impossible to control at present.6 Therefore, concentration on preventing Lassa fever would be neither efficient nor efficacious.

Ascaris, the giant intestinal roundworm, causes the most prevalent infection of man, with one billion cases throughout the world.7 Yet disability appears to be minor and death relatively rare.3,4 Treatment, however, requires periodic chemotherapy for an indefinite period.3,4,8 Control may ultimately require massive, long-term improvements in sanitary and agricultural practices to reduce reinfection. In view of the difficulty of eliminating exposure to the roundworm and the low morbidity associated with the infection, ascariasis deserves less attention than its ubiquity seems to suggest.

Malaria is associated with a far smaller mortality rate than that of Lassa fever and a far lower prevalence that that of ascariasis. Yet its mode of transmission is well known, and it produces much recurring illness and death; about one million children in Africa alone die annually from malaria.9 What also distinguishes malaria from Lassa fever and ascariasis is that it can be controlled through regular mosquito-spraying programs or chemoprophylaxis.3,9 Of these three infections, then, malaria would be as signed the highest priority for prevention in the most effective approach to reducing morbidity and mortality.

By means of the process outlined above for Lassa fever, ascariasis and malaria, the major infections endemic to the developing world (Table 1) were evaluated and assigned high (I), medium (II) or low (III) priorities. Within categories exact rank is not of major importance, and rank may change or items may be added or deleted, depending on the geographic area under consideration. For instance, schistosomiasis, to which a high priority was assigned, does not occur in many areas of the developing world. Our results and rationale for the proposed hierarchy are listed in Table 3.

Table 1. Prevalence, Mortality and Morbidity of the Major Infectious Diseases of Africa, Asia and Latin America, 1977-1978.*

INFECTION

INFECTIONS (THOUSANDS/Yr)

DEATHS (THOUSANDS/Yr)

DISEASE (THOUSANDS OF CASES/Yr)

AVERAGE No. OF DAYS OF LIFE LOST (PER CASE)

RELATIVE PERSONAL DISABILITY**

Diarrheas

3-5,000,000

5-10,000

3-5,000,000

3-5

2

Respiratory infections


4-5000


5-7

2-3

Malaria

800,000

1200

150,000

3-5

2

Measles

85,000

900

80,000

10-14

2

Schistosomiasis

200,000

500-1000

20,000

600 1000

3-4

Whooping cough

70000

254450

20,000

21-28

2

Tuberculosis

1,000,000

400

7000

200-400

3

Neonatal tetanus

120-180

100-150

120-180

7-10

1

Diphtheria

40,000

50-60

700-90.0

7-10

1

Hookworm

7 - 900 000

50-60

1500

100

4

South American trypanosomiasis

12000

60

1200

600

2

Onchocerciasis






Skin disease


Low

2-5000

3000

3


30,000





River blindness


20-50

200-500

3000

1-2

Meningitis

150

30

150

7-10

1

Amebiasis

400,000

30

1500

7-10

3

Ascariasis

800,000 1,000.000

20

1000

7-10

3

Poliomyelitis

80,000

10-20

2000

3000+

2

Typhoid

1000

25

500

14-28

2

Leishmaniasis

12,000

5

12,000

100-200

3

African trypanosomiasis

1000

5

10

150

1

Leprosy


Very low

12,000

500-3000

2-1

Trichuriasis

500,000

Low

100

7-10

3

Filariasis

250,000

Low

2-3000

1000

1

Giardiasis

200,000

Very low

500

5-7

1

Dengue

3 4000

0.1

1-2000

5-7

2

Malnutrition

5-800,000

2000




* Based on estimates from the World Health Organisation and its Special Programme for Research and Training in Tropical Diseases, confirmed or modified by extrapolations from published epidemiologic studies performed in well defined populations (see references). Figures do not always match those officially reported, because under-reporting is great.

** 1 denotes bedridden, 2 able to function on own to some extent, 3 ambulatory, & 4 minor.

Table 2. An Approach to the Establishment Priorities for Disease Control, Based on Prevalence, Mortality, Morbidity and Feasibility of Control of Three Representative Infections.

Infection

Prevalence

Mortality

Mortality

Feasibility of control

Priority

Lassa fever

Unknown (thought to be low)

High (30-66%)

Moderate (bedridden 7-21 days)

Extremely poor al present

Low prevalence low, feasibility of control poor

Ascariasis

Extremely high (thought to affect 1 billion people)

Extremely low (approximately 0,001 %)

Low (minor disability & often assymptomatic)

Poor (continuous drug treatment required)

Low: mortality & morbidity low, feasibility of control poor

Malaria

High (more than 300 million infected annually)

Low (approximately 0.1%)

High (severe, many complications, often recurrent)

Good (chemoprophylaxis available; regular spraying programs for vectors practical)

High: prevalence high, morbidity high, feasibility of control good

Group I contains the infections causing the greatest amount of most readily preventable illness and death: diarrheal diseases, malaria, measles, whooping cough, schistosomiasis and neonatal tetanus. With the exception of schistosomiasis, all the infections receiving highest priority for health-care planning affect young children more than adults.10-14 Together with respiratory infections and malnutrition, they account for most of the morbidity and mortality among infants and young children.11,15,17 Members of this age group (five years old or less) have a death rate many times greater than that of their counterparts in Western countries - accounting for 40 to 60 per cent of all mortality in most less developed countries.11,15,17 It infant and child deaths from these infections are reduced, a large decline in the overall death rate will result. Such a situation would be an optimal outcome of a selective disease-control program.

Groups II and III contain health problems that are either less important or more difficult to control. Respiratory infections, a major cause of disability and death, are not listed in Group I because of the difficulties involved in preventing and managing them. A wide variety of viruses and bacteria are associated with pulmonary infections, and no specific causative agent has been found in most patients.16,28 As in the industrialized world, where pneumonia is frequently the terminal episode in elderly patients weakened by cancer or cardiovascular disease, lower-respiratory-tract infections affect children in developing countries who are already afflicted with chronic malnutrition and parasitic infections.16 Pneumococcal and influenza vaccines prevent only a small percentage of cases, and influenza immunization must be given almost yearly because the virus changes antigenically. When penicillin injections were given to all children with clinical signs of pneumonia in the Narangwal Project in India, the mortality rate decreased by 50 per cent,21 but this method must be evaluated more extensively before it can be regarded as a major improvement in prevention of respiratory disease.

A medium or low priority was assigned if control measures were inadequate. For example, there is no acceptable therapy for chronic Chagas' disease.3,4 Only toxic drugs and procedures of unknown efficacy, such as nodulectomy, are available for treatment of onchocerciasis.3,4 Leprosy and tuberculosis require years of drug therapy and even longer follow-up periods to ensure cure.4,22,23 instead of attempting immediate, large-scale treatment programs for these infections, the most efficient approach may be to invest in research and development of less costly and more efficacious means of prevention and therapy. To reiterate, the most important factor in establishing priorities for endemic infections, even when evaluating diseases with high case rates, is a knowledge of which diseases contribute most to the burden of illness in an area and which are reasonably controllable.

Table 3. Priorities for Disease Control in the Developing World, Based on Prevalence, Mortality, Morbidity and Feasibility of Control.

Priority group

Reasons roe Assignment to this category

I High

High prevalence, high mortality or high morbidity, effective control

Diarrheal diseases


Measles


Malaria


Whooping cough


Schistosomiasis


Neonatal tetanus


II Medium

Respiratory infections

High prevalence, high mortality, no effective control

Poliomyelitis

High prevalence, low mortality, effective control

Tuberculosis

High prevalence, high mortality, control difficult

Onchocerciasis

Medium prevalence, high morbidity, low mortality, control difficult

Meningitis

Medium prevalence, high mortality, control difficult

typhoid

Medium prevalence, high mortality, control difficult

Hookworm

High prevalence, low mortality, control difficult

Malnutrition

High prevalence, high morbidity, control complex

III Low

South American trypanosomiasis (Chagas' disease)

Control difficult

African trypanosomiasis

Low prevalence, control difficult

Leprosy

Control difficult

Ascariasis

Low mortality, low morbidity, control difficult

Diphtheria

Low mortality, low morbidity

Amebiasis

Control difficult

Leishmaniasis

Control difficult

Giardiasis

Control difficult

Filariasis

Control difficult

Dengue

Control difficult

EVALUATING AND SELECTING MEDICAL INTERVENTIONS

Once diseases are selected for prevention and treat. meet, the next step is to devise intervention programs of reasonable cost and practicability. The interventions relevant to the world's developing areas that are considered below are comprehensive primary health care (which includes general development as well as all systems of disease control), basic primary health care, multiple disease-control measures (e.g., insecticides, water supplies), selective primary health care, and research. Below is a discussion of each approach, with emphasis on the relative cost involved in undertaking and maintaining these programs and on the benefits that have accrued.

This section of our analysis relies on reported results from individual studies conducted in various parts of the world. In addition, we have examined estimates of cost and effectiveness in terms of expected deaths averted by each intervention for a model area in Africa. The model area is an agricultural, rural portion of Sub-Saharan tropical Africa with a population of about 500,000 (100,000 are five years old or less). For reference purposes, the average figures for Sub-Saharan Africa will be used: the birth rate is 46 per thousand total population, the crude death rate 19 per thousand total population, and the infant mortality rate 147 per thousand live births.24,25

Comprehensive versus Basic Primary Health Care

Comprehensive primary health care for everyone is the best available means of conquering global disease, the humane and noble goal declared at Alma Ata. As defined by the World Health Organization, this system encompasses development of all segments of the economy, ready and universal access to curative care, prevention of endemic disease, proper sanitation and safe water supplies, immunization, nutrition, health education, maternal and child care and family planning. Since resources available for health programs are usually limited, the provision of comprehensive primary health care to everyone in the near future remains unlikely.

Basic primary health-care systems are far more circumscribed in their goals, which are to provide health workers and establish clinics for treating all illnesses within a population. Nevertheless, this approach is far from inexpensive. The World Bank has estimated that the cost of furnishing basic health services to all the poor in developing countries by the year 2000 will be $5.4 to $9.3 billion (in 1975 prices).24 This investment, which includes only initial capital investment and training costs, would provide one community health worker or auxiliary nurse-midwife for every 1500 to 2000 people and one health facility for every 8000 to 12,000 people or every 10 km2, whichever is greater. In the model area in Africa, the World Bank estimated that supplying the minimum care offered by building one health post with one vehicle per 10,000 people and training 125 auxiliary nurse-midwives and 250 community health workers would cost $2,500,000, or $5 per capita. To this figure must be added the recurrent costs of salaries, drugs, supplies and maintenance. Other costs not included are for training facilities, continuing education, expansion of referral services and development of communication, transportation and administrative networks to supply and manage the health facilities. Furthermore, the effectiveness of this model program for averting deaths or applying such preventive measures as education in sanitation and nutrition has not been clearly established.

The pilot projects for providing basic health-cam services that have been evaluated vary in their effectiveness in improving the general level of health care. For example, an outside evaluation of primary health service in Ghana revealed that a third to half the population of the districts lived outside the effective reach of health units providing primary care. Only about one fifth of the births were supervised by trained midwives; only one fifth of the children under the age of five years had been seen in a child-health clinic, and two thirds of the population lacked environmental sanitation services. Furthermore, the services were often of poor quality, notably in the crucial area of child care.27,28

The cost and effectiveness of several experimental programs providing primary health care in localized areas have been compared in Imesi, Nigeria29; Etimesgut, Turkey30,31; Narangwal, India21; Jamkhed, India32,33; Guatemalan villages34; Hanover, Jamaica35-37; and Kavar, Iran.38 The estimated cost per capita varied widely among the programs, particularly because they were initiated at different times over the past 15 to 20 years and furnished different services to their communities. In general, however, the cost per capita ranged between l and 2 per cent of the national per capita income of the particular country. The cost For infant deaths averted were difficult to compare because of the paucity of control groups and inconsistency of the population groups monitored. Figures ranged from $144 to $20,000, with a median of $700. The only precise calculations for the costs per infant death averted ($144) or child death evened ($988 per one to three-year-old child) were for a medical-care and nutrition-supplementation project in Narangwal, India.21 The estimates were much higher for deaths averted by nutrition supplements.

Under some circumstances, programs of basic primary health care have been successful, but the cost and the degree improvement in community health have varied markedly enough that refinements in the approach are still needed.

Multiple Disease-Control Measures

These interventions, which include vector control, water and sanitation programs and nutrition supplementation, are more specific and easily managed than primary health-care programs, and they control many similarly transmitted diseases simultaneously. They can decrease mortality and morbidity and have served as interim strategies for health care in less developed countries.

Vector Control

Vector control is directed at managing the insects and mollusks that carry human disease. This approach has the advantage of being comparatively inexpensive, but it must be continued indefinitely and may be ephemeral since the vectors tend to become resistant. The examples below reveal some of the complexities of maintaining vector control.

The control of malaria transmission through insecticides has been highly effective. In the tropical regions and savannas of Africa, twice-yearly spraying has decreased the crude death rate by approximately 40 per cent and infant mortality by 50 per cent.39-41 The World Health Organization has estimated that the average cost for house-to-house spraying with chlorophenothane (DDT) is $2 per capita annually.9 Therefore, the cost per adult and infant death averted is $250, and the cost per infant death averted is $600. Unfortunately, eradication of malaria with insecticides is becoming more difficult to accomplish. Because mosquitoes can be expected to become resistant to DDT within a few years, other, much more expensive pesticides must be substituted; the use of propoxur or fenetrithion will raise the cost of the chemicals five to 10 times.9 Furthermore, there is no way of knowing how long these insecticides will remain toxic to the mosquitoes. Among the mosquitoes in which widespread resistance to insecticides has developed are Culex pipiens fatigans the major vector of urban filariasis, and Aedes aegypti, the vector of yellow fever and dengue.5

Two other vector-control programs illustrate the prolonged maintenance required by this type of health intervention. Onchocerciasis, a potentially blinding helminth infection affecting 30 million people in Africa, is being managed in the Volta River Basin through a 20-year larvicide operation to control the blackfly vector. The program is estimated to cost $18 per capita for the entire 20-year period or $.90 per capita per year.26 Disability will be prevented, and economic activity in the area may increase if the program is successful, but continuous, indefinite applications of insecticide will be necessary. Since 1965, St. Lucia has had a program to control the snail-transmitted helminth infection schistosomiasis through molluscicides. An annual cost per capita of about $3.70 and good results have been reported: the prevalence of the infection has decreased from 45 to 35 per cent in adults and born 21 to 4 per cent in children. Despite these heartening figures, eradication of the vector cannot be considered on the horizon. Schistosomiasis is a long-term, chronic infection and the death rate will not begin to decline until many years after continuous mollusk control.

Water and Sanitation Programs

Proper sanitation and clean water make a substantial difference in the amount of disease in an area, but the financial investment involved is enormous. The success of such projects also depends on rigorous maintenance and alteration of engrained cultural habits.

With the installation of community water supplies and sanitation in developing areas, deaths from typhoid can be expected to decrease 60 to 80 per cent,43 deaths from cholera 0 to 70 per cent,43-48 from other diarrheas 0 to 5 per cent,48-51 from ascaris and other intestinal helminths 0 to 50 per cent8,10,52-54 and from schistosomiasis 50 per cent42,52 (after 15 to 20 years). The World Bank has estimated that the cost of providing community water supplies and sanitation to all those in need by the year 2000 will be $135 to $260 billion.26,35 Construction of a rural community stand-pipe costs $20 to $26 per capita, and rural sanitation costs $4 to $5 per capita. In urban areas the costs are $31 and $23, respectively. In our model area of Sub-Saharan Africa the initial investment would be $12 to $15 million if amortization and annual maintenance costs are only 10 per cent of this sum, the annual cost per deaths averted will be $2400 to $2900, and the cost per infant and child deaths averted will be $3600 to $4300.

What must be realized is that the above sums are largely for public standpipes, which are not highly effective in reducing morbidity and mortality from water-related diseases. It is well documented that connections inside the house are necessary to encourage the hygienic use of water.56 For example, shigella-caused diarrheas decreased 5 per cent with outside house connections but fell 50 per cent when sanitation and washing facilities were available within the home.51

All these estimates depend on exclusive use of protected sanitation and water supplies, without continuing use of environmental sources. In Bangladesh for example, there was no reduction in cholera in areas supplied with tube wells, primarily because of the use of contaminated surface water as well as the protected water supply.47 In St. Lucia, contact with surface water could not be discouraged until household water supplies and then swimming pools and laundry units were installed, and an intensive health-education campaign was instituted.42 In other words, changing peoples' habits in excretion and water usage takes more than introducing an adequate, dependable and convenient new source. Realistically speaking, a pervasive and effective health-education campaign37,38 is required.

Nutrition Supplementation

Nutrition programs have been advocated as among the most efficient means of decreasing morbidity and mortality in children, but supplementation alone has had no notable effect. Malnutrition is an underlying or associated factor in many deaths from infections in children; in a group of Latin American children, it was associated in 50 per cent of the cases.39 Poor nutrition may also increase susceptibility to disease or predispose an infected child to more severe illness.60-62 Conversely, infection may be a prominent cause of poor nutrition61,63-66 since less food is ingested and absorbed by a sick child. Therefore, if infections could be controlled it is probable that the nutritional status of children would improve greatly. There have been some situations, however, in which malnutrition has been reported to protect against certain infections, e.g., the Sahel famine was thought to suppress malaria, and iron deficiency was reported to protect against bacterial intections.67-76

In view of these findings, it is not surprising that few nutrition-supplementation programs alone have effected a major decrease in the death rate. The Narangwal Project is one of these few, but even in that program the cost per death averted in infants was $213. In children one to three years old the cost was $3000 - 1.5 to three times higher than the cost of medical care alone.21

Selective Primary Health Care

The selective approach to controlling endemic disease in the developing countries is potentially the most cost-effective type of medical intervention. On the basis of high morbidity and mortality and of feasibility of control, a circumscribed number of diseases are selected for prevention in a clearly defined population. Since few programs based on this selective model of prevention and treatment have been attempted, the following approach is proposed. The principal recipients of care would be children up to three years old and women in the childbearing years. The care provided would be measles and diphtheria-pertussis-tetanus (DPT) vaccination for children over six months old, tetanus toxoid to all women of childbearing age, encouragement of long-term breast feeding, provision of chloroquine for episodes of fever in children under three years old in areas where malaria is prevalent and, finally, oral rehydration packets and instruction.

If even 50 per cent of the children and their mothers and 50 per cent of the pregnant women in a community were contacted, deaths from measles would be expected to decrease at least 50 per cent,71,72 deaths from whooping cousin 30 per cent,73 from neonatal tetanus 45 per cent,74 from diarrhea 25 to 30 per cent75,76 and from malaria 25 per cent.9 Oral rehydration has been used successfully in hospitals,77,78 in out patient clinics79 and recently in the home75,76 to treat diarrheas of numerous causes.

These services could be provided by fixed units or by mobile teams visiting once every four to six month in areas where resources were more limited. Mobile units have been successfully used in immunization programs for smallpox and measles,80,81 in treatment services directed against African trypanosomiasis and meningitis82 and in provision of child care in rural areas.83-85

The cost of fixed units would be similar to that of basic primary health care, although efficiency should be much greater. Cost estimates for a mobile health unit used in the model area in Africa for malaria control and water and sanitation programs were based on an extensive study of the Botswana health services by Gish and Walker.85 They estimated $1.26 as the cost per patient contact in 1974, on a sample 306-km trip that reached 753 patients; the estimated cost per infant and child death averted was $200 to $250. Medications accounted for 30 to 50 per cent of this cost, but this figure could be decreased with contributions of drugs from abroad or their manufacture within the country.

Whether the system is fixed or mobile, flexibility is necessary. The care package can be modified at any time according to the patterns of mortality and morbidity in the area served. Chemotherapy for intestinal helminths, treatment of schistosomiasis and supplementation with new vaccines or treatments as they become available are all types of selective primary health care that could be added or subtracted to this core of basic preventive care. It is important, however, for the service to concentrate on a minimum number of severe problems that affect large numbers of people and for which interventions of established efficacy can be provided at low cost.

Research

For a number of prevalent infections, treatment or preventive measures are expensive, difficult to administer, toxic or ineffective. These infections, which include Chagas' disease, African trypanosomiasis, leprosy and tuberculosis, may better be dealt with through an investment in research. In terms of the potential benefits, the cost of research is low. Indeed, the total amount now being spent on research in all tropical diseases is approximately $60 million, exceedingly small in relation to the number of people infected. As Table 4 shows, expenditures for research on some of the major diseases in the developing world have by far the lowest per-capita cost of all medical interventions discussed.84

The estimated cost for the research and development leading to the pneumococcal vaccine licensed in the United States in 1978 was $3 to $4 million (Austrian R: personal communication). Death and disability in developing countries would be reduced by heat-stable vaccines for measles, malaria, leprosy and rotavirus and Escherichia coli-induced diarrheas, by improved chemotherapy for leprosy, tuberculosis, American and African trypanosomiasis, onchocerciasis and filariasis and by depot drugs [or malaria and intestinal helminths.

Table 4. Research Funding for Major Diseases of the Developing World, 1978.

Infection

Amount of Funding ($)

Cost/Infected Person/Yr ($)

Malaria

15,000,000

0.02

Schistosomiasis

7,000.000

0.04

Filariasis

2,000,000

0.01

Trypanosomiasis

5,000,000

0.38

Leishmaniasis

1,200,000

0.10

Leprosy

2,000,000

0.16

CONCLUSIONS

Until comprehensive primary health care can be made available to all, services aimed at the few moss important diseases (selective primary health care) may be the most effective means of improving the health of the greatest number of people. The crucial point is how to measure the effectiveness of medical interventions. In all the foregoing calculations, we based our analysis of cost effectiveness on changes in mortality or deaths averted. We did not measure the illness and disability that would be prevented. No other benefits For which intervention may have been responsible were measured because they are much more difficult to quantify. The inadequacy of available data makes it impossible to measure distinct and undeniable secondary benefits. For example, water supplies close by would save time for the women who carry water, and increased amounts could irrigate a home garden.

Accordingly, Table 5 summarizes the estimated costs per capita and per death averted for the various health interventions considered. The per capita costs are calculated in terms of the entire infant, child and adult population or the area covered by the service. A-5 the table Suggests, selective primary health care may be a cost-effective interim intervention For many less developed areas.

Table 5. Estimated Annual Costs of Different Systems of Health Intervention.

Intervention

Per Capita cost ($)

Cost per infant and/or Child Death Averted* ($)

Basic primary health care **



Range

0.40-7.50

144-20,000 (I)

Median

2.00

700

Mosquito control for malaria

2 00

600 (I)

Onchocerciasis control program

0.50

Few infant & child deaths

Mollusk control for schistosomiasis

3.70

Few infant & child deaths

Community water supplies & sanitation

30-54

3600-4300 (I,C)

Narangwal nutrition

1.75

213(I)

supplementation


3000 (C)

Selective primary health care ***

0.25

200 250 (I,C)

* I denotes infant & C child.
** Delivered by village health workers
*** In this case, delivered by mobile units

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(From: The New England Journal of Medicine. Boston. Vol. 301, No. 18, pp. 967-974 )