Patrick Vaughan

Primary health care approach: how did it evolve?

The authors outline some of the important factors that shaped the primary health care (PHC) approach. First, theories about development changed; rather than concentrating on physical growth and industry in the belief that as the economy grew benefits would spread to poorer groups, it become politically unacceptable to tolerate large differences in health care between the rich and the poor. Second, there was increasing concern about population growth in a world of finite resources and about the political instability of rapidly growing populations. These elements led to a trend against vertical family planning services, and towards integrated maternal and child health services with a family planning component; the perspective became child spacing rather than limitation. A 3rd factor was the trend away from technological medical solutions to more concern with social, psychological, behavioral, and economic factors. There was concern about western medical models being imposed on developing countries. In the 1960s Maurice King emphasized the need to provide basic health services in the community; community involvement was the 4th factor behind PHC. China, Cuba, Vietnam, and Tanzania all had successful community based PHC programs based on the idea that health was integral to development. These successes combined with the differences between rural and urban health status gave the impulse to the PHC approach. The 5th influence was the World Health Organization (WHO) and international agencies which emphasized that health was linked to development; in 1975 WHO launched the idea of health for all by the year 2000 with the strategy of the setting of minimum targets for food consumption, clothing, housing, and provision of water, sanitation, education, health, and public transport services. WHO and UNICEF called a meeting in Alma Ata, USSR in 1978 as a culmination of all of these efforts.

Budgeting based on need: a model to determine sub-national allocation of resources for health services in Indonesia

BackgroundAllocating national resources to regions based on need is a key policy issue in most health systems. Many systems utilise proxy measures of need as the basis for allocation formulae. Increasingly these are underpinned by complex statistical methods to separate need from supplier induced utilisation. Assessment of need is then used to allocate existing global budgets to geographic areas. Many low and middle income countries are beginning to use formula methods for funding however these attempts are often hampered by a lack of information on utilisation, relative needs and whether the budgets allocated bear any relationship to cost. An alternative is to develop bottom-up estimates of the cost of providing for local need. This method is viable where public funding is focused on a relatively small number of targeted services. We describe a bottom-up approach to developing a formula for the allocation of resources. The method is illustrated in the context of the state minimum service package mandated to be provided by the Indonesian public health system.MethodsA standardised costing methodology was developed that is sensitive to the main expected drivers of local cost variation including demographic structure, epidemiology and location. Essential package costing is often undertaken at a country level. It is less usual to utilise the methods across different parts of a country in a way that takes account of variation in population needs and location. Costing was based on best clinical practice in Indonesia and province specific data on distribution and costs of facilities. The resulting model was used to estimate essential package costs in a representative district in each province of the country.FindingsSubstantial differences in the costs of providing basic services ranging from USD 15 in urban Yogyakarta to USD 48 in sparsely populated North Maluku. These costs are driven largely by the structure of the population, particularly numbers of births, infants and children and also key diseases with high cost/prevalence and variation, most notably the level of malnutrition. The approach to resource allocation was implemented using existing data sources and permitted the rapid construction of a needs based formula that is highly specific to the package mandated across the country. Refinement could focus more on resources required to finance demand side costs and expansion of the service package to include priority non-communicable services.

Zur zukünftigen Zusammenarbeit von ASPHER in der europäischen Public-health-Ausbildung

SummaryThe Assembly appreciated that in preparing these proposals, the Ad Hoc Group has been concerned: not to lose the cumulative experience which ASPHER has built up during the past decade; to be aware of the new situation in Europe with new opportunities and challenges to be faced if ASPHER is to respond effectively to the needs of its members; to identify opportunities for cooperation with both old partners (WHO and EHMA) and new partners, notably CEC19 and their new Public Health Mandate.The Assembly appreciated that in preparing these proposals, the Ad Hoc Group has been concerned: not to lose the cumulative experience which ASPHER has built up during the past decade; to be aware of the new situation in Europe with new opportunities and challenges to be faced if ASPHER is to respond effectively to the needs of its members; to identify opportunities for cooperation with both old partners (WHO and EHMA) and new partners, notably CEC19 and their new Public Health Mandate.

Book Review: Medex Primary Health Care SeriesMedex Primary Health Care Series by the GroupMedex (Director: Richard A Smith), University of Hawaii (Full details, including costs, from: Health Manpower Development Staff, University of Hawaii, 1833 Kalakaua Avenue, Suite 700, Honolulu, Hawaii 96815, USA)

But while we wait for adequate food, safe water and sanitation for all, there are some shorter-term measures to be taken. For example, oral rehydration can stop over four million children dying each year from dehydration due to diarrhoea. Control of diarrhoeal diseases will only be achieved by environmental improvements and health education, by better nutrition, and through immunization programmes to reduce the incidence of infections such as measles, which lower resistance and combine with malnutrition and diarrhoea in a lethal partnership. Immunization against polio has a special role to play. Polio may mean death or lifelong disability, but it costs only about 45 pence to provide complete protection for a third world child. Much can be done through rehabilitation for those already disabled. The booklet includes excellent papers about combining rehabilitation with everyday child care, and about simple aids that can be made at community level. Adult needs are not forgotten. The contribution on leprosy lists ten means of prevention, including the need to change peoples attitudes. There is a fascinating piece about an agricultural programme for the blind in Ghana, which also emphasizes the need for change of attitudes. The Secretary General of Rehabilitation International identifies four main obstacles which block efforts to improve the situation of disabled people in developing countries: poverty, ignorance, misconceptions, and faulty priorities. Ignorance includes misinformation, prejudice, superstition and fear. Misconceptions add to ignorance. Many serious impairments and disabilities do not fit into the traditional categories: for example, the lassitude and inertia caused by malnutrition, endemic diseases and other infections. Another misconception is to ignore social and environmental factors, and the possibilities for remedy to be found in the family, the community and the disabled individual himself. Faulty priorities may waste the international assistance available for immunization programmes. A recurrent theme of the book is that aid should concentrate less on providing special buildings and equipment and do more about helping third world people to help themselves. No-one will disagree with this message.

Book Review: Community Health Worker's ManualCommunity Health Worker's Manual by WoodElizabeth (Nairobi: African Medical and Research Foundation1982 pp 328£4.20)

Community Development and Primary Health Care (Community Development Journal, No. 2, April 1983, 18, 99-208 i6.00 (UK i5.25, US

Mortality Study of Construction Workers in the UK

14.00) from Oxford University Press, Oxford O X 2 6DP) While the primary health care (PHC) approach focuses stongly on communities, stressing participation, involvement, and self-reliance, proponents of PHC have been slow to appreciate and learn from the experiences gained by the community development practitioners of the 1950s and 1960s. Indeed, some PHC literature gives the impression that the wheel has been reinvented. This special issue of Community Development Journal is therefore particularly refreshing and raises many relevant issues on the relationship between health and communities, drawing on experiences in a variety of different situations and countries. One of the clear themes throughout the special issue is the fact of increasing urbanization. In the first paper Rossi-Espagnet describes the growth of squatters and slum-dwellers living in precarious socioeconomic conditions that forbode ill-health, but gives some examples of development projects that have been fairly successful in marginal urban areas. Rosenthal looks at community health projects in Britain, based on work with small groups of local people, and demonstrates clearly that the issues raised are relevant for many third world countries. The paper by Leigh makes the bridge between this theme and the next: whether PHC should be the entry point to a community, or whether it should follow community development. Leigh shows that in a slum area of Kuala Lumpur the community’s felt need for health services was low, and potable water, electricity, telephones and recreational facilities were ranked as more important. Stimulating income-generating activities as a first step, before introducing health care, was a more successful way of involving the community. This is supported by Misra, describing a project in the Philippines. In opposition, Macdonald argues that health can be used as a “wedge” to help under-privileged groups, but argues strongly for an integrated approach which includes action about living conditions, water and agricultural extension. There are interesting points in these, and other papers, on the important role of communities in decision-making, and the difficulties community workers may face in challenging the establishment. The final theme is concerned with effective methods of health development. How professionals and people best work together is covered in a series of contributions: Aarons looks at the partnership between teachers and health workers; Griffiths & Lirhunde at how community health workers are chosen by both professionals and people and Pagaduan & Ferrer at community-based evaluation. Cochrane & Fisher and Jackson explore the problem of raising health consciousness in the British context, and White discusses some of the constraints in community participation. The final paper, by Obomsawin, concentrates on the eroded self-reliance of the Indians of North America. Altogether this is a rich collection of papers that explore, in a practical and useful way, the fine connections between health and community development and between the less developed and developed worlds.