Primary Health Care Activities Research Articles

An epidemiologic study of primary health care service utilization of summer visitors to Abha, Asir, Saudi Arabia.

Primary health care (PHC) service utilization by summer visitors to Abha, Saudi Arabia was studied among 227 families including 1443 persons attending the Al-Manhal Primary Health Care Center (PHCC) during August 1991. Summer visitors added an excess load on PHC services: 1.8% for preventive activities, 3.3% for diagnostic activities and 17.4% for curative activities. A significant excess of utilization of curative PHC activities was observed among summer visitors compared to residents. On the other hand, a significant decrease in utilization of preventive and diagnostic PHC services was noted among summer visitors. This study demonstrates the importance of augmenting PHCCs with staff and supplies in residential areas during the summer to cope with the situation and of providing proper and adequate PHC services. More health education is needed to inform people about importance of preventive PHC for better utilization of the available services.

Impact of Selective Primary Care on Childhood Mortality in a Rural Health Zone of Zaire

Following the introduction of intensified child survival activities, use of health services for children increased markedly: measles vaccination reached 74% of children aged 12-23 months, and the use of oral rehydration therapy for the treatment of diarrhoea had increased. During the same period, childhood mortality declined by 33% for children aged 1-4 years. Data on cases of measles in the local hospital reveals that the pattern of measles epidemics characteristic of the years preceding programme implementation was altered in the years following programme implementation. The mean annual number of inpatient measles cases declined from 108 before the programme to 36 after its start. The high correlation between the number of inpatient measles cases and mortality at ages 6-35 months suggests that the programme reduced mortality largely by reducing the incidence of measles. Primary health care activities, supported in part by the Combatting Childhood Communicable Diseases Project, is estimated to have reduced mortality at ages 6-35 months by at least the 18-23% associated with the change in the incidence of measles and may have been responsible for the full 28% reduction recorded between 1980-1984 and 1985-1989.

Developing applied medical anthropology in third world countries: Problems and actions

Recognition of the usefulness of ethnographic research in Third World community health projects and programs developed rapidly during the 1980s. As a result, the various agencies and organizations promoting community health programs (UNICEF, WHO, NGOs) have greatly increased their recruiting of social scientists, particularly medical anthropologists, for research and other programmatic activities in primary health care, child survival (especially diarrhea, acute respiratory infections, maternal and child nutrition, infectious disease, and AIDS). However, it has proved very difficult to identify well-trained anthropologists and/or other social scientists for these roles, particularly in Third World countries. This paper examines some of the background of this problem, and presents examples of methodological training (in both qualitative and quantitative research techniques) that seek to increase the skills of social scientists and other researchers in the arena of international community health.

Care for AIDS patients in developing countries: a review.

As an ever increasing number of HIV-infected persons develop AIDS, treating the manifestations associated with HIV infection has become a new challenge to health sectors in developing countries. Given resource constraints of health systems before the AIDS epidemic, there is an urgent need to start examining ways in which health care can be delivered to the large number of AIDS patients, without infringing on other primary health care activities. This paper reviews current experience with AIDS patient care management in developing countries and determines some of the areas where further research is crucial. The main issues identified are: (1) that reliable data on standardized treatment schemes for AIDS patients are scarce; (2) that there is an urgent need for research on low-cost supportive treatment of AIDS patients, comparing costs and outcomes; (3) that outpatient and home-based care can be a valuable alternative to hospital-based care, but that cost-efficiency of these alternative treatment strategies should be examined more closely; and finally, that (4) the potential benefit of using HIV/AIDS patients to promote prevention of HIV transmission should be acknowledged.

The use of selected interventions in monitoring primary health care implementation in rural Nigeria.

Nigeria's Primary Health Care (PHC)-based health system development aims to strengthen PHC in the local government areas (LGA) through technical planning and implementation that emphasize maternal and child health services. Convenient variables, including expanded programme on immunization (EPI), antenatal care (ANC) utilization and attended births, were selected as interventions to monitor the progress of implementation of PHC activities during 1985-90 in Odukpani LGA. Analysis of available data at the LGA showed that immunization coverage for most EPI antigens increased; ANC services showed increased utilization; health worker-attended births increased as traditional birth deliveries declined during the period. Some of the increases were modest but are considered important. The study offers a pilot approach to monitoring implementation of PHC activities in Odukpani LGA. The implications of the findings for similar studies are discussed.

Maternal Time Allocation in Relation to Kind and Domain of Primary Health Care

In this article I review research questions and findings in the area of maternal time allocation and child health and nutrition as an introduction to more general issues related to time allocation and primary health care. I present an organizing framework for thinking about primary health care activities which focuses on the kind of care required (prevention, management) and the domain in which it takes place (home, clinic, community). I hypothesize that the determinants of people's participation in different health activities vary according to kind and domain of care. This proposition is examined in relation to maternal time constraints by presenting four examples of time‐related studies in Haiti and Rwanda. The examples identify two key factors, child's age and availability of competent caretakers, which influence health behavior across different kinds and domains of care. I conclude by considering the implications of these ideas for new research, study design, and health policy.

Issues in primary health care development in Vanuatu

Although the primary health care model was adopted officially in the Vanuatu archipelago in 1984 inherent obstacles of limited resources manpower conflicts of interest and geographically dispersed small units necessitated a national task force in 1989 to co-ordinate implementation at the local level. Vanuatu with a population of 142600 in 1989 over 80 islands has a traditional Melanesian culture and 45% under 5 years old. Health problems include both tropical less-developed country issues and increasing degenerative diseases. The health care system formerly emphasized curative care by doctors in hospitals in the capital where a nursing school also focused on technologically based care. The new primary health care system adopted in the 2nd National Development Plan and coordinated by a committee in a Workshop in 1987 puts control at the district level. Each district consists of 2 or 3 local governments. The plan established rural health districts of 2- 40000 people under rural health supervisors requires cooperation of the PHC nutrition environmental health and AIDS sectors trains local aid post workers established a drug list and includes primary health care in undergraduate nursing training. Due to increasing problems a regional review of the plan was held in 1989 which found problems such as poor role definition and accountability in the districts competing demands on local sanitarians low community involvement with unused resources conflicting training programs no evidence of improved regional planning since the 1987 workshop insufficient resources for transport reduced budget with increased proportion going to hospitals too much emphasis on sanitation. Some improvements were noted to immunization prenatal care and medically assisted deliveries and placement of 110 aid post workers although many were untrained and not engaged in preventive activities. Some benefits could probably be obtained by integrating the vertical programs of malaria control immunization and maternal-child health; by seeking ways to involve Melanesian culture in primary health care activities; and by extending nurse training to include practical experience in the islands.

Monitoring the growth of the world's children

Growth monitoring and promotion is a difficult operational strategy for communicating with mothers which is based on a simple technology of weighing and charting young children and an assumption that the undoubted early warning of future low nutritional status provided by monthly growth monitoring enables corrective action to be taken to avert death. Doubts have been expressed about the efficacy and cost-effectiveness of existing growth monitoring programmes. There is an urgent need for good demonstrations of programmes in which health professionals and communities cooperate in empowering mothers to promote their children's growth, while marshalling all the primary health care activities, and yielding valuable straightforward data on the growth of the world's children.

Social Science Perspectives on Primary Health Care Activities

This paper summarizes information on the characteristic-flaws in primary health care services, and their geographic patterns of occurrence, with reference to their local, medical, and bureaucratic contexts. The data are derived from published medical ethnographic reports, evaluations of programmes, surveys of physicians in developing countries, and some anecdotal reports. Several key issues emerge from this combination of sources. There is a lack of high-quality services in developing countries; most centres lack medicines, caring and skilled personnel, and convenient locations and scheduling. Also, the professional medical personnel are rarely sufficiently trained to communicate effectively with patients of different economic and ethnic backgrounds or to manage a health team of different backgrounds. The most successful programmes are those that have effective local leadership, adequate training, some curative potential, and powerful political will. The combined public health, medical, political science, sociological, and anthropological studies suggest no “cookbook” solutions as to what exact set of factors will make any programme successful. They appear to illustrate the effectiveness of flexible regional or local policies as opposed to global ones.

Child survival: should the strategy be redesigned? Experience from Bangladesh

The paper examines recent studies which focus on the effectiveness of primary healthcare activities and concludes that in Bangladesh the potential for substantially improving child survival and growth is severely curtailed by unbalanced strategies. More specifically the paper argues; 1) that focusing interventions on at-risk children at 6 months of age is more effective and less costly in preventing malnutrition than monthly monitoring of growth; 2) that attempts to reduce deaths from diarrhea with vertical oral rehydration therapy programs will not have a major impact unless other interventions are directed to the persistent diarrhea-malnutrition complex; 3) that the impact of diarrhea on growth is transient and community efforts to control diarrhea are unlikely to show a sustained improvement in childrens nutritional status; 4) that the benefits of breastfeeding are still underestimated in view of its vital role in preventing deaths in poor malnourished children; and 5) that given the numerous constraints on full Expanded Program on Immunization (EPI) implementation tetanus toxoid and measles vaccination form the most cost-effective immunization strategy for child survival. (authors)

Preventive activities in primary health care in Stockholm county; Sweden

A survey was conducted, during November 1985, in 110 Stockholm Public Primary Health Care Centres (PHCC) to study ongoing preventive activities. In 71% of the Health Centres there was an awareness of special risk groups in the PHCC area, such as alcohol abusers, elderly people and single parents, and in 40% of more specific risk factors like unemployment and loneliness. Individualised preventive activities were provided in 25% and group oriented activities in 50% of the health centres. There were great differences between the different regions of Stockholm County and, for example, quit-smoking groups were not distributed according to the geographical needs, i.e. to the areas with the highest prevalence of smokers. Involvement of PHC in community-based preventive activities is still rare but has started in the area of accident prevention in some PHCC. The study also underlines the need for more education as well as support to increase the element of prevention in primary health care activities.

Evaluation of a simplified method for estimation of early childhood mortality in small populations.

The provision of simple health technologies in less developed countries has far outpaced the capabilities to evaluate their impact on health in general, and early childhood survival in particular. In rural Haiti, attempts to monitor the impact of health care delivery programmes have been frustrated by some of the same problems encountered elsewhere; ie lack of practicable yet scientifically sound methodologies that interface well with ongoing service delivery programmes. The 'preceding birth' technique, originally advanced by Brass and Macrae, holds promise as just such a method. Its practical appeal derives largely from simple data requirements. In its simplest form, the method requires only responses to a single question put to mothers at delivery regarding the survival status of her previous child. They have shown that the proportion of immediately preceding births dying before the 'index' birth date provides a good approximation of the standard life table probability of death before the second birthday. Given that in rural Haiti, as in much of the less developed world, few women deliver in clinic or hospital where such data could be systematically obtained, exploitation of the preceding birth method would require identification of a convenient and unobtrusive point of contact between questioner and mothers who have recently delivered. In Haiti, two options arose: (1) interview women at home after childbirth, and (2) interview women when they bring the 'index' child seeking vaccination or some other child survival intervention. Both of these deviate from the original technique of Brass and Macrae with respect to the timing and method of data collection, and could therefore introduce serious complications to the interpretation of trends in child mortality. To study this, we examined the effects of adapting the preceding birth method to a rural less developed country setting in Mirebalais, where since 1983 primary health care activities have been administered by MARCH (Management and Resources for Community Health), a private voluntary health organization. The Mirebalais study used a pregnancy register, originally developed for targeting of services, to identify women who were expected to have given birth during the 12-month period before each of two survey rounds. Brief interviews with these women would provide direct life table estimates of child mortality level and trend with which to compare estimates produced from use of the preceding birth method in modified form. Direct estimates of the probability of dying before the second birthday were 138/1000 from first round data and 134/1000 from second round data, indicating a 3% decline.(ABSTRACT TRUNCATED AT 400 WORDS)

Swaziland: health sector financing and expenditure

A Health Sector Financing and Expenditure (HSFE) survey was conducted in Swaziland against a background of growing concern about resource constraints on policy implementation. It sought to provide basic financial information which could be used when discussing policy options for addressing these constraints. Under a wide definition of the health sector, expenditure in 1984/85 was found to be equivalent to 9.8% of GDP and E73 ($US35) per capita. Recurrent expenditure dominated sectoral expenditure, at 86.7% of the total; 57% of recurrent expenditure was for primary health care (PHC) activities, but only 17.9% for the core preventive programmes which the policy emphasizes. Moreover, the Ministry of Health's own expenditure was biased in favour of curative care. Out-of-pocket payments largely supported general PHC activities and the core programmes were predominantly funded by foreign aid. Policy calls for increased PHC funding, therefore, are justified on the grounds of existing inappropriate allocations. If this is to be achieved there must be improved efficiency of resource use within services and improved coordination with other sources of finance in the sector. It is especially important to address efficiency issues within the Ministry. Particular attention should be paid to strengthening the role and effectiveness of decentralized management structures in resource allocation. The Ministry should also address concerns about the quality of care provided by its services, especially the poor availability of drugs. Increased PHC funding may, further, be made possible through the recruitment of additional finance. More discussion of alternative financing arrangements is necessary, but their efficacy may be dependent on improving the quality of care provided within public facilities.

Value for money in the health sector: the contribution of primary health care.

Since the Alma-Ata Declaration in 1978, primary health care (PHC) has been seen in most countries as a vital part of any strategy to improve the health of the population. Economic evaluations of PHC delivery and PHC activities are therefore needed to assist in decision-making on resource use in the health sector. A report was prepared on such economic evaluations in the Commonwealth and this paper summarizes those findings which relate to developing Commonwealth countries. After a brief explanation of the main methods of economic evaluation, existing evaluations, classified according to the eight essential elements of PHC, are reviewed. The literature review throws up a number of methodological issues of which policy-makers need to be aware when interpreting evaluations. These are pointed out before moving on to a consideration of what lessons the literature may hold about the value and affordability of PHC and the most efficient ways of delivering PHC activities. The final section suggests that, although economic evaluation techniques have an important role to play in decision-making, they have not so far been used to best advantage. A number of ways in which health ministries could increase the usefulness of the evaluations they commission are considered.

The effect of scale on cost projections for a primary health care program in a developing country

Accurate estimation of the recurrent costs of primary health care (PHC) activities is essential in light of the need for governments to assess whether and how these costs can be financed. This paper argues that expansion of the PHC activities will result in diseconomies of scale that are not captured by constant average cost projections of recurrent costs. An alternative estimation method which captures the effect of rising average unit costs is proposed with application of this method to data from the Republic of Niger. Results of the analysis show that the ‘ r-coefficient’ (ratio of investment to recurrent costs) for PHC activities can double and costs can be 3 times larger after 12 years.

Primary health care for whom? Village perspectives from Nepal

Over the last decade, many developing nations have embraced Primary Health Care (PHC) within their national health plans. PHC, in contrast to earlier approaches to national health development, emphasizes community participation and basic health care for the poorer segments of society. The research reported here finds that in the enthusiasm for the PHC concept in Nepal, important sociocultural processes have been overlooked. This paper describes the relationship between certain sociocultural factors and PHC activities in rural Central Nepal. It reveals a contradiction between the stated PHC intentions to address local interests and promote community participation on the one hand, and the actual approach taken on the other hand. Specifically it argues that PHC is encountering problems in Nepal for three reasons: (1) PHC fails to appreciate villagers' values and their own perceived needs. In particular, PHC is organized primarily to provide health education, whereas villagers value modern curative services and feel little need for new health knowledge. (2) PHC views rural Nepali culture only pejoratively as a barrier to health education. Alternatively, local cultural beliefs and practices should be viewed as resources to facilitate dissemination and acceptance of modern health knowledge. (3) In attempting to incorporate Nepal's traditional medical practitioners into the program, PHC has mistakenly assumed that rural clients passively believe in and obey traditional practitioners. In fact, clients play active roles and are themselves in control of the therapeutic process. Thus, instead of attempting to recruit traditional practitioners to do its work, PHC should recognize the precedent for community participation in Nepal's traditional medical system and develop the respect for villagers' own ideas and values that traditional practitioners already possess.

Primary health care and Protestant medical missionaries in Kenya.

In spite of a long relationship between medical missions and primary health care, relatively few medical missions and missionaries have actively embraced and implemented primary health care programs. This study reports on the present activity level of Protestant medical missionaries in primary health care (PHC). From September through December 1983, the 79 member organizations and facilities of the Protestant Church Medical Association in Kenya were provided with questionnaires to be answered by expatriate medical mission staff. A total of 61 individuals returned questionnaires. Background characteristics of the respondents and self-determined estimates of the % of time spent on various activities are presented. The major site where work was done was reported to be the hospital for 64% of respondents, while the remainder reported working mainly outside the hospital setting. Doctors were significantly more likely to be hospital-based than nurses. PHC activities account for a mean of only 13% of the work week and hospital-based activities, 62%. One might expect that missionaries of longer experience would be more aware of local needs and become more involved in PHC, but this survey does not lend support to such a hypothesis. Such evidence of little involvement in PHC ought to be a major challenge to medical missionaries. It is argued that medical personnel within the church are in a unique position to develop and promote PHC.

Mobilizing indigenous resource for primary health care in Nigeria: A note on the place of traditional medicine

Noting the challenges posed by the goal of Health For All by the Year 2000, this paper re-echoes the need to mobilize traditional medicine for Primary Health Care in Nigeria. The paper points to the inadequacy of modern health facilities and the obstacles that stand in the way of providing enough modern health facilities to meet the demand of Nigeria's population by the year 2000. It is observed that traditional medicine offers an alternative model not only because it is relatively inexpensive both to the practitioners and patients who often settle their bills in kind or cash but also because of its acceptability among Nigerians. Finally, it is suggested that government and traditional medical practitioners should cooperate for it is in this way that the practice of traditional medicine can be improved and the practitioners encouraged to add Primary Health Care activities to the repertoire.

Evaluation of primary health care: approaches, comments and criticisms.

A broad definition of evaluation is that it is a "process which attempts to determine as systematically as possible the relevance, effectiveness and impact of activities in the light of their objectives." Impact is the ultimate improvement that all primary health care (PHC) is aiming for but very good PHC must be implemented over several years before a measurable impact can be produced. The Narangwal Project in India has been one of the most successful examples of an evaluation of a PHC program. Another large PHC project that had a successful impact on improving health status was initiated in 1972 in West Azerbijan, Iran. The impact evaluation suggested a considerable effect in lowering infant mortality and neonatal tetanus. The 5 main components of PHC activities are: 1) peripheral or basic health services and village health worker (VHW) schemes; 2) intermediate level support to the basic health services and VHW schemes by regional and district services; 3) intersectional activities; 4) community and individual participation in all aspects of health care; and 5) cooperation and coordination with the traditional, private and nongovernment systems of health care. An evaluation of PHC must take into account how well the basic principles have been adhered to, and how well they are working. PHC activities are ususally implemented at the level of national government, intermediate administrations, and local governments. The debate about evaluation concerns who is involved. Should those who are managing PHC activities be involved, or outside experts? There are 2 sets of objectives which must be considered. The 1st are objectives of the PHC program itself; the 2nd, the objectives for evaluation. Methods used range from informal, unstructured conversations to large sample surveys. In depth local case studies can be valuable. The most useful indicators for evaluating PHC are enumerated.

Primary Health Care Activities: What are They?

Primary Health Care Activities: What are They?