Comprehensive Primary Health Care Research Articles

User fees plus quality equals improved access to health care: Results of a field experiment in Cameroon

Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people. A “pretest-posttest controlled” experiment was conducted in five public health facilities in the Adamaoua province of Cameroon. Three health centers which were to introduce a user fee and quality improvement (i.e. reliable drug supply) policy were selected as “treatment” centers and two comparable facilities not yet phased into this policy were selected as “controls”. Two rounds of household surveys were conducted (each to 800 households in 25 villages surrounding the five study sites) to measure the percentage of ill people seeking care at the health center before and after the implementation of the policy. The experiment was tightly controlled by conducting monthly observations at each study site. Results indicate that the probability of using the health center increased significantly for people in the “treatment” areas compared to those in the “control” areas. Travel and time costs involved in seeking alternative sources of care are high; when good quality drugs became available at the local health center, the fee charged for care and treatment represented an effective reduction in the price of care and thus utilization rose. Moreover, contrary to previous studies which have found that the poorest quintile is most hurt by user fees, this study found that probability of the poorest quintile seeking care increases at a rate proportionately greater than the rest of the population. Since the poor are most responsive to price changes, they appear to be benefitting from local availability of drugs more than others.

The role of the nurse practitioner in adult day care.

During the past 25 years, nurse practitioners (NPs) have become health care providers in a variety of settings. Adult day care is one of the settings in which it is increasingly clear that there is a role for the NP. Nurse practitioners have the potential to provide increased comprehensive primary health care to clients participating in these programs.

Comprehensive primary health care antiepileptic drug treatment programme in rural and semi-urban Kenya

A programme of antiepileptic treatment in a rural and semi-urban region in Kenya was assessed. Patients with generalised tonic-clonic seizures were treated according to one of two simple drug protocols. Health workers screened cases reported by key informants in the community. From the 529 patients identified by health workers as having active seizures 302 patients aged 6-65 years were recruited by a psychiatrist for therapy with carbamazepine or phenobarbitone. Treatment was supervised largely by primary health workers, and the programme was monitored by a research team, which assessed the effectiveness of treatment. Of the 249 patients who completed the study, 53% became seizure-free in the second 6 months of therapy, and another 26% had substantially (50% or more reduction) fewer seizures than in the 6 months before therapy. The similarity of these findings to those obtained in newly diagnosed patients in the developed world, the low drop-out rate, the low rate of withdrawal due to adverse effects, and the acceptable compliance with therapy indicate that health workers can monitor therapy adequately. Most patients had had several years of delay before starting therapy for their epilepsy, yet they responded well—a finding that does not support the suggestion that the disorder becomes intractable if not treated early.

Child psychiatry in Thailand

Thailand, unlike many Asian countries, never experienced colonial or imperial subjection and thus lacked the portal through which psychiatric services usually gained entry. As a result, progress in this field was initially slow. The first mental hospital was established in 1889, a century later than in India. The country has been fortunate inasmuch as it has been spared involvement in the wars, revolutions, and other social upheavals that have plagued Asia in the 20th century. Recent national stability and impressive economic growth have provided a sound base for the development of health services, and progress has been rapid in comparison with many neighbouring countries. Due attention has been paid to family planning, maternity and child welfare services. The provision of comprehensive primary health care in urban and rural areas is improving all the time. The education of children is universally regarded as important. Schooling is compulsory and attendance satisfactory.

Process evaluation in a Colombian primary health care programme

In a comprehensive primary healthcare (PHC) project evaluation was carried out for decision making purposes over a 5-year period. All information gathered by different methods was then analyzed and ordered using a systems approach; the system of the project with its inputs process output and outcome was defined and data arranged and analyzed accordingly. Criteria for the analysis were reliability and validity relevance costs of obtaining the data and use of the data. For decision making purposes the information on the process the interaction between the project activities and the community with all of its different components was the most relevant. It was obtained by use of the WHO protocols by external evaluations and from participatory evaluation. Output data (mainly on coverage) were easily obtained but only when combined with information on the process could it be known whether such data gave indication of effective coverage. Methods used for process evaluation are described and it is suggested that process evaluation should always be built into PHC projects and programs. WHO protocols adapted to local situations and used in a participatory manner are good instruments for evaluation of the processes at the service and community levels. (authors)

Comprehensive Primary Health Care

I n my last letter, I indicated that I would write to you again concerning the questions you raised about the type of health care program that I provided for all office patients. In regard to whether there are enough physicians to provide comprehensive primary health care, I have always felt, speaking in purely economic terms, that medical care is a commodity that is bought and sold in the marketplace. When the demand is present, the supply will become available. Actually, the predominant request today is for<i>symptomatic</i>care rather than<i>comprehensive</i>primary care. Training two types of physicians, one to provide symptomatic care and the other to provide comprehensive care, has been suggested. I agree with the statement by George Engel, MD, Professor of Medicine and Psychiatry, Medical School, Rochester, NY, in the reprint that I sent you: "It is better to have two categories of health professionals, one

Comprehensive primary health care. A letter to a medical student

Comprehensive primary health care. A letter to a medical student

Consensus and Coercion: Primary Health Care and the Guatemalan State

During the 1970s international and bilateral development agencies actively began promoting and financing comprehensive primary health care (PHC) programs in underdeveloped countries. The stated goal of these activities was to provide rural peoples with a modicum of basic health services, and access to health care did increase as a consequence of the PHC effort. However, this article examines the relationship between capitalist development processes, the state, and the peasantry in Guatemala in order to demonstrate another consequence of PHC interventions: that they ultimately operated as an inherent part of this relationship and bolstered legitimacy for the existing social and economic order. Although the delicate balance between the state's need to garner consensus and its potential for resorting to coercion to establish its legitimacy is clearly highlighted in an extreme example like Guatemala, the same relationship between processes of capitalist accumulation and social legitimation pertains to other settings.

International Organizations, Health Services, and Nation Building in Nicaragua

Recent studies have noted a new conservatism among international health organizations as they shift from policies of comprehensive primary health care to more vertical programs of disease control in the Third World. Health care efforts in Nicaragua since 1979 offer an arena in which to analyze the role of the World Health Organization (WHO), the Pan American Health Organization (PAHO), and the United Nations International Children's Emergency Fund (UNICEF) in the elaboration of Nicaragua's health development policy and practice over time. I conclude that international health organizations can play an important role in the consolidation of popular democracy in developing nations, especially when this is part of the political agenda of the host country.

Hepatitis B infections in the Arsi region of Ethiopia.

In a sample of inhabitants of the Arsi region of Ethiopia prevalence of hepatitis B is around 80% in the age group 20-24. In addition to age, sex and size of family, exposure to tribal practices is a determinant of seropositivity in this group accounting for as much as 20% of the total burden of the infection. Waiting for a mass vaccination campaign, presently unrealistic in this area of the world, health education, as part of a comprehensive primary health care program, has to be considered as a potentially effective preventive tool.

Gobi versus PHC? Some dangers of selective primary health care

This article enters the debate concerning comprehensive versus selective primary health care by focusing on UNICEF's ‘child survival revolution’. It is argued that UNICEF is dangerously mistaken in believing that its present emphasis on selective primary health care is a precursor or ‘leading edge’ of comprehensive primary health care. The approach of UNICEF—diffusion of a package of technologies by campaigns organized from the top down—is more likely to undermine the social basis for comprehensive care. The kinds of implementation UNICEF has chosen in order to minimize costs and maximize impact on child mortality, namely ‘social marketing’ via mass media and massive, ad hoc delivery systems seriously undermine the development of grassroots organization among parents and primary health care workers. Indigenuous, local organizations are distorted and limited to conduits of a delivery system. Needs are defined outside the communities affected. In addition, UNICEF's so-called revolution has in common with other selective approaches an ideology accepting as inevitable the health effects of economic crisis in the 1980s, further undermining the confidence of local groups and health workers who might otherwise conceive of their desire to control health conditions as a right. The UNICEF interventions popularly known as GOBI-FFF are ‘targetted’ at individuals, in particular ‘ignorant’ mothers. As such they are especially destructive to the process of group formation and self-organization of the poor around their just demands for water and sanitation, land, shelter, and employment. This article concludes that UNICEF's GOBI should either be abandoned or integrated into comprehensive primary health care programs that put parents and local workers in control and that emphasize continuing political struggle for health rights.

The evolution of selective primary health care

This paper traces the evolution of the selective primary health care (SPHC) concept, from its presentation at a meeting in Bellagio, Italy, and its subsequent publication in the New England Journal of Medicine in 1979. It reviews the early debate between those in favor of selectivity and those in favor of comprehensive primary health care (CPHC). While this debate was going on, a breakthrough in terms of implementation came with UNICEF's launching of its Children's Revolution in 1982/83, promoting four specific ‘social and scientific advances’ for improving the health and nutrition of the world's children. They were growth monitoring, oral rehydration therapy, breastfeeding and immunization. Meanwhile the interest of a number of people for achieving ‘Health For All’ by targeting for action an essential short list of diseases was the impetus for another conference in 1985, Good Health at Low Cost. Through analysis of the achievements of four societies (Cost Rica, China, Kerala and Sri Lanka) efforts were made to define further a prioritized health development strategy, and a number of measures were identified as helping countries achieve good health. While some have argued that SPHC and CPHC are irreconcilable and diametrically opposed, this paper suggests that both SPCH and CPHC are both acceptable. Technology has its place. The field of view of SPHC has enlarged drastically, from individual diseases to the role of other sectors such as education and agriculture. The concept of SPHC has broadened to accept Rifkin's and Walt's assertion that “developmental processes need further exploration and research strengthening capabilities within countries”. But research effort should not be an either/or: the development of technology is an important as research into developmental processes.

Priority setting and economic appraisal: Whose priorities—the community or the economist?

Scarce resources for health require a process for setting priorities. The exact mechanism chosen has important implications for the type of priorities and plans set, and in particular their relationship to the principles of primary health care. One technique increasingly advocated as an aid to priority setting is economic appraisal. It is argued however that economic appraisal is likely to reinforce a selective primary health care approach through its espousal of a technocratic medical model and through its hidden but implicit value judgements. It is suggested that urgent attention is needed to develop approaches to priority setting that incorporate the strengths of economic appraisal, but that are consistent with comprehensive primary health care.

Is there a middle way? Categorical programs for PHC

Comprehensive primary health care and selective primary health care are often unnecessarily considered mutually exclusive positions. It is frequently assumed that as they are defined the frameworks of each are different and that acceptance of 1 approach precludes the acceptance of the other. A problem-oriented approach is suggested as a middle way. This approach takes a middle ground by defining a series of tasks or strategies that are focused and manageable. Although individual government institutions such as health ministries necessarily operate in only 1 sector taking a problem--solving approach does not necessarily imply that the strategy will be a top-down effort. This may be appropriate in some circumstances where the intervention. The tasks may just as well include the establishment of community organizations to assure autonomous management of specific activities and inevitably must include information education and communication programs where personal behavioral change is essential for effective implementation as for example with educational activities. The point is that a categorical program that is poblem-oriented sets out some specific goals and tasks with designated endpoints to be reached. Relating inputs to outputs and to impact is permitted. The family planning movement could be considered a categorical program that clearly stands somewhere between what is defined as comprehensive primary care and selective primary care.

Urban poor and primary health care: an analysis of infant mortality of an inner city community.

This study analyzes the effect of the establishment of a primary health care center (the Atlanta Southside Health Center) upon the health of an urban poor community using infant mortality as an index of health. Data from the area is compared to that for the surrounding county state and the country as a whole. Results showed that infant mortality in the Southside community was reduced 46.8% since the establishment of the community-based health center compared to 22.2% for the county 21.3% for the state of Georgia and 19.14% for the US as a whole. The analysis covered the period from 1977-1982 and indicated that the gap in infant mortality between the inner city poor and the larger surrounding areas was markedly bridged over this period and effect the authors attribute to the availability of simple affordable and comprehensive primary health care services to this population. Emphasis is placed on patient education as well as community participation.

Why health improves: Defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’

What is the impact of technology on improving the life situations of people, especially the poor? How is this impact analyzed in terms of health improvements? These questions are paramount in the minds of health planners as they pursue national policies of primary health care, a policy popularized by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) and accepted by over 150 governments at Alma Ata in 1978. The purpose of this paper is to explore these questions in depth. It begins by giving the background to the debate, then examines the origins of two concepts which have dominated the field, those of ‘primary health care’ and ‘selective primary health care.’ On this basis it suggests areas of differences in the two concepts and discusses the policy and practical implications of confusing the two approaches. The paper suggests that the differences are firstly who controls the outcome of technological interventions and the perceived time frame in which plans can be carried out.

Selective primary health care: a critical review of methods and results.

In the aftermath of the Alma Ata conference, three types of Primary Health Care (PHC), have been identified. Comprehensive PHC (CPHC) and Basic PHC (BPHC) both have a wide scope of activities, BPHC however does not include water and sanitation activities. Only one year after the Alma Ata conference, CPHC was attacked as not 'feasible' and selective PHC (SPHC) was offered as an interim alternative. SPHC only addresses 5 to 8 diseases, almost all of them falling within the realm of pediatrics. Our article critically analyses the methods and results of SPHC. It contrasts the lack of supportive data for SPHC and its methodological deficiencies with the extent of its adoption by bilateral cooperation agencies, foundations, academic and research institutions, and international agencies. We suggest that rather than health factors, the major determinants of this adoption have been political and economical constraints acting upon decision makers exposed to a similar training in public health.

Pediatrics and Psychology

The growing relationship between pediatrics and psychology is described. Differences and similarities in training and orientation between psychologists and pediatricians are discussed, as well as three different models of collaboration. Pediatrician-psychologist collaboration can result in significant improvements in: comprehensive primary health care, treatment of psychosomatic disorders, and management of children suffering from a combination of medical, family, and adjustment problems. Research and health care legislation are two additional areas where collaboration between pediatrics and psychology is proving to be valuable.

Does Pediatric Home Care Make a Difference for Children with Chronic Illness? Findings from the Pediatric Ambulatory Care Treatment Study

The ongoing care needed by children with chronic physical illness is a topic of national concern. The Pediatric Ambulatory Care Treatment Study ( PACTS ) is a classic pretest-posttest randomized experiment designed to evaluate a Pediatric Home Care (PHC) program in which an interdisciplinary team provides comprehensive primary health care, support, coordination, patient advocacy, and education to chronically ill children and their families. Home interviews were conducted by an independent research team with the 219 families at enrollment, 6 months, and 1 year; 80% completed all three interviews. Analyses indicate that pediatric home care is effective in improving the satisfaction of the family with care, in improving the child's psychological adjustment, and in lessening the psychiatric symptoms of the mother. The functional status of the children was equally well maintained in both groups, and there was no significant difference in the impact of the illness on the family between the two groups. There are indications that there may be a dose-related effect with respect to the child's psychological adjustment with those in the program for the longest period of time showing the greatest benefit. Such a home care program can be an effective intervention for minimizing the social and psychological consequences of chronic illness.

Primary health care in practice: A study in Mozambique

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.