Primary Health Care Project Research Articles

New partnership for health care.

A £4 million primary health care project in London is to be funded by a new partnership involving business, government and charities, the Kings Fund announced this week.

What are the lessons from evaluating PHC projects? A personal view

This paper gives an overview of methods used in evaluation of primary health care (PHC) projects and health sectors by different donors. It is based on a synthesis document written for the Development Assistance Committee (DAC) evaluation committee of the OECD, which analysed 83 evaluation reports and policy statements by donors, successive evaluations of one PHC project, and the author's own experience in carrying out evaluations of PHC projects. The paper concludes that most donors either have no guidelines on PHC evaluation, or do not use them. Evaluation missions are carried out in as many different ways as there are consultants. Reliability, validity, relevance and use of these reports is therefore questioned. The paper recommends more co-ordination between donors and ministries of health in the development of guidelines for project evaluation in PHC, so that results can be more comparable, and policies can be adapted and formulated, agreed on a more solid base.

Which way to sustainability? External support to health projects in developing countries

The purpose of this paper is to analyse the process by which donors decide whether or not to support specific primary health care projects. First of all, there has to be an ‘eligible situation’: an inability to start without external support, coupled with an ability to sustain the project (without such support) once it has started. Secondly there must an ‘eligible project’, that is, a project that requires support of a ‘one-time-only’ nature (for example, capital outlay); or recurrent support to temporary activities (such as salaries for a temporary campaign), or temporary support to recurrent activities (for the initial stages of innovative programmes). Proposals for really innovative programmes are seldom readily available, and the most appropriate form of support may then be to support an institution charged with the development of such innovative programmes.

Effect on mortality of community-based maternity-care programme in rural Bangladesh

Various community-based interventions have been proposed to improve maternity care, but hardly any studies have reported the effect of these measures on maternal mortality. In this study, the efficacy of a maternity-care programme to reduce maternal mortality has been evaluated in the context of a primary health-care project in rural Bangladesh. Trained midwives were posted in villages, and asked to attend as many home-deliveries as possible, detect and manage obstetric complications at onset, and accompany patients requiring referral for higher-level care to the project central maternity clinic. The effect of the programme was evaluated by comparison of direct obstetric maternal mortality ratios between the programme area and a neighbouring control area without midwives. Random assignment of the intervention was not possible but potentially confounding characteristics, including coverage and use of other health and family planning services, were similar in both areas. Maternal mortality ratios due to obstetric complications were similar in both areas during the 3 years preceding the start of the programme. By contrast, during the following 3 years, the ratio was significantly lower in the programme than in the control area (1·4 vs 3·8 per 1000 live births, p=0·02). The findings suggest that maternal survival can be improved by the posting of midwives at village level, if they are given proper training, means, supervision, and back-up. The inputs for such a programme to succeed and the constraints of its replication on a large scale should not be underestimated.

Nairobi Perspective: Lessons from the East African bush

The goals set at the Alma Ata Conference--community health care water and sanitation schemes mobile rural clinics for nomads and nutrition and immunization programs--are being implemented in the Kenyan bush by the African Medical and Research Foundation (AMREF). AMREF currently has over 100 projects underway in 5 states in East Africa a staff of 600 and an annual budget of 10 million pounds. Among AMREFs 24 projects in Kenya is the Turkana hydatid control effort. A community research program launched in 1976 in this nomadic group uncovered the epidemiology of hydatid found that it could be diagnosed by ultrasound and serology and demonstrated the effectiveness of treatment with albendazole. 10% of tribe members were affected by the disease which was spread through the practice of having dogs clean up infants bowel movements. AMREFs mobile clinics include not only nurses parasitologists and laboratory technicians but also an anthropologist charged with devising ways of getting the tribe to abandon this tradition. AMREF has been able to establish community-based primary health care among another nomadic tribe the Maasai because this group is large enough to have base to which the adults return and the young and elderly never leave. Here community health workers are attempting to reduce the prevalence--now at 60% of village children--of trachoma. This infection is spread by contaminated drinking water and flies that are drawn to the huts constructed of cow dung and branches. Most successful has been a primary health care project among the Kamba in Kibwezi which includes monthly training for birth attendants construction of pit latrines community-based contraceptive distribution clean water projects a scheme for the rehabilitation of the disabled a health center and an information office to collect data on unmet needs.

Did the project fail? A community perspective on a participatory primary health care project in Ecuador

This article examines a UNICEF/Ministry of Health primary health care programme in Ecuador from a community perspective. It contributes to the debate concerning the way in which the relative ‘success˚s or ‘failure˚s of participatory projects is measured. It argues for evaluators to distinguish between the perceptions of the different actors involved, and to extend their enquiries beyond the actual lifespan of the project. It also provides lessons for the future by discussing the contribution that technical projects can make to capacity building and the empowerment of community-level organisations.

Childhood Mortality among Users and Non-Users of Primary Health Care in a Rural West African Community

To evaluate the effectiveness of primary health care (PHC) interventions implemented through the Pahou PHC Project, the utilization of PHC by 74 children aged 4 to 35 months who died in 1986 or 1987 was compared to that of 230 controls who survived and were individually matched by date of birth, sex and place of residence. The crude death rate was 35.9/1000/year. Measles vaccination before the first birthday significantly reduced the risk of mortality (Relative Risk/RR = 0.4). Children with less than 75% weight for age early in 1986 had an increased risk (RR = 4.3). Children who died had had significantly fewer contacts with the village health worker (VHW) in the last six months prior to death (RR = 0.3). A similar association was not observed for periods more than six months prior to death. Children who had more regular contact with the VHW throughout life were better protected than children for whom contact had been less systematic. We conclude that VHWs contribute to a better survival of young children through regular personal contact with the household.

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)

A cost-effectiveness evaluation of primary health care projects for the poor.

A cost-effectiveness analysis was conducted to determine the relative efficacy of nine primary health care projects serving low income persons in urban and rural areas of Texas. The projects were created as part of a government program to provide services in medically underserved areas of the state by contracting with local public and private providers. While they vary widely in terms of sponsoring organizations, service strategy, and scope of services, the projects share a similar goal of providing an array of basic medical and preventive care services to the poor. This study compares the average cost per encounter for diagnosis/treatment, emergency, family planning, and preventive health screening services provided by the various projects during the first year of operation. After adjusting for differences in input prices and patient volume, the cost differences are examined and related to organizational model and personnel mix. Those projects with the highest ratio of nonphysician to physician practitioners proved more cost-effective, as did those projects following the public clinic model of service delivery.

Community-oriented, primary health services: lessons drawn from international experiences of the W. K. Kellogg Foundation.

Primary health care projects in Latin America aided by the W K Kellogg Foundation (WKKF) aim to provide comprehensive care--maternal-infant health immunization dental care and home visits by health aides for example--to all members of the family as a unit. The Cotia Hospital project in a semi-rural community outside of Sao Paulo Brazil and the University of El Valle project at both urban and rural sites in Cali Colombia embody the Foundations approach to community-oriented primary health care. The Cotia Hospital Association provides a complete range of acute care disease prevention and health promotion services to over 80000 people as well as continuing education to physicians nurses dentists administrators and community volunteers. The Cali project is a model of regionalized health care and integrated community development programs aimed at family-oriented primary health care delivery. In addition this project has conducted research and development in 4 geographic regions provided continuing education for health personnel and generated data on the impact of innovation on mortality and morbidity the cost-effectiveness of services rendered and acceptance of services by the community. Initially the WKKF encountered resistance to the concept of family practice as a specialty but acceptance has broadened over the past decade. Among the lessons learned from the Foundations 50 years of experience in international project support are the importance of comprehensive and multidisciplinary approaches articulation between teaching and service tapping into the creative energies of the private sector drawing on both Western-based and traditional medical principles sustained local leadership and community involvement and obtaining support for a project from several founders.

The Kisumu Primary Health Care Project

The Kisumu Primary Health Care Project

Finding the Keys to Success: What Makes Family Planning and Primary Health Care Programs Work?

The key to successful family planning and primary health care programs in developing countries is a careful assessment of local conditions according to case studies of programs in Thailand Mexico Kenya Bangladesh and India. The case studies were presented at a conference sponsored by the Rockefeller Foundation. An evaluation of each of the countrys programs showed that success was achieved where the family planning and primary health care programs were integrated with the respective countrys culture religion level of socioeconomic development gender roles bureaucratic tradition and political commitment. Also contributing to a programs success were: good planning; careful implementation; personnel policies emphasizing training supervision and good management; sound financial policies; continuous monitoring and evaluation; and the establishment of clear objectives with achievable goals. An evaluation of 3 family planning and primary health care projects begun 15-30 years ago showed that the 3 still in existence (Haiti India and Thailand) emphasized community participation and support and relied on active outreach by locally based health workers visiting individuals at home.

A primary health care project in a Colombian shantytown.

A primary health care project in a Colombian shantytown.

Primary health care is not cheap: a case study from Guinea Bissau.

In 1977 the Ministry of Health in Guinea Bissau started two regional community health projects. In this article we describe the progress of the Tombali project. Three aspects are discussed: the "Learning Process Approach" used in the project; measurement of the effectiveness of the project and the problems of collecting and interpreting these data; and the ratio of investment to recurrent costs and the proportions borne by government and by villagers. Primary health care projects evolve slowly, and the importance of the willingness of project workers, donor agencies, and the national government to work without a blueprint plan is emphasized. We discuss ways of evaluating the success of primary health care schemes; the measurement of any change in health status is difficult and discounts other benefits that may result, such as encouraging community participation and involving villagers in government activities. Both government and villagers contribute significantly to the scheme, the government and donors bearing most of the investment costs, while most of the recurrent costs fall on the villagers. The data show that for neither government nor villagers is the scheme a cheap option to secure health care for rural populations. Finally, we discuss the lessons to be learned by national governments, donor agencies, and health workers from this attempt to implement a primary health care program.

Designing community financing schemes in two developing countries

This article describes the application of operations research (OR) to the design of community financing strategies in two primary health care (PHC) projects, one in Bolivia and the other in Liberia, during the period 1984–1986. It highlights the use of preference-based heuristics to select appropriate financing schemes, and illustrates how such heuristics can accomodate the preferences, judgments, and knowledge of community members and health professionals alike in arriving at program decisions which have a reasonable probability of being both feasible and acceptable to those most concerned. The paper begins with a description of the Bolivian community financing study. It follows the decision heuristic step-by-step through the identification and initial scoring of alternative strategies, the selection of the most promising of these, and the resulting decision to undertake a field trial in eight villages. Turning to the Liberian study, the paper reviews a considerably less complex preference-based heuristic used in three remote rural communities to select a community financing strategy. That heuristic led to the implementation of a strategy combining four different modes of community support. The results of a 12-month field test of that strategy are described. Although the heuristic decision processes followed in the Bolivian and Liberian cases differ in detail and complexity, the approach used to design a community financing strategy was based on the same principle: the systematic ranking of alternative financing schemes according to the preferences of the relevant decision-makers in order to select that strategy which appears most likely to solve the financing problem in a given community. Officials of both projects conclude that the basic approach affords an effective way to enlist community support in financing a portion of PHC costs from local resources.

The primary health care project in Belgium: A survey on the utilization of health services

The article consists of two major parts. In the Introduction a general overview is given of the Primary Health Care Project, carried out in Belgium from 1975 to 1978 in the broader framework of a large National Project in the Social Sciences. An explanation is given of the scope of the study, its method and sampling. Since the very broad study design, it was decided to make a selection of interesting results. An overview is given of the most relevant data with respect to the utilization of health care services and of medicines. After a short clarification of the concept of utilization behaviour, some data are presented in order to describe the use of medical services and the consumption of medicines. Secondly an attempt is made to explain utilization behaviour. For the explanatory model used in this project, the WHO-model functioned as an important source of inspiration. In this way it surmounted the limitations of much previous research. This model included variables on the level of the individual—perceived morbidity, predisposing factors and enabling factors—as well as system variables—such as degree of urbanization, proximity and the way of functioning of the medical supply. The research results have successfully shown that: there is a strong relationship between perceived presence and perceived seriousness of morbidity on the one hand, utilization behaviour on the other hand; the health perspective (including medical knowledge, values and attitudes) seems to have a differential influence on utilization behaviour, depending on age and social background of the respondent; the inclusion of socio-structural variables is an innovation in the Belgian health care research. The hypothetical character of the relationships found here is largely supported by the research simultaneously conducted in the French-speaking region of Belgium; accessibility and socialization are factors having a clear influence on the use of general practice services. The importance of the presence and the organization of the supply in the explanation of utilization behaviour is partly confirmed.

Characteristics of family planning acceptors at aprimary health care project in Lagos, Nigeria

Analysis of data collected from the family planning section of a Primary Health CareProject in Lagos, showed that the majority of the 275 acceptors in 1979 were aged 25–39 years, monogamously married, had primary or no education and had between three and five children. A comparison of the data with those from the Lagos University Hospital in 1972 showed that women with two or fewer children continue to be under presented in relation to their proportion in the population. It was also found that even though the project was catering for a geographically demarcated target population, most clients came from outside of the area, and some from very far away. This suggests that other strategies for delivery of Family Planning services may be called for.

PRIMARY HEALTH CARE WILL FAIL IF WE DO NOT CHANGE OUR APPROACH

The implementation of primary health care seems seriously hampered because it is not properly handled by many of the international agencies. Initial concern is the haste with which primary health care projects are being established and executed. These projects are expected to improve the health status of the target group within 2-3 years. Almost everywhere health officials are trying to expand primary health care schemes as rapidly as possible and to provide a maximum of the population with village health workers, yet little attention is directed to the structure needed to support the village workers nor to the problems related to their training motivation and financial reward. There is also the tendency to ignore the complex interrelations between the socioeconomic, cultural, and political factors and health improvement in general. A better way of attaining permanent improvement in health is to build slowly, using the local results and positive experiences in primary health care to reinforce the awareness and political organizations of the poor so that they will have more power to demand a shift in money allocation in their favor from their governments. In most countries this is not likely to happen even after the year 2000, and the World Health Organization (WHO) should stop advertising "Health for All by the Year 2000" and call for slow and careful expansion of the primary health care policy. There are some negative aspects to the amount of money available for primary health care. Donors keen to help with primary health care may not see that it needs the assistance of all medical departments to operate effectively. Despite considerable financial investment in primary health care over the past few years, few countries have been able to change their health budgets from hospital-based services to primary health care. The priorities in the ministries of health still seem heavily biased toward the existing curative and urban-based health services. Through primary health care, predominantly Western values are introduced into the countries to be served by the projects. 1 such case is the emphasis on efficiency in establishing and running primary health care projects. The preoccupation with data collection in primary health care is another example of Western influence as is the tendency to plan, in as much detail as possible, the objectives to be met at each stage of a project. A less ambitious approach to a community health care proposal by the government of Giunea-Bissau with less defined objectives would have been preferable, but it is questionable whether the Western donor would have accepted such a "vague proposal.

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.

Appropriate research for primary health care: an anthropologist's view.

In Primary Health Care (PHC) projects, it has become customary to conduct all-purpose surveys early in the project. These are usually based on questionnaires administered to a relatively large sample of the population and elicit information on demography, living conditions, health status, sanitary facilities and socio-economic attributes of the population, in addition to providing baseline data on the indicators of program success. It is recommended that a distinction be made between different types of data collection efforts and that consideration be given to the timing of such surveys so as not to raise community expectations. Early in the project a survey of demographic characteristics and health indicators may be appropriate. However, major surveys of living conditions and health problems are better delayed until the program is in operation and such surveys can be used as mechanisms for community participation, motivation and education. The limitations on the use of questionnaires is discussed. Because anthropological methods are more suited to the skills of health promoters and yield valuable behavioral data, it is suggested that anthropologists encourage the use of these alternatives to questionnaires. The use of participant-observation, life stories, interviews, mapping and essays are discussed in the context of PHC programs.