Primary Health Care in Developing Countries: A Look at Some of the Problems

Primary Health Care in Developing Countries: A Look at Some of the ProblemsAuthor(s): STANLEY GREENHILLSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 70, No.1 (JANUARY/FEBRUARY 1979), pp. 38-40Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41987998 .

Accessed: 17/06/2014 23:18

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

Canadian Public Health Association is collaborating with JSTOR to digitize, preserve and extend access toCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique.

http://www.jstor.org

This content downloaded from 185.2.32.24 on Tue, 17 Jun 2014 23:18:41 PMAll use subject to JSTOR Terms and Conditions

http://www.jstor.org/action/showPublisher?publisherCode=cpha

http://www.jstor.org/stable/41987998?origin=JSTOR-pdf

http://www.jstor.org/page/info/about/policies/terms.jsp


Primary Health Care in Developing Countries:

A Look at Some of the Problems

STANLEY GREENHILL, M.D.'

"... aid given for medical purposes must be given wisely and be accepted by both sides; it must fit into the overall development programs of the emerging country and it must be used to provide what is most needed and accepted locally for the maximum benefit of most people. It is essential that the donor should cooperate completely with the recipient and not work on the avuncular and still too common basis that what is good for the developed sophisticated industrialized world is automatically the best thing for the developing world." Maegraith, B. One World. London: Athlone Press, 1973: 4.

Politicians, and planners economists,

involved with bankers,

aid and planners involved with aid programs to Third World nations rarely consider the national health as a national resource. Health policies are not usually linked to development activities. A major responsibility of a health consultant in such countries is to con- vince the planners that prevailing health problems are one of the key factors that will determine the success or failure of any socio-economic development program. The concept of health as a natural resource is difficult to quantify. Yet implementation of any program is de- pendent upon the quality and quantity of the human resources available - and these are a reflection of the prevailing national health.

History Nearly all of the so-called developing

countries at one time or another in their history have been colonies. The medical care in early colonial days was provided by doctors of the colonial power. Gradually an increasing amount of medical care was provided by nationals trained in the medical schools of the colonizing nation. Eventually in some colonies medical schools were established but the curricula, if not the faculty, were "old-country" based. Local graduates generally took their

1. Professor & Chairman, Dept. of Community Med- icine, 13-108 Clinical Science Building, University of Alberta, Edmonton, Canada T6G 2G3

postgraduate training in the medical institutions of the colonizing power.

The result was that these graduates became familiar with the health problems met with in industrialized nations but remained unfamiliar with the health needs of their own populations. The medical graduates of those colonial days represented an elitist establish- ment that wielded considerable political pressure, defended its own interests, and generally had only passing interest in the health of the people. Their training and orientation was to the cure of the individual, a high regard for entrepreneurial medicine, and minimal appreciation of the need for prevention and promotion of health of the population at large. The absence of any significant decision- or policy-making power by local and/ or rural com- munities facilitated the entrenchment of western-style medical practice in the urban centres.

Some of the colonial powers, real- izing they were creating a medical profession moulded in the image of their mother country and so unsuited to deal with the health problems encountered in their colonial territories re- sponded by developing "colonial medical services". The medical personnel of these services were by and large expatriates with some ancillary health workers drawn from local populations. These health workers - nurses, auxiliaries, assistants, and others -

received their training in the colony. Some received additional training in institutions of the colonizing power. Other health workers acquired additional special training as circumstances warranted.

The colonial medical services at- tracted dedicated and often gifted expatriates. It was through the activities of colonial medical services that tropical medicine became a specialty, and the means by which the under- standing and control of previously devasting tropical diseases was achieved. A colonial medical service not only provided services to large populations hitherto without health services - other than those provided by indigenous healers - but also established an administrative and support infrastructure. Epidemiolog- ical and biostatistical data were collected, disease surveillance was established, and the compilation of clinical records from field stations and hospitals commenced.

Decolonization In the decolonization that followed

World War II, these colonial health services were taken over by the new governments. In the immediate post- liberation phase high priority was given to socio-economic development. Prob- lems of health, health manpower, and the health care system were given lower ratings. During this same period many expatriates left, sometimes to be replaced by new "outsiders", but sometimes the gap was never filled.

The weaknesses of previous colonial administration became manifest during this transitional phase. Though some colonial administrations did train a cadre of mid-level administrative officers and support staff it was rare for

38 Vol. 70, January/ February 1979 Canadian Journal of Public Health



a local national to be given executive authority or decision-making power. Policy- and decision-making had been a function of the colonial power's central office mediated through local expatriate officials. The exodus of senior administrative expatriate officials produced a serious disruption in administrative duties and functions. In many Third World countries this deficit of competent administrators accus- tomed to decision-making remains.

Training and Education of Medical Personnel

The medical care in Third World countries was provided either by expatriate doctors or local medical graduates trained by expatriate faculty. Third World medical graduates still seek postgraduate training in the technologically-oriented health-science centres of the industrialized nations.

The result is that graduates from Third World medical schools still ac- quire the medical mores and professional attitudes generated in the developed countries. They still seek the specialization and higher degrees found in Europe and North America. They remain to a large extent ignorant of the morbidity and mortality which prevail amongst their own people. They wish to

- emulate the practice of specialized technological medicine. Their research concerns are by and large those of Europe and North America, not those of their own region. The professional challenges of treating and preventing disease endemic in their rural populations are no compensation for the discomforts and isolation of rural living. Their orientation is still to the sick individual and not to the ills of the community. Preventive medicine and health promotion are neither as attractive nor as lucrative as an urban hospital-based private specialist practice.

Post-Liberation In the post-liberation phase in Third

World countries there has been a serious attempt by governments to ensure that future doctors are recruited from a more representative cross-

January/ February 1979

section of the nation. But the best pre- university educational facilities are still to be found in the urban centres. Some countries have begun to select medical- school candidates on a regional quota basis, while other countries have established medical schools far from the major cities. There have been serious attempts to broaden the selection process and to increase representation of medical undergraduates from rural areas. Yet on graduation the lure of the big cities beckons and the rural-urban doctor disparity remains.

Curricula Attempts are being made to intro-

duce curricular changes, to "demote" the status of technological medicine and "raise" that of community medicine. Medical students are given increased opportunities to take rural electives. Block time is spent in rural health centres or peripheral hospitals so that students can gain firsthand knowledge of local health problems. Some medical schools expose undergraduates to the team concept by sending them with student nurses, engineers, laboratory workers, and hygienists to villages to carry out assigned tasks.

Yet these innovations are not producing the hoped-for results. The "team approach", although to a Western consultant a seemingly logical and practical method of providing rural health services, does not take into account the cultural, linguistic, and other determinants which tend to nullify the efficacy of the team concept. Social class, sex, religion, and strict hierarchical customs are frequently incompatible with a genuine team approach.

Those from the West tend to forget that their brand of democracy is a minority concept, and often inappro- priate to patriarchal societies with age- long beliefs in pre-ordination, reincar- nation, and rigid credos as far as sex, class, and caste are concerned. An impecunious villager, a doctor from a land-owning family, and a nurse from a wealthy urban home do not necessarily make ideal team-mates.

Medical Assistants If local doctors cannot be directed or

persuaded to work in rural areas of the Third World, and if the health team is not always a practical solution, what other methods have been or are being tried?

Prominence in recent years has been given to the training of medical "assistants". These assistants go under a variety of designations but basically they are specially-selected represent- atives from specific rural areas trained to perform clearly-delineated health- care tasks. Many have had little formal education but with training they perform their assigned tasks satisfactorily. Their training period varies from a few weeks to months to years.

By training a number of assistants to perform specific functions total medical care is broken down into functional modules. This may at first sight appear to be wasteful of manpower but this is one resource not in short supply in the Third World. Problems are, however, encountered in the training of medical assistants: the dearth of candidates with adequate education to take advantage of such training, and the hesitation of villagers to talk about their illnesses to a medical assistant who if not related by kinship is frequently known to those seeking medical care. Another problem that has developed in those countries producing "assistants" or "auxiliaries" is that the rural population cannot distinguish a doctor from a person who has the power to dispense medicines. The trained health assistant is often assumed to be a bona fide physician by the local community. Some countries take a pragmatic view of this fact and make assistants honorary "doctors" after they have served their district fora certain period of time.

"Doctors" Attempts have been made in coun-

tries with no medical school to produce medical "doctors" in their medical insti- tutes. Medical auxiliaries with proven aptitude and experience can proceed up the promotional and professional ladder by taking extra training to increase their skills and competencies. Such individ-

39



uals for all practical purposes become practising "doctors". Their degree or diploma may not have international recognition but within the country they perform nearly all the duties of a licensed practitioner. In addition to acquiring professional skills, these individuals are taught administrative, epidemiological, and data-collecting techniques. This new breed of "doctor" thus becomes an all-purpose physician/ administrator for a defined health region. It remains to be seen how successful these ventures will be. Already problems of a professional nature are arising between the diploma- bearing doctors and the degree-carrying physicians. Concerns are being expres- sed by physicians that for all practical purposes there will be no differences. But in fact there will be a difference, and an important one: the "diplomate" in medicine will not be eligible for ap- proved overseas postgraduate training. He will never become another brain- drain statistic.

Indigenous Healers The other source of primary care

personnel not yet fully utilized by government health systems is the indigenous healer. About 90% of the rural population in South-East Asia first seek health care from the local healer. Several, governments, with WHO backing, are now seeking ways and means by which these healers may become an integral part of the health care systems.

The indigenous healer is held in regard by the local community. His therapy is held in high repute. It is felt that if this therapy can be made more effective by an appropriate blend of the old with the new then an entirely new cadre of health-care personnel can be incorporated into a government health plan. The indigenous healer has another point very much in his favour: he is an established and respected member of his community. The problems already described concerning the returned trained medical assistant will not arise with the indigenous healer. However, he will have to be educated with respect to use of antibiotics, anti-helminthics, etc.,

as well as indications for referral to other types of health care facility.

Midwives Though perhaps not being capable of

being categorized as "indigenous healers", village midwives in many Third World countries have had their skills upgraded by inservice training, their ability to record work done made possible, and their usefulness as health educators enhanced through instruc- tion in such matters as birth control, nutrition, personal hygiene, and child care. Midwives, like the indigenous practitioners, are accepted by the local community. Hence their already high "therapeutic" and "educational" effec- tiveness is further augmented with their newly-acquired skills and knowledge.

Conclusions (a) Improvement in the health status of

the people must be an integral part of any developing country's long- range social and economic development plans. A healthy population is an essential precursor to the successful implementation of any socio-economic planning.

(b) The colonial legacy is still apparent in many Third World countries with respect to medical services and education. Though much that remains of that legacy can be put to good use the rest produces con- straints in innovative planning and operational experimentation with medical services.

(c) Primary health care to be effective requires (i) an effective, efficient, and acceptable service at the local community level; and (ii) a respon- sive national health administration that sets realistic attainable health goals in the light of the observed health needs of the rural com- munities or under-serviced urban areas.

(d) Medical school curricula patterned after those found in the industrialized and technologically-advanced countries will not produce physicians with the attitudes, skills, and competencies appropriate for the

delivery of primary care in Third World countries.

(e) The problems which arise when new groups of mid-level health workers are introduced into an established health care system have been discussed. As a long-term measure to increase the number and calibre of health workers in a developing country the training of mid-level health workers should be pursued. Their placement within the county's health services will be a slow but steady process, but this will provide the necessary time for their acceptance by the more highly qualified medical personnel.

(f) The underutilization of the tradi- tional healer and local midwife in most of the existing health services in Third World countries has been emphasized. The potential of these two groups in the provision of basic primary health care has probably been under-estimated. The midwife with very little additional training has proved to be an excellent means of disseminating health education with respect to family planning, personal hygiene, nutrition, cook- ing methods, sanitation, and child care. The indigenous healer's therapeutic armamentarium has been dramatically improved by the judicious addition of potent medi- cations from the pharmaceutical industries of the developed nations. The "lead time" necessary to make these health workers operational is small, but their impact on the health of their community can be great.

(g) The provision of primary health care to the predominantly rural populations of Third World countries is probably the most chal- lenging problem facing the health planners in the developing nations today. This paper has dealt with some of the health manpower problems. The problems of geogra- phy, topography, communications, and logistics are further factors in an already complicated subject.

40 Canadian Journal of Public Health Vol. 70



Documents

Primary Health Care in Developing Countries: A Look at Some of the Problems