Disease control in primary health care: a historical perspective
Prof. em. Harrie Van Balen, Formerly Institute of Tropical Medicine, Antwerpen, Belgium. Tel.: + 32-3-2390320; E-mail: email@example.com or firstname.lastname@example.org
The effectiveness of disease control by mobile teams decreased when countries became independent. Early case-finding and continuity of care require permanently accessible health care facilities where rationalization by professionals and participation of the users are well balanced. The Primary Health Care concept, a plea for this equilibrium, has been discredited by different types of misapplication. Correctly functioning and accessible first line health services, completed by a referral level, are a precondition for effective participation of the users. Where ‘ideal health districts’ cannot be realized, a form of steady exchanges between generalists and the specialists of the referral level has lead to diverse ‘functional districts’.
Evolution of vertical structures for the control of endemic diseases
In the 1950s, scientific advances fed the great hope that disease could be overcome if modern health care and medical technology were made available to all people. Before 1950, yellow fever was already under control as an effective vaccine offered protection for at least 10 years. Several very rational control programmes of endemic diseases had been consigned to vertical structures, often with the aim of eradicating those diseases. This indeed led to the eradication of smallpox – possible because human beings were the only reservoirs and the attack rate of the disease was relatively low.
The malaria eradication programme of the 1960s, striving to definitively interrupt the transmission of the parasite, turned out to be too ambitious. The mosquito control programmes still have to be executed by specific structures and the adequate and timely treatment of cases still requires permanently accessible health care facilities.
Until recently, the prospect of the eradication of poliomyelitis was deemed possible. It is now doubted that polio can be eradicated globally within a few years, in which case the routine immunization has to be continued (Razum 2002).
In the 1950s, mobile teams drastically reduced the incidence of sleeping sickness by active compulsory detection and treatment of new cases but, in a democratic setting, preventive measures imposed on people without their consent could hardly be maintained. During the 1960s, active case finding by mobile teams deteriorated into a yearly passive case finding. Once simple serological screening tests became available, the advantage of permanently accessible facilities became obvious: the delay of detection amongst patients with symptoms could be reduced and by focussing on high-risk groups, the periodic outreach clinics were able to actively detect infected cases (Kegels 1995). This potential of greater effectiveness and efficiency was not considered and the orientation of specific human and material resources to vertical structures was maintained.
The multicausal deterioration of people's health, above all if conditioned by poverty, is hardly influenced by isolated immunization campaigns (Kasongo Project Team 1981). It requires a combination of vaccination with early treatment of prevailing ailments and nutritional rehabilitation.
Above all, a study on early case finding and treatment of tuberculosis patients (Banerji & Andersen 1963) conducted in 1960 in Bangalore, showed that easy access to credible health care facilities, alertness of the practitioner, good communication, counselling and retrieval of defaulters are far more important for the result than the maximization of the technical components of the diagnosis and treatment. The conclusions of this study are applicable to practically all disease-specific programmes.
So in the early 1960s, there were compelling arguments for the allocation of more resources to the organization of permanently accessible adequate multi-function health care facilities, as an essential contribution to the efficient control of endemic diseases.
Evolution of the general health services
This did not preclude most newly independent countries from maintaining the broad lines of the inherited health services: expensive hospitals and a network of dispensaries conceived as the second best solution for people who lived too far away from a hospital where ‘really good care’ was provided.
The activities organized in those services were based on health needs determined by medical experts while the public had to accept what was proposed. Yet people did not react as health workers thought they should: they consulted late, they did not adhere to the treatment, they disregarded preventive advice pertaining to hygiene, systematic screening or lifestyle. Meanwhile their demand for care, responding to the problems they were worrying about, was met by drug hawkers, drugstore keepers and ‘healers’. In the meantime, the community development movement of the 1950s and 1960s had emerged, encouraging communities to identify their needs and find solutions themselves in all areas of social life, including health (Van Balen & Van Dormael 1999).
During the 1970s, in rich and poor countries, field experiences in health care, where individual patients as well as population groups were viewed as active partners, have shown the relevancy to cope with the felt needs of the people, to cope with their own knowledge, with their ability to deal with health problems and with their overall subjective aspirations (Newell 1975).
The Alma Ata Declaration
Those field experiments and research on the optimization of health care inspired the Alma Ata Declaration on PHC, adopted in 1978 by the WHO. PHC was seen as a component of overall development based on social justice. The concept responded not only to the need for accessible and trustworthy facilities, but also to the social pressure to strike a satisfactory balance between the participation of the population and the rationalization of the care.
Article V of the Declaration describes PHC as ‘essential health care based on practical, scientifically sound and socially accepted methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination’. Hence the importance ‘to bring health care as close as possible to where people live and work’ in order to improve ‘the first level of contact of individuals, the family and community with the national health system, which constitutes the first element of a continuing health care process’ (WHO/UNICEF 1978).
The place of disease control in PHC-inspired health systems
The implementation of PHC as defined in Alma Ata entails substantial change in health care. Organizing basic health services, one has to take into account that their prime objective is not epidemiological but social: the reduction of health problems impeding human well-being. The timely detection, cure and care of endemic diseases and relevant personalized preventive care and advice is thus their main role in disease control. Therefore, the decentralized first line health services have to be strengthened. Technically they should perform well. Moreover, they should generate an interface, a channel of communication, for interaction with the individual users, their family and representative groups of the population it serves. Such an interface makes it possible to take into account the demand and the know how of the people and to negotiate their contribution as well to the solution of their problem as to a better functioning of the health centre (Van Balen 1990, 1994).
The network of health centres has to be backed by a referral level. Mahler (1981) claimed that a health system based on primary health care cannot exist without hospitals for the continuity of care requiring techniques which cannot be realized adequately at the first line (Mahler 1981; Van Lerberghe & Lafort 1990). In Harare, the WHO formulated recommendations for the realization of such health systems: the integrated health districts (WHO 1987). Ideally, the district health system was to be managed by a direction committee, accountable to the target population. In several countries health care services have been patiently oriented that way, sufficiently to show that the system can play the expected role in disease control as long as the indispensable resources are available.
In countries where doctors were too few in number to be assigned to health centres, experiments have shown that it was possible to delegate clinical functions to less qualified staff without detriment to the clinical quality of the care (Kasongo Project Team 1980). When budgets became insufficient, they were completed with affordable cost sharing patient charges (Pangu 1988).
In the 1980s, there were comprehensive training programmes in Thiès (Senegal), Kinshasa and Dogondoutchi (Niger), which prepared medical doctors for the role of district medical officer and saw to a follow-up on the job in order to enable young doctors to manage or at least to coordinate, in a team, the components of a coherent system (Unger 1989, 1995). Unfortunately funding to the above scheme was withdrawn.
The PHC concept discredited
Several governments, funding agencies and NGOs, eager to obtain ‘instant success’, have failed to notice the complexity of the proposed change and the time needed, for the appropriation, by the actors involved, of an acceptable expression of the conceptual model. Many of the early initiatives, dealing with only one aspect of the system, were harmful for the evolution towards an integrated system. Moreover, successful local initiatives were, for political reasons, too rapidly extended to a national level (Berman et al. 1987). The multiplication of village health workers, seen as the magic bullet, did indeed increase the geographic accessibility but did not bring along effective care, complementary to what people were able to do for themselves. Similar programmes, defined at national (or even international) level were pushed through at a local level, often including a fake interface. As a consequence, neither system adjustment nor adaptation to local situations was possible.
In many countries, PHC became a vertical programme with its own structure, alongside the apparently undisturbed ‘modern’ health services and the existing traditional health care (Senghor 1984). The enormous amount of money spent on this simplistic interpretation of PHC, was held back from the strengthening and multiplication of health centres.
In the 1980s and 1990s, the budgets of the first-line health services went down. In some places a productive interaction between representatives of the population and the health staff succeeded in the mobilization of local resources. But the top-down imposition of local health committees did not automatically lead to an increase of resources for the health service. Too often the mobilized resources were diverted to the committee itself. Not everywhere does the population demand to be involved in the development of the health service; for them, health is but one concern amongst others. In such situations, the first step to be taken is the establishment of an adequate health service which enables users to judge in practical terms what is being offered to them.
The adoption of the Bamako initiative has undoubtedly contributed to an increase of the income of the first line health services. But as an isolated measure, the raising of the income proportionally to the sale of drugs often boosted the dependence on drugs.
In order to cope with smaller budgets, Walsh and Warren (1980) proposed ‘selective primary health care’ as an interim strategy for disease control in developing countries. How could health personnel, not bothering about the felt need of the population, boost dialogue and participation? When the budgets of mobile teams went down, in some places proposals were made to integrate their activities in the existing basic services but without allocating a supplement to their budget. It became clear that without resources these tasks could not be performed correctly by those basic services.
Another initiative was the allocation of important premiums to health centre staff for tasks related to specific diseases or problems but taking too much of their time, prejudicing other activities of the centre and hence its credibility. Sometimes single-purpose personnel was allocated to the centre for these tasks. Often this was counterproductive for the real integration of disease control because it disrupted teamwork.
Workshops and seminars have been organized in order to train the personnel of general health services in the control of specific diseases or problems. Generally speaking, the instructions took into account neither the real context in which that personnel worked nor the other tasks they had to perform.
In many countries ‘integrated health districts’ were officially recognized even if there was not the least trace of a system. The time and effort it takes to change an established hospital-centred approach into an ‘integrated systems approach’ was underestimated. It is indeed not self-evident to reconcile the approach of the specialist, who aims for maximum use of available technologies, with the approach of a general practitioner, who talks to a patient to see which effort he or she is prepared to make in view of the improvement that can be expected and keeping in mind the patient's other priorities. Therefore, formal arrangements where the staff of the district office and the medical staff of the hospital, joined in a direction committee, organize the complementarity of the levels of care for the control of diseases, are exceptional. Such a committees can only work adequately if the staff is competent, experienced and motivated. It is therefore illogical that their remunerations is budgeted so ridiculously low that even were they to be found, they could not be maintained at this level. In contrast, funding agencies offer very high salaries to this type of staff for the implementation of vertical programmes in specialized structures.
Effective control of endemic diseases requires a trade-off between investments in specific programmes and investments in general health services
The alternation of technocratic and populist excesses show that we certainly have underestimated the complexity of an integrated health care system and the difficulty and cost to implement it. We also underestimated the conservatism of the medical establishment and the time the appropriation of the change by the actors involved requires in diverse circumstances.
The basic health service has to play its obvious role in disease control: personalized curative and preventive care. Therefore, we first of all have to create conditions which can enhance the development of the system: correctly functioning and accessible health centres and referral levels. Indeed, an accessible and effective therapeutic service meets with public approval worldwide. If the performance of the service enables users to judge the advantages of what is being offered in practical terms, the reinforcement of the system by individual or collective participation will be more likely.
A platform for steady exchanges between the existing staff of the first-line and of the referral level, ‘involving the specialists responsible for the implementation of the disease-specific programmes’, can orient their activities towards a performing integrated system. By a common analysis of the diseases and problems to be tackled, by understanding the complementarity of each other's role in the control of diseases it can bring about an agreement on the distribution of tasks. It must not necessarily lead to a formal geographically defined district. In the last two decades workable flexible health systems, realizing such kind of exchanges, came into being: e.g. SILOS (sistemas locales de salud) in Latin America (Paganini & Capote Mir 1990); l'espace sanitaire coherent in urban settings in West Africa (Grodos & Tonglet 2002); the experimental SYLOS (système local de santé) which started in Belgium in the mid-1990s (Unger et al. 2000).
Carried out in diverse ways, the PHC concept becomes more inspiring. It also shows the need for never-ending health systems research in a continuously changing environment (Grodos & Mercenier 2000).