Success south and north / by Steve Serdahely

Healthy food for a little Burmese boy. PhotoWHO/J. Mohr Successes south and north by Steve Serdahely he Brandt Commission report North-South * declares: " Now that both North and South are increasingly aware of their interdepen- dence, they need to revitalise the dialogue to achieve specific goals, in a spirit of partnership and mutual interest rather than of inequality and charity. The dialogue must aim to give every society a full opportunity to develop as it wishes and satisfy the essential needs of its people at an acceptable pace ; and to create a dynamic world in which every country can achieve its own development, each respecting the other and respecting also the imperatives of a shared planet. " In both North and South there is a growing awareness of the wide- ranging advantages of the primary health care approach in achieving the goals of Health for all by the year 2000. The following articles describe a "South " success and a " North " success in applying this approach. * North-South-A Programme for Survival: Report of the Independent Commission on International Development Issues (headed by Willy Brandt) , Pan Books, Ltd., London, 1980. 18 Burma: sell-help The way it was Ayadaw Township of Sagaing Divi- sion covers an area of 688 square kilometres and has a total population of 147,000 . About five per cent of the people live in the town proper and the rest in the neighbouring countryside. Situated in the dry zone of Burma in sandy and rocky terrain , Ayadaw (de- rived from " footprint stone of Budd- ha") existed as a trading centre from the time of the Burmese kings. During the 19th century and early 20th century , high levels of cotton production made Ayadaw famous. But an increasing shor- tage of available water, coupled with the relative inaccessibility of the Township caused hard times to fall on the inhabi- tants. One of the first efforts of the central government to improve the primary health care picture took place in the early 1960s, when the Ministry of Agri- culture and Forests dug ten wells. How- ever , the hand pumps yielded only about one litre of water per minute , and families had to spend most of each day in collecting sufficient water just for that day's use. At least it was a beginning. The long tradition among the Bur- mese of say-ta-na (deeds of the heart and soul without remuneration) , com- bined with a political decision to em- phasise rural development in a spirit of self-reliance and self-determination and in the framework of a decentralised administrative system, provided the groundwork for enunciating an overall health plan. Using guidelines suggested by WHO in its " country health program- ming " methodology in 1975 , the health care delivery system was restructured so as to concentrate on priority health problems and the rural population. The result was the Burma People's Health Plan. Although mainly conceived on the initiative of the central health auth- orities , the Plan gave the local people an opportunity to evolve , expand and strengthen their health activities in a flexibl e way. The Ayadaw Township People's Health Plan (PHP) really began in June 1978 with the formation of the PHP Committee . The committee was given responsibility for the following : - development of the health profile of the Township ; - planning of the Township's health programme; - supervising the way in which it was carried out ; W o RLD HEALTH, Octobe r 1986 - managing the community finances; - coordinating activities with rel- evant sectors; - taking the lead in motivating com- munity participation; - evaluating progress; and - reporting to divisional and central offices. The way it is The impressive progress in health de- velopment reported since the PHP ac- tivities started eight years ago in Aya- daw Township can be measured by some particularly noteworthy achievements. Every village now has its own volun- teer health worker. The village people's council in each case is responsible for paying and supervising the VHW, the benefits of whose work are clearly rec- ognised by the people. A pilot scheme has begun to train "ten-household health workers", whose role is to gather information for health staff and to edu- cate the ten households in their care. To date, 2,500 of them have been trained and placed in the community, and 30 volunteer nutrition workers have under- gone training. The reorientation of trad- itional birth attendants has been com- pleted . - Safe water supply has received the highest priority. The Committee has provided every village with guidelines for safeguarding water, for building lat- rines and for disposing of garbage. Al- most all villages (98 per cent of the population) have access to safe water, at a per capita consumption rate of about 45 litres per day. Each household has access to one sanitary latrine, and properly maintained garbage facilities are in use in the households and villages. "Ayadaw Township community had been living a hard life with scarce water for many years; that's why they made their slo- gan: Need water, not gold." Dr Than Sein - Since 1979, there have been no out- breaks of cholera or plague , while gas- tro-intestinal infections including diar- rhoea and typhoid have fallen dramati- cally. The active prevalence rate of trachoma dropped from 12 per cent to three per cent. Early detection and con- trol of leprosy cases has improved. There have been more immunizations , more women have access to antenatal services, and deliveries attended by W oRLD HEALTH, October 1986 Above: Cooperative health clinics are now financed by village cooperative societies, which raise funds from various local sources. Below: Learning to read in a Burmese primary school; a literate community is much more likely to take a responsible attitude towards health matters. Photos WHO/J. Mohr trained personnel have increased from 40 to 98 per cent. Almost complete surveillance of the nutritional status of children aged three and under has been achieved , and 97 per cent of newborn babies have a birthweight of at least 2.5 kilograms. Community participation in food and nutrition activities has increased. "The people of Burma are aware and proud of the fact that a significant share of the resources expended on the health care de- livery system are contributed by themselves. Since the advent of the People's Health Plan (PUP) in 1978, contributions are being increasingly made in terms of kind, cash and labour. The driv- ing force behind such behaviour is attributed to the culture, belief and the spirit of mutual assistance which has evolved through cen- turies." Dr D. Kh in Hlai ng - The crude death rate has declined from 4.11 per mil in 1974 to 2.36 per mil in 1984, infant mortality from 63 to 50 per mil , and maternal mortality from 0.7 per mil to zero in the same period . - Cooperative health clinics are fin- anced by village cooperative societies. Funds for health development activities , including both capital investment and recurrent costs, are raised by com- munities through local financing schemes which include proportional donations , voluntary contributions and social welfare funds. 20 An increased rate of immunizations in Ay- adaw township has been reflected in lower figures for infant mortality. Photo WHO/K. Frucht The way it will be It might seem that the shining exam- ple offered by the Ayadaw Township PHP Committee in collective leadership at the community level , adhering to the basic principles of primary health care , already represents a level of achieve- ment sufficiently high for Ayadaw to let the process develop at its existing pace. Indeed the Township was awarded a share of the 1985 Sasakawa Health Prize , offered by the Japanese founda- tion for outstanding innovative work on health development. But the commitment to change , and to further improvement , still continues . The capability already shown for or- ganizing and managing the community's health will again be brought to bear on further improvements. Among the mat- ters receiving high priority will be: bet- ter career opportunities for volunteer health workers ; more efficient replen- ishment of drugs and other supplies ; new ways to improve the organizational activities of VHWs ; an improved trans- port system for health centre staff; es- tablishment of a proper cold chain sys- tem to keep vaccines cool and safe; and provision of health and medical care journals to all health workers and mass education materials for the towns- people. Active planning, resources success. community involvement in financing and managing has been the key to this • Burma postscript nd while the Ayadaw success story was unfolding, how did the villagers react? The fol- lowing eyewitness account de- scribes their response and invol- vement. "March 1st 1982 was the big day when people actually started building latrines. lt began at dawn when the sun had hardly risen . Men, women and children emerged from their houses, moving back and forth to their backyards carrying . picks, shovels, baskets and bam- boo. While men dug the pits, women moved the earth and chil- dren ran around doing chores. "A tray containing a pot of hot tea and a couple of bowls was placed on a deal wood box a few feet away from the pit. Stripped to the waists and sweating from head to toe, the men would climb out of the pits and walk to the tea pot to quench their thirst. Some hummed songs to the tune of local music which blared through the loud- speaker from a nearby house. Vil- lage lanes too were bustling with activities . Committee members roamed about inspecting the work and giving encouragement. The loc- al Doh-bat (drum) group danced in procession to lend a festive mood to everything. Two male dancers, one in glittering costume and the other in comic attire, took turns dancing at the head of the proces- sion. These were followed by musi- cians playing and singing to the rhythm of the Doh-bat backed by the wailing flute and the slap of the bamboo clappers. "The procession was followed by a crowd of onlookers, mostly children, who giggled or shrieked with delight as the comedian played the clown. Red Cross youths in smart uniforms and carrying white boxes walked about in readiness to deal with emergencies. lt was in- deed a happy occasion for both the villagers and the organizers. "These activities, although at a declining tempo, went on until April 1Oth when all householders had built their latrines. In most cases the superstructure was built of bamboo, but a few who could af- ford it built theirs with bricks . In any events, a strong effort had been made by the community to protect their own health in a manner which was within their means. " • W oRLD HEALTH, October 1986 z 0 I s 0 0 J::: Q_ Finland: pioneer count The way it was Traditionally, health care in Finland was the responsibility of central and local government. The practice of midwifery dates from the 18th cen- tury, and the system of municipal physicians was created towards the end of the 19th century. In the begin- ning of this century, the emphasis was on the prevention of infectious dis- eases. Between the two World Wars, a network of · mental institutions and tuberculosis sanitariums-separate from general hospitals-sprang up. In the 1940s, municipal maternity and child care centres became statutory, offering free service regardless of place of residence or financial status. During the 1950s and 1960s the em- phasis was on building hospitals. And from the 1960s onwards, the short- age of physicians was rectified ; the number of inhabitants per doctor fell from 1,100 to the present level of 500 per doctor . A re-evaluation of health policy followed in the early 1970s. At that time about 90 per cent of public health care resources were being used for special medical care and 10 per cent for primary services. The Finnish de- termination to face problems head-on ensured the adoption in 1972 of a Primary Health Care Act , which reoriented health policy towards inte- grated development of health services, W oRLD HEALTH, O ctober 1986 with emphasis on outpatient care and accessibility fo r the whole population. Under this Act , health centres run by local authorities are in charge of the functions of basic health care. This comprises preventive care , including maternal and child health, family plan- ning, basic medical care, school health, dental care and transport for the sick. The Act also assigns to the health centres responsibility for preventing and treating infectious diseases and for the environmental health service. La- ter additions to the centres' tasks were training of health care staff (1976), occupational health services (1979) , and the provision of health care to seamen (1980) . Development of the health service systems during the past ten years has been guided by national plans. As a result, Finland now has a sound prim- ary health system and a high standard of specialist care. The way it is Now available to 100 per cent of the population, primary health care re- ceives more than 40 per cent of the resources channeled into public health care-compared with the 10 per cent figure when the planning and state subsidy was introduced. In 1982, 6.7 per cent of the gross national product (GNP) was spent on health in Finland. In several critical areas , the general state of health of the population has improved . The exceptionally high mortality rate among middle-aged men is falling , as is the rate for women and children. The occurrence of coro- nary disease and stroke has decreased. The incidence of cervical cancer in women and of gastric cancer in both sexes has decreased. Promotion of healthy life-styles has proved successful. Smoking has started to decrease , and alcohol con- sumption among the young seems to be declining. There have been notable improvements in dietary habits, and more women are breastfeeding their babies . Dental care in children and young people has improved. Family planning and contraception are now more effective. Access to safe water supplies is available to 76 per cent of the total population , and 70 per cent of the population have adequate sani- tary facilities. Over 96 per cent of the newborn babies have a birthweight of at least 2,500 grams. Life expectancy at birth is 74.2 years for males and 78 .1 for females. The adult literacy rate stands at 99.5 per cent. The percentages of children fully im- munized are: diphtheria 93.9 per cent , tetanus 93 .9 per cent , pertussis 78.9 per cent , polio 82.2 per cent , tuberculosis 84.3 per cent , measles 80 per cent. Finland has collaborated closely with WHO in formulating its na- tional strategy. In 1982, Finland · and WHO endorsed an agreement whereby Finland would act as a "pioneer country" for Health for all development, so that its ex- periences in health policy and primary health care can be shared by other nations. Prevention work during the past decade has reduced the number of fatal road accidents by half in ten years , and the number of fatal occupa- tional accidents to one-third that of 20 years ago. Despite all these benefits , there are still some challenges to be met. Exist- ing dietary factors cause one-third of the cases of cancer and cardiovascular diseases. Obesity results in a predis- position to many diseases. Smoking still causes about 4 ,000 premature deaths per year , and the number of alcohol-related deaths is estimated 21 at 2,300 per year. Accidents (some 700,000 per year) are the third highest cause of death , after cardiovascular diseases and cancer. The way it will be The Finns are giving high priority to the following aspects of health policy : - The promotion of health and the primary health care approach , with emphasis on the needs of the under- privileged and those at greatest risk; - Improving national nutrition by guaranteeing a sufficient , healthily balanced and varied food supply; - Still greater efforts of education, instruction, and guidance to reduce consumption of tobacco products and alcohol ; - Restructuring the physical and so- cial environment so as to increase social intercourse and provide more opportunities for healthy physical exercise; - Environmental health measures to reduce biological, physical and chemical risks ; - Maintaining general immunity, a high standard of hygiene and effec- tive vaccination, to bring about further improvements in the infecti- ous disease situation; The basic aim of Finland's health policy is to promote the health and welfare of each individual. It can be summed up as: Adding years to life, Adding health to life, Adding life to years. - Increasingly more human and flex- ible health services , and additional health care personnel according to . changing needs ; - Reallocated health care resources to meet the needs resulting from the increased proportion of elderly persons, the prevalence of chronic diseases and the introduction of new prophylactic and treatment measures; - Education of health care personnel to reflect the new attitudes in health policy. In opting for these new approaches, Finland has formulated its long-term planning to handle the known as well as the" what-if" occurrences of tomor- row, reflecting both innovation and pragmatism in its quest for Health for all by the year 2000. • 22 WoRLD HEALTH, October 1986 Finland postscript ne Finnish success story evolv~d from a bleak beginning followmg WHO's publication of cardiovascular disease statistics dur- ing the late 1960s which identified North Karelia as an area of high mor- bidity and mortality from heart dis- ease. Although the area was beset with other pressing social and economic problems. this added bur- den galvanised citizens' groups and women's organizations. as well as individual doctors and nurses, into action. t With the backing of .the provincial governor, these concerned people enlisted WHO's support for a large population study and an intervention programme to combat heart and car- diovascular disease. The North Karelia project tackled the issues of smoking, unhealthy diet and lack of exercise. Women's groups initiated "long life parties". Medical stugepts joined in with health education activities. Other groups launched, exercise pro- grammes which covered disease pre- vention as well as rehabilitation. Food industries cooperated by increasing low fat milk and healthier sausage production, and improving the dis- tribution of fruits and vegetables. Schools, youth groups and volunteer bodies climbed on. the bandwagon. Five years after the project began, exciting results became apparent. Cases of stroke, for example, had been reduced by almost 40 per cent. Similar reductions in cases of heart attack ,an,d high blood pressure had been achieved. An authentic '' peo- ple~s movement" for health had been created. In addition, a new media form-a press conference that was, in effect, a mini-seminar on health-had been generated. The entire province was motiv- ated-and that motivation spread to the whole country-while apathy and despairvyere replaced with prid~ . ~nd a universal sense of great '·accom- plishmept. · • Nutrition classes for Finnish housewives have helped to bring about notable improvements in dietary habits. Photo WHO/T. Farkas