A health care paradox

A health care paradox Kausar S. Khan, Kamallslam, and John H. Bryant A lma-Ata's challenge to view health as a human rights issue has not been adequately met by most Third World countries. Barring a few examples, health services continue to be either substandard, inaccessible, unaffordable and under-utilised, or to suffer from varying combinations of these factors . While governments of many coun- tries, Pakistan for example, have spent millions on building physical infrastruc- tures at district levels, the over-all health status, especially of the urban and rural poor, remains deplorable . It is now more than evident that con- structing a hierarchy of health centres, and even staffing them with doctors and paramedics, does not resolve the deeper issue of developing a health system that can achieve the goal of equity in health: universal coverage and care according to need. This challenge is faced not only by governments but also by the non- governmental sector concerned with the health of the people. There is a pressing need to develop primary health care (PHC) systems which are technically sound and predicated on these principles of universal coverage and care according to need, but which at the same time involve communities so as to ensure that their own percep- tions of their needs are fully recognised and that they are fully involved in the effort to address those needs. The health services of Pakistan are well planned and the health leadership has continuously pressed for effective implementation . But scarcity of resources and shortages of manpower (particularly as regards key roles of management, and as regards women as health care providers) have pre- sented massive obstacles to making effective services accessible to large numbers of people living in deprived areas. Recent favourable shifts in the politi- cal landscape of Pakistan have given rise to a new resolve to extend services to these populations, and fresh national health strategies are being drawn up. Of particular importance to health system development are: the design of PHC systems so as to achieve equity; the role of communi- ties in ensuring progress towards that goal; and the contribution that a non-governmental organization - the Aga Khan University - can make to the nation's effort to improve its health services. Like many Third World countries, Pakistan finds itself caught in a para- doxical situation. There is a hierarchi- cal infrastructure of health services, on the one hand, and a large under- served population of urban and rural poor on the other. Services are largely facilities-based and curative-oriented, though some vertical programmes, such as those for immunizations and diarrhoea treatment, do operate spor- adically. For the most part, the people who receive care are those who seek care - though whether the care they receive is the care they need is another question. It should be no surprise that these approaches have not brought about significant changes in morbidity and mortality patterns, especially for the urban and rural poor. A variety of organizations and agencies both inside Pakistan's health 'services are well planned despite staH shortages. A woman doctor checks these small child- ren for telltale signs of leprosy. WHO/ Zafar and outside of government have been working toward improvements in these systems. The Department of Community Health Sciences ( CHS) of the Aga Khan University has been attempting to address these problems through micro-level experiments in the katchi abadis (squatter settlements) of Kara- chi. Over 40 per cent of Karachi's eight million population live in these areas. During the past five years, CHS has developed a series of prototypes · of a PHC system in five different katchi abadis. Each prototype serves approxi- mately 10,000 of population and aims to provide affordable care appropriate to need. The key elements of the system are: simple and sound PHC technology, and community involve- ment. CHS believes that the paradox mentioned above cannot be resolved without close partnership between technical expertise and those in need. Under the CHS-Ied approach, literate or semi-literate women are selected with the help of the com- munity and given brief training in the 6 University and community have interac- ted positively in health services develop- ment in Pakistan. community as Community Health Workers (CHWs) . Each CHW is assigned 150 families who are visited at least once a month. The CHW monitors the nutritional status of all children under five by checking their weight for age, and also notes the immunization status of all children. She provides nutritional education to the mothers, propagates the use of oral rehydration salts, identifies the children and women at risk, arranges for immunizations, and makes referrals to the community-based PHC clinic. A simple record-keeping system enables information to flow from the home to the PHC centre, thence to the hub of the PHC network (currently the university) , and back to the field- based PHC centres. In addition, lady health visitors (LHVs, middle-level personnel) super- vise the CHWs and assist them in handling difficult problems and summarising information on malnu- trition, immunizations, births and deaths. Meanwhile community health nurses and community health doctors supervise the CHWs and LHVs, pro- vide clinical and managerial backup, analyse the data on the entire com- munity and prepare appropriate inter- ventions. House-to-house surveillance These prototypes, once in place, showed that house-to-house surveill- ance by CHWs ensures that care according to need can be extended to the entire population of a poor com- munity; and that a community-based PHC system is relatively easy to set up and to manage on a small scale. We also found that the system had a favourable impact on immunizations and the nutritional status of children under five (the impact on mortality rates is still under study), and that the system is affordable: the current cost is US$ 2.50 per person per annum (exclusive of costs of referral care), though a still lower cost is possible. While urban in location and not part of a formal district, this network of PHC modules - providing care for 50,000 people and organized around a uniform management system - represents the urban variant of a district-level, integrated PHC system. The CHWs are socially close to the community, and represent a special resource for reaching women in the community. Although this approach to community-based PHC was a distinct advance compared with the more usual health services, some drawbacks became apparent. The overall mor- bidity and mortality rates did not dramatically improve; severely malnou- rished children often died despite close monitoring, even when they were sent to hospital, and diarrhoea coupled with malnutrition remained the major killers of children. The CHWs and the PHC teams felt frustrated with the limited effects of their work in the face of the deep poverty and depressed living conditions of the communities. The farther one looked, the deeper the roots of the problems appeared to penetrate. The roles of communities now appeared in a new light. Their involvement in identifying problems, finding solutions and planning and implementing actions was an impera- tive. The CHS-Ied model, though technically sound, was weak in the extent that it involved the community. Consequently, the model was re- examined, and new strategies were explored. W ORLD HEALTH , May 1989 A closer assessment of the social dynamics of the urban poor and the implications for the role of CHS prompted two significant changes. Firstly, a new criterion for field site selection was developed that led to the selection of a community that had an active local organization committed to improving the quality of life. Secondly, CHS was to reverse its approach, so that the local organization would retain the leadership in identifying problems, setting priorities, getting programmes under-way and sharing costs, while CHS would act as a facilitator for the local organization in making its de- cisions and seeking outside assistance and resources. The need for stronger social expert- ise at the field level was also recog- nised , and the PHC team was rearranged to include a social organizer who would make the com- munity organization more aware of its enlarged role, and would mobilise the community at large to reflect over and analyse its own social realities and plan action for change. The community-led model is cur- rently being developed and monitored in a traditional fishing community on a small island in the Karachi harbour. It Tracking down possible cases of tuber- culosis_ Community health doctors and nurses provide clinical and managerial backup for the community health workers and lady health visitors. A health care paradox is based on a new kind of partnership, in which health personnel and social organizers work jointly with a com- munity body. A community-oriented physician and nurse together with the social organizer act as a team to ensure that a technically sound system and the community come together. It is too early to know which of the problems of community health and development will be resolved through this approach and which will remain unresolved, but CHS believes this is a fresh and positive step forward. So the micro-level experiments in the katchi abadis have established two types of PHC models: CHS-Ied and community-led systems. Although technically sound and appropriate to the needs of small communities of 10,000 people, can such small islands of success have an impact on the health services and health needs of the country? This underlying concern gives rise to two critical questions: how does a university like the Aga Khan University influence the design and function of the vast system and staff of the governmental health services? And can one go up-scale to real world applications with the model? An open process The new changed environment of Pakistan, with recent elections which installed a politically popular government, includes an open process for formulating national health strat- egies. The university has been invited to participate in that process by presenting its ideas, showing its experi- ence and joining in the give and take of policy-making. This will call for a dialogue between policy-makers and those people and institutions who are in a position to do practical health systems research. Pakistan bristles with social , economic and political problems that torment many developing countries. Desire for change is too frequently dampened by the poor carrying out of strategies. Such overall failures to boost the quality of life engender a tacit despair that gnaws at the will to change. Energies are then dissipated into platitutes and cynicism, and it becomes difficult to keep alive the flame of hope. However, five years of intensive field experience by the Aga Khan University have given a ne\v dimension to the role of a university and to the role of communities in health services development. That ----- experience has shown that community .Z! involvement need not remain only ~ rhetoric, and that the usefulness of ~ micro-level experiences for national =:: policy need not remain in doubt. • 7