Report of a visit to the Onchocerciasis Control Programme in upper Volta and Ghana in relation to the provision of primary health care in the resettlement area: August-September 1977

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE cNo/78.5 ONCHOCERCIASIS COII?NOI }NOCRAJ;I III TilE VOITA BIVDR BASITI I:IEA ]IATIO]'IAI CO][,IITTEES FOR OI.ICHOC]]RC]AS]S Second meeting Cotonou 6-BJune1978 I]EPORT OT A \I]SIT TO TiIE O}TCHOCIRCIASIS COiTTROI ?NOGRA.I.,TIIIE il'I U?I?ER VOITA AI,TD GI.tAlrIA Ii,i REIATIo]T I0 [H]l pROVISIOIi 0F PRI}{.ANY I.IOAITH CARE I}I TIIF] RESIIITINI'IXITT ARDAS (aucusr - sEputI,TBtrR, t97T) I BACKGROUIID RECOiTLtrT_TD[11elISI] BY DR IRAITCIS I{. SIIATIOCIa, FFC}i, IipH A FFJI^I OI.' 'IIIE NECIiSSARY I.'ACTOR. TN CON ]TDERING PRIMARY }EALTH CARE IN T1[ ONCHOCEIICIASIS CONTROL PROCRAMI-IE AR]iA'; Itlrrltipllclt.y of proqralnmcs : Tn llcsb Africa t,here are a mr-rltlprliclty of both inter- and intra- natlonal pnograrrnes for development and health care. These include the countrles belon[inr: to the ]Iconomic Comnnrnlty ln the l'Jest Afrlcan Region, the Trcaty belng slgned 1n May 197'ti the Sahe1 prograrnme followlng the SaheIlan drouglrt and the 0nchocerclasls Control Pnogramme. ECO//AS Liahe 1 OCP Benln Ghana Ivory Coast Ma11 Nlger Togo Upper Volta Chad Gambia Senegal Mal i l{lger Renln (oafromey) Ghana Ivory Coast Mal I Nlger Togo Upper VoltaUpper Volta Chad 0ambla Senegal Cap Verb fslands Cameroons Gulnea Illssau Llberla Mauritanla Nlgerla Slerra l,eone Ttrese lnternatlonal program'nes are of importance both in that they m:st be fulIy aware of eacir other's aims and intentlons and also because varlous OCP development proJects which have an lnternatlonal or regional lmpl-icatlon may recelve help from ECCtu-lAS. There ls also a multlpllcity of intra-natlonal prograrffnes such as OXFAM, Save the Chlldren Fund and other proJects and agaln all these must be fully aware and as far as posslble cooperate wlth each other's work 1n development. T'he area of the OCP programme: Thls area l.s declded on entomologlcal grounds which affect the seven countrles very unevenly. The majorlty of Upper Volta ls lncluded except for a small part tn the north (g\fr of the country) but ln Niger only the Arrondlssement of Say, a part of one of the seven Departments 1s included (L% of the country). In Ghana the two northern reglons (Northern and Upper Reglon) are lnclrrdecl and form le'rt of the country; ln Benln two of the slx reglons are lncluded, 5Ufr of the courntry; ln the fvory Coast the northern reglon ls lncluded,, 18rt of the country; tn Mall only lUft of the country ls lncluded and ln Togo two of the flve reglons or )2% of the country. II Z Tlrus rcfatively speaklng, apart I'r'om Upper Volta, the OCP Programme area forms only a smal} part, of the countrles, from l% b 5Afi. Further- more, each country retalns lLs own sovelelgn right to decide on its own developmenb prol5rarnnre and thls ls considered on an overall natlonal basls. Ttris means, therel'ore, that development or advice 1n relatlon to develop- ment ln the OCP area, may be accepted or reJected by lndividual countrles accordlng to their own prioritles. Lastly, all the OCP countrles already have Flve or Ten-Ycar Plans for development. Ilowcver, the fi)P countries all set great store on the onchocerciasls- freed areas and expect ma.jor agnlcultural and agro-industry and hydro- electric proJects to be undertaken in the'freed areas so that they may weLl be lnterested tn the varlous constralnts to full development which w111 occur unl.ess guarded against. Ii4pe<1tq!1on cf Ilfe at blrth, 1970-1975, in some OCP countries (r) MaIc Femal-e I4aI i )(t.J yrs )9.6 yrs NiBen )7.O yrs 40.1 yrs Upper VoLta )2.I yrs J\. I yrs ,) Po latlon under 20 ooo Benin Ghana fvory Coast MaI1 Nlger To6o Upper Volta in rural arable Land areas with Iations t17 ?50 )f) 41 29 7O 96 r965 t968 r968 r970 1969 t965 L9'(O AveraSe populatlon composltlon l>y age E5roups of the ocP count.r"=(2) These are the mearr flgures for the seven countries: 5-t4 15-4,t 45&overAgcO-lt tB.7i1 27.4'rt 40.B% t).t% The a6e-sex structure in somc of tlre countries ls distorted by the emlgration or lmmlgratlon of mal.e labour. Rurallty: The OCP countrles, llke othcr developin6 countr'les, show a great migration to the urban areas. Tirus ln Ghana the number of towns wlth a population of IO,OOO and over in 1960 and ]970 rose from seven to el6lrt and those with poputatlons of 5O,0OO and over from two to four. The average urban populatlon growtlr in thc at,ove <iecade was (;2.1',{ or 6.?/" per annum wlrich ls three times the average annual birth ral;e of 2-1/'. I'lowever, desptte tlte urban migratlon the OCP countrles, Ilke other developlng countrlcs, still show a net galn ln rural populatlons. : _r) t. T'lre only flgures reported frorn West Af.i"a(2) "orp""lng these rates lnthe urban and ruraL settlngs are for MaIl from a Nlger VaIIey study 1n 1957:- ItertlllLy Ilate ancl Crudc Deatlt llate: Fcrtlllty Rate Crucie Death Rate Urban IluraI Urban Rura1 185 205 47 I{arrlaBe: Marrlage for females 1n the OCP countrles 1s almost lnvarlably the ruIe. It occurs at a youn4 age,end Is not lnfrequently polygamous. In the OCP countrles 9A/, or more of' the females were marrled In the following age Sroups Benin Ghana Ivory Coast Ivlal i Nlger ToBo Upper Volta 20-24 2514 2O-2)t 20-2tt 2L-21 20-24 not available Populabion dlstributlon by size ol populatlon gnoups: O) (4)Ghana t97O Upper VoI!M 1L (z ) Under 5,00O per{lons 5,OOO - 2O,OO0 2O,O0O - 50,OOO 50,OOO and over' 7L. t'/" ro.9,( 5.)t';d t2.(,y'" EII.Ufr 8.1'fi 2.(til, 5.ti too.u/, too.o% Demographicatly the OCP countries sirow a veny low expectation of life at birtlt so that, although the crude birth rate ls hlgh, the naturaf increase is held aL 2-).)% per annum. Despite the urPftq,,migratlon with urbanization ranging from ll l',tr in Nirjer to 17.4'$ in Ghana\ ''' Yura]- popglations still shcrura net r:aln. Rural populat,lon densttles vary trcn ZJO/km- in Ghana to 29/kn" 7n Nlger and some thrce quarters of the countrles' populatlons live ln population clusters of unrler 5.OCO persons. TIIE CONCEFT OF A PIIII,IARY IIEALTII CAIIE DELfVERY SYS'fFilvl The pyramldal structure: Trarlltlonally ln mral areas prlmary health care ls dellvered through a pyramldal system vrhose apex 1s the ruralr/Oistrict hospital and whose base is the ald post/dlspensary. f b ls, hottever, becomlnlq increaslngly obvious that suetr a system is not meeting Ltre nceds of the villagers and lt ls necessary to vriclen the base and concenLrate more on the existing vlllage lndlgenous practitloners, or persons selected for tralnlng by the villagers. .)p Area of care: TradlblonalLy lt is ireld Lhat a rllstrlct/rural irospltal wiII look afLer the lrcalth nee,ls of a populatlon of from IOO,OOO - 20O,OOO; a Health Centre lto,ooo - 5o,ooo ard an Al<i PosL,/Dlspcnsary 5,000 - 1o,0oo. SuJrervlsion: Tire concept of srrpcrvlsion is besL descrlbed in the Irrench phrase 'supervlslon en casc;r,-le'. 'Ihe rural/atst'rict hospit,al superviz:lng from three t,o fl're tlcalth Cent,res each of vrhlch in turn suoervli:es four to ten Health Posts/Dispcnsarles. In the ncvrer concept of incluClng the lndlgenous village practltioners ln ttre }iealth system the Ilealth Posts/Dispensarles vltll each supcrvllze a number of vlllages. Such a system, however, ls not excluslve and lt ls to be expected that the rural/atstrict hospltal and I{ealth Centres w111 aLso supcrvlze t,}re vlllage practj.tloners and the Dlstrlct Medical Offlcer wlll supervize the complete pyramid. o It ls customary to state that tlre radlus of actlvlty of a IIeaIth Centre wlII be flve nnlfes, covering an area of 7t).5 =q. miles (B km; 2Ofkm*). TheIIeaIth PostrlD{spensary wlII cover 20 - 5Okm- ancl the rural/dlstrlct hospital 6OO - 1,gookm'-, on thls assumptlon. The fallacy of thls sphere of actlvlty by radlus of coverage ls tttat it wltl only apply to a populatlon with a fatrly evenly d istrlbuted populatlon ab a medlum denslty. Ttrese faetors are not founcl ln Afrlca ancl As1a. Tlre situation in Upper Volta ls but one of many examples tlrab "mf Ft chosen. fn Upper VoIta the population distributlonby population, ln t97O'-', vlas: Urban (tO,OOo/+ populablon) It7O,o92 in 1) urban centres whlch lnclude Ouagadougou wlth l]r,OOO and Bobo-Dloulasso wlth 115,00O, together constltutlng 61 .)'fr of L]ne urban population Seml-urban (5,000 - I0,0OO) )49,O25 ln 40 semi-urban areas averaglng B,7oo each llural (r.rp to 5,O00) 4,75),1!4 in 7,o72 administrative vi1lages, averaging 670 each. firc rural population, as a l)er(:enLa6e of the t Ilved 1n vlllages of the follollng compositlon rr11 rural population, in 1970 t 2) 4 l roo 250 )oo oc0 ooo ooo ooo J.OO populatlon ln 250 500 r,ooo 2,OOO J,OOO 4, ooo 5,000 94[] villages r,TL(t|,7gg 1,550 79tt uo 75 ?t+ t).4% ?4.)',( 2's.l+'ft 2r.91 LL.2"( 2.4/, I.Lft o.),1 7 ,O72 rco.q, 5+ The average vlllage slze ls tlrerefore il5O - 500 persons so that on a populatlon basls of ',),OOO - IO,OOO per'.jons an Aid Post/Dispensary vlould have to cover some 20 - 5Q,,yl)1ages. The 4verage populatlon density ln the rural areas of Upper Vo1ta\"/ *as !6 per km' in 1970 so that to cove6 5,OOO - 1O,OOO persons the Ald Post/Dlspensary would have to cover 1O - 50 km-. Slmliarty a lleal-t,lr Centre covering 40,OOO - 50,OOO persons wouJd l.)ave to cover lOO - 160 villages and witl'r a pr,,pul4tlon denslby of p6 per km'- would have to cover an area of some 4OO - 5ookrr'-. The logistics are such as to makc lndigenous vlllage practitioners cssentlal aml aLso rnoblllty 1s an essentlal for tlte various unlts both for arlequate supervislon and to enable patients to be referred up the pyramidal system of health care. Iitaf f lng: The staff of'er llealth Centre shoul.ri consist of three persons - a State Reglsterea (Otpf0me ri'l.ltat) nurse-mldvrife who has received some dlagnostlc - curatlve tr,ainln; 1n lrer/hls baslc tralnlng; an auxlllary nurse (Brevete) r,rhose trainlng is rnalnly orientated tovrards <llagnosis and therapy but who has also harl some midwifery tralning and a comrn:nlcable dlsease nurse who has also received Lralnln5 1n hyglene and sanlLaLion. Tlre first will concentrate maln).y on the Materna] and Child IIeaIth aspects of primary healt)-r care; thc seconrl on the diagnosis an<l curaLive activltles and the last on the control of conrmunicablc diseascs and envlronmental health. Such a multlpurpose trainln11 v;il.I enable each to fcave thc Ileal-th Centre to visit the vilLages and yet have their actlvltles covered by the remaining staff. The Ilcalth Post/Dlspensary shou-Lri bc nranned by an auxlliary nurse-midwlfe vrhose trainlpg has lncluded first ald, the diagnosis and treatment of the common minor dlseases .'rrrd environmenLal health witlr control of comnmnicabJe diseases. DEVDI,OPF{IiNT IN TliE (fP AIII]A (6) Currr-nL I.l ituatlon: Bcnln Ivory Coast Chana MrIi Agrl cul turaJ- l,1inJ.ng Inclustnlal FxlucaLior:/Tralnlng llealth Vlater-weIIs, cianrs Roads, Lransport, comrmrnicatlons Other u I 10 2t) 6 v Niger Togo 2 1I I I I1 Upper VolLa 19 2) z 4 4 2 19 2 I 6 I 1 I t I I t 1 5) 1I +(: Ti re nrain Lrrrust <.r1'tlre dcveloprnent projer:ts conslsts of agricultural and agro-lndusLrial- proJecLs, many of'wlrlclr lnclude irrigation projects either prlmarily or seconr.larlly from a llrojecLed hydroeLcctric development. The slrort Lerrn ainr of tlresc pro.Jects ls to provide a subslstence agrl- eulture for a lart.:e nurnirer of peasants followed by tl-re agrlcuftural provlslon- lng of the ari.jaccnt anrl then natlonal areas. The long term alm is both to rcriuce food lmSrorbatlon and to provi<le for foodstuff exportatlon thus releaslng government monies to other flelds. The project.s range from large to small-. The Ferll6sscrleugou sugar plantatlon pro.)ect in the fvory Coast is to be urdertaken ln tr^ro stages flnally employlnrl sonre 8,)OO employees and making the Ivory Coast self- sufflclent ln sugar. Attached to lt wil I be a maJor ranch proJect using the waste products of the sugar plantatlon and accommoclattng 8,0@ head of cattle and an abbatol-r'. Other maj or pro.Jecbs lncLude hydroelectric dams. Smaller pro.)ects lnclude flsh ponds and minor lrrlgatlon developments. Most of thc air6{cultunal projects envlsj.on resett}cmenL projects, the IAG Mlsslon Rcport''' cltlng flgures of 66,OOO people in Ghana, 66,0O0 ln the Ivory Coast, )O,OC0 in Togo and 27O,OOO ln tlpper Voi.la. Ilowever tire AW(Arrt,orlt.6 ctes Am6nallements des Valldcs des Vo1ta) tn ttre Ited, White, Black 1/oIl,a areas, the Tanema and Karankasso areas and from the Bagre hydroelectric proJect, plans to reset'bLe over a perlod of L5-2O years 55,000 - 65,000 famllles consisting of 65O,00O persons 1n l,OOO villages at a cost of 145 mllltards f.Cl,'A (US $596.7 million) of whlcir U[; $7otj.6 ml]lion will be for the Bagre hydroelcctric schenre. These reseLtlenrent flgures refer only to the planned reseLtlements and excLuclc the spontaneous reset,t,lerncnt 1n the oncltocerclasis-freed areas whlch ls, and will- contlrtue, to take place on a mounting scale. One5ocerclasis, posslbly'as onJ-y one - but a vcry major - factor ln the OCP apeas, fias rlr-lverr t]re people from t]re fertile rlver val)-eys to the Less fertlle platearr;< v.'hlch by over-population and over-cropping are yielding dlmlnishlng agrlcultural returns. The soil is belng eroded and ttie faltowlng perlod ls belng fessenecl 1n an attempt to provide more crops for the lncreaslng populatlon. The yleld.s of the nraln cereal crops 1n the Dlebougou-Gaoua OI1D by the :il:l"l;:1",1'ox,l:,,ll:i ll"'33,i,303,,1#nf,o;l"}ill ffiT";"i"$"i: 133-r*u* /noo) The dimlnishlng crop returns 1s also seen ln the per caplta food production for the Ocf4qguntries ln L974, taking the lndex year of IOO as line I96L-65 productlon' ' ' i Tncle.x 1()74 Year ln whlch index fell below lOO] q61-(i5=lOO Benln Ghana Ivory Coast MaIt Nlger Togo Upper VoIta 107 o? L ltl 61 66 8z Bz Only ln 1l)72 Conslstently below 1OO slnce 1972 IIas never fallen below lOO Consistenbly below IOO since 196E Consistent15, below 1OO since 197O Conslstently below sin're index year Conslstentty below slnce 1971 7There 1s. therefore, a natlonal slrorta.rle of food pro,Cuctlon wtrich is made up by importatlon whtch does not benei'j.t the subsistence farmers who are largely outslcle tlre cash economy. These farmers and their families suffer ln the 'lrungry season' whlch ls also the period ln which the hardest farm work ls requlred f,o*(7) 1r, Go*r.,ia measured the energy spent and the energy-foo<i lntake and showed that dur1n1; the heavy cropplng season farmers were workln6 under a conslcler.able enerlj:/ cleflclb. In Malawl and Gambla, Platt showed that the energy deflclt could be as much as 6Ofi uith a resultant loss of body welght ln an artult of attout llk8 clurin8 the busiest season of tlte agricultural year. In Genlerl vlllatje, Cambla, one thlrd of the viJ.lage populatlon showed evldence of famlne oedema durlng the seasonaL food she tage perlod Dr Martln-soro"(8) cltes blrth wetght flgures ln Gambla ot 2'94os for blrths in the dry season and 2.5)Og ln the wet season when agricultural trork is maximal and food stores minlmal . I"le further cltes flgures of food lntake .whtch strow tlrat the dcficlency ls ln calories and not ln proteins: Mali 197O Upper Volta 1970 Requirements Avallabl11ty pen caplta per clay: Kllocalorles Proteln, in 14. 2riio 72.2 9 70 5ti 2t 19rr0 65 9 24OO-25OO 45-60 Drergy as a '/r of requlremcnt %.afr 92.6'fi 82,o/, The rural popr.rlatlon, son)e 896+ of thc countrles'populations, who are very largely subsistence agriculturlllst,s are tlrerefore sufferlng from under- nutrltlon. i:ut malnubrltlon and undernr.rtrltion are nrultlt'actorial productlons vrhlch eannot bc solved by a mere lncrease ln agricultural production. Baslcally they are soclo-economic problems. In Upper Volt.a the AW ls tlre organlzation ln eltarge of the economic developmen,t of tlre onchocerclasls-freecl zones and must be Judged as a rural development programme rather than only ln relatlon to controlled migration. Ilovrever lts concept, and plannlng of the resettlemenb progratnme are magnlficent wlth each resett,Iement area only chosen after many baslc studies have been undcrtaken and a complete lnfrastructurc provided ln the lntended resettlement zorla - roads, cIlnlc, hospltal, stora6e, wells, etc. Thc AW ls Upper Volta's response to the three maln impediments to a sufflclency of agrlcultural productlon: a) Raln, the most serlorrs lmpediment b) Lack of an lntcgratlon of crrltlvatlon and stock-rearlng c) Tkre tradltlonal practlce of slash and burn agrlculture for brush flelds, the maln fieLds f'or family food requirements, with cultivatlon for l-1O years followed by fallowing for 8-25 years. Niger I97O ti Ilesettlement famil-lcs unclertake t,o foLl"ow a certaln agrlcultural pattern ancl weII water ls providcd with, in sorne resettlement areas, lrri6atlon- Uncler the programme self-sufflclcncy wiII be obtalned in tlte second year, after the second harvcst, followlng wh1ch, as more agrlcultural. larrd ts taken in' each family wlll prorluce a surplus for iLs own benefit and then will become fooci-producers for artJacent areas and towns. Tkre pr-erJlcteci outcome of a CulIy developed improved r?&l1d of agrlculture has been calcul.aterl for bhe Dagarl area by the PAG Misslon'-': Trarlitional Irully-,lcleloped Value total crops l4lscellaneous and Ilve stock Total Expenses sys tem 5[],81:;F Cr.'A 10,0OO 68,8L5 9,0@ 1mp roved system 112,2OOF'CFA (t?-,O(fr l'(t+,?oo)n.,549 There wll1, therefore, be a gross margin of 59,815F CfA (US $T9) under ttre trariltlonal system and, I)2,65ttr CFA (US $:lt) under the futly developed lmproved system. T6is lmproved economlc income together with the clean water provlded from AW wells, horrsing whlch wllI improve as the settlers become more indepenclent, AW credlt an<l the AW-provided lnfrastructure of roaris, cllnlcs and schools, w111 provld.e tlrc necessary impetus for the vlllage's economlc take-off and lncidentally wlIt greatly improve their health status and soclo-economic well-belng. Tire AW's parallel thrust ls ln thc fiel-d of stock-rearlng by ranchln8 and lmprovements ln exlstlng technlques and facl1ltles. In Upper VoLta ln the l97O' s animal exports accountecl tot 5Ufr of the total exports although animal ralsing, one of Upper Volta's prlnclpal natural rlchnesses, employs only 5 - (>rt of the economleally actlve populatlon. In the Sahel countrles the drought killed a very targe number of artlmals so that in L975 tn Upper Volta the total herd strength was only the same as Ln 1969. there ls al-so a very hlgh mortality rate in calves and anlma1 health ls affected by rhindcrpest, pleuropneumonla, foot and mouth disease and trypanosomlasls, r:omblned wlth a paucity of veterlnary services and a poor infrastructure of abbatolrs and irygiene. It is also of interest that ln cattle, unllke irumans, breedlng ls mope difficult than fatteni'ng. n\fv, through collcctlve and state ranches and trelp to the tradltlonal stock-ralser:; and by constrrcting a muclt lmproved infrasLructure, will conslderably alLer Lhe future of stock-ralsin5 Lirus lmproving the soeio- economlc condltlons of the ranchers as weII as the country's economy. The other 6P countrles have slmilar p1ans. In 1976 an agreement was reached with the llorlcl Bank for US $9 miLlion tc, flnance stock-ralsinq over five years in the ORD Bobo-Dloulasso an<1 D6dour]ou, througtr nine colfectlve ranches which wl11 lnfl-uence some )OO,00O tradltlonal stock-raisers' () The araricultural and agro-lnclustly developments wll1 be of conslderable economlc value to lhe OCP countrles as well as to the lndividual peasants. IIowever, 1t nn:st never be forgotten tlrat such developments carry maJor health hazards. hlh1le these are cerLainly not sufficient to halt such develo$ments, lt is essentlal to be aware of them and Lo guard against them. Mlnor lrrlgaLlon works from small darns and ma.)<lr irrlgatlon programmes such as man-marlc lakes produced for hy<iroelcctrlc pul'poses are maJor economic blesslngs - but are noL always an unquallfled benefit. AII too often only the main objective ls considered and not enough thour:ht ls given to the fact that the exploltation of a naturaL resource w111 upset the ecologlcal balance. Tl.re delicate bal-ance of a man-m.e<ie lake may easily end on the deflcit slcie. A thrlving agrlcultural and fl:;hj-ng tndustry nray be dlsplaced and devltallz:ecl for many years. At Kalnji a fairly palnlcss displacement of ,I2,OOO per:plc was exchanged for a potential !00 l4w; at Koussou 12O,O0O were dlsplace<,i for'l[iO l4vr. The Kano area proJect in Nlgeria will flood 5lt,OOOha anci cilsplace ISO,OOO for an lrrlgated area of 49,OOOha. The Asvran h16h dam destroyed Egypt's delta sardine fisherles. The construct.ion of Lakc Volta displacca [-]O,OOO persons (l% of the natlonal populablon), destroycd 22,,1159 houses and J)) vill-ages and disrupted t4,657 famj-I1es. Irif Ly-t';ro resettlement vllla8es were created. Iakes and lrrlgation works arc all born wit)r an lntrlnsic fault - they attract, bottr people and vectors, aII requlrln6 speclal attention. Ilealth conslrierations arlse ln s1x ficlds: Recrultment arxl lreal.tir of the lat>orrr lorce cortstructing tlte dam; Ilouslpg and sanltation for Llre t,enrporary and permanent Iabour force; ConLrol of cr>mmunlcable disease atrd vectors; Rescttlement of the displacod antl Llreir medical and social care; The hr:altl r an<l soclaL wclfarc zrn<l an accident servicc for the vtork force; The health arr<i soclaL wellare of tlrose J.lvlng ln new towns or villages on tlre lakes' edgcs and of tourists. The populaLlon 1,o be rcsebtled: Many wlII be unable to 1.5rasp the reason for the requlred move to a new area. Thcy wlll leave behind thelr ancestral Braves and sltrlnes, gardens ancl somebln:es ritual lcarlers. Ties of klnshlp and frlendship w111 be torn an{ known forests, wlld frrlits and fanrlne roots wllI be Ieft behind. In some projects zurlmals could not be taken and so were so.Ld at greaL loss due to the mar)<et g1ut. At Lake Nasar many animals died ln the quarantlne statlons and a signlflcant number after arrlving in the resettlement areas wtrere, as yet, tirere was lnsufficient food for tlrcm. Anlmals, Iike }tumarts, would bri.ng establl-shed diseases into t,lre arca and encounter Ilew ones an<l are more prone to contracting <lisease when ln a poor nutritional state. At Lake Karlba the people were removed after an lnadequate l"Iarvest when they were alrearly subsistlng on famlne roots. I Irrigal,lcn: IO Settlers take two harvests to bc<'omc self-sufficlent. F'amine in some Lake Volta resettlcment v1llages in Clrana caused some resettlers to leave after one ycar. Tn the AW v11la11os ln Upper Volta the supply of World F'ood Programme food for only one year, untll the flrst harvest, ls not enough as hturger exlsts 1n tlre second yc'ar. As so often ls the case, unfamlliar crops havc to be grcrwn ln unfamillar grounris. Also, ln Ghana the rescttlecl vlllagers harl no, or little, access to thelr traditional mlddlemen on vrlrom tlrcy depencled to organize markeLs and marketing facilltles anci 1oans. Flslrepmen found nice vlllages awalting them - but no fish in some areas. Rlver flshermen rvho remained by the lake requlred. nel gear and boats and harl to be tauplht new flstrlng methods. They also requlred an lnfrastnrctrrre of roads and transport wtth freezlng faclllties to enable thelr products to reach the market. Malarla was named by Professor G. Macdonald as ttMalaria of tropical agglomerations of labourtt clue to 1ts rapldly rlsing prevalence in both work forces ancl resettlecl villagers. Slnce the Aswan dam was finlshed, bllharzla has spfqad and the mentality and healLh of lndividuals has deteriorated. Landix\t | / has reporbed how ln tirree years after the dam was constructed in four arcas the bllharzla infestation rates rose from rcrt - 44%; L1l - 6t+fr ana art - 75%. The presencc of lake or irrigati<.rn water may also procluce enterlc lnfectlons, dlaprlroea{i, cercarial lnfcstatlons, ruinca worm lnfestation, pollomyellbls ancl posslbly hlst-plasm<.rsls. Ib vrill also offer potentlal breedlng sltes fr>r the vector.s of ma1arla, bilharzia, yel-l-ow fever, dengue, encephalltls ancl flLarlasls. @: Resettlement villages 1n the OCP area, even 1n the absence of lakes and trrl6atlon works, themselves produce healtlt hazar'ds as migrating v1llagers brln6 their loa,<i of <llseases lnto tlie ncw area anrl ln tlte netv area come lnto contact with dlsea{';es previously foreign to them. They are expose<i tottmalaria of troplcal aggregations of labour'r and also water-borne diseases through botlr the rlver systems (as the resettlement areas are in river valleys) and badly kept rvater r.re.ll.s. Unl1kc the settlers from lnundated areas, these scttl-ers are 'volunteers' but even so suffer tite same psychlc and social trauma, though not as badJ-y as the lncreasing nuntber of ,spontaneous' settlcrs vrho, on tlrelr arrlval at their rlestlnation, are not welconp<l wlth tfie already prcparecl AW's lnfrastructure and food support from the WFP. Llvestock; agro-lndustrY : Tn the cleve'loplnrl countrles there are nrajor lmpedlments tcr exportlng anlmals or meat. One n6lable barrler ls sanltary due to tire anirnal dlsease sltuatlon, the Iow stan<larrl ol meat, ilygiene and meal lnspection and the lnadequacy of Llte veterlnary l;crvlccs. Suclt concliti.ons present hazards to the health of not only ttre anlmals ahct the consumers but also to those who work wlth the animals. 11 Many meat/anirnal lmporters requlre that the contractlng partner be free of speclflc dlseases for varylng tlme perlods of up to 12 months. In tle developlng eountrles the most troublesome conditions ln that respect are foot ancl moutlr cllsease and r}-rtnderpest. European Economic Comrmrnlty rcqulremenLs lnclucle regulatlons that stlpulate that any animaLs showlng any forn: of tubcrr:ulosls or traving a positive tuberculin test or carrylng one or more cystlcerci cannot bc Imported lnto EEC countries. Some of tire l-ivestock dlscases ciul also affect man - bruceLlosis, foot ancl moutlr, anthrax, tuberculosls, porclne cystlcepcosls, etc' Foot ancl mout[ cllscase ln caLtle 1s lmportant in N18er and has been recently recognlzcd in MaIi and porclne cystlcercosls ls falrly colrrnon ln Mall and Nlger. Of olher imporLant animal dlseases, whlch are not transmlssible to man, rhlnderpest and contaglous bovlne pleuropneumonia are common ln l4ati ancl prcsent in some re,Iio??.,Qf Niger and cysticercosis bovis ls falrly common ln both counLries\^"". Anthroc, bovine and human, ls also found ln Upper Volta and Ghana. rmportlng countr"les also require a hlgh standard of hygiene in slaughter-houses, cultlng plants, cold stores, packing plants and in transportatlon as vrel.] as a hlfih standard of ante- and post-mortem lnspectlon. Such conditlons are c.ften of a low standard in developj.ng countrles, lncludlng the OCP countrles, as also ls thelr disposal of wastes and sucir coprlitlons leari to llt-health amongst the workers and the people consumlng tlie Prcrciucts. Anlmal offal ls also of consi<lerable economlc lnterest to the @P countrlefr. Normally, hldes represent 5 - 18rt of the total value of an anlmal\rvl. Thcbbloo<i,. bones, Eut contents, horns, Itooves, faL, wool, halr and brlstle are also valuable. In slauglrter-houses the blood is wasted yet the countrles lmport blood-mea]; crude bones are exported at nomlnal prlces and. expensiys gattle Ilcks and rock phosphate is lmportetl; slaughter-house offat ls thrown to t,hc vul-tures or Jackals and protein conccntrates or ottrcr compound feed.s lmported. tlides and skins are sold in the raw and repurchasecl from abroa.d as exf)r,r).,ive finlshed leather and leal,her products. T1e lndlgenous mcLlrcr-Is of prci-:arirt; hidcs and skins also downgrarles them ln quallty. Notlce shorrlci also be taken of tire fact bhat meat brduction by the converslon of arable lar-rd Lo grazi.ng Jand ls an inefficient way of using both gralp and ]anri and so is an inappropriate way to attempt to rcduce malnutrltlon. It is necessary to concentrate on scavenger-type anlmals and chlckens ln the backYarrls. Agrlculture an<i agno-1n<lust.rles cm do a great deaf to make tlre CCP countrles m<>re selt'-sufflctent anr-l lncieecl 1,o become exportlng countries and the ggP countrles arc prlmarlly p)acing lrlliit i-topes ln tlre agriculture and agro-lndustry <ievelopment of tlre onchocerclasis-frecd areas. The AW and development agencies lp tlre OCP countries arc aware of the limitations placed on development I:y tlre lack of propcr faclLitles and veterinary servlces and are taklng, or wllt be l,aklng, st,cps to lmprove Lhese services. However, no attenLlon ls pald to t,he concurrent lreaLtlr hazar'<-ls to tlre I'ivestock ralscrs. l,ixcepL jn Cl rana, tlrcre are lro medlcal services available speciflcally ln connccLlon wlth organlzed migrant resettlement, and, wlthout exceptlon, there are no lnclustrlal health servlces available ln any of t)re @P countries. I:] Industrlal healblr: (2iJ )Rosow Ilsts the seven essentlals for lmproving worklng Ilfe: Occupation Job securlty Thc rlgtrt to organlze Vlorklng condltlons. These sirould be clean and safe and not enclanger the health of tlre worker nor hls famlly I,lages and salanles shoul-d be falr and equltable Bencflts for the v.'orker and h1s family, e.B.LL1ness, death, old age, pregnancy Ieave, tlme off for breast feeding Ielsure time for rest and recreatLon. The practlcaL lnterpretatlon of such ldeals of improving the working llfe of the Iabour force w111 vary ln lndustriallzed and industriallzlng countrles, but they should not be narrowly defined in relatlon to the deflnltlon of an 'industry'. fn the industrlallzlng countrles the vast ma.lority of tlre 'vrorklng' populat,lon 1s en6aged ln agriculbure, as subslstence farmers and not as employees. This type of a6rlculture Is the dominant factor ln the economlcs of tirese countries and 1n all the OCP countries will be explolted by lmprovlng methods of subslstence agrlculture, stock-ralsing and agro-lndustrles. It ls neccssary, therefore, to create an lndustrlal irealth servlce ln Lhesc countrles vlhose emphasls would be largely agrlcultural. The prevlous seven fact,ors required for improvln6l 1;he soclo-economlc aspects of tlre vrork f<-rrcc are equally tenable in the OCP countrles. Of especlal lmportance is Lhat concernlng the suitablllty of the occupatlon to Lhe lnrilvidual. In tire OCP countrles emphasis should be on the rchabllltatlon of Llre onchocerclasls bl1nd so that after blindness they may conLlnuc a useful form of employment thereby benefiting themselves and the country. In East Africa for example lt ha-s been shown that the blind and tlrose wlth c.rther physlcal dlsabilltles can be traine<l to unclertake useful a6rlcultural ulork, ln some cases helped by the creation of approprlate Leclrnolo6y, artlficlal llnrb and working appllances outlets. The restoratlon of sueh people to an e()onomlcally actlve Ilfe, albelt somewhat reduced, not cnly resLores l,ircir oln dignity as useful human belngs but also decreases the clepenclency ratlo on already strained famllies. Certai Iy 1n Upper Volta j.n re.l-atlon to the AW vlllages the question of Job :;ecurtty can be relabed to the question of land tenure. In such areas thc land belonfis to the government and there is no guarantee by law that a clrllcl can lnhcrlt thc 1and, evcn as a tenant from his father. fn some cases Lhe lanrl used by govelnment, or parasl;aLal , resettlenrent schemes ls already tra<lltlona]ly ownerl by a tt,:hef de tcrre'f who, hlmself, migirt have left the area due to his vlllage's migratlon because of onchocerclasis. Thls matter ls of even 6lreater lmportance in relatlon to the on-golng and lncreaslng spontaneous migratlon wtrlch is taking pl.rce lnto onchocercla-sis- freed areas wlthout the quasl legal beneflt of a'directed'migratlon. Apart from such soclological conslderatlons there are a number of lmportant health hazards ln agricult,rrre, aljro-industry and other industries. As a basic health requlrement the following should be provlded: t1 Access to art arlequate and safe supply of water Sanltatl<-rn Ilousing I.ledlcaI facllltles wltir good access Schools wlth 6ood access Ilealtlr promotlve actlvitlcs lncluding nutrltion educatlon I,'aml}y PJ-arurlng and infertillty servlces Occupatlonal hyglene and safetY' The maJority of these are alrearly recognlzed in the AW vlllages but there ls no such servlce avallable for spontaneous migrants. It ls of lnterest tirat new agrlculturaL technlques are being taught and supervlzed ln the AW villages by 'encadreurs' . f t sl-tould be posslble Lo provi.de such agrlcultural personnel, as weII as a new form of encarlrcur ln t'elalion to ]realtil , at least at a distrtct fevel in all provlnces. The serviee provlded tirereb;7 becomes one of inforrnation' etlucation and. suoenrlslon, so tirab tire people themselves provide thelr own wells (vrhere p<-rssiblc), latrines, hottsi ng and, b;1 cooperative effort;, bulId up t5e1r orvn scli<;ols and cl-inlcs - althou6h ln sucLr a ca{je it Is absolutely essentlal ilrat the [overnment be in a. positlon to provide the necessary auxlIlary c<lucation/medical s taf f . In reIaLion Lo r;pr;slf1c Ireal.th JrroltIcrtrs tirc industrial health servlce shall be fulIy akrar.e of Lhe r1enelaL, occuoational , pllysical exposure, chemlcal e)tposure ltazan-ls as t'leIl as 1lt lustrlal accidents, many of which are preventablc. Plrysl ca I ,';(I)OSUTC As a number. r>f OCP countries arc comrnencing nra.lor sullar plantations It stroulcl be noterl tl'rat lreat strol,le and heat exhaustion have been reported from Kenya on sltgar and slsal planLat,lotts. Ae c lcien t,s Betwcr:n lc)'ll-'l) 1n Zamiria ?(>) a],rlcultural accicients were reported of vrhlch lL wcre fat,a] and J8 caused a permanent disability. They were causerl by traet,orr;, tree l'elllng anc falllng off builciings. In Zambia fr.om Lhe reporlccl li15ur.es one ln tvrenty-four wcre fatal" and i.n Kenya one 1n thlrty-three of agrlcultural acck-ients. To ti:e rnore comrnonly experienced accldcnts rnust also lte adrlccl snake bites and scorp.ion stlngs. Many aceldents are prcventable but require lrealth cducation in relation to the correct vtorkln6 Procedures. Chemicals Each ;lear several t,housalcls of ne',v clremlcal sui;stances are used ln agrlculture and lndustly and ln rnany cases their toxlclby and posslble dangers are not yct knowT*1 FertllIz,inrl aJ;ents and especially lnsectlclcies can be letlrat. fn Ghana\// "o..,",,or.I was mixed vrtth a small amount of gamaclne, whlch Looi<s }1ke cassava, ancl ten pcopJ.e were poisoned vlitlt three deaths. More recenLly in Ghana tliere were lllll cases of alkylmercury poison- lng with trventy deatlts. Dresseci mal:le wirlch was lntended for sowing was eaten after waslrin6 iL - as ln the past thls metl-to<l harl worked witll DDI- contaminate<l graln. C[l].dren are espcclal ly prolre to poisoning from agrlcultural clrcmlcals. r4 The. especlal hazanis to womerl fl'om the varlous hazards is considered under Female -Emanc lPatlon. Occupatlonal healt,h hazanls : These are causeci elther throufh the rvork ltself or from the locatlon of tlre worl< force. Consi<ieratlon ls Iimited to agrlculture (cultivation and stock-ralsing) and agro-industrles. The hazards encou:rtered incl-ude: Anthrax, bovlne tuberculosis, brr:cel}osls, mycosls, bllharzia, Iepto- spirosls (as there are many rats in cane flelds), onchocerclasis, malaria, trypanosomiasls, draconlasis ancl in some'countries kala azar, sylvatlC ptague and sylvatic yellow fever. Due to the accumulation of workmen anC thelr famlIles, malarla wltl become vcry prevalent as well as tuberculosis, malnutrltlon ancl venereal dlsease. In many sltuatlons the women wlll be exposed to bllharzia, draconlasls and onchocerclasis when fetchlng water or washlng. Certaln fiaZarr]s are re]ated to speclflc occupations. Cotton flax and soft hemp dusts cause <llsab1ing respiratory condltlons such as byssinosls, farmer's lung. In saw mills certaln wood dusts cause resplratory conditions ancl speciflc alLergies are found as in the case of cane flowers and tea dust. Sugar cane and latcx also can causc a conjunctivitls. Bagossosis is a non-speclf1c broncftltls causcd by the In]ralatlon of bagasse soot; a large sugar factory may urie ltO tons of bagasse a day as fuel for its bollers. }II{AT IS BtrING DOi'IIi IN TIIE OCP AREAS A Ger,man a4ricrr)tural economlst in Ghana, when asl<ed-about the dangers of bllharzLa Ln connectlon wlth the many small dams a project was constmctln8, 'too}: thc vlew tlrat lb was not a matter of concern to the proJect but one for ttre Mlnlsbry of llcalth'. Later ln the conversatlon he agreed that as the projects could cau??r \rouble the Mlnlstry of }lealth should be notlfled of tmpendlng pro.Jects t *-' . Thls ls an lncrcclible at,titudc and unfortunately one of the maiorlty of pro.Ject planners ancl flnancers. It r:ould be equated to notifylng the local hospltal when one is about to shoot someone. It ls absolutely essentlal that proJect costs lnclude finances to control healttr hazarcls brought abourt by the proJect - hazards which would not be present but for the project. 'Iirls applles to controlled mi8ration, agrlcultural projects, agro-lndusbrlal projects, Iarge and sma}l dams and lndeed all forms of develoPment. It 1s of int,eresb that the AW or6anlzatlon in Upper Volta does not contaln a meclical dcpartment nor has a ptrysician atl,ached to lt, using the servlces of the Mlnistry of IIcaIth wlrcn lt ls bellcved that they are requlred. fitere is, tfierefore, no on-golng medical survelllance of tire very large resettlement schemes nor of the ranches and agro-lndustrles. On the otlrer }rand, the Vol-La lllver Authorlty ln Ghana has a very large and ambltlous IIeaIth and Safcty Department as an intrlnslc part of the Authorlty. T5e crrganlzatlonal plan of tl-ris Departmcnt sltows four different sectlons wSlc[ arc uncler the Jurisdlctlon of an extremely able Medical Director, Dr L.K. Derban. The sectlons consist of: 1. (a) (u) r5 Ilplclemlolo6lcal research, malnly lnterested ln the onchocerclasls and scirlstosomiasls Lakesl<ie IIealtir Unlt, vrhlclr 1s concerncd vllt,h (1) Iinvlronmenlal lrealth, (f i) [4eAfca1 aspccts - vector cr.rnLroI ; epidemlological survelllance; comrmrnlcabLe dlsease control; mass treatment; lmmunlzatlon aC. Heal-th section, Akosombo Lortnshlp: Thls ls divlded lnto(t) Occupatlonal healt)r and (ii) envtronrnental sanl Latlon 7, Akosombo I'lospltal wlth lts communlty care outreach Accra clinlc. ft ls of lnterest tirat an epldemiological survey before the Lake was constpuct.ed 1n T96O-6L, shorved a lolv endemicit,y of schlstosomlasls along the VolLa river, wit,h a prcvalencc rate of 5/, ln sclto<;lcirildren. Surveys In l)6lt-6l after the Lal,.e was constructed shovred o t\O,( prevalence rate in sciroolchllclren. T1rIs hu15e grr>wt]r vras probab]y due to a corntrination ol factors includlnl: t,lre migratlon of infecLed flshermcrt ancl the explosive growth of hoth vral,r:r r.reed and snall-s. The fast vlater flort ltel-ow tlte darn encourafcrl simulj-um breedin65. fn some areas a prevalencc rate of onclroccrciasis o[' up ,,o cl};i, was found ln people af:ed 15 ]/cars and over; lnfection t.las founcl 1n tvro-year oId clrildrcn and oncltocerciasis nodules in four-year ol-d clrllriren. YeLlorv fcver also lnercascd dunlng the early part of the Lake's trlslory but tlrls was due Lo a brcalldorvtr in thc refuse collectlon and water supply ln the resettl"ement vlLlages and rvas brougll! under control by a mass inoculatlon altci an attack on the breedlng sltes'-'. Ihe AW ls runnlng a first class programmc in tlre resetblemcnt field from a soclologlcal polnt of view and Lhe provision of an infrastr:ucture and. on-going care 1n tlre rescttlement vllIages. However, there is no medlcal examln:rtlon of accepted settlers be.Sore they leave their prevlous areas(sufflclcntly belore tirelr <leparture clate so that existin6 condltions can be adequatcly breat,eci) nor of on-golng trealth and envlronmental- survelllance ln tlre resettlement areas. Sincc the AW is responslble for all- the development proJccts 1n the OCP areas ln Upper Vo1ta, a medicaL department along the Ilnes, but posslbly smaller, of the Volta Iilver Authorlty shouLd be created with a speciflc lntcrest ln surveilfance and the provision of lndustrlal and occupati6nal heaLth cat'c - l:oth preventlve and curatlve. It 1s essential tlrat cllrected mi8rants sltoulci be examincd, and treated 1f necessary, before traveIlln4 to the resettlement area and there must be not only a pre-settltng epidemlological survey, but a continuing epldemlological survelllance after tire settlers arrive. It is also essentlal that health provislons be marle ln resettlemenL areas or lndustrlal areas and this lnclucles not only the provislon of manpower but also of some form of transport and a rellabte and continulng supply of drugs. Durlng a vast rcscttlement prorlramme in East fpia the death rate of new lmmlgnants rose by JOI durlng thelr first year\"/ and in both East and VIest Afrlca resettlement schemes have ireen accompanled by exploslve out- breaks of malarla. lvlalarla 1s currentJ-y presentlng a considerabLe problem ln the AW vlllages desplte nlvaqulnlzatlon- 4 tlr In cc;,nclusion it rnay be said tha t, the AW in Upper Volta ls provldlng a flrst-class and very well thou,r'It-out soclo-economlc programme in relatlon to resett.lcment vlllages - but, there ls no medlcal Input. The Volta RIver Autirorlty in Ghana has a flrst-class medlcal department ln the Authority. It ls not known lf tlte VIIA's socio-economlc progratnme in the pre- and early settlement days was as efflelent as Upper Volta's, but lt is knowrr tlrat only sonc ?',(' of ttre AW resctbled leave the vlllages whereas by now sgnc 65fr of tfiose resettled 1n corurectlon wltlt tire Volta Lake projects ]rave left the settlemenL areas, I,la.lor natlonal developmcnt authoritl'es such as the VRA and AW must have an attached and ln-bulIt medical department for investlgation and survelllance. Ilowever, the natlonal government should provide for salarles and. drugs for t,lre medical personnel (unless tirey are bullt lnto the proJect programmes). The cllnic buildings can be crected by the vlllagers and for sma1l areas viJ-J.agcrs cam be chosen by the vlllagers for a short tralning 1n the dellvery ol appropriate healtlt care. As wetl as tltls, governrnents In the OCP countries sltoulC con.slder the setttng-up of a nablonal- Occupatlonal lleal"th Unit anrl couple it witlt a national fndustnlal liealth Unit. Ttrls does not need to be expensive. For exampler.Ihe Occupational Ilealth Untt ln Maurltius cares for 140r@O workers(tti wltlt a staff of: 6 pl ry:;le Ians J enr;ineers) safety itrsPectors Il+ .[abour inspectors J enforccment officersI industriaL relations oll.'icer 2 scnior labour irtsPectorr-; Jl prlnclPal Iabour ofllccrs. In the Suclan(l2l) ur*tllar.y inspectors are tralned in three months. Tlre course conslsts of JtO# occupational safety, ?5'rt occupationaL health, ?5'fi FLrst Ald and 1Ol fire flglrtlnz and civir defence. Such a scrvlce must encompass not only t)re settlers, but tltc whole agrlcultural flcld - lnLernal, spontaneous and cont,rolled settlers; the subslstencer/peasiurt cadre; cooperatives and prlvate and Bovernment commercial- lnstltutions. Thelr trainlng vrould take especlal note of tire hazards associated wlth lrrlgatlon anci. reser.volrs since ma.jor rescrvolr progralnmes are likely ln Togo, Benln, Gttanta, Nlger, MaIl arrd Upper Volta. Sovlel, trade unlons lrave Li relr ovrn lnspectorate consistlng of 6,O0O staff lnspecLors ancl sonre tirrce mll"Ilon voluntary lnspectors regularly checklng on worl'.lng conditlons. r"l FEI4ALS EI4ANCIPATTON In largely allrlcultural countrles, such as those ln the @P zone, women perform a nmltitucle of functlons. They function as proclucers both of agrlcultural produce and. of livestock; they are actlvely engaged ln commcrce as ln Nlgeria and most other Afrlcan countrlesi they are the family, or famlly group, cooks; they have thcir reproductive function; they look after the health anci welfare of all tlie famlly members and especially the young cltifdren and they teach the younS chlld In the early years and since many of these chlldren do not go to sclrool later', this teachlng ls aII they receive. Indeed, lt has been been clalmed that women are the pivot on whlch all rr,rral development should turn. Ilowever, 1n the @P cor.rntrles, as ln other cleveloplng eountrles and tndeed in the so-called developed countrles, women are cllscrlmlnated agalnst, elther intentlonally or unlntentionally. l.lomen often recelve the furthest and worst ftelcls from the rrchef de terrett. They usually have no access to good seeds, fertllisers, lnsecticides, stock-fattcners and often crcdlt. Agrlcultural extenslon work ls almed towarrls the male farmers desplte the accepted fact that the woman plays a maJor role ln agrlcultrtral procluctlon - a fact recognlzed ln Artlcle p of the Internatlonal Women's Year Mexlco declaratlon. Wlthout speclflc soclologlcal lnvestigatlon it ls nob possible (Uut hlghly probable) to say lf the ruraf women ln the OCP area can be included wlth the Tanzanlan rura] women includbd in the 1967 Arusha Declaration ofpresldent Nyererc , " .. .. Tl-re bruth 1s that ln t.iLe villages i'Iomen work hard for 12-14 trours a <lay lncludlng Sundays anci holldays. But villa8e men, aIld urban women, are orl hollday for half tirelr 11ves.tt Tkre 'modern' agrlcultural developments such as the substltutlon of hand plouglrln,,: by oxon ploughing makes a hard task easler for the men but matchln6 lessenln'l of thc women'srqq5icultural tasks has yet to be conslderccl . In one Nlgen proJect\L'/t a prosralnme rvas started to show women how to use rnanure for thelr gardens. But even if the manure was produced by the wornen's anlmals the men had tire customary rlght to take it as they Were masters of tlre concesslons on wlrlclt the anlmals grazed. Custcrnary ]aw ls, as 1t was orlillnally lntended, an excellent form of Jurlspruclcnce. Ilowever, many countrles ln which customary Law is still an lmportant form of Jurlspructence must r:arefu1ly examine tlleir laws and either ensure tirat tlre conrp),et,e customary law requlrements are followed or other- wlse reJect tlre cust,omary lavr. In many countrles by customary law a widow, her chlldren ancl hcr dead huslland's property belong to the husband's brothcrs ancl thus 1,he1r continuccl well-belng is malntained. Ilowever, aIl too often only that sectlon of Lhe customary latv concernlng all the late husband's possesslons 1s followed and the widow and her chll-dren are Ieft destltutc. Polygamy ls not uncommon 1n the OCP counLries although no flgures more recent than the late 1950's and. early 1960's are obtalnable: }B l'erccnt;.rie of husbarrds Average number of rvitir one wlfe wives per husband not avallableBenln Gl-r:ura Ivory Coast Mall* Nlger** Togo Upper Volta I'rlmary Sccon<lary tg6L I 9bO t957-5t) L')';6-5t) 1959-60 L95,t-60 L956-57 I)'fr IT1 ?7tfrTT 2).7 )t1:o-t t73 7) 7O / () 7'.1 68 'f t+ ()(J 9 9 6 I 5 1.4 1.4 1.4 L.7 L.) t.5 'I 7*** t fvory Coast excludes towns ** MaIl - Central Nlger delta +*t Upper volta - husbands aged 60-61+ Source: INJI.:i.l linqu6tes demograpirlques rdcentes rdal1s6es en Afrlque Nolre d'exprcsslon frangaise (2) Blsilllat(rl) ,,* potntcd out ln relaLlon to francoplrone Africa, and lndeed the rest oI' Afr'Ica, tlrat polygamy and arranged mal'rlages are belng less and less accepted by women and tlrat by enterlng the money economy they are now able to repay blre brlde prlce, leave thelr husbands and survlve. In Nlger the married woman ls insecure 1n that lf she Is dlvorced she cannot keep any chlldren over thc age of seven. If they are dlvorced before the harvest they forfelL thc work they have put into the crop. Nor is the wlfe motlvated to lncrcase the husband's financlal remuneratlon as by doing so she may only be enabling h1m to remarry. Such an attltude must have an llnportant lnrpact on attempts to lmprove rrral output slnce more and more the wlfe ls givlng less and less to the husband to makc hlm solel-y dependcnl" on hls own work and on her slde ls tryin6 to accumulat.e capital to pay bacl< the brlde price and ensurc her own economlc staLus. fn tlre (fP countries, as in very many countrles, vJomen are dlscrlmlnaLed ar:ainst in cclucation. One example of this is the Fercentaggr',' of 41r.ls ln eaclr cfass ln tire publlc (55overnment) sct-roofs in Upper Volta\^ " tctc 197)-74 t 456_Tn ffi vcT Tot c-l 7??.2 it).) L5.9 L).96 University L97t+'. 166 boys to ,+5 girrs. Such flgures lrave three lmportant lmplications 1n relatlon to development. Flrstly 1n relatlon to overal-I development the saylnr5 of Chelkh Ben Badls must not be forgotten:'rFxlucate a bo:/ and you educaLe an lndlvlciual , educate a glrl and you eciucate a generation." Secondly, in relation to agrlcultural and lndustrlal developmenL 1t 1s essentlal to have an educated cadre of female worl<ers and ttrlrrlJy in respect to tlre clelivery of health care 1t ls essenttal to have a large and quallfled pool of vtomanpower aL the vanlous educatlc,nal Ievels from wlrlch to draw an<l sel"ect. Presently only )6.L'fr of clrlldren ln t.he top prlmary form are girls, 17.6rt of puplls ln the fourth year of secondary educaLion (the pool for auxillary nurses 1n Upper Volta) and If.9fr Ln the flnal- year of secondary eclucatlon (the poolfor reglsLered nurses). Only 7.9ft of ttre studdnts 1n the Unlverslty are female. ) \19 The rural areas are badly servecl, in Upper Volta, wlth secondary schOols whlch ilrus affect both the male and f,:rnale educated rural manpower. In the rtrral areas there are special rural scltools offerlng a practical three- year course of eclucatlon. In 1974 there were 58I such schools for boys and p4 for Blrls wlth l7,6lto boys and 2,547 glrls attending' A slmllar sltuation ls met wlth in othen Afrlcan countries with the result that re6istered nurses - who have flnlshed secondary school and also had three years of professlonal tralning - represent a large proportlon of the female ellte. This results ln thelr belng eagerLy sought after ln marrlage by senlor government offlcers and thus ensurlng that the few nurses there are are drawn lnto the cltles- Tkre tasks of Lhe rural housewlfe ln all tlre OCP countries must be eased both for thelr own health and to enable lhem to partlclpate more fully in t5e overall development plan. 'llireir arduous tasks must be made a prlme target for approprlatc technolo6y in any ruraL deveLopment plan. Small mllls must be deslgned and introduced to obvlate the tlme-consuming a4d heavy work of pouncilng corn, etc., for flour; there rm:st be ariequate and cfeart supplles of water near, or in, the vlI-lages. Firewo<-rd must be grown near the villagcs. The women's agrlculturaL tasks must be made easier by approprlate technology speclfically ciircctecl towards tirelr tasks. Only ln ttrls way can thelr burden be lessenccl, their trealth improved and they can be glven sufflclent tlme to devote to the better care of the young cltildren. They nmst be provlcleci wlt)r arlcquate rural heaLttr care ln whlch a very great emphasls Is placed on maternal ancl ctrlld health rvhlch lncludes an adequate astenatal, dt:Iiverv and post-natal care system. Presently the rural women, by becomlng prellnant evcry tvro to three years, are pJ-acing thelr }ives in Jeoparrly at re6uJ.ar lntervals - no male vl1lager ls ever expected to placehls ovrn Ilfe in JcoPardY. fire bunlen on repeateci pregnanclcs presently resulting ln a hifjl wastage rate of abortlons, stillblrLhs and chlld deaths unrlcr the age of flve years must be reduced by the rural health servlce comblned wlth a pregnancy spacing service so tlrat the ruraf mothers can have tlte number of clrildren 6ey w1s5 for, but at properly spacecl intervals. The concept of famlly plannlng (whlch for many years has become lnextrlcably lnlermlxed with populatlon <:ontrol) cer.talnly cannot be lntroduced (even if wished for by zr f4ovcrnment) r-rnti.L tlre health servlces can glve some form of guarantee that tite chlldren born wlII at l"east stay a1lve. In Francolrhone Afrlca only Togo and MaIl have an operative Familyplannlng Assoclatlon and lormally establlshed national programme. But a 'FamlIy plannlng'progranrmc has an equal duty 1n relation to sterility (a fact whlch 1s <llsregarried by most F.P. prograrnmes) and thls 1s of especial lmporLance ln Afrlca vrhere stertl11,y 1s a ma.ior curse and 1n customary law is often grounds for dlvgrce. In many countries a sterlle wlfe unvrlllingly agrees to polygamy only to ensure her r>wn contlnued support. In the f1eld of lndustrlal health women present certaln dlfficultles of whlch an lndustrial lrealth service should be fuliy aware and be backed by the necessary leglslatlon, ln regard to whlch it ls rnost sensible to consult thc BuLgarian system. In Bu1garia, men and women have been regarded more ln the light of machlnes wlth capabllltles dlfferlng according to physlologlcal make-up rather than the more chauvanlstlc 'hlt or mlss' method of European leglslatlon. 20 IJeat stress 1s especlally dangsl'ous for women when they are pregnant and can glve rlse both to toxaemla and a hlgher neonatal death rate. Nolse anci vlbratton of certaln frequencles can aggravate menstrual dlsturbances. In thls regarrl Butgarla lras passed leglslaLion concernlng the low frequency vlbratlons from agrlcultrrraL machinery to protect women. There ls some evldence that pesLlcldcs and otirer compounds can cause abortion. Some chemtcals have a teratogenlc effect, organic solvents can pass through the placenta and lnjure the foetus. Renzene becomes fixed in the ovaries and damages them. In thc same way that the AW v1l1ages ln Upper Volta are provided wlth 'encadrcurs' to tcach and supervlze tlrc new agricultural methodology an 'animatrlce' 1s pro'rlcled as a stlmulus to female deVelopment. However ln the one vlllage investlgated tirls lariy spent too much of her tlme on the 'health' aspects (undertaking work which should have been undertaken by a Dlspenser/AuxlIlary nurse), thus mlnlmizing her posslble overall- effect, and also undertaking work for whlch she harl not been tralned. HEALTTI PEITSONNEL IN ]IIi' OCP COUNTRIES Benln Physlclans BI+ (r5) 99 Nurses: Dlploma Certl flcate Assistant 'Other Nursing' Mldwlves: Nurse-mldwlves Matrons Medlcal assltant.s Multipurpose hcalth auxlllarlcs (vltlages ) Medical soclal workers Nutrltlonists Health educators Sanltary engineers: Health fnspectors Health Asslstants Sanitarlans Sanltarlan auxl I iarles Pharmacists: Pharmaelst Asslstants Lab. Teclurlclans: Lab. Technlclan Asslstarts X-ray Tecl'rnlcians: X-ray Technlclan Assistants Dietlclans )20 6zt 2)5 Girana ?r56 7,6Ou 1,)+o5 4, 168 r, o28 1, r15 L,?-64 )5t I , OCX' 5lu Togo 95 6t) 46 t74 )4) ro7 Upper VoIta 274 L,O)2 )87 B6 Ivory Coast Fla11 )L2 r40 Niger 109 tB7 547 99 6rJ lBL 146 50 47 L27 I78 t1 I )9 r50 10 I t79 )7') J1 11 Jg 211 186 2tr 7r 97 17 I 2 2 2 9 I a I l t ) 6B 24 5 ll1 9 7 I 25 IO 22 II (rr) 52 27 14 ]5 5 I 2l Ilenln Medlca1,Statlstlclans : Statlstlclan Technlc lans Dentlsts: Dental Auxlliarles Dental Teclmtclans Dental Attendants Veterlnarlans: Veterlnarlan Asslstants dlfferences. In Upper Volta ln 19'16 th nurse mldwlfe : populatlon ratlos were: Ivory GIrana Coast MaIi Niger Togo 6 \6 211 t rB 1" to.Tnurs e/mldwl fe/auxl I i arv 5,000 It,0\)0 150,0OO llo,ooo 6oo 500 7,)OO 2) , O0O ,,()oo 5,000 25O, OOO None 25,O@ None 20,0oo JO, OOO Upper VoIta (I?) ) 400 44 L) 5 67 B I L2 2 21 92t 24 1 1 46 4 2 Populatlon ln same years 'OOO ln 7,O29 9,607 4,765 4 ,666 4 ,476 2,tL7 5 ,897 The document from whlch these data are taken states that the figures for Ivory Coast and Ghana are for Bovernn)ent personnel onJ.y,. One rm:st, there-fore, assume that for the other OCP countrles the whole personnel are enumerated. Natlonal flgures conceal great lnter-reglonal" and greater urban/rural I docton I nurse 1 midwlfe I auxiliary I)er per per midwife per Ouagadougou Lown Bobo-Dloulasso town RuraL sector averagc Sector u* Accrrr Populatlons of 2O,O@/+ Populatlons under 20,OOO *sector [J ls t]re leasL provlded for T'ire cllsLrlbutlon in Cirana, as 1n Upper Vol.ta and all the OCP countries, Is also uneven with a heavy preponderance of staff in the urban areas. Ghana at the end of Lc)T) Lhe distrltrutlon of doctors to populatlon was: Doctors fr of doctors I of populatlon )6.ti)o.4)2.8 too.ofr )uo 1L)))t) IB Bz rco.ortl,Olr Flnatly one can conslder the ratlo'of popul.atlon:d,octor/nuese/midwlfer/ auxlllary sanltarlan ln tiie l1ght of the targets set for the African Reglon ln the Sccond Development Decarle, 1971--1980: 2n Nllrl; r )s Doct<.rrs Auxl Il arv SRN Target - Ilenln Ghana fvory Coast MaIl Nlger Togo Upper Volta 29,OOO t2,)oo l),600 )6,?oo 't7 ,5oo 2r7 ,9(o0 77 ,O@ I :1O,O0O Actual I :1 ,OOO Actual 5, OOO 7, OOO 14,5oo 5,200 135,000 ActuaI 27,7OO 22,4OO 4,)oo 72,700 790 1,066 I ,159 t J6tt I,297 5t+7 t,?7) Doc L,ors Aux. rlro;om .:.:Foo 1:L,OOO Actual 629,4oo 1B8,7OO )67,OOO 409,10o 1:l,OOO L:1,OOOlncrcase 'OOO* 't90 ),066 1,159 1,161+ l r?()7 )74 L,?7) t4 il na na na 00 CO oo 9,6 1,2 ,,6 ooo 200 Mldwlves 1:5,OOO ActuaI 16,7oo),600 2L,600 5L,)OO ?-5L,600 16,7oo t2),600 Sanl tarians The figures for nurses are broken ciown into au-xl1iary nurses and RegisLered/ Diplomatecl nurses, but lt is not known I t the flgures for mldwives ls for the sum of fuJ-ly tralned and auxillarles. Such flgures also hide conslderable lnter-reglonal and very Breat urban/rural dlsparltles. At the beglnnlng of the second development decade only Ghana had reached t5e target for reglstercd nurses and midwlves and both Ivory Coast and Togo had reached the target for registercd nurses. Both Ghana and the Ivory Coast were close to the tan8et for doctors. The most cruclal ]ack ts ln sanitarlans and there ls a very ma.lor lack ln mlciwlves. Tlris 1s a matter of prlme lmportance as they are the key personnel ln prlmary health care and between them could prevent some 508 of the total annual deaths ln a developlng country. The tralnlng of health personnel: Tralned hea}tit personnel requlrerl to meeb the needs of the population lncrease durlng ttte second development decade: Nurses Popu.l at lon Midvrlves Sanitarians Ilenln Ghana Ivory Coast Mal I Nlger Togo Upper Volta 79 )o7 I 16r))(; r)o 57 t27 ReE. I :5,OOO 15u 6r4 2)2 272 ?60 1t ,t 2r+ 15il 6tlr 2)2 272 260 114 251+ (2) 790 ),066 L,L59 t,164 I,297 547 L,27) *Thls ls the popuJ.atl<.rn lncrease ln Lhcrusands betw?Fq estimated mld-year populatlon 1n Lhousands in ltBO"/ mid-1971 and the These flgures represent the number of tralned staff requlred over the decarle to meeL Lhe targets set for staff:population ratios - solely for the populatlon lncreasc durlng the dccarle. As well as thls, staff are requlred to replace {eaths ancl retlremcnls and also brlng i}re exlsting populatlon:staff ratlo lnto llne witlr the tar6ets set for the second development decarle. t .\7 c) In 1975 the posll.lon in Ghana wa:; as follows: Schools State ltegistered Nurses PubIlc Ilealth Nurses Communlty IIeaIth Nurses Enrolled Nurses Midwlves )l) L1 5 Intake 150 )o 75 500 260 a Assuming that the annual lntake of 15O SRN students aII quallfy then fu1ly four years of the decarie's output wlll be required solely for the estlmated populablon lncrease. In the case of the comblned communlty health and enrolled nurses, over flve years lntake and, 1n the cases of midwlveS, over two years lntake. IB,Upper Volta the number of nurses who diplomated (SRN) In L975-'16 was ltj\"/ so that over six years' output of the decade would be required solety to cover ttre populatlon lncrease t"o the target ratio. Nor ls the output Ilkely to lncrease greatly each year since the outnyf6r;f dlplomated nurses from 1970-7L tc-, 1975'76 was: )1 , 1L, 25, 17, )4, 78\'-t ' Tn 1975-76 tfre npmber of auxiliary nurses in thcir flrst year of tralnlng was 62 an<l the number of first-year mldwlves belng trained outslde Upper Volta was 29. On these figures ll wouLd take 2lO years outpuL of aux1llary nurses solely for the populatlon increase demands and just under nlne years of tire mldwlves' output. Frlucatlonal ]eveIs of c;rlres' intake These.var"y slightJy ln Ghana and Irrancopltonc OCP countries due to the dlfferlng educat,lonal sYstems. In C11rrn.( 18) t.)re entry rcqu.tr.emenb for an ertrolfed nurse is a Mldclle SchooI Ieavlng cert.lflcaLe as a mlnlnrum, followect by a two-year ,professional corlrse. Tlrere is tlre same edrlcat,I<-inal requirement f,or the auxillary grade eernmunlty Ilealgr lJur;e, albirour3h f'or t,lrls grarle the minlmal age tlmit is l-f3 whereas for tfrc auxi1. lar11 nursc tt is I'I. The Community Health Nurse is an auxlllanf IIcaI th Visitor. The SRI'I r)rrrse rr:quires a l,Iest, Afrlcan School Certificate or GCE r0r level pass ln five suir.iects ancl a minjlnum;r[!e of 18 years. Ilourever, Enrol]ed or Auxlllary Nurses ape acceptcd for SrtN Lralnlne (as ln Upper Volta) on a competltlve apbltuce test, in Ilrnited numbers each year. A 'sLralr.;lit' midrvife (auxltiary) requlres a MlddIe Jlcittrol leaving cert1 flcate and a mlnlmum age of I8 years and ts then glven two-and-a-half years' tralnlng. The Reglstere'l nurse-nridwifc requlres either an sRN or QRN certificate' f,lre former receivlntj one-year and the laLter one-and-a-hal"f years' tralning' The publlc llealth Nunse requlres both an SRN and a Mldwlfery Certiflcate and then recelves one year's tralnlng. 2t+ Lastly, a c;uire unique to Ghana ls the Fleal"th Centre Superlntendent w1:o requlres itn SI1N or QRN an<t five years' post-reglstratlon experience followed by one year of trainlng. Tfie posltlon in Llpper Vol-ta ls vepy siml]ar. Flve years of pnlmary e6ucatlon ls followed by the CEPE examlnatlon, the Prlmary School Certificate. Followlng an entry examinatlon puplls may enter a Secondary.School where, after four years, tlrey take the BFIPC examlnatlon, or Mlddle School Certlficate. fhls can be foltorved by a further three years' educatlon Leadlng to the BAC(Baccalaurdat ) examinatlon. AuxlIlary caclres ltave tvro years' prgfcsslonaL educatioh and professlonal cadres such as the SRN Nurse (Otpt6me d'Etat) three years. The requlrement for the SRN stuclent is the Middle School Certificate (BEPC) and for the agxlllary 6rarles bhe Prlmary School or. CEPE Certlficate. It would thus appear that Upper Volta's requlrements are somewhat lower than Ghana's. In Upper Volta, as in Ghana, an Auxlllary Nurse wlthout the requlred educatlonal quallf'lcatigns stilI has a chance of becomlng a Registered Nurse. Wlth an annual intake of some 40 SIN training places, )O are open to the holclers of the RIIPC Certlficatc ancl IO are open to competltlon amongst Auxlliary Nurses. Hor,rever', tlre positlon 1n Upper Votta 1s somewhat worsened by the trlage ln the eclucatlonal system. Of every tttousand pupils entering Primary School(ana only 14 of ttre ellglble poputaLton ln 1976 entered Primary School) on;1y 275 Ret the CIIPii or Primary School. Certlflcate (and thus are ellglble to apply for auxlllary nurse tralntnr:). Of these ?75 only 7O eo on to Secondary School t)y passlng the cntrance examinaLlon. In Upper Volta the nattonal intake lnto Secondary School ls l-.lmited to 1,!OO a year for the whole cotrntry (as far as the Government Schools are concerneri). Of each 1,0@ enterlnr{ Secondar.y SchooI only 4up wlII receive the Secondary Scirool Certifi- cate (gEPC) anci so be ellgible to apply for SRN traininn. Of the 489 who receive tire BEpCr 1(r1 wlfl enter the Lrigher seconciary school. (tfrus leavlng only )2ti for selectlon for SRN tratnlng) and of these 161 only 70 wlII ,u"Llr" tirc BAC, enaltllng them to enter the Unlverslty ent,rance examlnation. Uslnq the abovc flgures (Xfnafy supplled by Mr l{.N. Tri, Prlnclpal TechnlcaL Counsel lr.rr, Mlnlstry of Eclucat,lon, Ouagadou8ou, (UUiSCO) ), it can be seen tlrat as Ln I9'(t there rverc lJ.t I,()gtJ government and prlvate pupils ln prlmary schoo).s we can expect no mc)re tltan some 4,tJ42 hofders of the B1pC/year who rlo not 6o orr to Secondary School and thus are the pool from whlclr auxlllary heal-th workers may bc cirosen - although this rtumber may well be increase<l by sccondary scirool tirop-outs prlor to the REPC (amounting to some 766 J>rrplls a ycar nationally). Vllth a Ilmltecl intake natlonally of 1,5OO BoverTlmenL sclrr>ol seconclary puplls and only )?8 per l,OOO and therefore 492 natLc,nally passlng the IlliPC an<l not golng on lnbo Lhe hlgher secondary for.ms, augmented by some of the l,to natlonally who pass the BEPC but not the BAC, the selection pooL natlr>naIIy for the higirer medlcal ca^lre such as the SRN nurscs ls limited to sonre (rOO - aLl of whom, lf thcy wish, may apply for any other LralninSl apart from wlth the health tearn that ls open to thelr educablonal quallflcatlons. 25 Concluslons: The overal.l plcture of the health staff manpower avallabl-e ln tlre OCP countrles 1s a desperate one showlng, natlonally, great shortages Judged by the standards set for the Sccond Development Decade. When this ls consldered from the staff dlstributlon polnt of vlew the picture ls even tvorse with a great preponderance of the avallable staff ln these areas wlth populatlons of 2O,O@ or more. Such areas, ln Ghana for example, account for only L876 of the country's total populatlon. lhe staff shortages are greatcst ln the cadres of midwlves and sanltarians - the trvo carlres of the most vltal lmportance in the prlmary health care fleld. Tralnlng of personnel must be sufflclent not only to provlde for the annual lncrease in population but also to replace staff deaths, retirements, etc., and al-so to improve the exlstln11 staff:populatlon ratios, which in many arcas are far. below the ratlos sct for the Second Development Decade. Staff training, of all cadres, but cspeclalJ-y of the au-xlIlary crulres, must be greatly incrcascd but in Upper Volta, at least, tlre pool of availabl-e people wlt,h the required c<lucatlonal standards is very low. IIEALTII FACII..II5T.S IN IIIE OCP CqJTJTIIIES These are consl<lered by comparing what was available in the OCP countrles tn 1971 wlth tlre LargeLs set for the Second Devclopment Decarie of one Health Centre per 25,OOO p<.rpulablon ancl one Sub-centre f<.rr 6-8,0@ populatlon: HO.'iPITAm IIEAL'I]I CI.]NTIU5 SIIBCEI.rIRE,S Tars'et] :25t rarget t:6-8,ooo No. l bcd 1.o: No. Actual- No. Actual Benln Ghana Ivory Coast MaIl N1fier Togo Upper Volta Poprrl atlon 'Ofi) 2,7(1O [], ti2ij l+,1+zo 5 ri'j L6 ),a(:8 2, OlO 5,6?L [Jg,ooo I[J]r,ooo 2Iu,OOO I1(;, OOO r42,ooo IJ4 , OOO 54,0O0 L's,)oo )2,8OO 20,1OO ]-7,5oo ?2,8OO 12, BOO 2),BOO 6 I)L ,,5 L2 (: 20 7 8'()i' 7'.r.) 57(, L,7L? l,rt)+ 9't's 1'175 )I 4ii 20 tt5 ?-d l5 104 lBO 272 2rti 298 l-74 t57 2)5 If the,Second Dcvclopmenb Deca<ic targets are accelrtecl they can be applied to thc OCP corrntt'les' popuJ-atlons In 1971 and also to the countries' expected pr:pulatlon lncreascs in ttre decade,'to glve the overall buildlng requlrements in the decade to meet the targets. Deflc lency OveraLl- ln 1971 II.Cen. Sub.Cen. F'or population irrcl-a"e tg-lf-ZU II.Cen. Sub.Cen.* to be buitt I{.Cen. Sub. Cen. Benln 79 z]-tt )? D) I11Girana 1o5 9b9 12) 418 42t) Ivory Coast l's'l t+I) 1t6 L()6 20) Matl 16'r )tttT ,5 rg5 2LgNl6er L)L )91 )2 1tj5 rB)Toso 65 L)o ?-) 8z tJu Upper Volta I2t 5(tB jL tu2 t'12 tlhe target for subccntres ls 1 pcr 6,OOO-8,OOO population. calculatlons lt 1r; taken as I per 7,OOO population. )?7 1,427 579 642 57tJ 2l-2 750 For these 26 The f1nal two columns of the Iicai th Centres and Subcentres wlilch would irave to be bullt covcr a perlod of' ten years. Even so, they represent very large, and cosbly, bulJ.dlng ;irogrammes and, of course, requlre to be geared to a very llreably increascd staff tralnin6 programme so that new bulldlngs can be matctred wlth existlng staff. Thus Chana would need to bulld an average of ltl IIcaIth Centres and 14J Subcentres a year and Upper Volta 17 tlealth Centres arrd 75 Subccntres. Such prognalnmes represcnt both a capltal bulldlng expendlture and rccurrcnt building expendlture rvtrlch lt ls unllP.ely if any OCP country wouLd roceive for their heaLth budgets. They also lntrlnsicl.y presuppose tlrat thcre wllJ- be a considerable capital expendlture avaiLal;le for lncreaslng staff tralning establlshments and a comespondlng lncrease ln the recurrcnt health budgets for the lncreased persorurel. To even attempt to meet such a prosrarnTle lt ls absolutely essentlal to conslder serlously the lmpllcations of stafflng these unlts (slnce staff salarles take up suclr a great proportlon of the recurrent health budget) as well as thelr constructlon. Martln-Samo"(l+) iras conslclererl the question of patlent coveragc tn Uppcr Volta by tlre dist.'urces pat,ients r,rould have to travel to health units to obtain a lO% coveraBe. Thls is presented by showing thc percentage coverage of the populatlon for lncreasing travelllng dlstances: Provlnces Central East Central North Central West Central East Ilauts-Bassln North Sahel South Wcst Black Volta IOkm t2km t4l<m l6krn 18km 2lOkm(t.?mls; 7.5m1s tj,TrnIs 9.9m1s II.2mls 12.ltmls loo,,$ LOo/, tou/, loa/, TOUfr roo% roofr too,{ 2Zkm lJ.7mts Loofr 84/, Natlonal average ryr/, 64;t d'(';! lOUft Thls Tablc sitows tlrat on the avera6e the national p<-rpulation is entirely covered vrltlr a r:ullus of 16km (9.9mfs) trc,m a health unit; seven of the ten provlnces are covcred wlthin radil of l,lkm (8.7mfs) Uut the remainlng three requlrc rarlll of 2Okm (l2.ltmls) or mor.e. Tlrc validity of this Tabl-e therefore dcpends on thc translrort avail-ablc since it ls 6enerally acceptedthat for a Ilealth Centre thc radtus o{' coverage s}rould be 5mls (B.Okm) ifpatlents are requlred to waIk. 4.4....a4. aa.a..aaaa cl IIIE IMAI,TTI NJDGET IN TIIII OCP COUNTIUIIj Unfortunately a complete breakd<.rwn for all the OCP countrles ls not aval]abIe for comparlson ln relatlon Lo capltal anrl recurrent l1$gets. Those that are aval.lable, as percentagcs of the natlonal budget'-'are shown bclow: Recurrcnt Capital Bcnln@ rc.5f, Irlal i W-ft :,o.4,fi Nlgerw 'd.)"{ o.4rt 5 2 Glr.ena Ivory Coast L9'.l', na na t9'lr-? )-5 Lg'.l?-) ).7 8i, eft Togo Upper Volta na na t97) 8.e% In the case of Upper Volta tlre natlonal buclget tn 1960 and in 1tl6> arnounterl to 5,650,55ta,0ooF cFA ancl 21,122,70(),OOOF CFA with 111 and 5% respectlveJ-y for ttrc heal-th bu<iget. 'I'lie health budgct was thus 621,560,940F CFA and 1 ,O5(t,l)5JOOF C!-A respecbively. Bctween 1960 and L976 the natlonal budget rmrltlplled by 1.7 times and the health budget by I.7. lllth cxceptlons Ln L961 an<f 1965 Lc> )969 the national bu<lget has been stearllIy lncreasing vrhereas the perccntal5e for health iras cither been stearltly decreaslnfi or rcmalning statipngy. The percentage of the natlonal budget for healtir ln thc varlous ycars' '' wrs : It ls bctter to consldcr the hcalth burigcts as tire per caplta health budget. Only in the case of Ghana are these flgures availabLer?Uqr a tlme period and after they have l>een correctcd for the cost of llvlng\*'/: L96O t9(rt L,.)62 rgt;) 1964 t9(;5 Lg6(t tg(,7 1968 L969 L)7O t97L t972 t97) l-974 t975 t976 LL16 L5 ro 10 U u u 9 9 9 9 B 7 B 9 B 5% ycl7O_l t97)-tt 5.L r97tt-5 t975-6* 's.B 4.1 1976-7* 1.)Ce<lls: 4.O *Budget flgurcs T'he exact US $ ertuivalent rcquires a know.ledge of tlrc excl:ange rate at the varlous perlcxls, whtclr is not avall-abl.c. Hovrever in L977 the WHO was uslng a raLe ot f, t.15 to the US $. Of the OCP countrles, ln Ghana at least, the per capita )realth expendlture ls fa111n6. Ilowcvcr, other OCP country fi5lurcs would be desirable slnce Ghana ls havlng lts own partlcular financial dlfflcultles. Ttre pcr capitgr.gealth bud6cbs of Ma1i, Nigcr anrl Uppet'Volta are known for speclflc years\" i., F CIIA ancl tircse may be converted into tlreir US $ equlvalcnts at 2JIJF CIIA to thc US $ (tttlo rate ln August f977\ althou6'Ji bhe exchange m1$rt have varied sllghtly in the dlffcring years: 28 Mall 1975 Niger 1976 Upper Volta 1976 Ghana (from above) **'rris flgure secms exbremely Low and indeed ln another publlcatlon the health budget for Upper Volta Ln 1976 ls cited as 1,2L9,4)O,OOOF CFA and wlth an estimaLed 1976 populatlon of 5,572,O0O the per capita health budget would be 219F CFA or US $0.90. (4) Wlth the exceptlon of Ghana these fi.Sures are sma1l when 1t ls conslclered that lt Is generally accepted ttrat the annual per capiba health expendlture ln a <leveloptng country ls US $1 per year. Tkrercfore ln the OQP countrles it ls vltally essentlal that pl,ans for the deIlvery of health servlces should be not only cost-effectlve but that they sho-t1d also be kept at a mlnlmal cost. In Upper Volta lt 1s of interest to consider the annual cost of one pupll for one year at the various educatlonal levels - primary school, secondary school and technlcal education such as that of a health auxiliary. These costs have becn estimated.as: Prlmary school IO,OOOF CFA Secondary scirool 82,OOOir CFA Tecirnical sctrool IO5,OOOF CFA As a health au.xlliar'.y takcs tvro ycars to traln Lhe cost vrill be 2IO,OOOF'CFA and tlrls reprcsenLs the per capita heal-bh budget tor 959 people. A vcry largc proportion of Llrc various @P countrlcs' hcaltit budgets ls'spent on salaricsl,,lln Uppcr Volta in l-9'(6 personnel accounted tor \llfi of ttre hearth budget'''. 'Ihe ever-grcrving signlflcance of staff salarles ls shovrn by Upper Volta beb.reen 1960 an..l 1976 whenrf;\e Rersonne] payments are concidercd as pcrcenta6cs of the ltcalth buciget''': y)6o Lgrjt y)62 r,X)) LgO+ 1965 rg66 1()o7 Lg68 1969 r97O t97t 1972 t97) 1974 1975 127, 70 61 7?- 78 6)t T?. ilo iJ7 Bz Er tjl tl4 84 8,1 B0 86 B/r If tlie ]rcal-th lrrr:lJ"nf, ls broken clovrtt l'1y' tlrellglal ancl urban sectors in Upper Volta as lra: bccn done for the I97J t>ur111et'*"' lt ls seen that the personnel budget ls larger for ttre rural sector but the nraterlal- budget ls conslderably smaller for the nrral sector - albhough that sector conbai-ns tto-gb/'of thepopulation. Thls ln all probability ls due to the higlr cost tectmology medlcal care practlsed in thc urbarr hospitals rvhich is draining money away from the rural sectorS Personnel ltlaberial Mcdicine t,'ood )z)tt cFA ]BOF Ct'A 1)b' cLrA US $0.5I o.'14 6.111** 2.87 H:il i?rl',;ii '';',?:t; I r,,o+u 16,480 thousands or F cFA It may also be noted that of thls tr:tal cxpendlture of 79),57L,OOOF Cf'A onLy 6.5'rt were spcnt on mecilclnes ' er5i{'bclng spent on staff salarles. ?9 Conclusions: Tlhe ovcrall plcture of health staff manpower avallable ln the ocP countrles ls a desperate onc, furtl-rc' exacerbated by t1-re great rural/urbal lmbalance of staff. The trainlng of the varlous cadres 1s insufflcient. fire health facllltLcs are also very lnarlequate and to bring the populatlon: health faclllty rabio up to tlre SeconrJ Dcvelopment Decarle, Afrlcan Reglon ratlos r.rould necessitate a vast capttal ancl recurrent expenditure both for the facllttles tlrcmselves and for thc staff necessary to man them' Ttre natlonal ircaltl: budgcLs arc very small. In Upper Volta in L976 lt was onLy 5'fr of tlrc toLa1 natlonal iruclget and appcars to be steadlly falllng as a percentage of thc natlonal budget. Ttre pcr captta heal'th budget' ad.Jrrsteri for the cost of Ilvlng is also faffln8, at least in Ghana' Whlle ln Glrana tftc alnual per caplta health budget ls 2.87 US $, 1n Ma1i, I'llger and Upper Volta it ls below US $I.0. FlnaIIy, a very large perccnbage of the health budfet (]tyft Ln Upper Volta in t9il6) goes in staff salaries atrcl emolumcnts wlth a very small ^ - percentage on mecllcines. AJso in Upper Volta ttte rural payroll is some ]Bl larger than the upb;rn payroll whcreas the materlal costs, excluding meclicines ancl food, in the urban areas ls over four times as large as in the rural sector. TI{E USE OF MANPCIIEII AND IIEALTII FACII.JTIIIS IN OCP COU}IIRIIS paramcdica-ls: Mi<iwives and IIcaIth Ccntre Superlntcndents (otrana) and Public IIeaIth Nurscs. The pat,amcdlcaL carlrcs form tlre middle sccLlon of the tradltlonal pyrir.mlcl ancl are expectcd to supervlze tire auxili-ary cadres' Tile maJority of thls carlre sltoulr] w<-rrk ln lrospita-Ls ]rut there shoul-d be at least one from each cadr.c as a distt.ict supervlsor, working similarly to a Distrlct Medlcal Offlcer. It is very dctratable lf the trailitional training of midwives ls really necessary, 1.c. Llrpee years' traltrittg as an SI]N equlvalent followed by a further year's tpalnlnp5 t<> becorne an SCM equlvalent. It ls equally debatable lf tlre tralnlntl ol'unlpurpose Sltl'l nurr;es is Justlfied' Ttre ldeal wouLd be a comblnecl genelal tralnlng of tlrc two cadrcs as a slngle cadre in a period of thrce years ancl Lhis would provldc the delivery servlce with a much Sreater fLexlbllity so bir;rL the grariuale coul-<l bc usecl as a nul'se or mldvrife as dlfferlnn siLuatlotrs arisc. Tt].e 'product' could be cattcd a nurse-midwife and after a numbcr. of ycars of fielcl scrvice, furtlter specializcd trainlng could be glven to thosc w)-ro wlslt to becomc 'cllniczrl'nurses or fuII midwlves' In gencral , the functlons of a Pr-tb1lc tlealtll llttrse are those of a specia]lst In conrnrr-urlLy trcalth vrlttr an emphasls r'rn worklng ln patients' homcs. As her maln functlon -Lies ln Lhe ltomc arxl ln comnn:nity hcalth it |s surprlslng that prior to uncicrtaklng the Publlc IIcaIth Nurse course 1n Ghana, as in m,tny countrles, shc ls rcqulrecl to unclcrgo a full SRN course in liospital- nursing foll.owc{ by a fu}I CMB course in mlclwlfcry lncluding the dcllvery. Thc maternity worlt of a Publ-ic Ilealth Nurse will include ante- natal work but unless she Is hospltaL-bascd 1t wltl not incfude deliverles nor wlll s5e be avalllng lrerself of her full SIIN tralrtlnll. This ls a vltal carlre ancl flve yoars tralnlng ls rmrclt too long, expensLve and lncludes too rmtch l<novrlcdge wlrlch shc will not require in her Sencral ciuties' It strould be posslhle to construct a three-year course for t)rls cadre' )o Tlre Ilcalth Ccntre Superinbendent carir"e.ls unlque to Ghana. Following a thrcc-ycar SIIN coursc anri flve fuI I years of post-reglstratton experience and thcn a f'urther ycar's tralnlng, Liris cadre 1s able to supervLze a l{ea1th Centre and undcrtake the dlagnosls and treatment of the mone common iII- nesses. It, therefore requLrcs nine ycars to produce a cadre at paramedlcal level to undertake a Job of work whlch 1s done excellently ln many African countries by an arrxlllary with tlrree years' tralnlng (thc Medlcal Asslstant). fiurthermore, as (.roc such person ls requlred for every llealbh Centre and there shoul<i be one Hcalth Centre per 25,00O populatlon, a very great numben wlll be requlred. The 'waltln6'perlod' of nine years (and the expense lnvolverl) and Llre conslclerable amount of knowledge galned in those elgirt ycar'{i prlor to urrlertaking thc year's course that wlll not be required ln thc future Job would appear to render thls ca<ire as presently constituted non-vlable. Anxlllaries: These cadres form the base of tfrc classlcal pyramld although 1n the newer concept the base 1s one step jower down at the 'grass roots' Ieve1. These are the cadres who should be responsibl-e for stafflng the Health Centres - certatnly t,he Ilrral llcalth Centres and the Lack of these cadres ls very noticeable In the OCP countrles. In prlnclpJ-e there should be threc such cadres: (a) tne auxlIlary mldwife;(U) tnc 'Medl:al Assistant' and (c) ttre communlcable dlseases offlcer. Ttre main function <,'f Lhe auxillary midwlfe ls ln re-LaLion to Maternal and ChlJ-<t Ilealth work (pUf) but she should. also have some knowleclge of the dlagnosls and treatment of the more common dlseascs. At the IIeaIth Centre Ievcl a nurse-midwlfe wlth I'our years' tralning ls not requlred - nor would she have thc faclllties to practlse all she harl been taught. It is unfortunate.thaL, apparcntly, tlle trainlng of auxl1lary midwives has ceased in Ghana as thls car-lrc ls requlred In very large numbers. Ttre 'l'ledlcal Assistant' requircs three years' tralnlng in elcmentary dlagrosls and treatment and the administrative slde of the ruming of a heaLth cenLre and should have some l<novrledge of MCII work. This cadre does not appear to exlst ln the OCP countrlcs :urd thc rvork in Ghana 1s being unclertaken by ttre IIeaIth Cenl,re ljuJraplnggndentr; (vide supra). A cadrc of auxiliarry comrmrnity hcalth lrur'sc{; doe; exist and wl Lh a reorientatecl trainlng programme could flt thls role. Tirc 'Comr:unlcable Dlseascs O1'flecr' ls the third member of the llealth Centre trlarl anrl ln,a nrrml-rer of countries 1s expected to be an auxillary sanltarian. Ilor.rever, Lhe probJems of lural health requlre nn-rch more than a unlpurpose sanlLarlan and the vrork slrorrld lnclude all aspects, oC comnunlcable dlsease cc.,ntrol - wlrich lnelurles r;anitatlon anr-i hygicne. Srrch a cali.re coul.d be produccd by reorlentatinli thc prel;ent traininlt syllabi of auxlliary sanltar.lans. As wlttr the auxlLiar'.y mldwlves and thr: 'I4cdical Asslstants' thls callrc r.rlll be needed 1n very Iar11e numbers atrd prescntly tite tralnlng of sanltarlans ls -1aggin51 far bchlnd tirat of otirer carlres in the OCP countrles. )L Mc,blIe Servlces: fn all the OCP lrnancopir<rne countries and ln Ghana there are a number of moblle servlces with vehlcles underbaking dlfferent Jobs. Some teams are concepned wlth Maternal and 0h1kl tlealth (ptvll), others wlth epldemlologlcal work an<l the treal,mcnt and case flndlng of lnfectious dlseases such as trypanosomlasls, ancl ,yet others mobll-ize<l ln response to outbreaks of speclflc ccimmunlcable cllseases. T'he 'cpidemiologtcal' teams operate through- out the country rvhereas thc ottrer Lcams operate |q,.,qreas not covered by Ilealth Centres, arcas descrlbed by IU-ves 1n 196Z\") asttl€s zones DTPrt(Ddplstage, traitement, propagande). Thcse teams crperate from Health Centres, outslde the .lurisdictlon of the Health Centre, but under l,he Jurlsdlctlon of the Dlstrict Medical 0fflcer. Presently their work is greatly lrampered by a lack of spare parts for vehiclcs, replacement vehlcles, tlrc dlfficulty of gettlng petrol- to bush areas and the rlslng costs of petrol and vehicfes. The members of LIre varlous tcams ane uniyrurpose personnel and thls ls a wastage of pers<.,nnel uslng an cxtremely cxpenslve method of service- dellver:r Most countrles are relucilInt, ln viewle$1thc costs, to provide art adcquate moblle scrvlce but as I^lbusqulese' has so aptly put lt a vehlcle 1s as esscntlal to rrrral work as a ]srifc to a surgeon. He has also emphaslzcd ln hls book that enou6h vehlcles rm.rst be provlded for a<lcquate supervlsion ...'S'll- exlste J2 responsables 1I faudra 12 v6hlcules, s'll y en a 40, 11 I'audra 40 vdhlcules.' VehicLcs are requireci as an esscntlal part of ttre outreach of Health Centrcs wfilch only have an action radlus of five mlles, usua]-Ly ln areas wlth small scattcred populations. They are also requlred for adequate supervlsl<ln - ancl the comrnonest causc for auxillary cadre fallure 1s the Iack of adequate supervlslon. Ilowcver, as an extension of the llealth Centre work the moblle teams shouLd be rnultipurposc instcari of unlpurpose and sl:ould bc reganle<J a:; part of ttrc Ilcalth Centre compllment (remalnlng, a:; rvith the stattc staff,. urtdcr thc Jtrrisdtctlon and guldance of the Dlstrlct l"ledlcal Offlcer) so that thelr work can be coordlnated. Varlous otlrer auxlllary stal(' cxist suclt as tlrc 'Dlstributeur des comprlmds' wlro rver.c descrlbed as 'bari clressers'. filelr worl< consists of dlspenslng pl1ls as f<.rr TB cases, bandagin56 and l,'lrst Aid and they receive a shorb ln-servlcr: tralnlng. It is doubtful 1f such a cadre could be absorbed into a IIeaIlh Centre 'Medlcal Asslstant' cadre as ofLen t'hey do not have the requlslte sclroLastlc ablllty. In Zambla when the Dresser cadre was stoppcd an atLempt was ma(le to absorb as many .ts possible lnto the Medlcal Asslstant gra<le and some succceded, for those who dld not succeed the cadre was allowed to lapse by attrlblon. Tlso further arrxlllary ca<lrcs are the }eprosy and tuberculosts workers, tralnecl by short courscs and 'mobil-e' r:sing scocrters or bicycles wltlr englnes' Ilovlever, these carircs are unlpurposc carlres aILhoufih Upper Volta ls trying to amalgamate Llrem lnto leprosy-LullcrcuLosis worllers. )2 T'lre tEr"ass rootst -l.eve1 : In tire past I'ew years It has become lncreasingly obvious that the cxlstlng health ser.vlces are not reaclrlng the people ln the rural areas, indeed ln some countrj.cs titey are reachlng only some ZUrt of the rural populatlon. It Lras also become lncreasingly obvlous that a form of health care rm.rst be provlded in thc vll-lages themseLves and by tire vl11agers themseLves. 'llcalth personnel' alre;rdy e,rist ln tlre vlJ. Ia55es in the form of varlous lndlgenous practltioners and the usc of indlgenous medlcines - whlch are often powerful , lm;ture and of unP.nown dosage. Ghana ls actively under- taklng pharmacological research lnto lndlgenous medlclnes. The bcst known of these lndlgenous practitloners are the TtsAs or Tradltlonal Birth Attenclants and it is wlth this cadre that most work has been done ln varlous developlng countrles. Many countrlcs includlng Ghana, fndla, Inclonesla, Ma).aysla, West Paklstan, thc Phillppines and Thal}and have tricri to up6radc this cadre and some countrj:s have trled to includc them ln famtly plannlng programmes. Ilowever, somc countrlcs lncludlng Togo, Slerra Lcone and Costa Rlca are trylng to replace Lhem witl, a 'modern set'vlce'. (Rcport of Review and Analysls of Infor.matlon and Data on Tradltipq+i Rlrth Attendants. Unpubllshed document prepared by MIO, Gcneva, cltcd ln t-"). T'he Glrerra Health I'.Lan includcs the ldentlflcatlon and tralnlng of the TllAs and valuable r.rork has alrceuJy been underLaken in thc Danfa proJect under Profcssor S. Ofusu-Anraah and his unll at Korle Ilu Medlcal School- and ln the Klntampo WHO-MlnLstry <.rf llealth proJcci. Mrs M.E. Pappoe of Ltre Korle Bu l)epartment of Comrmrnity l{ealth stated that therc t^Jerc four tralnlng centres vrherc TTJAs wcre instructed once or twlce a vreek over a peniod of eight months or so, the }cngtlt of Lhc 'course' varylng wlth lnrllvidual's capabilLties. On 'quallfication' tltey receive a UNICEF klt contalning a razol" b1adc, bandal5es, soap, handbrush, etc. PresentJ"y there arc over lOO TBAs ln training and }ast year )7 were pa'ssed. Tcachlng ls not d1<lactic, but iry discussion and qualification cc,,nslsts of the gcncral lmpresslon of the TBAs pro8ress by her teachers. The Danla pro,Ject lias lrientlfled 2)T 1tsAs anci 26 apprentlces. Their avcragc age ls c,ver (iO ancl thls must be taken lnto account in training prograrunes. fntcresLlngly over half of those tdentlfled and registered were males. fn Chana thc 'l'IlAs baslcally del-lver relatlvcs. Of tltose rcgistered by tlre Danfa proJecL t,he averar-le lcn6bh o1'practice was 2) years so that wlth an average age of over 60 it would appcar that tt ls a professlon arrd. undertaken falrly late In llfe. On averagc Lhose reglstercd undertoc:k 6.9 riellverles a year each. Such a Iow delivery rate (as ln Ghana l,lrey only clellver relatives) requlres that a large number have to be tralned to ltave any slgnlficant lmpact on the maternal and neonatal mortality and morbidlty. However, ln other countries TBAs Lake care of non-relatives as weLl s<l tltat one or two scrve an cntlre vll.la11e. In Zambla thcrc was also a carlre of 'consulLant' 'IRAs whc.r wcre c;rll.erl ln when tire 'usua-I' TBn gob into dlfficulties. Where such a ceuire exlsts 1t ls vital to identlfy and traln them. 1) rn Mali, at slkasso, Ln t97oQ-2) there was an operatlon Matrones Rurales. ltris took pl:rce tn 7-10 vllla6es. TLre Matrones (auxlliary miciwlves) were glven furbher tralnlng in PMI (Maternal and Chlld tleatth); were taught minor treatments so that they could look after schoolchildren: undertook the Nivaqutnizatlon of chlldren; birtir registratlon ln the vlllages and were taught about weLls, sand flltratlon and Iatrlnes for 100-2@ people. An lnLrlnsic parb of the programnre was that the Matrones should each ldentify the TBAs fn 4-5 vl1lages, glve them each two months or l"ess lnstructlon and then supervlze them. Each Matrone was expected to supervlze 4-6 tgRs. fire result of this prograrnme was that the number of del,lverles supervlzed by Health Unit supervlslon rose three tlmes between I97O and L975- In the Danfa proJect the TBAs arc assessed by villa6e-based health workers comrmrnlty treatth nurses, nutritlon technlcal offtcers, health assistants,(aII of auxiliar.y nrade), thus undcrtaklng the last stage of supervislon ln the concept of 'supervislon en cascatle'. In areas wl'rere government ctlnlcs and qualified lrridvtives are avalLable, frce or ab a nomlnal cost, lt has been found tlrab the ltsAs are stlll preferred. Ttrcy provlde a servlcc whlch 1s not provlded by Wester-orientated 'scientlflc' mldvrives. Thelr scrvice lncludes vlsiting postnatally and tltls involves fielping ln tire hour:chold work suc]r as vrastring clot]tes and preparing food. I'luch mr-rre lmporLant 1s that t)rcy tlremselves bclievc in tlre custr:ms artd trariltlons of the peol>le thcy serve. '[hey understand that a placenta is the scul-iorother or soul-slstcr of the dellvered ctrlld anrl are ful1.y awarc of .Just how ancl wlrere Lhe p)acenta has to be burled - such as before the l-eft or rlgtrt cloorposb anrl elsewhere. They also know, in somc areas, that immediately after deltvcry the bat>e must be touclrecl to the floor; 1n other areas the exact lengLlr at wiriclr the umbllical eor"l must be cut, e.g. to touch the knee; ln st1l1 ot[cr arcas tlrey are fully aware that if t,he umbi]ical cord happens to touch tlre chl.l-d's i4cnitals thc chll-d wiII be sterile and take action to prevent lt. T'hcy are brusterl l>y tlre pcople arri havc tlie same bellefs and customs ancl as such are prcf'er.red to 'scj.entlflcally-tralned' midvrivcs. This is probably a more c<.:mpelting ar5Sunrent for tralnlng and exploltlng thls cadre than the vcry large number of auxlLlary mldwlves wlrich wouLd have to be trained to replace them. Other indigenous vi.IIa6e personne.l.: To clate, unforbunately, thc ldentification of lndlgenous healblr carires 5as been conflnecl to'ItsAs ancl as yet there are no prograrrunes on thcir tralnlng. Ilowever, they are a potent factor ln vlllage llfe and trusted by. tlle villagers as wlth the TBAs often ln prcferencc to 'western-tralned' hcalth personnel. Suclr carires cxlst ln large nurnberr;, be thcy bone-setters, dog blte experts, snake bitc experts or other experLs. In the prellminary soclological survey of the prograrune area for the Llvcrpool School of Tropical ltlediclne and Banares IJindu Unlversit.y (l;oth tlre Departments of Community Mediclne) ln India it has been founci.tirat ln an Indtan vlJ"lage some lol of the vlllagers play some part ln the dellvery of health carc. It+ Llke the TBAs t;hese othcr membel':; of the v1l1a13e health team must be lclentlf'led, Blvcn a sirort tralning all(i accepted as fulL members of the natlonal health team. THE USE OF HEALTII F'ACTIJTIES IN TTIE OCP COUI'ITRIES In thls context only Savclu6o IIeaIth Ccntre ln Northern Province, Ghana; the AW Kaibo clinlc; the l'lidinaba vllLage subcl-inlc and the Ccntral Ouagarlougou PIvII Cllnic will be consldered although it ls posslble that these cllnlcs vlslted were not typical. In general ln Ghana the staff of a Health Centre conslsts of:- A liealth Centre Superlntendent Dist,rlct Publlc Health Nurse Vlard s ls ber Registercd nurse Enrollcd (auxlllary) general nurses Certlflcate mldwife Comrnunlby health auxlliary nurses Dlspenser I^eboratory techniclan Ilealbtr lnspector Nutr'ltlon officer Admlnlstratlve staff. In practlce tlrls ls often reduced to:- Ilealth Centre Superintendent Jinrolled nurse l-J auxillary nurses Pub1ic heaLth nurse il auxiLiary midwives Ileal th inspector Admlnlstrabive staff. At Savelugu IIcaIth Ccntre wlth a stated sphere rarilus wlth sal;elllte mobile cllnics up to rarlii of conslsted of: of ac 2O mi tion of 2-] miles les the staff I Ilealth Superintendent I Dlstrict Pub]ic Hcalth Nursell Comrnunlty IIea.Lth Nurses (auxlliary grade) undertakin8 <iellverLes and home vlslts 2 linrolled nurscs on tlre curativc slde I IIeaLth lnspecLor i3 I;rbourers, a clerk and his assistant and an englne attcndant. The Centre harl four maternlty beds ln which patlcnbs were kept for 24 hours. Seven days after dellvery the midwlves hand the case over to the Dlstrlct Publlc l{ealth Nurse. Behind the Health Centre was the staff houslng, the Iabourers livlng in the nearby town. e )5 Thc Antenatal Cllnlc for repeat patients was held on Tuesday mornlngs and for new maternlty cases and for imrmrnlzatlons bhe cllnlc was on Frlday morrrings. In the Antenatal Cllnlcs tire Dlstrict P.H. Nurse takes the hlstory and tlte mldwife palpates. The conrnunity health nurses undertaklng dellverles and home vislling. A mldwlfery helper tidles the ward.'rnd makes the becls. The Under Fives C.l-inlc ls held on Thursday mornlngs. The historv ls taken by the midwife and a comrrunlty health nurse; the welghlng is undertaken by a helpcr and tire diagnosis and treaLment Is unciertaken by the District Pub1lc Health Nurse and a conrnunlty nul,se. The Slck Cllnlc ls taken by the IIeaIth Superintendent who also under- takes the Ilealth Centre zulmlnistration. Work unclertaken by the Cllnic ln Jul v 1977 | Maternlty: New cascs seen 186 Old cases seen 719 Postnatals seen 4 TotaL consultatlons 509 averaglng l7J/wcek Averagc dellverlcs ln llealth Centre - 4-6 a week Slck CLlnlc: Ncw consultations 57t Repeat consultations 68'8 Total consulLatlons 1259 averaglng )L5/week Under Flves Cllnlc: lJew, Save.l.ugu cLlnlc Repeat, tt rr New, satelllte clinlc ilepeat, rf 'r Immunlzatlons: Transport: Totat consultatlons 914 averaging Z?)/week DPT first second thlni['oIlo Measles Smallpox llcG 52 ttir) It 4oJr t42 6') ?7 nl1 9) 120 nil - referred to Tamale Hospltal as Ilealth Centre only has 25-5O dose bottles The Ccntrc's VW bus ls 1n the workshop, staff use thelr vehlcles and recelve a mlleage allowance. T\+o Moblle Flcld Unlts are based at the Health Care Centre with thelr own transport. Thcy operate outslde the Ilcalth Centre's ran5lc of actlon and admlnlstratively are lndependent of the llealth Centre. Mobile unlts: )6 The IIcaIt[ Centre ls ver.y heavl.l'r' oVer-staffed both in qua].iflcatlons ancl numbers and both ln theory ancl acr:ording to the amount of work under- taken. In rclatlon to Lransport lt slrolrLd also be mentloned that wllen the Tamale Communlty Nurscs' School was vlslted although they required three vehlclcs the Sctrool only ha<i one whlch greatly lmpeded the practlcal field teachln6. The Hcalth Post ln Ghana: UnfopLunately one was noL visltcd. The accepted staffing for thls unlt conslsts of:- I Certlfled mldwlfe 2 Oonununlty hcalth nurscs J" Dispensary asslstant I Nutriblon assistant I lleatth Inspector may or may not be attached Ttrls ls a;r ove:-stafflng for such a unit whlclr would be responslble for a populatlon of a fcw Lttousand. Northcrn Province: Thls Rcglon vrltlch lrarl a poprrlat lt.rn of 728,OOO 1n thc 1970 census(a )6.6,fr populatlon lncrease over tlrc 1960 census) is divlded into JDlstrlcts. It lras ll hospitals, S llealth Centres and ] A1d Posts as well as 8 MoUIle Fleld Unit teams whlch arc nrainl-y conccrnecl with trypanosomlasis, cerebrosplnal nrenlngltls and lmmunlzatlons. There are I Chlef Heal-th Inspector, 2 llcalth Asslstants and ] auxtllary sanltarlans (Or n. Darkwa, Reglonal Medlcal Of'tlcer). Tamale Ile onal llos ItaI: Thls ls a large, falrly new, ancl excellent bulldtng and is a very good example of the tyJre of butldlng requlred for zr reglonal referral hospltal. Althougtr a lleglonal and Dlstrlct Ilospltal are not parb of the Prlmary Care complcx, cxcept for thelr out-patlcnt/Casualty departments, they are the essentlal rofcrral ancl supervlsory back-up to the Prlmary Care system. Thc hc.rspltal has lrlO beds conslstinl of ?.5) adult beds for gcneral mecllcine and sur,lieryl 40 obstctrlcaL/1a1naecological becls; !B paediatrlc becls - conslstlng of 42 berls anrl 1(r cots anci ln lhe ol-d Dlstrlct llospital tltere are a further 20 beds for chest dlseases/LubercuLosls and 20 beds for snake bltes. Excluding tire paedlatric beds of the remalnlng 2)2, the Medlcal Superlntendcnt (Or X. Arvarlzi) informe<I me that some IJO or so were empty dally, a 7),$ occupancy rate - vrirlch 1s rather lovr. The exception to this Is the paedlatrlc wani whose 42 beds ln two months had an occupancy rate ol lll\ft and, t6Ofi, 1.e. cirilclren were nursed elther two ln a bed or on the floor. Ttre staff conslsLs of 26 aoctors whlch includes consultants in all the maJor speclalities excepting paecllat,r'1r:s which ls managed by a Senior Medical Officer. Ttrere are 6? Registcrcd Nurses , zOL Enrolled Nurses and 49 Midwives as weII as )9 puptl firolled Nurses 1n the tralnlng school. )7 Wldlnaba Vi.Llage, Nortltern licUlon, Gfrana! Thls fatrly smal.l. vlllage ls a satelllte cllnic where a cllnic ls held once a wcek ln t.hc school br-rllding. llinaba Health Centre }ies 19 mlles away and Tilll Angllcan mi-,blle clinic 7 mllcs away. Apart from smal-l village markets the mairr rrrarl<eb ltes (i milcs away throu$h the bush or 21 nrlles by road. There are Tra<lltlc,na.l lllrth ALtcndants but lf a prellnant woman wishes to see a member of tlre 'of1'lclal' heaLtlr team or is 11I, she has to walk 6 miles. The Villagc Clrlcf. one of whose sons 1s the teaciler at the vll-Iage sehool, belleves that tlre vlllage's tlrrco chief troubles are a lack of water, hunger and the black flles are.Less numerorrs since ttre OCP progrannne but stlll cause troubl.e ln conJuncllon wlth mosqultoes and tsctse flics. The vlllage produces onc crop a year of mtllet and the prcvlous harvest was poor so that the vlllagers wcr.e now well lnto t,he hunger season during the vlslt and their posltlon w111 dcterlorate untll the n<:xt harvest is brought in in November, 2-J months later. The villagc has three bore-hole vrclls but thls supply is noL sufflcienL, alttrotlqLr tiier.e ls alvrays vrater at tire bore-hoJ es. The nearest waler supply ls l mlle avray ancl when that fai.ls tircne ls the Ued Volta three miLes away. Tire Chlef stated that viltafie anlnrals were already dying from the lack qf water. He also said that chlldrcn of 6 years lrave eye troublcs and that the vlllage had many bllnd older persons, Iooked aftcr by thelr reLatives. The vlllage's hcalth problems, apart from onchocerclasls, are therefore under- and maLnutrit,ion, malaria, the riiseases carried by lmpure water and the infectlous dlseases of cltlldho<xi. Rinaba Moblle IIeaIth Servlce: Thls ls a moblle cllnlc nrn by Sister T. lrinlay, CUSO. She ]ooks after ! villages, lncludinl5 l.lldlnaba, and says that the common conditions are malarla, malnutrlLlon. dlarrhoea, worrns, skln diseases and measles. She has alrearly noticed chltdrcn's welghts dropplng on tlre l4orley-type Road to Ilcalth Charts. IIcr flvc clinics cach avera8e 5O-)OO attendances, that of Wldlnaba averaglnJ:15O - though she sa.ys, |t would be I,50O if she had any food to glve away AW CIlnIc, Kaibo. Uppcr Volta: T[is c].lnlc ls leprcscntatlvc of a llealth Post or subcentre in the Primary Care set-up. It ts supcrvlzed, or should be, by the I{ealth Centrc and ln turn s.hould supervlze the vlllage anci.Iiarles. T'Lre vlllagcs ln Kafbo are AW resettlement vlllages and unrier its Jurlsdictlon. The AW pays the zruxtllary nurse and also provides some drugs as not enouglr are received from ttre novernment sourccs - althougJr even tlte comblned supply ls pltiful. Ttre nurse looks after four vlllages wlth I2J famllles, some l,?-)O persons, and professlonally comes under the Dlstrlct Medlcal Offlcer at Manga. Itre AW send onc indlrjenorrs mldvrlfe for one month's tralning to a local- hospltal and she undertal<cs ttre clellverics 1n the vlllages. The nurse is also hclpcd by an Animatrlce, a type of auxll-iary home economlst, whose functlon ls to educate the women ln thelr homes 1n home economy and development. )o In her. tralnlnrj, (r) baslc educirLlon of middle secondary scliool w'lth BEPC Certiflcatc followed by one year of professlonal tralnlng) she spends a month rlurlng whlch she ls glven tralnlng ln lmnmnizatLon, normal chlldblrth and PMI, This, Irrobabl.y fort.unately, was not enougl-t Lo glve her sufflclent confldence to undertake dellveries so that she confined herself to 'supcrvlzing' the Tradltional Birth Attendant. fire agrlculturalists of the AW who supervizc the rescttlement vlllagcs and are based ln OuagadouSou belleve that the vlllage anlmatrlces (tfrcre bclng one anlmatrlce to every two vlllages) spend too grcat a proportlon of thelr tlme on the healtlr aspects of thelr job. Cerbalnly this one was undertaking work which should have been underbaken by the nurse. Looklng through the cllnlc recorris ttrere was no mention of any cases of malnutritlon and the nurse sald ttrat he had not seen any. The anlmatrlce at once sald that she lrarl seen many in the vll-Iage houses and tltat the chlLdr.en were not brought to the C1inic as the Clinic harl no supplles of mllk nor vltamlns. This would appear to lndlcat,e that the nurse never went lnto the vlllage houses. It was also salcl that the PAM (VIorId Food Plan) focxl provlded by the AW as a supplement in thc flrst year of resettlement and sometlmes extended somewhat lnto tire second ycar, was not sufflclent ln quhntity so that there was under-nutrltion amongst the older froups. tlowever, such a statement caru:ot be accepterl wltltouL a full lnvestlgatlon. TLre C]lnlc saw 50 patlents a day and the main compLaints were rnalarla, dlar,rhoea and ab<ir:nr1na1- paln. Some Z/1 of the cases of malaria were ln chlldren undcr the age of flve although tlre nurse sLated t)rat he r.rtdertook NlvaqulnlzalLon of tlris age Broup. Tlre 'round figure' statement of 50patlcnts a da.y wouj.ci appcar to be hlgh 1n that ln the month of August the records showecl )?.6 new attenders and 4O4 rcpeat attenders, a total of 7)O consultatlons a rnonth whlch on a flve day weck w<.rrks out at less than 40 a day. Tirls ls by no mcans a heavy work load and shou.ld all-ow the nurse plenty of time to home vlslt and glve health educatlon, etc. Thc cllnlc pos:iesscd no eLectriciLy, nor was lt avallable in the area. llowever, the prrovlslon of a small pctrol generator or a gas refrigerator would enable an inunuttlzatlon programtne, evcn excludlng measLes, tu be underLaken. Tlrc cllnlc lriul no veiriclc and lts slze does not Justify one. But lf a patlent was sufl'lclently 1II lt. was necessary bo walt until an ambulance came from Mzrnga lf onc were avalJab.l.e. fn the dellvery of Prlmary Health 1t ls al;so]uteIy r:sscntlal Lltat t,lre back-up units irave sufficient transport avallable to gl'rc a<lc<1uate and rapid :;upport to units further down the pyramldal strucLure. The cllnlc's dru6 supply was extremcly deflcient, althopgh the A\[/ provldcd sornc supplles to bat:k-uJr b]re [overnment's very meagre supply. It is probabLe ttrat, as wlth nralnutrltion, the records lnformatlon of the dlsease pattern is cllstorted due to potentlal- patlents knorlng the cllnic's drug state not golng to tlre clinlc. Adjaccnt to, bub detaclred from, the cllnlc 1s a small nraterrrity sectlon. As dellverles arc un<Iertaken by tlre Tralltlonal Blrt;h Atiendant, in the patlentS'homes it,1s only uscrl for antenatal work undertaken by tlre anlmatrice. It worrlcl appear Lhat there would be some cost saving if lnstead the maternity was an lntegral pant of the cllnlc whlch consists ol a tlrree-roomed bullding, one of the general. cllnlc and two for tlre Nursc's quarters. )9 It r.rould also trc very rmlch bettcr lf the nurse in such situatiorls was a nurse-miciwife of an auxillary ilrade whose tralnlng included tite dlagnosls and treatment of thc more common conditlons as well as tlte control of comrmtnlcable dlseases . Ouagarlougou Central PMI : Tirls cllnlc is run 1n a separate buiLding whlch is part of a complex of bulldlngs ln ccntral Ouagarlougou. The other buildlngs are used for a Slck Clinlc, mcdlcal stores, etc. Tkre cllnlc deaLs only wlth pregnant women and infant,s; pre6grant women with a concument lLLness also a'btend thls cllnic and not the general Slck C]lnlc. Althoufl under the PMI concept chlldrcn should attend u1: to flve years, 1n fact they rarely attend after the afie of I 12 years. Ttre staff consists of two doctors althouglt prescntly there ls only one as the seconcl ls <-rn maternlty leave, 5 miclwives (Cerbiflcated), ) Reglstered Nurses, 7 quxlllary nurses, I soclal worker and I asslstant social worker. This staff Iook aftcr both tire CentraL Cllnic and also Dapoya PMI cllnlc as well as unclertaklng trome vlslting and some hospltal-/maternlty dellverles. New maternlty cases arc secn on Mondays, repeat cases on T\rcsdays and chlldren on Thursdays and lrr.ldays. It ls unfortunate that here,as elsewhere, therc.arc speclflc days for matcrnity and chlld work whlch should be comblned on the samc day. Very frequently a prcgnant mother has a slck chlld at home and thls necessltales two cllnlc vlslts In the Under lrives Cllnic the Morley-type lloali to Ilca]-t]t Chart d"s kcpt at the Cllnlc an<i the mothers arc 151vr:n a small notebook 1n which, at each vlsit, ls entere<i a noLe on the chil<l's weiS;ht and condltlon. lhis ls a quite polntless redupllcatlon - but nob an Infrequent one. It is extremely dlfflcult to wean staff from tlre conccpt that cllnics rmrst keep the records and that the mothers can be trusted to keep and bring thelr records. In this clinic as in clinlcs seen ln (;hana, welghlnf is undertaken by means of a balanccrl beam scaLc. Thcsc scaLes tal:e an apprc'clable time ard effort to use. Tlre essence of primary heal.th care dellvery is that the actual cllnic worl: rmrst tre lifl]rtened ar; much as posslble with approprlate teclurologl . .As far al; vrelghing sca.ler; are concerned the approprlate technologl conslsts of a Salter'-type sprlng scalo wtrlclt ls hung up near the clinic nurse. The baby/young chlld is placed in the reccptacle by the mother and thus negaLcs botlr Lhe use of a helpcr to put tlre babe on the beam balance ancl hold lt ther.e ancl l,he Llme-consumlnl5 mcbhod of welghlng by beam balance. With the SaIter-type spr.lng scalc Lhe nurse has only to look up to note the welght. Cooking demons'bratlons are un,-ler"l;akcn oncc a week and dlfflculty ls encountered as the majorlty oI' mothers cook wlth a wood fire whereas gas ls cheaper than woorl so thab cLlnlc budllets may be orientated to gas cooking demonstratlons. Yet the crucial polnt of a cooklng demonstratlon is that the mothers' horne cr>nclltlons are repruluced so that the requlred finattce for wood must be provlded otherwlse the whole aim of the demonstrations w111 be los t. Immunli,,atlons arc undertaken on ;rlternate T\resdays whereas the baby cllnlcs are held week.Ly on Thursdays and Fridays. T'ltis means that many opportunltles to lmmunlzc are l-ost. t 40 The CIlnIc's 1976 work consisted of: Pregnant patlents wlthout concut.nent 1lInoss rrwlthailil Total pregnancy vlsits Under Flves Clinlc Total Und6r Flves Cllnic chlldrcn Imrmrnlzations Nevl Repeat New Repeat ,l+7o ,6oj ,)TtI 2),501 6 1a) 7 46,576 New Repeat 2,799 t6,74o 6,12t tt,7l5 L9,519 6,72t Mothers glven foocl Patlents scen ln 1976 72,4)6 firls works out at L,')91 consul'tatlons a week wltlch 1s a very'heavy loa.d and Justlfies the large staff - who are also lnvolved ln a conslderable tralnlng programme ln Plvtr. Imrm:.nlzatlons: 'I'he imnmnlzatlons p51vcn In L976 conslstecl of antitetanus tolro)T pregnant wonren; chirdren - )r14r vrhooping cough ancl tetanus; 682 measles i 551+ P/C,G; )7t pollo i L76 smalJ-pox and JO yellow fever. In both Ghana and Uppcr Volta therc is fan too Iittle emphasls on lmmuntzatlon. In some areas, lmmtrnlzatlon supplies rr-m orrt; ln many areas lmrmlnlzatlons are tirought to malnly concern the varlous moblle teams. The lnfectlous dlseases of chlLdren arc lethal in the developing countrles where they are ofl.cn combined wlth a degree of malnutritlon. ft ls also neccs{iar.y to adopt the concept of the Protccbed Child(2o) ir', a1I cllnlcs ancl nrontlrly returns. A statcmcnt Lha'L ),141 children have recelved whooplng cougir ancl tetanus; 682 measLesi 554 wG; 17L polio and smallpox ls.Just;r statement of a clinic's workload. rt ls necessary to know ltow many chlJr.ircn recclved bhe futl baslc course of immunizations.fn Zambla it vras scen that oncc the cl-inics adopterl thls concept they were able to see for tlremsel-ves how tlttlc communlty good they were achieving and thls Led to a grcatly lmproved lnrnunizatlon programme. In somc areas a hypcractlvated tetanus toxoid lras been used. whicl-r requlres only one lmrm.rnlzatlon for a pregnant vroman and very good results have been achleved. Ilowevcr, lt ls extremely hard to obtain. As yet there are no resul-ts from the Ghanatan trials w1 bh tlre use of only two doses of DPT and pollo as primary courses in young chtldren - and the outlookfor the results does not seem too hopefut. McasLcs lmrmrnization ts vltal as measles ls one of the 6reatest killers of youn13 chlJ.dren, yet we are still hin<lered in lts wlder apptication by thc cold chaln. A suibable and sufficiently fundcd intcrnatlonal rcsearch prograrnme should bc ablc to prodrrce a more thermostabLe attenuated v1rus.Until thls ls acltleved many, many thousands of small ctrildrcn wlll continue to dle - un.Less every health post is provided with electriclty.' I 4] Nutritlon RehablLltatlon Units : These units' potentlalltles 1n nutrltion education are not yet widely recognlzed so thab no great number exist. It was, therefore, a most pleasant surprlse to flnd 4 tUttUs ln Ghana and 19 ln Upper Volta. They are one of our most effectlve 'me<llcal' answers to ma]nutrltlon. Corumrnity diagnosls: The teaching of medlcal students, paramedlcals and auxillary cadres must be orlented towards the more common dlseases in an individual country and the emphasls ln teachlng time must be proportional to a condltlon'spriorlty ln the overall dlsease pattern. fn I?[X a total of I,)+25,564 patiehts were seen by Ghana,s medical servlces\rr /. Ten reasons accounted for 6a/' of the patients attending:- lvlalarla An Lenatal-s Gastro- enterltis Bronchltls Chlld wel fare Upper resplratory tract lnfectlons f mmrrnizatlons Aldomlnal paln Sl<in lnfectlons Measlcs 6L.9% In 1974 ln Upper votta(re) r,27g,gTL patlent visits were made to medical unlts and 85.)/, arc accournbed for by:- Ga..; trolntes tinal Ilcsplratory J,ocomoLor system DermatoloS;i r:aI I.iye condl tions 85 J% In the follorving year, 1975, thcle wcrc L6,740 admlssions to Ouagadougou Hospltal. I.'lve 6eneral hearllngs contrlbuted 81.7fr of the ailmisslons: Trauma )+o.art Gastrolntestlnal 14.6 l+9.5i4 of these r.rere medical conctlLlons wlth lnfant dlarrhoea accoru-rtlng for 5L.)ft ot them Infectlon and parasltlsm L5.5 )O.,J,'r, of these were rneasl-es vrith a casefatallty rate of 26.7'fr Obstetrlcal and gynaecoiogleal 7.4 24.7'fr 8.o 5.0 4.9 4.2 4.0).9 2.9 aa 2.t ?1J'rt 19. O u.o t5.2 10.8 Tlrese exclurle normal blrths. 41.4fi were abortl'ons and 29.5fi were Caesarian sectlons Of these 18.L% werc tuberculosls and )4.A/, pnntlnrrn i1. Resplratory 6.2 42 There arc, holcvcr, cclnslderable dlftcrences in both morbidity and mortallty by age {:roups. Furtherrnorc it ls necessary to have a disease plcture of the smaller hcalth units and, mosL importantly, <.rf the actual populatlon sLnce many, when 1II, do not report to a health unlt. The patlents who attended the AW Kafbo cllnlc 1n August 1972 new patients) were dlagnosed as: ()26 ABe O-I )9 I-lt 5-:5 Aclurt, M Actult F Total 64 6 15 5 4 L2 27 B8 L2 75 5B I )26 Dlarrhoea Malarla AMominal paln Resplratory Infectlon Skln lnfectlons or Despite the overa)l 51'rt of the dlagnoses clted above, the coverage by age Broups was 1006 fr.rr the under 1s; 78ft tor the 1-4si 57% for the 5-l5s and 18fr arrd l+tfr tor the males and females aged over 15. llowever, these flgures mrrst be vlcwed with caution as they are a good exam;rle of cllnlc figures not givin6 tl,e overall health plcture of thepopulatlr-,n. As has been previously mentloned, ttrere was a conslclerable num'er of chlldren wlth under- and malnutrltlon who did not attend the C1lnlc. I cz\fn Ghana\'// the Latest avallablc figures shovred that comnmnlcable dlseases vrere responstble tor )Ort of tire certlfied cieaths and 696 oftrospltal admlssions. Ten percent of tlre children under ! years of age have cllnical malttutrltion. Neonatal tetanus is an important problem, but ... rMeasles ls the most drea.d,ed diseasc'. ln fqaff (24) lnfectlous dlseases accounted for 50.2% of the deaths. fn Zambla vlllage mothcrs were asl<edrfq,,the cllnlcs which llIness they most feared ln relation to bhelr childrcn\--l. Of L,1O9 mothers who replied, 28.y/' stated measles i ?-5.?-tr, whooping cough; 9.2fi d,tarrhoea arfi. 9.2fi malnutrltlon. Thenty-seven-polnt-flve per cent gave a number of other condltlons. fn Upper Vo1ta the mortallty per l,OoO of eaclr age Eroup(I6) "* t" abstracted to show tlre morLallty of the Under Ls and I-4s ln comparison wlth the total- populatlon:- Under I I.-Jt All populatlon Measles Malaria Dlarrhoea Pulmonary, non-tuberculosls Other abdomlnal Meningltls Cardlae Whooplng cough I I 5 0 7) oo 1) uB 24 1B 27 Tqo- 58fr 6 6 9 Ig 6 5 o 5.7).2 5.6).1 I.B 1.4 r.1 o.9 26.t 4.9 r).4 l.,t 2.1 r. ti O.7 r. tl ?6.r t+o.5 19.2 11.2 7.1 tt.5 ?.(t rr.9 4l CONSTRUCTION AI.ID ITECURRENT COSTS The Deslgn Team of the $qf,ional Plannlng Unit ln Ghana produced recent costlngs fop the cnd of l976\tvl anrcl other 79q\ings are available ln the Flve Year Dcvelopment PIan Lg75/6 - l97g/BO\^r/. Ilospitals: The Five year Development PIan mentlons a number of hospltals to be built and glves tire total cost but docs noL menLion the numbcr of beds. Ilowever, in one case mentton is made of a JO-bedded infectlous dlsease hospltal which wiII cosL i,25O,OO0 to construct. lrrom t]ris lt can be deduced that the capltal cost ls 18,)r, (US $7,246) per bed' The capltal costs of llq{.;lelel llospitals at PO and. Sunyanl are 92.55 mlltlon (US'$2.2 mtllion) @pltats. A Distrlct llospltal to bq bultci ln the Plan per'lod is cited as costing /,t ntttffi--j..6ffiiffion (us $o.86 mirlion to us $r.r+Z milllon) which woulcl lndlcate a lrospltal wlth a I2O-2OO bed capacity' A RuraI Ilospttat of 50 beds woul<l therefore cost fi,4t6,65O (Us $162,)00). The hospltal recurrent cost was estlmatecl by the Desi5Sn Team by basing thelr estlmate on the Fv 1976-77 wlth an operatlng cost per bed of /tt,7OO per year or US $fO,f74. It must be assumed that this ls an ove'ral1 costing for aII gre hospibals so woul-d be hlgl-rer for the larger hospltals and smaller for tlre smalLer oncs as these costs must, vary with the number of staff and faclllties, 1.e. the number of beds' HeaItLr Centre costs are clted by the Design Team and are based on costs-fffiffirn Regton for 1974-l! and adiusted for infLaticrn'to December 1976. Tlre Team polnts out that, they krave inc'Iuded a dcprcclation allowance alttrougir Llre government does not usually includg this ' The clepreciation allt]w"rr"u Jor"rs JO yeal's t'or bulLdings and ! years l'or furnlshln6s , equlpnrcnt and velticlcs ' Capltal costs 2sq.fb. ),oo9 tt,?4ti 7,?56 ?79.7 )95.t (r7t+.8 ln Enclosed area Open/roofed area costlns il)5 o, us $lo. \)/sq.ft. Costlns lt5 or US $r).04/sq.ft. cost: rtt5,7ta or us $t1,611 Ttre enclosed area would lnclude a consultlng room cf l2O sq'ft' whlch woulcl be used by 2-l+ persons, the Health Centre Superintendent and an asslstant, o pitl"nt and frlcnd. This room would be expected to be ln use for an average 6 mlnutes pcr patient' It also lnclu<Jes a recovery room of l.lt4 sq.ft. for 1-5 persons - one atLendant, two patlents ancl 1,wo patlents' frlencls' Patlents would not stay ln thls t'oom for over 24 hours' 44 The tota] capltzrl costs are: Archltect's costlngs for 7,2's6 sq.ft.Staff quarters for five & lnfra- structure F\:rnlshlngs, equlpment, vehicles TOTAI,: i 160,OO0 15O,OOO 40, ooo $ LSO,LrO L)O,4)5 )4,781 y'15o,ooo g)o4,148 Ilecurrent costs I ciocLor for L/5th of h1s tlme I Health Centre Superlntendent 1 l{ealth Inspector I Comnunlty Ilealth Nurse I Enrolled llurse I Record clerkr/typist 2 Orrlerlles/l abourers at /,725 eacltI Drlver/mecha.nlc Add for satelllte work, J clinlcs/week I Communttrv llealth Nurse I 0rlterly/Iabourer Add: The recurrent annua] budget is then: Payroll Other Drugs & dresslngs Annual medlan salaries il 1,750 2,600 I '750r,lloo l,4oo 1,050 1, /t50 875 1,'lloo 7?5 $ 2,Ot1 )6tr ,26L 76L L,2t7 6)o $t),9t)),9L) r),9t1 17 t7 t7 L1 o 2( (), 2 2 t t I L),)25 ll ,759 i)l),45o $t),6o6 l2y2% for social sccurit,y and National Insurance fund;2fr forovcrtTnc; y',?,OOO-1,2,5o0 f<.rr equlvalcnt share of physlclan's private pnactlce all-owance . . /)+ ,5OO Add: Drrrgs and dressinl5s l,L6,oN fi,t6,ooo 4,5o0 16,0oo Total recurrent budget /16,,)oo $)r,T)9 att5 The centre's rcvcnur-'wl}1 l'tc y',4,OOO a ycar from users' fces so that the net oJreratlnr cost wtII be i)'1,5ryo or $21),26I to wirich has to be addeci l,18,OOO or $1516');, lor overalL annual dclrreciations. The annual operating cost vrl1l therefore lte / ,o,ooo or d1+5,9L3. Note: 1. llre above starfflng is sorncllrab less than that usually advised in Ghana eurd is certainly Iess than ln the Ghanaian ltealth Centre vislterl. It is, however, a nuch morg reallstic stafflng pattern. 2. Thc above capltal buclgct fl6ure Is /,)5O,OOO whereas, ln the Five Year Development Plan, a flgure of fr4OOTOOO 1s given, a <ilfference of Jlti(. It may be that tlrc PIan has added a factor for expected cost 11ses. J. Conversion factors used: I sq.yd = O.t15n y't.t5 = $t /_ Isq.ft. = O.))n2 llcalth Post: Thls ls costcd ln the Five Year Development Plan at, /,IOO,OOO or $86,957 capltal cost and.ju<lging by thc PIan's cosblng <.:f IIeaIth Centres thls flgure shouki lnclude staff housln4, lnfrastrrrcture, furnishings and equipment. The Design Tcam, howcver, has costed patlcnL contact.s and gives a ranSe:- Range of cost per patient contact: Salarles and payroll Dru6s arrrl clressini5s Otlrer currcrrt expenses /.o.9(, o.U0 o.?)t 60 rr(.)cl) tt2 -it .I .O Totztl: /.z.oo fll.eo ($r.z+ - $2.t8) V1 l.1a8e Dis Jrcnsar..r : Tl-rc DesltrJr Tc;rm states tlrc parametcrs .for this unit but no cosbing 1s presentcd. The unlt servcs a populat,ion of from (rOO to I,2OO wltir an average of !-I2 patlent contacLs a day and a maximtrm of 25. Thc facilltles slroul-rl bc: 2 roorns ln a house or community hal-1(a) for consult;rLlon and treatment, mcasurlng lOft. x loft.(u) a storage room, nreasurln6i 6rt. x Loft. Itrere shoukl also be an exterior covered space l8ft. x ?lfL. 46 If we use the same costlngs as 1'or the l{ealth Centre t}ren the capital cost wlll be: Enclosecl baslc structure of 2 rooms (f6O sq.ft.) Open roofed area 4]O sq.ft. Total capltal for strrrcture: fr9,95o t8,652 To thls capttal cost must be added thab of ttre staff quarters anci flttlngs furnlshings. Ttre Flve Ycar Development PIan reveals a few more capltal costs: ltlon Rehabllitatlon Unit 0L4,ooo $tz,r74 500 450 frt 6 ft is dlfficult to understand the capltal costs given for Maternal anci Clrllcl Iiealtlr (pt4f) Clinlcs as there ls a great varlation wtrich nn:st depenrl on varying slzes. ttre figurcs citcd beinr frtO,OOO; 20,0@; JB,0O0; )9,OoOi 4o,oor.l and l+2,@0. Thc range ot /,tO,0OO-42,OOO representlng $8,696 - $)(',52?-. There is, lrovrcver, no loglcal Justlflcatlon for lsol-ated MCH Cllnlcs wirlch lnstearl sirould i>e an lntegral part of aII prlmary health care dellvery unlts and using tlre staff of those unlts. Flgrres can also be obtalned for three dlfferent types of housln8: (") (b)(") Self-lreIp eooperatlve projccts Low lncome houslng IVRe Slla SIIJ l4atenIaI Manhours Contrlbutlon* y'.4,5oo r5,o0o 7,7\4 'iD,9t) L),O4.1 6,7)4 Lastty thc Ptan mentlons the cost of only one vehicle separately - thls ls a Combl-bus. The sma1l version costs fitZ,OOO ($f0,47!) ancl the large verslon y',a5,ooo ($at , T9) . Upper Volta: Tkre only brrlldini: costs wlrlch cou.Id be obtained were from the Ministry of fiealth and tlrese wcre only for a sr1. meter. The flgure given agreed well wlth a flgure from the WIIO offlce in Ottagadougou. Bulldln6 co"b por *2: 5O,OOOI' cl'A ($205.76; In Dr l4artln-samos' IleJrort for 197(r(60) rre states tlrat the Voltaic Bovernment ancl PNUD (UNDP) rqere trylnry under llabltat to bulld some good houses. These vroulcl be 43n'and have four rooms. The costing clted was: 16!,oooF c!-A \Jr,0oo 58,OOO J54,OOOF CrA ($r,t+57) +T'hls appqars to be a contrlbutlon towards costs requlred of the future houseowner. 47 Vehlcle costs ln UnPCr VoIta: The vehicle required for rural" work wiII depend largely on the road eonditlons in botir Llie wet uurd dry season. fn many countries, however, there ls a tenclency to use the very expenslve four-wheel drive vehlcles when a small Vtlrlcttro6n would tlo Just as weII. In poor rural condltlons a velricle does not last rm:ch longer than three years and in betber rural conditions may last up to five before requlrlng replacement. Dlstrlct Supervlsors requlre vehicles normally Just for themselves and, to enabl-c titem to reach the lsolated Healtir Centres and Aid Posts, a four-whee1 drlve 1s necessary generally. A IIeaIth Centre requlres a vehicle to act as an ambuLance and also to attend satelllte cllnlcs - though ln many areas satellltes can be vlslted by blcycle or mobylette. $ Prlces lncluslve of tax: Peugcot mobylette 106,OOO(a moped blcyclc) Peugeot CT (a moped) 80,000 ltre flrst, the Peugeot Camico, ls a sturdier and safer machine. It 1s an extremely common form of transport for Voltalcs, both male and female. fn Ghanta, ltowever, lL 1s not the 'done thtn6' for women to ride bicycles. Cltr<-rtJn 2-chcvaux x(tgl6 ) r,20,1, ooo A sturdy mlnl-car Pcugeot 504 opcn van I ,25O, OOO 416 729 These costs are for 1977 unless otheruise lndicaLecl. The cost of petrol Thc oCP Management neport(26) gtves a survey of the cost of I lltre of regular petrol ln F CFA as of Mareh L977 z Volkswagen combl- bus La.ndrovcr Toyota station wason (tgl6) Jeep Vl'l 2,7O0, OOO 4,72o, ooo J r,too, ooo 1,051,50o Totjo t+t|.7o 4,955 5, 144 11,11I L9,42) r),992 t+ J27 Upper YqrleBcnln Ghana lvory Coast Irlali N1[er 64.5? 7tt J568 t+7.81 90.75 Bl.te F CFA 4ti TIre same report g lves the estimiLted runnlng cclsts of velricl-es(Landrovers, VW Combl-bus and sbatiott wagori)-ome;f wtiich run up 72,5}Okm/year. fncl.usive of fuel, sl)are parts, lubrlcants, batteries and contrhcted repalrs, Lire esttmated cost Is US $O.l)2/kn. Salarles: The oCP Manarlt:rnent nepopl(2(') gives a comparlson of staff salaries by countrles, the eldrl,6rades of salaries as weighLed averages and enabl"e a staff cost comparlson of the OCP countries. Tlre figures are tn US $ per caplta:- Benin Girana Ivory Coast llpper Yqltq 2,LO2 ),6)0 4,658 2,8W Traln InB: Tlrc costlng of t,ralnln6 for tlre merltcal cadrcs has not been undertaken 1n Upper V<.ilta nor, apparently, in Ghana. Ilowever, an lndlcatlon can be obtalned from Mr M.N. Tr1 's costlngs r-rf educatLon ln rlenera.L. (tlr Itl .N. Tri, UNESCO, Prlnclpal Technical Cuur)sollor, Mlnlstry of Educatlon, Ouagadougou.): Mali Nlger L,969 2,186 Togo ),670 10, OOOF CF A,/stucle nt/ y ear u2, OOOF CFA/s turlenL/ y e ar 105, OOOI' CFA,/s tudenL/y ear Pnimary Schoo.llng Secondary licirooIin6S Technlcal Schooling $4r$tx$82 The tralnln6 of auxlllarles sucli as auxlIlary nurses, mlchrlves and health assisl,ants, is a two-year teclrnlcal trainlng, so probably an approxlmate educatlon expencllt,ure of $gOO. The three-year trainlng of the Reglstered Nurses, Certlflcabecl Miciwives woulcl bc in the reglon of $I ,)OO. Salaries of Mctllca} Staff ln Uprrer Volta and Gitana: These f115ures have been obtalned t'rcrn the respectlve Ministries of Health. Upper V<-lIt.a fire salarles of pensionable civil scrvants. Montlrly salarlcs, net pre-tax but wlth a 6'11 pension dcclucl,lon and a housin6 allovrance lncluded. It |s not knovrn if Voltaic doctors receive a private practice allowance. As of August L<)77:- Mon Lh Ly Mcdlan monLhly CateEory Minirnum Maxlmum Steps F CFA $ Doctor Reglstered nursc Registered nurse special* Auxlllary l'lurse Auxlllary nurse special* Drivers Iabourersr/employees llouse servants** 7t+,8)1 4(t,19-) 51,'l)6 )'t,?(to )(t,O)I 17 ,67') 12 '51o12,51 O 1l)0 <)o l.ol. ,)L6 ,t>)B ,(,?5 ,i11,508 60,976 ?u,799 ')1 ,7 rL 20,4)4 I1 11 11 11 11()() 8 7 11?,575 .68 ,166 7(t,(>81 t+1,f38'> 4tl,5O4 2),L-'19 ?),ILL ]6,74? 545.5t) 28L.14 )l-5.56]rio.60 199.60 95.6) 95.rr 68.90 * a 'speclal nrrrse ls r>ne wlro has recelvcd further tralnlng a house servant ls nr.rt a penslonable clvll scrvant (and probably not drlvers and labourers, but have bcen includecl in the Table for lnformation. ry\,i.. .,r-r.'.- ? I 1 ,, i,,i' t* 49 I.. Cl.A !+j = $I accorrilng to tire August 1977 WHg converslon rate. Girana The doctors' salarLes lnclude a non-t42cabl-e professlonal allowance of l,tr5OO - ),OAO but unllke the Upper Volta salarles d.o not include l.,kre 616pension cieductlon nor bhc addltional houslng allowance, these last two provlsos relatlng also to the other grades. AnnuaI Category Mlnirrum Maximum dq/ ; 277 184 r10 tL7 Median montlr Doctor Reglstered nurse Auxlllary nurse Ilealth Centre Orderly Drlver 5,796 2,21+O ?. 1116 l,)+2? r,507 5,)70 2,940 t,671 L,TL7 / 76L )LB 2t2 L27 t14 12,\62 fire pay raLes of the }{ealth Centre Orderly and drlver are based by the Mlnlstry on the mlnlmal rate of fi per day. Ttre Augusf 1977 WIIO converslon rate of $t = f,t.I5 1s used. Tlre Gtranalan clvll servlce pay scales were changed on Ist JuIy 1977 from the prevlous scale of 1 July 1974. The lowest pald recelved increbses of 80. Lfr, l]ne hlghest pald 20.5'fi wLth a mcdium ot t+6%. 5o Ivllr graLeful thanks are due to the followlng: Mr M.Is .Bazln, Dlrector, @P Pro65ramme, Ouagadougou Miss F. Ral<er', OCP Programme, Ouagarlougou Dr D. Carney, Chief, Economlc Development Unlt, @P Programme, Ouagadougou lrlr R. He1mholz, Chlef , Admlnlstrative Servlces, OCP Programme, Ouagadougou Dr C. Gboho, Entomologlst, OCP Programme, Tamale, Ghana Mlss M. Desbols, OCP Prograrnme, Ouagadougou Mrs. M. Sorgho-Lafosse, Economlc Development Unlt, OCP Programme, Ouagadougou Mr J.D.M. M;rrr', Entomologlst, oCP Programme, Ouagadougou Dr B. Thyleforr;, Ophthalmologlst, Epldemlological Evaluatlon Unlt, @P Programme, Ouagarlougou Mr J.F. Walsh, Entomologist, OCP Programme, Ouagadougou Mr D.G. Zerbo, Entomologist, Sector Chief, TamaLe, OCP Programme, Ghana N.ll. Akim, l'JIIO Representatlve, Accra, Ghana F. Martln-Samos, l,lHO Eepresentatlve, Ouagadougou J. Markovic, Team Leader Manpower Project, [,1H0, Ouagadougr,,u Dr Douamba Tlnga, Mlnister of HeaIbh, Mlnlstry of HeaIth, Oragadougou Dr J.14. I(yel-em, Dlrector-General. of Publlc Health, Mlnistry of Health, Ouagadougou Dr P.K. Compaore, Dlrector of flealth Servlces, Mlnistry of Health, Ouagadou6ou Commanriant VJcck, Sous-Dlrccteur MaLerial , Ministry of Health, Ouragadougou Mr A. Keita, Dlrcctor Adminlstratlon & Finance, Mlnlstry of Health, 0uagadougou Mr S. Sorgho, Director-General AW, Ouagarlougotr l{r K. firomas, Clref de Bloc, Kalbo, Upper Vo1ta, AW Mr M. Chaveau, Dlrecteur Mlse en Valeur, A\fV, Ouagadougou Mr J. IIlSel, Resiclent Representative, UNDP, Ouagadougou Mr M.N. Tri, Conselller Tecturique Prlnclpal, Mlnistry of &lucation, UNESCO, Ouagadougou Sow, lJecretary-General, OCCGE, Centrc Muraz, Bobo-Dloulasso, Upper Volta . Morcau, Dlrector, Centre l4uraz, Robo-Dioulasso Dr K. Awarlzl, Mcdical Superlntendent, Tamale llospltal , Tamal-e, Ohana Mr Al-Hassan Amldu, IIealLh Centre Superlntendent, Savelugu tlealth Centre, Ghana Dr A. Darkvra, Re6Slonal Medlca] Offlcer, Tamale, Ghana Dr L.K. Derban, Chlef Mcdical- Officer, Volta Ia.ke Authorlty, Accra, Ghana Slster T. Finlay, Blnaba Mobile Ilealth Servlce, Ghana Mrs M.E. Pappoe, Department of Communlty IIeaIth, Korle Bu, Ghana Dr Dr Mrs C. J.P Dr Dr I51 Referenccs Aperqu lnformatlf sur sant6-cau-nutrltion sans les pays du Sahel(Draft). Martln-Samos, It., Stabllc-Wolcan, A. & Kersaume, R., CIub des Amis clu Satrel, Dakar, March 1977. A-Sahel/Drs F'I,LS ASW/Mr. Px/ rV ol/JJ ouasadougou c. Demo6raphic tlandbook for Afrlca Aprll L975. Economic Commission for Africa, Unlted Nations, L975 ). Some envlronnrenLal heaLLh problems associated wlth industrial developmentin Ghana. Derban, L.K.A. In: Ilcaltir and Industrial Growth. CIBA Foundatlon Symposlum )2 (new series), L975. (EIsevler, Excerpta Medlca) Amsterdam 4. La sarrt6 publiquc en llaute-Vo1ta, Sltuatlon actuelfe, L976. Martin-Samos. ANA.tfv/Dr. I,lvlS,/r'k/tg'f6. ouagadougou '). Afrlcan Statlstical Yearbook L<)75. Unlted Nations 19'16 6 Onchoccrclasis Control Progranrme. Socto-economic development in the Volta Rlver basin. Annual Report 1977. Ouagadougou 7. Marrlage of agr,lculture and nutrltion: Food and nutrltion policy forAfrlca. Idusogle, F:.0. Jolnt I?AO/rilHO/OAU Reglonal Food and Nutrltion Commisslon for Afrlca, Special Paper no. lO 1977. B. El{ments rie strat6gle Sant6-Eau-Nutrltlon clans le cadre d'un delveluppement, soclo-dconomiclue harmonleu.x des pays clu Sahe1. Synttrbse tecirnique prepar6c i Ia demande de Ia Commission 'Santd-Eau-Nutrition' CIub des Amls du Sahel. Martln-Samos, F. & Kersaume, R. Ouagarlougou, Aprlt 1977 Onchocerclasis control ln the VoLta Rlver Rasin area. Report prepared for ttre Govcrnmcnts of Dahomey, Ghana, Ivory Coast, MaIl, Niger, Togo and Upper VoIt,a. Annex \fI'2.A: I3ackground data and proposed integrated rural development proJects in Upper VoIta. Geneva, L97t lO. Iixporting aurlrnals and rneat from <jevel-opinf countries: the major impediments. Kafel, S. Wor.l"<l Animal Review (ttno) 1975. f4, 15 II. Ileport on an lnlormatlon vlsit to Glrana. 14-19 February Lg77. Carney, D., Unlt6 de Ddveloppement Economlque , @V/BCO, Ouagadougou February 1977 L2. Occupatlonal lrealth of agricultura.I vrorkers. East Africa Conferencc, Addls Ababa, September L97). Africa-American Labor Center, New York L). La contributlon des fcmmes au dejveloppement. Blsllllab, J., Consultant au Centre de D6veloppcment de I'OCDE. Dupllcated & not dated 14. Statistlqucs ScolaLres L<)71-il.' Mlnistbre de 1'Educatlon Natlonale. Ouagadougou, 1975 15. l,lorld Healtir litattsl,ics Antrual l'/l)-7(>. Vol-.III IIeaIth Personnel & I{ospltal Estab.l-lshments. l,HO, Ceneva I97(> 9 L6 52 La SanLd PubJ.i<1ue en IIauLe-VoIta. Profi-Ie Sanltalre. Martln-Samos, F- PS.HVTlDr. Ll,,'t1ShVL976. Ouagarlourlou Flve Year Developmcnt Plan L975-I976 - 1979/BO. Republic of Ghana, Mln1stry of Economlc Plamlng, Accra, January L977. VoI. II Nursing Educatlon ln Ghana, VoI. II (revlsed). Mlnistry of Health, Aecra, L974 Ghana: Courttry profile. Aklm, N.ll., M{O Representative, Accra, 1976 WorkLoarl v. Community Goo{: Ttre conccpt of the Protected Chllci. Shattock, 1". J. Troplcal Paectlabrics & Environmental Child Health, L976, August, p.L79 Tpadltional Blrbh Attenciants - a key to rural maternal. and ch1ld health and famlLy plannlng servlccs. Neumann, A.K., Ampofo, D.A., Nicholas, D.D. et aI. J. Tropical Paediatrlcs & Environmcntal Chlld Health, L974, L,2L Mlsslon on ll6publique du Mali, f"ebruary 26 - Match ), Lg-17. RandriamamonJy, Unitd de D6vetoppement Economlque, OCP/WO/11.5/\ttrf,.. Ouagadougou L977 Protectln6 Glrana's cltlldren. Beausolell, B.G. World IIeaIth (MlO Geneva, 1977 February - March, !. 28) Profll de La R6publlrlue du Mall. d'AJ.me1da, J.J., Ol4S Representatlve, Bamako, 19'16 Pararncdlcals, Agxillarles and Maternaf and Child IIeaIth. Shattock, F.M. In: Commr1nit.y Ilcalth and tlealth Motivat,lon in .South East Asla. Proceedings of an lnternational semlnar, BerIin, November L97). Eds. Diesfeld, H.J. & Kroger, I'i. Irranz Stelner Verlag, Wiesbaden, L974. pps. 64'76 Management Survey Report No. 15'+: oncl]<>cerciasls Control Programme: Tkre management of cosLs in veetor control operations. Schmidtkunz, H., Aprll 1977, Ouagarlougou Landlx, J.ll., WllO Bulletln, 195iJ, No. IB For a better quality of worklng ltfe, Rosow, J.M. IIO Information(ccnevzr) L977, L)1, (> Santd lfur.a-l.e et M6dlclne Pr6ventlve en Afrlque. Labusqulese, B. L974, Salnt-Paul, Meuse L7, IB. Lg. 20. 2L. 22. 27 2t+. ?.6 ?7. 25 28 29. II RECOIITIEIIDATIONS Note: Relerences ln thls sectlon reJ'cr to pages in the previous section Constralnts I fire OCP Programme covers onIY a small ortlon of some of lhe OCP countrles: Upper VoIta Benln Ivory Coast Togo MaIt Nlger Ghana 2. AI1 Lhe OCP countr'les already are 1n varylng years of 5-IO Year Development Plals which lncLucie a heaLth sector. In general the health sector lncludes: Communicable disease control- Envlronmental health prograttmes Tlte'strenSl,henlng of natlonal healttr servlces Tire tralnlng of health staff at aLl levels fire establlshment of natlonal plans for health actlvltles Only Ghana, MaIl, Togo and Upper Volta have formal reglonal organizatlons. 98'fr 5w !)rt z^ry')CP IUfr L,/" 4o'rt ) l1 The development of the "onchocerclasls-free<1tt areas, Whils component of t,he OCP Programmer IS not uncier OCP 'control' lts planning ancl lmplementation sovereignLy of t,he Parl,lcipatlng advlse antd sltould be ln a Poslti 1ts connectlons wlth World Bank. and financlng remain wl t an lntrlnslc . Development, in the OCP can both es through countrles. Ilowever, the on to help promote flnanc 5 There are a mr-rLbl lic1 of rol rammes 1n the OCP countries. Some of these progranunes lnvolve non-OCP court trles as well. The Club of the Frlen<.ls of tlre Sahel; IICOI'JAS (Iir:onomic Community of the West Afrlcan Region); Worl<i Food Progranrmc; UNICIiF; OXITAM; Save tire Clrlldren Fund, etc. Indlvidual countrles arc also recelvlnS varyln6 amounts of external ald. This multlpllcity of development prograrnmes musb be closeLy lntegrated to avold pUrposeless and expenslve reduplicatlon and even worklng at'cross purposes. 6. Exls b financlal llmitatlons of l-realLh budr:ets and wlthln these anclal 1lmlts the small share vrhlch ls provided for preventlve- promotlvc health care(e.f:. crash Programme team:frealth f'aclIltle a Iarfier sttarc of th grounds to manoeuvre health bu<iget, allocat all the countrles' de ,,iiltrelzt). render lnapproprlate grarldiose lreaLth plans s t,o achleve stated populatlon :health s|a It is not olitlcal to re uest c natlonal budget for ttea lth but there maY be for a small- lncrease in the proportlon of the total ecl to prrevent,lve-promotive health care ln vlew of claratlons of emphasls on primary health care' 27. The !r1q cruclal problems sf sorrcern to prlmary health care are: (a) (b) (") (d) (e) Ttre ecc-,n1;nrIc facl;ors of thc primary l-realtl-r care dellvery system ff,e@ manpowe r system as an effectlve approach to the masl; epl<iemlologlcal problems Ttre dltenrma posocl by wl-rat we know about dlseases and our inabl1lty to deliver heafth care to bhe maJorlty of the people Th;-Effi between the cllnlcal care of lndlvlduals and the coilffiTr the care of the health of the comnnrnlty The necessltY for a rea<l.y ac cesslblllty to care by the communlty B. The rurall and de f C(-a ml 11 ion of Ghana' 5,OOO persons and only )Afi of them have ally access to formal In Upper Volta the correspondlng flgure for the populatlon 11 concentratlons of under 5,OOO ts 8t1fr. 9 The ticeds of +,lre o le. A recent householcl morbidlty survey of 2,000 randomly selectcd rural househol<is uslng a two weel< reca}I perlod showed uC d-1_s-pe.{s_1on of the m.a-ss of the pcople. Seven f pobufattoh ttve ln concentratlons of under health caP€. vlng ln that ln that perlcd,, Zlfr reported some lllness, lnJury A recent survey ln Ghana of 2OO,O@ deaths showed that: dlseases, as w11I developntent, lnt,o the as well as contracblng dlseases alrearly or dlsabtltty. I2O,OOO deaths rvere ln persons aged uncier 15 of whlch 90,ooo werc Preventable SOTOOO 4eaths were 1n persons aged 15 ancl over of which 4O,OOO were Preventable. IO. Oncltoecrclasls is not the prlnclJral health obstacle to deve)'opment' It ls rather a wllole s ctrum of cllseases and soclo-economlc clrcumstanccs produclng L e dlseases. Migrants wiIl brlng new onchocerclas ls- con lrol led areas exlstlng in those areas. Spontaneous mifiration lnto the oncltocerclasis-controlled areas wlI1 comltoun<l t,he problem. Accordlng.ly, tlte contr<>I of onchocerclasls alone does not leave the roa<l wlde open to development' ln the rrrov[slon of a lc.rw-cost , cost-effecLlve method of a DrimaryS t,eps hcalth care deliv<-'ry s.ys Lem: I programmes. The OCP countrles' governments }iave alreariy accepted and ln a maJor way are lmplementlnq the parame<llcal-aux111ary concept and are uslng Health centres, Ald Posts and 'supenvlslon en cascarle'. 2. Mlsuse of ersonnel In ure unlts seen at a Health Centre l-evel (rrrhlch may have been non- representaLlve) there was over-sbaffing and the use of too hlgh a gra<le of staff for the unit,s concernc<l . Staffare being trained to too htgh a level , e.E. thc llealth centre superlnLendent In Ghana, ()r glven too lltt1e tralnlng ln wot'k tlrey are expected (but sirould not be rrndertaktng) to do such as Anlmatrlce ln relatlon to pregnancy and dellvery. Irollowing dtscusslon at a nat,lonal leveL,heall,lr eare dellver;1 system plans slroul<i lrol,h receivc accepLrutce and be {nl,ggrated lnto the natlonal health stfuture, or elie tfrey w1II fall even as pllot j7 In vlew of tlre smalf proporLlon of 16" tot'al countr.y lnvolved ln the OCP Programme ln aIl countries t:>rcept for Upper Volta and possibly Ghana, |he imp-Lementation of concepLs must be limlted to a slngle pirra are.q/r)t"tfr,t. rn Upper Volta and Ghana more than onElffit area/ <itstrlct can bt: etrvlsaged. 4. A c<.r rehens i ve lma hcerlth care del lve o tem can be provlded wlthln exlstlng flnanc aI constralnbs 1t s tire tas o the pllot areas to show that tl-rls 1s so. The exlstlng coneept be modlflBd. ramidal- s Lruc ture Centre and tlte sub-c 5 , as appllect 1n.@P eountries such as Ghana, rmrstfn the dellvery of prlrnary health care ttte conslsts of the Distrlct Hospltal, the tlealth entre (statlc or moblle). The staff of the Health Centre shoul d, conslst of onl.y bhree healbtr personnel. P.tl.C. Teams Tl're three persorurel shcluld be: (u) an auxltiary nurse-mldwife who wllI undertake matcrnal healttt lnclrt'i irrl' tnatal work; pregnancy spacing; chl tri lrt-';rl'1,t'antenaLal., dcllverY and Pos and trealth educatlon; (b) an auxlllar.y vritose l"ralnlng has been orlentated to the cilagrtosls atrd trcat,ment of the more common diseases; (c) a communlcabl e dlseascs auxlLi who has also recelved training ln hy ene and sanltablon. Tralnlng t These arxlllzrrles wopld eaeh havc }tari sorne trainlng itr eac)t-obher's flelcls, e.g. tlrc nurse-mldwife could undertake tlre dlagnosis and breatment 6ffi-me of ttrc conrl i blc,ns cornmonly mc l, wlth i bhe 'Medlcal Asslstant' woul<] have hari .s()rne l,ralnlnrl in PP[I (MCll), etc. Tltus, each cou]d, to a certaln extenL, ulrdertake s<>me of tlre work of oLirer st,aff when those staff are vlslting vlllagcs or subcllntcs. AII would be frrlly capable of ttndertakinq Lrealth eclucatlon. Very a,lequat,e dlal5nostlc-curat,lve staff can be trained ln tlrrec ears. It cioes not re<ltrire tlle three years SRN tralnlng, flve rience as an SRN, fo1 loweci by a fur.bher year's trainingyeans' field expe as ls requlred of Lire Ilealtir Centrc Superlntcndent ' Flnanclal Ilconomlcs: Such a concept greatly recluces tlre staff tralnln8 budget, th9 tlmg- requlred to traln staf'|, the recrrrrcnt, s[aII'buciget, t]re number of slaff houses attached to a llealth Centre, tne slze of the Health Centre, etc. 4AccesslblIlty: Rural work deprlved of transport lp tlrc equlvalent of a surgeon deprlved of a scalpeJ.. T'he sphcre of act lon of a Rural liealth Centre ls a rarllus of 5 ml1es and wlthin thls splrere of actlon patlents must themsel-ves come to the Health Centre. In the many countrles wlth wldeIy dlspersed and very poorly concentratcd populations, thls results in a mlnlmal proportlon of the populatlon belng covcred by a IIeaIth Centre. The key to the provlsion of prlmary health care ln rural areas should lle not, as at present, wlth the'radlus of coverage' on a five mlle basls, but rather on one of populatlon denslty and for thls moblllty ls an absolute essentlal. Moblllty allowe a Health Centre to lncrease lts 'sphere of actlon' many-foki. Moblle subcllnlcs may be ireld lO or 15 mlles from the Centre. Moblllty alIows efficlent supervlslon of sbatlc subcllnics (q.v.). Moblltty allows the brlnglng of very 111 patlents from subcLlnlcs or vlllages to the Health Centre and from the l{ealth Centre to the Dlstrlct Hospltal. Every second or fourbh tleattlr Centre could also be provided with a moblle team conslstlng of a team of tlrree auxlliarles (mldwife, Medlcal Rsststffi conrrmrnicable dlseases auxillary) and a drlver wlbh thelr own vehlcte. Thls would enable a very wlde coverage lndeed of areas not covered by the other Ilealth Centres even with tirelr moblle subcllnlcs since tirey are tied wlthln restrlctlve rad1l of tlreir Centres - belng the only staff of that Centre. Subcentrcs: The moblle subcllnlc Is descrlbc<l abovc and is undertaken by one or more Ilealth Ccntre staff, usually some flve mlles from the Centre, by one of the Centrc's auxlllirles usln15, where posslble, a scooter such as the Peugeot Mobylette Camlco. The sEatlc subccntre is lnanned by a nurse-midrvile of qqxlllary gra4le, wlrose tralnlng has lncluded flrst ald and some mlnor dlagnosls and treatmenL. IIer maln functlon wlll be in the field of PMI (mcH) but Lhls auxlllary will also be ln a posltlon to glve minor first aid treatment and minor treatments such as for coughs, dlarrhoea, etc. Accommqlatlon wlll conslst, as in the AW vlJ-lages, of a three- roomed bulldlng. LVo room$ are for the auxlllary's llvlng quarters and tire thlrr.l ls for tlre cl.lnlc wlth a covered area turning the L-shapcd bulldlng lnto a square. Ttrese house-cllnics will be bullt of local materlals and by villarlers wlth the Eovernment providing mlnoffiancing, the underlylng prlnclple belng that, 1f the vlllagers wlsh for a cllnlc, Lhen they themse.lvcs must bulld 1t wlth only mlnor financlal help from the government, which wlll also provlde the atuclllary staff, drugs and equlpment. 5FoI[ practltloners: Below the subcenLres there musb bc a new carire of lndlgenous vlllage health aldes. In a number of @P countri0s this concept has been accepted to the extent thaL now a falr1y considerabfe use is belng made of the Tradltlona.L Birth Attendants (Ulns), as ln Ghana. But tlris prlnclple must be extended to lnclude aIl traditlonal providers of health care in a vl1lage. Albcrnatlvely, vlIlage Chiefs can ask thelr villa6e counclls 1f they would prefer other villagers, chosen by the counclls and vlllafers, to rccelve some tralning th health care. Such training would lnclude flrst ald and the use of mlnor medlcat,lons such as nlvaqulnizatlon, cough mlxtures, antlpyretlcs, dlarrhoeal mlxtures, etc. Comrmrnlty lnvolvemcnt : As mentloned above, the vlllage chlefs wll1 consult thelr councl.Is and vlllagers ln the cholce of villagcrs to be tralned as vlllage health auxlllarles. the auxlllary 1n charge of a statlc subcentre and the auxlllaries ln chaBge of a Rural IIeaIth Ccntre, must cooperate fuIly wlth the relevant chlefs and always approach the villagers through the vll-Iage chlefs. In sonre countrles, as ln Zambla, vlllages were requlred to elect VlJ.Iage Development counclls and the Iocal health auxlllary was required elther to scrve on tlrese counclLs or Lo report to them regularly. This concept of Vll1age Development Councll would be a veny sult,able one ln relatlon to the development envlsaged ln the onchocerciasls-controlled areas. Supervlslon I T'hls system of prlmary heal,th care delivery requires a constant supervlslon from above downwards, besL described as I SU rvlslon en cascade:. The Dlstrlct IIospltal supervlzes HealLlr CenLres, HeaI Centres supervize stabic subcentres anrl statlc subcentres/llealth Centres supervize the vlllage health aldcs. T'he Dlstrict Medlcal Of'flcer, aided by a team of paramedlcals and auxlLlarles, lras an overaLl supervislon of all tl're unlts. This system of 'supervlslon en cascarle' 1s utterly dependent on rn<,,I>l1lLy vrhlclr is also requlrcrl f'or a 6uaranteed drutl supply to the llealth Ccntres and othcr unlts. ft h;rs becn dcmonstrated tlme;rnd time agaln that thls sysbem of health care dellvcrv can succee<l PRO\IDING on1y that there ls (a) adeqrrqtc r;rrpervls lon ancl (tr) , r'egular supply of clrugs. Wlthout the former the auxil-lar,ies wlll falI and wlthout the latter the villagers wl1l lose falth ln the unlt and wlll not atLend. The exlstlng nroblle flelcl ^crvlc{rs ln t}re OCP countrles are inarlequate. Many unlts are lmmc,billzed by a lack <-rI'spare parts, replacement vehicles or a lack of petrol. In a number of OCP countrles such mobile teams (which are extremely expcnslve) are unl-prrrpose workers so bhat ttrls expensive service requlres dup]lcat,ton. .Such unl-purpose workers, be they tubercuLosis, leprosy of lddpistage' workers requlre further tralning to become cost- effectlvc poly-valent workers. 6Tralnlng: The tralnlng of poly-valent workcrs at Ilealth Centre, statlc subcentre, moblIe staff ancl Dlstrlct supervlsory staff, is all-lmportant. 'The maJorlty of defec!s found ln countrles uslng thls system of heaLth care dellvery can be traced either to a lack of supervlsion or to an lll-advlsed tralning progralnme. The essence ol tralnlng ls that lt be approprlate. Even before a currlculum can be envlsaged a conrnrunity diagnosis must be undertaken to ascertaln the prevalllng health problems and thelr prlor'ltles. FoIJ.ovring thls, a comprelrcnslve Job descrlpbio4 must be drawn up flor each cadre lnvol-ved In the prlmary health care dellvery system. Only ln thls way can the varlous currlcula be gearcd to the Job descrlptlon whlch ln turn 1s geared to the communlty dlagnosls. Teachers: _ Tho next step consists of ttre selectlon of tcachers as personnel selected often rertrrrlre a reorlentatlon ln thls relatlvely new fleId. At thls stage the provlslon of teachcr-tralnlng and student-trainlng rnanuals and teachlng alds must also be consldered. It ls often sensible to use standarri texts whiclr have been modlfied to sult the country and condltlons concerned and these nray be translated lnto arl appropriate language. Students: Ihe sLudents may now be sel.ectcd. The lenglh of the course rnay vary wlth tlre ca<.lre concerned but normally an auxlliary course lasts two l,o three years and the students have reached the middle-school stanEFsuch as the IIEPC. (Paramedical ca<lres are usually requlred to have flnished secondary schoollng and reachc,l the 'O' Ievel grarte. ) In ttre case of vl}Iage level health aldes, courses should have no tlme limit, , each being geared to the pace of the lndlvidual. The prlnclpies of all tralning oourses are that the.y shall c<;nslst of tire mlnlnral comJraLil.rle vrlth safety, feaslbillt,y and effectlveness and Lhat they shal.J be approprlale. They shall also contaln a hlgh proportion of practlcal wgrk especlally ln a fleld situatlon. Qlqtulqry control: Throughout the foregolng process the requlslte moves will be lnitlated to secure a Ie[aI rccollnltlon of thc varlous cadres arrd the work they wttl be expected to do. This 1s facllltated by the establls}:mcnt of a licenclng procerlure and tlre malnl,cnance of llolllsbcrs of successful studcnts wlth a<idltlonal Ilcences and Reglsters lor any addltlonal skllls acqulred at a Iater stage. Tlre obtalnlng of a llccnce ancl entr.y lnto ttre Regi.ster should confer legal recoggrltlon and protectlon of ttic pnacLltloner provided an accepted standard of sklll ls employed and w11] also confer prctection cn the communlty. 7The eUIlliqry !n ttre !iel4: Tear:hers nnrst also concern thenrselves wlth tfre cadres' career prospects, work l'ac111tles and condltlons and wl1l perlodlcal Iy undertake a contlnulng assessment ln the fie Id in con. lunctlon wlth the cadres' lmmediate supervlsors. The teachers wlll also be concerned wlth the rec.ycling of past stuclents both as a means of refreshlng thelr knowle<lge and to lmprove thelr range of sklIls by teaching extra sk11Is. F\rnds for tralncrs and supervisors t In thls system of the dellvcry of prlmary health care the only two maJor cosLs are the capltal and recurrent costs of Lransport and the fundlng of teacher-tratnees and supervlsors. The provlders of primary health care ln the rural areas will be the provlders of sur:h care to sonre 8Q{ of the countryrs population and will also be responslbl e for the trainlng and supervlslon of the staff at a Ievel lower down l,he pyramid. It ls, thercfore, of cardinal lmporl,ance that both the teachcrs of tho tea<:Irer:; and the teac)rcrs of the varlous cadres be well verserl. It ls also of canllnal- impo rtance tlrat Lhe senlor medlcal and paramedlcal sl,aff who wiIl supervlze these auxlllary cadres should be well versed ln eomnnrnlty health servlces ). Gfrfctr fncludes the dellvery of health care There ls, therefore, a useful and vltal area for the provlslon of Fellowships to hhe senlor nredlcal and ;laramedical staff, the teaehers of, teachers ;rnd Lhe teachers of tralnees ln the OCP countrles. Such l.'el-l-ow- shlps should be botlr lnter-llcg lonaL and lnternatlonal and may also be lnter-A frl can. In thls conncct,lon one may mentlon the Master ln fnternational Comrmrnlty }Iealth degree open to doctors and non-physlclan staff at the School of Troplcal Medlclne of Llverpool Unlverslty as well as the new J-4 month coursc vrhtch ls presently betng formulated both for the teachers of paramecllcalsr/arr,xlLlarles and for the teachers of teachers ln tire developlng countries. 5. fndusLrlal health service: fn ttre OCP countrles somo tJA/, <;t t,he populallon }lve ln the t'ural areas an<l the maJorlty galn thelr llvelittood from agrlculture. Ttre maln thrrst of thc. devel<;pment prograrnnres in the onchocerclasls-controlled areas ls a1;rlcultural - crop-rais1ng, stock-rearlng am<l agro-industrles. Many of these pro.)ects rely on irrigatlon varylng from small lrrlgatlon proJects to maJor hydro-electric dams. Irrlgatlon, Ilke resettlement, presents conslderable health rlsks. Tlrese rlsks are not sufflclent to negate sucir projects, but are sufflclentJ.y serlous to warrant the necesslty of lncluding sufflcient funds 1n developmenb proJect.s t;o.lltlgate l,he health risks. It ls not morally rc:;ponslbl.e for a pro,JccL to create health risks and to dlsclalm alI rcsponslblllty - as 1s presently being done in some maJor projects. IJ A8rlculture is an lndustry an<i r,lt9\4Sl !e ro regarded. An lndustrial heal-th servicc should be createrL towards the agricultural sector ft!9rtli" shouLd be largely orientated The Ia.ke Volta Authorlty ls an example of an ldeal medlcal structure bul'lt lnto a major proJect. Ilor.rcver lt ls a large departmenb and has been built up over a period of tlme. On the other hand the AW ls an Authority wlth a simllar functlon to that of the LVA but lt has no medlcal departnrent, although lts plannln6 and infrastructure approach to resettlement may well be superior to that of the Lake Volta Authorlty .Judglng by the percentage. of resettled vlllagers wholater leave ttre resettlemenb areas. 'fhe AW shoulcl have a medlcal departmont and such a department and that of the LVA can become tlre nucleus of an lndustrlal health service. Wlth lrrlgatlon and resettlement pro.iects a constant vlgllence ls necessary, an cpldemiolollical survelllance. Settlers must be examlned fuIIy before thcy leave thelr home areas so that actlve cases of comrmrnlcable dlsease, be lt draconlasls or tubercuLosls, can be ldentlflcd and l;reated so that bhey wlll not be lntrcxluced lnto the resettlement areas. fn the receptlon areas the vlllagers wlll face new health hazards either from new vectors or from populatlon concentraLlon. The agrlculturallst and agro-lndustrial worker wlll also face new lrazards such as tirose from pesticldes, cirenrlcals and accidents from rnachlnery, and tlrese rmrst be guarded a6ainst - the. duty of an lndustrlal health servlce and epldemlologlcal survelllance team. 7. Spontaneous nrlgratlon: Tlte health problems of the spontaneous, as <-rpposed to 'dlrected', mlgrant must be accepterl . Nc.rt only rvill many of these mlgrate lnto area.; arlJacent to officlal resetblement areas, but tireir needs wlII be conslderably greater. Thcy wlll thus act as a health thrcat to the offlclal mlgrants. Official resettlement areas are only chosen after cardful arrd prolonged surveys sirow that the land is productlve and water is avatlable, ebc. The unofflclal migrant (who must be conslderably m<-,re mol"lvated than thc offlclal mlgrant as he mlgrates wltlrout the AWs lnducements) will not have those benefits. Ihe famllles may well mlgratc lnto un:;ultable areas and rviL] suffer from malnutrltlon so tfrat, Lhere will be an augmerrt,ablon of communicable dlseases whI.:h can spread to the offlclal mlgrants, in adJacent area-s, markets, etc. Ihey are a prlorlty grouJr for mlgrate and after they settle. 'dlsease cleanslng' both before they 9B. I,'cma1e Iimanc.ipaLlott : The majorlty of the developmcnt programmes ln the OCP areas are deslgned for tire scrclo-economlc improvement of the rural populatlon and at a later stalie wiII aid tlre nattonal economy by augmentlng the export marl<et and reduclng Lhe lmport market. I-lowever, they are heavlly blasecl towar<ls lnrproving socio-economic clrcumstances of the males and there ls llttle eonsideratlon of the females. The educptl,rBq{ opportunlties ol the females should be greatly lmprovecl\cL'L) /, agrlcultural extenslon services and crecilt facilltles shoulcl be avallable to tlrem a.s well as to the men. Speclflc approprlate teclmology programmos should be devlsed to llghten the women's present burden of housework - the plantlng of firewood groves and the provlslon of a safe, clean water supply near the vlllages; small mills to replace the dally back-breaking pounding of flour, etc. T'ire vromcn's lerqal posltlon should also be ]ooked lnto as tneYfg1l ofterr cliscrlmlnatcd agalnst botlr ln customary ernd enactecl law\'' 9. Concernlng the Progranrme at Ouagadougou: Ilre post of PublIc llealth/Communlty Medlclne Officer remains unfllled. There ls a vasl, amounL of documentation avallable wirich must be read and the appropriate materlal collated by this Officer. At present such lnformatlon is not rearilly avallable so that sl-rort-term consultants spend a p5reat deal of the llttle tlme at tirelr disposal attemptlng to collate such materlal as a baslc framework. Such an Officer, when appointed, shorrld work very c),oseIy wlth bottr the llpldemlologlcal Evaluatlon and Economlc Development Unlts as the tlrree units have a great deal ln common and thelr work-and lnvestigatlons are mutually supportlve. It ls neee:';sary to obtai.n a great, deal of background lnformatlon on the @P countrles ln order tc, brril<1 up a compfete medico-denrographlcpicture of tlre area, including <letalls of all lrealth trainlng pnogrammes, cllsLrlbutlon of stafl' anr-l facilltics, etc. Mucl-r of ttre rerluired information ls not avalLab.l e ouLslde thc Mlnistrles of Lhe countrles concerneci arxl r:rur bcst bc obtalnecL i>.y natlonals who have access to thelr Minlr;trles as weLl as a conslderable experlence of thelr own coun brles . Such lnfornrat,ion is best ccrllectr:ti b.y a nrrnrber of wori.,shqp-seminarq at whlch the lnforrnatlon frorn tlre vanlous countrlcs will be presented as posltlon papcirs. Onec thls baslc background lrrformatl<;n has been collated by tlre PubLlc llealth Officer at Ouagadougou, furtirer workshop- semlnars coul.d be held vrlth t,ire varlous Universlty Departments of Comrmrnlty ilealtlr and Ministry representatlves so thab ongoinl and past pro.Jects coulcl bc evaluated (one learns as muclr from fallures as from successes ) and future projects acceptable to. the varlorrs countrles could be fornulated. 1() Some of the requlred lnformatlon wlll not be avalLable but coutd be obtalned by tlte creatlon of treaLbir sentinel posts wtrich would not only act as valuable data collectlon points but would a)-so act as an epldemlologlcal survelllance unlt - lncludlng the requislte onchocerclasls survelllance whlch wlll be necessary 1n the onchocerclasls-controlled areas. These health sentlner posts would be provlded by the addltlon lwo extra rooms to the standarri Rural Health Centre, one as a laboratory and the ot,her as an offlce for the auxlliary epidemiological survelllanceperson. This person would be an aux1llary Medical Asslstant or communlcable disease auxlliary who has recelved furilrer tralnlng. Part of the work of survelllance. wlII conslst of the recordlng of vltal data and part F.M. Sltattock. , TN :<L) -( t-. nFi ii(n tJ f'r I a .a r{ [1() !:: E< Ff t: lir F] Er Ir i1 i,l L-l f,l ni C) Ir}J .::i! )r a', ,.,i: t.: JI, n t': I L7 1' l: ,lilIrttt o tr l)r AT:O<)tr .,{ .l-) I )r: n,c,P o ."t t;o(l, a() r,l() r{() rJ .e t | ',d r:(rl c.l 1i r-l ,l ,() o(; ,t(.) .. 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'd elc) (t r ?j 'ii I .-t 3tt l'i i; I r ';;:l t () f.{i i: o I (;\ rn & 1\ 1,, l) () A. rl() L: .1J F: c', an .(-: ,P -1 rJ c) TJ JL l-r i) (? t ,,O . a. .. ... a a . .. . o o t ct-:b, a a a. . , .+l a ii.ti -.6) "-\lr'1 "(.) ; orl F: -4O[< c) t4 .J O.(no C)Olr.' t'J r -1.f{()(J()l H ()' {) .{ii -r () 11[-r c, r',r i)ln o it..tHFI{r,dA @a t E,i, ..) ?rt\ ir\ rf \ .- ,- .:)\i) ..' C) r:; -u' r? rp .c) o-) c{ Li\ OJ , e > (., C -,{-'rl) ''o :rl !,! 1l rl -Ll t)cri ct.I ) t-- -- tr\ '\.) .JR: .P ., l ,-1 ?.1 rl ,.1 ,() ot: c, t: +-' I r.l rl ;tlrr t.t f.t- ()t1 .-lC) t,t-r rl ..tt1 ,)l: c,qt ltti 0, ..t trl z1IlP't c, .,t a1 ct '-l13r r I ; t () -t ti(J ..{( '.1 It r,j -"|CtrJ tr +, it ..1 :1 l-)r ()('J o(Jr{ x, aJ .9 I Y rl() .rl il 6) .1 "o ...(, ) tf L]i-j .(.' /.'.1 i t :'.-^.t. -r ,t) ;J -.\ ri\ -) ,v :) C) tt rl\ \r:\., 1. -r .) ,C, .J tr c: +, U' I . r) ,-:. " )O r',(t r ILl\ \ ? aaaaaaaaaaaa lrI !...,i aRURAI, I{EAI.,Tl] CIIMIII]|. .'JTANDARD .I WTTIi ADDITION OiI IMALTII .SENTINNI, POST ?5'6" [J' 1]'6rt 15'6" :-5, 6" L7'6" t5'6u ;) lJ n{ L q) +)d 2 bed ward L5'.6n L o.Pd ti o .o s rddl(4 trooLO.ou, Pt{OA +) .rf,d+rout rl ..{ ,d U, oq,E< () , .r{ d11 r-{ +.1 rJ r-1J1 c.rO UI 0)A oq-i I ao llr "1 L..r dE "'{ .r{oo .{d > or{ .r{t{()X a,a c JIrIodd .>, ooL ..{odCto.1drd-rE Or{E(/,xo.Aa()1J.d Stone or cement blocks Concrete floor Tlled roof Plaster internal- walls 'lclotex celling Stee1 wlndows Ralnwater gutters and storage tanks ELectric 11Bht if posslble (HonAa Benerator)Walting andhealth educat- 1on 15'6tt 15'6tt Modelled on Vlhiga Health Centre, Kenya (Fendatl, N.R.E., Rural IJeaIth Ccntres 1n North Nyanza Distrlct of Kenya. J.Trop.med.llyg. , L955, 58t6/7, 12J) wlth additlon of Health Sentlnel Post. Populatlon serverl: 25, OO0 Staff: Auxlllary nurse-lnldwlfe or ar.rxlllary mldwlfe Me<llca} asslst,ant Comrm-micablc dlseases auxillary Cleaner/ at tencl ant DrIver/mechanlc ffunetlon: To act as the Subcentre for a population of B,O@ and as the referral polnt for 2-) subcentres. To hold moblle subclinlcs; to srrpervize the 2-J statlc subcentres. To provlde prlmary health care - PIv[, family health, dlagnosis and treatment of l.he more common dlseases, control of comnunlcable diseases, health cducat,Ion. Supervlslon! By Dlstrlct llospltal staff (tlre II.C.'s referralpolnt) a.nd the DlsLrlct Medical- Offlcer and team. Tfeln!1g period: The three auxlllarles - ] years after lovrer middle schooL (enPc). Baslc Ilcalth Centre Capltal Costs: (I US $ = 24JIr CI.'A) F CFA US$ Tralnlng: J staff at tO5,OOOIr CFArlyear/personfor I years .) Iti5.Zm': at 50,ooolr cFA/n' J llabltat-type aL )54,OOOIT ClrA each(cleaner & drlver llve In adJacent vlllage ) Bullding: Staff houslnl;: g45, ooo 9,285 , OOO r, 062,ooo ) '8"3978,?LO 4,77o aIiquipment: I Peugeot Camlco scootcr (lf suttable for tracks) I Toyota stallon waggon (ambulance + subcllnlcs) Bore-hole well F CFA 97,OAO 106,o00 J,4oo,ooo 72,900 US$ )99 D6 L),992 )00 TOTAL CAPITAL: ilt,96T ,9oo 6t,59t1 .II{E SUI]C],INTC Llvlng Covered over-walttng area )n )n PopuJ.atlon served: About B,OOO Stal'f : Functlon: Supcrvlslon: Tralning: B_ulldlng: Auxlllary nurse-midwlfe or auxlliary mldwlfe Maternal and chlld healtl'r; fanrily health; first ald; elementary dlagnosls and treatment wit,tr simple medlclnesl health educatlonl supervlsion of vlllage health aldes. 1. By Rural Ilealt;ir Centne staff. 2. by Dlstrlct Medical Offlcer and irls team. F CTA US$ rs Cl1nl c Ti'alrrlng pcrlcxl z ) years afl,er Lower nriddle schoo] (BEPC) qqp&ql qorlq: (r us $ = z47n cnn) for.-) years at lO5,OOOF CFAr/year =?fmi basic at )O,COOF Ct"lt/ni' 9n,'' covercd 25, OOO Total, bullding 1L5,OOO) ,2JO ,(t{\r't 225,000 L,575,OOO 2t+,100 ijo, ooo 52(t,(hO 89,4zo J+86,<.loo t2,l5o 52,rOO 20,8()O L,296 6 ,4Bt roo 2,167 168 Thls lncludes staff quarters Equlpment: Transport - 1 Peugeot CT scooter TOTAT, CAPITAL: Ilecurrent costs: Staff, medlarr salary Add overtime Pr soclal- securlty, )7'/' Drugs and dressings ab $o.z')/p.c., for 8.oCD Petrol & repatrs at $O.Ot/kn for 5,(frokm/year Depreclation: Rui.ldlng over JO yeaps Equlpment ,t vehlcle over 5 years fi)TAL ruiCURnEM'/YEAn )29 L,gg4 )oo 8,eo5 2,0o0 50 2L6 86 I , r{J6,9 ,o lt ,8[]4 Note: The caplbal costs wlII br: considerably reduced by tlre vlllagers bulldlng Lhe accommoclatlon and clinic and using loca] materials. aF CITA r,o5),24o L79,O5t toz,767 2t+,100 48,600 945, ooo l,062,ooo 2 ,70O,0O0 48, f)OO US$ \,)r4 717 t Ilecurrent costs: Salary of 2 auxillarles, nretilan 'j?-6,6i1ott CIIA p.a. ^(ld, 2f, overtlne + l5'fr soclaL sccurlty Depreclatlon ol two staff houses ,% two extra Health Cent,re rooms, over JO Years Laboratory equtpment over 5 years Chemlcals, eLc. for laboratory estlmated at TCTfAL RIfURRF]}IT Costlng of moblle unlt: Capltql_qqs,!s: Tralnln8 foe ) tor ) years at lo5,oooF cFA at 1')4,oooF' CFA eachStaff houslnq, 1'Habitat' VehlcIe, I U,, Comblbus Equlpment TOTAL CAPITAI, Recurrent cos1,s: Staff: Mr:<llan salar.y ,fon auxlLiary nurse- mldwlfe; mcdlcal asslstant; commrtnl- cable dlseases auxlIlary aL 526,620 cach Drlver/mechanic medlan salary Overtlme & soclal securlty at L7fr Drugs and rjrcssings at $0.?5 p.a. for [J,0O0 Statlc subcllnlc llealth Centre, basLc wtth full-tlme moblle ADD wlth llealth Sentincl Post ADI) 421 100 I ,4A7 ,95',8 5,794 200 ),BB9 4,17o 11, r11 200 )+ ,755,600 tg ,57O L,579,860 278,868 4U6,000 8or,9oo )\4,400 5\9,720 6,50L 1, r4B 2,O00 ),100 146 2,262 )L5,gB4 t,)oo I Pebr<;l and rt-'J;alrs ab tO.t7Z/Xn for 25,CDOkm/yr:ar DcpneclaLlort: Ijulldlngs over JO years Vehlcte & equlpment ovcr ! years TOTAL ITECUIU ilit{t/YEAIt 4,)66,71?. t6,657 As wlth a}} other unlts tlre bulld1ng costs, and therefore tlte depreclatlon as wel1, could be conslderably reduced by ustng local materials and village self-he1p buildlng. SUMIV1AIIY: Capttal, US $ Recurrent US $ B,zo5 61,'t95 t9,570 t5,781 ,+, BB4 28,rgg L6,657 5,794 +t Basic llealth -Cenbre: TI CFA US$ Recurrent costs: Staff, annual medlan salary: Nul'r;e-mldwlfe auxlliary 526,6?-0 2 MeclicaL asslstant " 526,620 2Conun.<llseases " 526,620 2Cleaner/attendant 277,n2 IDriver/mechanlc 278,868 I Add 2'i overtlme . and. l5'fr soclal securlty Staff salarlcs and emoluments: Drugs and drcsslngs estlmated at $I .p.c. for 4?,7?-t t76 2 ,L78,78t 8,966 lO,OOO 2,4)O,OOO 10,000 Vehlcle running costsl 'I Y{ L67 L67 L67 141 148 Toyota statlon waggon: $O.l)2/kn lior ?-J,OOOkm/yr Peu8eot Camlco estlmated at $O.O5/km for 1O,O@km/yr 8o1,9oo 121,500 ,o9,000 I ,0ro,7oo ,,100 500 1,27t1 4,t59 Depreclatlon: BulIdlngs over )O years Equlprnent and vehlcles over I years TOTAL TU]CUHRIaNT/YrIAR 6,85t,88t zB,t99 'Ilre builrtlng caplt,al cosl,s can be reduce<i l>y uslng loca} materlal-s and self-help bulJdlng by the vlllagers. The Toyota statlon waggon (ambulance & moblle subcentres) and the Peugeob Camlco scooter may not be sultabte ln all condltlons. fn some areas a WI comblbus could be used, savlng a capltal of O.7 miIIlon I.'CFA, Ln oLhers a Cour-wheel drlve vehicle may be nccessary requlring an lncreased capltal expendlture of some 1.J mtlllon F CFA. All capl bal and recurrent fl55ures are based on Upper VoIta. In Ghana, sLaff are somewhat more expenslve but bulldlng'ls somewhat cheaper'. Tralnin6 cosLs are not normal.ly lnclude<l under capltal expenditure - but slrould be as all too ofben }rospitals and llealth Centres are l>ullt wlblrorrt havlng Ltre st,aff to man them. Including thelr tralnlng as a capltal ltem vroul"d ensure the required finance for trainlng them. Ward paLlents would have tlreir food provlded by rel-atlves who would cook lt. Extra cost for tho addltlon of thc llealth Sentinel- Post,unlL: Notes: Capltal: Z c T\^ro exbra room:i, botal 47.5*" at 5O,OOOF CFA/m' 2,)75,@0 Tralnlng 2 exLra auxlllary staff J ycars cach 610,000 T\ro e.xtra staff Ilabitat-type houses aL )54,Ooo each 708,OOO Iaborabory equlpment, etc. 12I,500 9,77)+ 2,59) ?,914 5oo TO4AL CAPITAL: ) ,tJ)tt ,5oo 15,781