Primary health care [full issue]

PRIMARY HEALTH CARE PRIMARY HEALTH CARE Photo A lex Volkoff Design Peter Davies Contents Helping people help themselves by K. W. Newel I . 3 Tanzania: The way forward by 0 . Gish . . . . . . . 8 Cuba : Revolution in health by E. Liisberg and I. Tabibzadeh 14 Iran: House of health by R. Repond 20 Indonesia : Starting from scratch by G. Nugroho 26 Young World Health 30 World Health appears in Arabic. English. French. German. Italian. Per- sian. Portuguese. Russian and Spanish . Articles and photographs not copy- righted may be reprodu ced provided credi t is given to the World Hea lth Organization . Signed articles do not necessari ly reflect WHO's views. World Health . WHO. Avenue Appia . 121 1 Geneva 27 . Switzerland. Poverty with its implications of under- nutrition , crowding and ill-health nar- rows the opportunities of human devel- opment . It is essential to involve the un- derprivileged population in improving their own standard of living and their health. (Photo WHO ) 2 helping people help themselves There is no single world solution to the problems of rural health. People must be asked what they need rather than having solutions imposed on them BY KENNETH W. NEWELL v:ery few of us in industrial countries have ever known what it is like to live in a village in the developing world. Therefore, it is not strange if we fail to understand the problems or if we propose unworkable or ineffective solutions. The developing world is wide and covers the humid tropics as well as the slopes of temperate mountains. A stark mountain village in the Andes, some round huts among scattered brushwood south of the Sahara, a group of houses in the dust of an Jndian plain, or a glimpse of people through the lush greenness of Java are so dissimilar in appearance that one does not associate them with a common problem. Yet there are similarities as well as differences and if one examines these the picture which emerges is one of quiet sorrow and helpless- ness rather than of emergency or dire tragedy. One inside view of a composite of some of these developing villages could be the fol- lowing. A man and his wife are se<J,ted on the floor of their house made out of sticks, mud or leaves. It is dark except for the light slant- ing through the open doorway and it is hard to see clearly because of the smoke curling up from the smouldering embers of the cooking fire . Grandmother crouches in the corner shadows and two children scramble quietly on the floor while a baby on the mother' s hip periodically suckles a half-empty breast. The only meal of the day is finished and all know that there is no more until tomorrow. It is clearly insufficient if judged by the feeling in each belly and has been insufficient for some time if one observes the obvious signs of under-nutrition typified by the lack of growth in the children, the visible ribs, lack- lustre hair or the dull eyes. There is food stored in the roof and in the storage jar but this must be made to last until the next harvest. The family has land but it is only a little piece quite a long way away. It can bear few crops because it is poor land with no water except during the rain season. The farmer uses no fertilizer because he has no money and because no clear reason has been given for him to use it. He sits with his family rather than work because his crop is already planted and weeded and there is no work for him to do in a village made up of farmers like himself. Possibly he could go to the city or to one of the big estates and earn money, leav- ing his family to farm his little plot, but this is frightening as it could end in failure or disas- ter if he did not find a job. It would mean that he would be separated from his family for a long time. They do not want him to go. The young woman who is the wife and mother must get up and fetch the water con- tainer and spend the daily hour going to the river to carry water for the family. This is not difficult but it is time consuming. Because it does take time, water is husbanded carefully in the house and is only used for drinking and cooking. On the other hand, to the wom- an this trip has some advantages, if the prop- er time is chosen, because she will have the chance to chat and laugh with the other women of the village on the way. A fourth child has been coughing during the past week and now lies quietly by him- self. He will not eat and appears to have a fever. His parents are worried about him and could take him to the Government Clinic, ten kilometres away near the market, but it would take all day. If they did, they would need to start early because there might be a queue of people waiting if it was one of the days that the doctor was there. If he was, they could expect a half minute of questions in a crowded room by the strange city man who speaks in a different, brusque way and who does not seem to listen. It might cost them a chicken and their boy might get some pills, medicine or an injection. They took grandmother to the clinic once because of 3 her eyes but they did not get better and now she is nearly blind. They do not go . The next day the child dies. Such a picture is not of earthquake, flood or famine. It is a different type of drama; a family disaster with a built-in inevitability; a low-key event which one can see will be repeated and repeated unless some radical change of direction is initiated. One must remind oneself that this is the " inside" ap- pearance of the rural 80 per cent of the deve- loping world which itself is the majority of the world's population. If one looks in through the door of the same family from the "outside" it looks different. As one tenderly examines the body of the dead child one sees that he is small for his age and underweight. He is clearly a survivor of an earlier malaria infection and carries a full load of intestinal parasites gathered from the infected water and ground, and from the dust of his house. He has not been protected from the usual infections by immunization ; and while he may have had in his final illness a disease such as diphtheria it is more probable that he' had a common respiratory infection which we would call 'flu, and then pneumonia. If such a thing had happened to a child in the house of an urban, middle-class family , he might have had to stay away from school for two to three days and have a day in bed. But this child is dead. It is possible for the outsider looking in to be indignant when he asks why this child has 4 died. This boy who had what we would call a minor infection has had a mortal illness because of lack of food, lack of knowledge, lack of health care, lack of attention , but not from lack of love. There is food in the house, but not enough of it has reached the child throughout his life for him to cope with growth and the health hazards which all of us must pass through. There is a health service only ten kilometres away but the parents have not taken him there. Only one of the reasons for this is money, because the family does have a chicken which could be used for payment, but this is being saved for the next festival day. Whichever way we look into this village or this particular family it is clear that something is wrong. This boy has died for stupid reasons. But if they are stupid , let us look at what would be the usual solutions for the health services of many countries. On the proper grounds that our indicator family was unin- formed about health and nutrition, a special- ly trained health educator with at least a high school and possibly a college education could be assigned to the wider district of one to two hundred thousand people. This urban specialist who may never have lived in a vil- lage might make special materials available to the doctor or the nurse in the village, and might ensure that posters advocating eggs, meat and beans as essential dietary items were available on a village wall. He or she might advise the boiling of water, the wash- ing of hands before eating or the safe disposal of garbage or faeces. Even if the reasons for these messages were understood, they are un- likely to be acted upon . In our observed fam- ily, chickens are one of the few sources of cash income and are rarely used for food. There is no water in the house for washing, nor soap; and garbage is almost an unheard of commodity since everything available is eaten. Perhaps the lack of food in this village may be understood by the authorities, and a sup- plementary feeding programme may be orga- nized using food from donor countries. But is this a real solution? Even with the best of programmes it is not possible to plan for such food distributions to continue for ever, and this food shortage is not due to sudden famine but is a continuing shortage with periodic seasonal peaks. Even in the short term it is difficult to organize a method of preferential food distribution to the children of the village as there is no clinic there. The children cannot travel ten kilometres to the clinic each day, and food given to families is eaten according to family and not pro- gramme priorities. It may go to the pregnant wife or the wage earner rather than to an ailing child . One solution to one problem may be the digging of a well in the village or the provi- sion of a piped water supply which gives sufficient safe drinking and washing water. Opposite page: The drudgery of the water hole, a major occupation of African women. Pro viding safe, sufficient and accessible water is a priority in many developing countries but is difficult without a community organization . ( Photo WHO/P. Almasy) Above: Granaries near a village in the Ouaga- dougou area. Most people in the developing world live from farming. Better agricultural methods and land use mean a better standard of living and better health . (Photo WHO/ P.A . Pittet ) Left: This woman suffers from enteric disease and has already lost one baby. Illness and death may be the result of infection but simple curative actions alone cannot solve the prob- lem. ( Photo WHO/ P. Larsen) But if this is provided , by a benevolent government, who will service the pump or pay for the up-keep of the pipe, since there are no means of collecting payment for water and there is no village organization? Such a supply will not increase the resources of the village. It could be said that what is wrong is that the basic health service is deficient even though this village is already "covered" by the health services, in that it has a clinic within ten kilometres. But if a clinic was built five kilometres away and it was staffed by a doctor and a nurse, and if it was free , are we confident that this boy would not have died? It seems unlikely. The "care" needed would have to be deeper than that based upon an examination and an injection- however ex- pert- and these deeper ills are outside the competence or interest of health personnel made up of city strangers ordered to the area by government decree , or enticed there by bonuses in cash or in kind. The boy died of pneumonia, yet this was but an episode in a life-long slide towards death which started at his birth and which might be postponed but not prevented by such a service. 5 These "usual" solutions have purposely been presented in their worst light. But even if they had been described more optimistical- ly they are not necessarily relevant because they are rarely applied on a wide scale. The economic realities of villages in developing countries are such that services and support- ing facilities like these cost at least US$5 to I 0 per person per year, while the annual fam- ily income may be less than US$100. Many countries have a government health budget of less than US$1 per head per year for all serv1ces. The problems of the boy are clear. The present solutions are questionable technical- ly and may be impracticable politically and economically. It seems likely that the boy we have observed, and the millions like him in the world's developing belt, will die- if not on a certain day then on some other day, week or month- unless we can propose a quite different set of actions. This dilemma has been called " rural un- derdevelopment" and it is widely accepted- at least philosophically- that " rural health underdevelopment" is a component part. It is a dilemma which has faced the world for a long time, and while the problems involved appear intractable, they are not insoluble. Some people, areas and countries have faced them directly and there are living, continuing examples of successes which can be seen and experienced now. Some of them are present- ed in this issue of World Health, and in " Health by the People", a recent WHO publi- cation dealing in detail with this theme. Many of these successes appear to have some common qualities. There are two cor- nerstone ideas upon which actions are based. The first is that people must be asked what they want or need rather than having priori- ties or solutions forced upon them. If one does ask the question as to what a village wants and the reasons why it does not have it, the answer is frequently simple, well known to the villagers, and does not require the specialized analysis of economists, sociol- ogists, ecologists or epidemiologists. A typi- cal reply starts with a clear statement that the village is poor and there is not enough land, water or technical skill to produce even sur- vival food for the inhabitants and certainly not enough productive capacity for needed development work. It may be that the village lies in a fringe area where there is little long- term potential. It is an unsuitable place for people to live and eventually some or all of the inhabitants will need to move and the land will be converted back to pasture land or forest. But this is only a small fraction of the rural world, and the vast majority is dif- ferent. In this larger fraction one can observe with surprise that often the poorer areas are the ones which use the least efficient produc- tion methods, where there is the greatest This woman is in need of help. But can she feel confident about the advice she is given in the strange surroundings of a "model" health centre ? (Photo WHO/E. Schwa/e) waste of land, and where there is the greatest misuse of the human and physical resources. The people understand this but appear locked into a situation where they do not know how to start to improve. This is the point of hope because there is an awareness of the problem, a potential for change, and a local will to be harnessed. The second idea is that many of the prob- lems of these rural villages are of a nature which are insoluble by individuals but require the combined efforts of many or most of the inhabitants. If this is true then there is a need not only for agreement upon the problems and the solutions within the village, but also for a village organization which can harness the village resources and direct their expressions into action. This is a more difficult idea to reach agreement upon and to promote. In most villages there is some organization. It may be a person identi- fied as the spokesman of the district or national administration; it may be a tribal structure; or it may be no more than a re- spectful deference to the elders or to a wise rrian or woman. But this structure may not be the type of organization in which the vil- lage is willing to put its trust. It may be the reverse and be considered as a reactionary or distrusted expression of the past or an im- posed will from outside. It is possible in many areas to encourage the formation of a village organization which has real authority from the village itself and which can be the mechanism of action, whether it is called a village committee or some other name. These two ideas may seem to be many steps away from and of doubtful relevance to health, or to the dead boy of our example. This is not the case. The boy's death was not due to a lack of penicillin but was an expres- sion of ill-health in that family and that vil- lage. In health matters we must jump from the idea that malnourished children need food to the conviction that healthy villages are those which ensure that children are fed . In the examples already observed, health as we know it has not been one of the initial priority concerns of the village people, but land, production, and alternative sources of food and income have. When a village organ- ization has been formed and has started the first simple steps to harness the combined talents of the people and the wider resources of the land, the impact has first been seen as an increase in food and income. This alone, without any specific health service orientated actions, has resulted in a decrease in death rates in infants and young children, and an improvement in the level of health in the community. The change from a village tott- ering on the edge of survival to one on the poverty line, is an improvement which ap- pears to result in a different social as well as a different economic situation. Such a village can afford to think of its priorities once again, and with a new sense of pride and dignity can consider how its newly accepted mechanisms for action can be used for other purposes. What comes out of this second or later village appraisal has varied, but often health and education appear as talking points for action. However, when health is the big issue it rarely takes the form of basic health ser- vices as we at present know them. The local expression of need may result in a children 's feeding programme using produce from new village, school, or family gardens ; it may be the harnessing of village labour to dig a well or pipe water from the river under the au- thority and administration of the village committee ; it may be an arrangement lead- ing to an increased availability of vaccines or drugs at the village shop or from the tradi- tional midwife or healer. Sometimes this complex of health needs and tasks is forma- lized by a village health subcommittee into an accepted health role for one or more vil- lage members, who are entrusted to organize or be responsible for these tasks as volun- teers, by fee for service, or by community or other payment. These village health workers or primary health care workers may be selected, ap- pointed, administered members of the vil- lage. From an educational base which may be bare literacy and three to four months local training, they can undertake all the above tasks plus primary health care for common illnesses and family planning. They are not what we are used to calling health workers, but they have proved able to deal with 85 per cent of the health needs of a village. From this base they practise what they know, but to survive and to continue working effective- ly they need support, understanding and a continuing practical education directed towards the problems they must continuous- ly face. For this they need a firm link not A health worker seeking the village wise man 's advice. Maintaining a viable village organiza- tion often means paying due respect to the experience of the elders. (Photo WHO/E. Schwa/e) only with the more highly trained health workers and facilities outside the village but within the district. They also need support from other helpers, and supporters in educa- tion and agriculture who can be a source of knowledge, equipment and supplies which can be used by village people to help them- selves. It is not possible to point to one system, with one class of worker, with one set list of tasks, within one clearly described organiza- tional base as the solution to all rural devel- opment problems. The solution must vary according to the type of village, the sort of people who live there , the type of govern- ment, and the range of hazards which need to be faced. There is no single world solution, but the principles for change appear general. The boy from our village family did not die because he did not have enough food, medicine or a loving family . He was a victim of our lack of understanding of the way in which people organize their lives and of our weakness when we attempt to face other peo- ple's problems individually or try to DO things TO people. Today's question is not what we should do, but whether we have sufficient humility to use our own resources to help people help themselves and let them take the credit. • 7 the way forward Offers of a big new hospital might be tempting- but Tanzania gives top priority to making basic health services available to all of its citizens Tanzania haS been designated by the Uni.ted Nations as one of the world 's " 25 poorest" countries. Its poverty stems from a history described by President Julius K. Nyerere as one in which " We (Tanzanians) have been oppressed a great deal , we have been exploited a great deal and we have been disregarded a great deal. " With the coming of independence in I 961 it became possible for the first time for the country to take hold of its own future. The history of health ser- vice development in Tanzania is not unlike that of the rest of Africa, and much of the rest of the Third World . Initially it consisted of scattered, partial and uncoordinated ef- forts aimed primarily at creating curative ser- vices for the country's urban minority. Al- though the country was dotted with "dispen- saries", these were generally manned by ill- equipped staff only capable of dispensing pharmaceutical palliatives- when these were available. Medical facilities and staff were not only extremely limited in number, but they were not distributed in keeping with the spread of population . Thus the ratio of hos- pital beds per head of population ranged be- tween 1:400 and I: 3,500 in different dis- tricts . Access to health care facilities also varied widely between districts, and so did the use made of them. Annual expenditure on health care averaged 18 Tanzanian shill- ings per head, but varied from 90 shillings in the capital, Oar es Salaam, down to two shillings in some rural areas (seven shill- ings = one dollar US) . As in mosi of the developing countries, the major causes of morbidity and mortality are infectious and parasitic diseases, which are made more serious by a generally low stan- dard of nutrition . All told , poverty-linked diseases account for about three-quarters of all deaths, while the diseases common in af- fluent countries, such as heart disease, are relatively unimportant. The birth rate is esti- 8 BY OSCAR GISH mated at 47 per 1,000 and the crude death rate at 22 per 1 ,000. Infant mortality is thought to be of an order of I 60-165 per 1,000 and expectation of life at birth is only 40 to 45 years. Today there is a fresh emphasis on the need for more rapid rural development. The impetus for this was given at the 1971 bien- nial conference of the national political party TANZANIA IN FIGURES Popu lat ion (total ) (urban ) (rural) Ann ual rate of po pula- t ion increase Cru de birth ra te (per 1000) Cru de death ra te (per 1000) Life expectancy at birth Infant mortality per 1000 live births Population under 15 years Popu lat ion per physicia n Populati on per profes - sio nal nurse GN P per cap ita Heal t h budget as a per- centage of t he to tal budget 13800 000 (73) < 10% (73) > 90% (73) 2.7% (73) 47.0 (73) 220 (73) 40 -45 years (73 ) 160-165 (67) about 50% (73) 2793 5 (73 ) 14919 (73) US$89 (70) 5. 1 (72) Sources : W HO. UN. World Bank. TANU (the Tanganyika African National Union) , when it was resolved that " from now on, the vital needs for water, schools and health shall be given priority in our expendi- tures". The ministries responsible for these services were instructed to move into action at once, and the Ministry of Health was or- dered to translate the Party's decision into specific planning actions . The essence of the problem was to spread the very limited volume of resources avail- able for health care in keeping with the needs of the entire population. This strategy recog- nized the fact the great bulk of illnesses en- countered in countries like Tanzania can be readily prevented and, when need be, easily treated . The techniques required are relatively simple and inexpensive, and depend primar- ily on auxiliary-type personnel for their appli- cation . Tanzania had always placed great stress on the importance of disease prevention, yet in spite of some significant successes this critical area of its health work had achieved only nominal gains. Now the Ministry of Health was reorganized so as to include a Director- ate of Preventive Services (the others are Manpower Development, and Curative Ser- vices), and expenditure on specific preventive programmes has since shown a marked in- crease. However the most dramatic development in Tanzania is the provision of comprehen- sive care through the rural health infrastruc- ture, which combines preventive health cam- paigns with health promoting activities. The actual planning process began with a calculation of the size of the expected recur- rent budget for health in the year 1980 (the end of the next five-year plan). This figure was accepted as the major constraint, along with manpower availability, on the develop- ment of new health programmes and facili- ties during the intervening years . Allowance A village medical helper providing first aid in the Kidomele ujamaa village. Village medical helpers are selected by their fellow villagers. (Photo WHO/D . Henrioud)

was made for additional resources that would become available from non-govern- mental sources, primarily the voluntary ag- encies and external aid bodies. The precise number of new rural and other health units to be constructed was determined within a political perspective that demanded increas- ing equality of access to health facilities for all the population. It was clear that hospital expansion would have to be sharply curtailed if the health ministry was to live within its expected 1980 budget. It was necessary to restrict the in- crease in the number of hospital beds to the growth rate of population; that is, freezing the bed/population ratio at the existing aver- age level of approximately l :750. The rapid expansion of small rural units and the limited increase in the number of hospital beds called for a manpower plan that would pro- vide for a very large "output" of auxiliary workers and a comparatively smaller com- plement of professionals. At the heart of Tanzania's rural health planning are the "ujamaa villages", rural developments whose members join in com- munal farming and social improvements on a basis of "love, sharing and work". Ujamaa, which means familyhood in Swahili, denotes the special obligations required in extended family relationships. About three million people, almost one quarter of the rural in- habitants, are now living in these villages, and it is intended that the entire rural popu- lation will have "gone ujamaa" by next year. The two main objectives behind this policy are: grouping of families geographically to 10 make it easier for the government to provide such essential services as adequate and wholesome water supplies, education and basic health services ; and to raise the pro- ductivity of the villages so as to combat more effectively the vicious cycle of poverty, ignor- ance and disease. Thus the ujamaa village policy indirectly contributes to the general betterment of the nation's health. The ujamaa concept is closely bound up with Tanzania's avowed aims of socialism and self-reliance. The Arusha Declaration of 1967, TA NU's basic policy statement, defined the path of socialist development as : the ab- sence of exploitation; retaining the major means of production and exchange within the control of peasants and workers; the ex- istence of democracy; and belief in socialism as a way of life, especially among the leader- ship of the nation's organizations. Self-reli- ance was proclaimed as essential to this par- ticular form of development. It also meant an end to privilege and leaders are prohibited from holding shares in any company, being a director in any privately owned enterprise, receiving two or more salaries, owning a house which is rented to others, or being associated in any way with the practices of feudalism or capitalism. The Arusha Dec- laration very clearly points out that a state is not socialist simply because all the means of production are controlled and owned by government. Everything depends upon how, and for whose benefit, that control is exercised . Something of the importance of the uja- maa principle was conveyed by President Above: A patient being examined by a quali- fied nurse in the Lugoba health centre, in Tan- zania. (Photo WHO/D. Henrioud) Opposite page top: A doctor interviewing a patient in the Bagamoyo district hospital. There were 494 medical graduates in Tanzania in 1972, of whom 195 were nationals. (Photo WHO/ D. Henrioud) Right: A fourth-year student nurse tutor in the library of the Dares Salaam school of nursing. ( Photo WHO/D. Henrioud) Nyerere in the same year as the Arusha Dec- laration, when he said: "A nation of such village communities would be a socialist nation. For the essential element in them would be the equality of all members of the community. The country would also become more democratic through this organization of ujamaa communities .. . Not only would the people be governing their own lives directly in village matters, but they would also be playing a more effective role in the government of their country." Let us now see how Tanzanian socialism operates in providing health facilities for all the people. Today village health posts, the most basic unit in the rural health infrastructure, are usually located in ujamaa villages. The post provides treatment for minor ailments and also offers first aid for more serious illness and injury. More important is its function as the basis for health campaigns . Posts do not usually function in a separate building but are more often located within a school or other public structure. As the village grows the post may be upgraded to dispensary level. There are now more than I ,550 dispensaries in Tanzania, 300 of which are operated by the voluntary agencies. Each year until 1980 another 100 dispensaries will be built, result- ing in an average ratio in that year of one dispensary to 6,500 rural population . New dispensaries are . allocated in keeping with population/dispensary ratios (by district), accessibility to existing health facilities , and the percentage of population living in ujamaa villages . The main function of the dispensary is to provide outpatient care and serve as a centre for organizing and running health campaigns. A standard dispensary has two maternity beds . The usual design is a two-roomed building providing areas for waiting, examinations, treatment, storage and a laboratory " corner" . There is also a latrine and one staff quarter. The two-bed maternity hut, the latrine, and some elements of the main building are included in the design as a "self-help" element. The capital cost of the dispensary "complex" is now around US$7,000. The key staff at a dispen- sary are a rural medical aide and a maternal and child health aide. The operating cost of such a dispensary is about US$4,000 per an- num. There are now more than I 00 rural health centres in the country. Each year until 1980 another 25 rural health centres will be built, to give an average ratio in that year of one rural health centre to 50,000 rural popula- tioq. New rural health centres are mostly allocated in accordance with popula- tion/rural health centre ratios (by district) and accessibility to existing health facilities . Rural health centres are capable of providing the broad range of preventive and curative services required by rural populations. They function in relationship to surrounding dis- pensaries, on the one hand, and to the dis- trict hospital, on the other. A standard rural health centre has an outpatient building, a public health structure, a ward containing 14 beds (6 maternity and 8 holding), a service block, and staff housing. The capital cost is about $75,000. The centre is staffed by 10 auxiliaries headed by a medical assistant (there are also 6 ancillary staff). The operat- ing cost of such a health centre is close to $25,000 per annum. In addition to the services described above there is a broad range of mobile activity whereby visiting health workers provide both preventive and curative services, including health and nutrition education, communi- cable disease control, the improvement of environmental sanitation, and maternal and child health clinics. Hospital expansion is no longer a priority area. There are 123 hospitals in the country (half of them run by the voluntary agencies), containing a total of about 18,000 beds. Ap- proximately 300 beds per year will be needed to cater for the roughly 3 per cent increase in population. These additional beds will be al- located primarily to those district hospitals 11 which now have the least beds to population, although consideration will a lso be given to such factors as bed utilization and hospital- based training schemes. The per bed capital costs of a new hospital range from $4,000 to $25,000, and the annual operating costs from $1,000 to $4,000. Manpower. The country's modest financial resources are also a constraint on the devel- opment of manpower and heavy emphasis is laid on the minimization of costs. The cost of training a graduate doctor in Tanzania is around $40,000, but the comparable cost of training medical assistants and rural medical aides is less than $2,500 and $2,000 respec- tively: the cost of employing these different cadres also varies very widely. Given the lim- ited catchment areas of health facilities and the costs of providing different types of med- ical manpower, it is apparent that most pri- mary health care in Tanzania must be deliv- ered by auxiliary personnel for very many years to come. The more important primary health workers are described below. Village medical helpers are selected by fel- low villagers, when they leave primary school after seven years of schooling, to undergo 3-6 months of training at a district hospital. Their training enables them to treat minor ailments, provide first aid for more serious problems, and help in the prevention of com- mon diseases. In an ujamaa village, the vil- lage medical helper is supported by the vil- lagers, with a rural health centre providing overall supervision . Maternal and child health aides (MCH aides) will work primarily at dispensaries and rural health centres. They will organize maternal health (including antenatal , deliv- ery, postnatal and family planning), and child health (under fives and school health) services; they will also organize health and nutrition education at village level. There will be one MCH aide school in each of Tanzania 's 19 regions, offering a standard 18-month curriculum that includes six months of practical field training. Minimum selection to training will be from amongst primary school leavers. It is intended that 2,500 MCH aides will be in employment by 1980. Health auxiliaries are also drawn into training from a primary school background, although many have had previous experience in health or community development work. They are employed at rural health centres and dispensaries . The expansion of this cadre is also proceeding ; two new schools are being developed, and 800 auxiliaries are expected to be in employment by 1980. Medical practitioners. Tanzania has had for a long time four distinct types of medical Left: Assembling a hand-pump in a foctory in Dar es Salaam. In Tanzania self-reliance is considered essential for self-supporting health services. It implies thinking in terms of what is available, or can be made available, at comparatively small cost. ( Photo WHO/ D. Henrioud) practitioner (aside from the medical special- ist/consultant). Of these four types only the university graduate is to be found in the Medical Register: this type of practitioner has had a full secondary education followed by a university medical course of five years, plus one year of preregistration medical em- ployment. A second type of medical practi- tioner is the assistant medical officer (AMO). The AMO is originally trained as a medical assistant (MA) and then has at least four years of work experience plus an additional 18 months upgrading course. The medical assistant, in turn, has 11 years of schooling plus three years of medical training. The final category of Tanzanian medical practitioner, the rural medical aide (RMA), differs from the MA in that he has only seven years of (primary) schooling before his three years' medical training. The number of rural medical aides in em- ployment mainly at dispensaries and rural health centres, will have risen by 1980 from around 600 to 2,800 (the output from 16 schools). The RMA is replacing the dispen- sary assistant (formerly known as tribal dres- sers). They are intended to function primari- ly as substitutes for the physician (as are the MA and AMO) and not necessarily as their assistant. The five existing schools for medical assis- tants plus two others that are planned will by 1980 have increased the number of medical assistants in Tanzania from fewer than 400 to 1 ,200. Medical assistants are in charge of the rural health centres, do much of the hospital outpatient work, and will be increasingly taking part in preventive campaigns and pro- grammes. The number of assistant medical officers will rise from over 100 to 300 during the rest of this decade. AM Os have been doing work that is often indistinguishable from that of a graduate physician, for example acting as district medical officers. Along with the other types of non-graduate practitioners (RMAs and MAs), the AMO is usually the only " doctor" known to the people in the coun- tryside. Because Tanzania must continue to rely heavily on medical auxiliaries for a very long time for the delivery of primary medical care it is especially important that their career prospects be carefully worked out. This has now been done. For example, the way is now open for a rural medical aide to become a graduate doctor by undergoing officially ap- proved upgrading courses. Tanzanian graduate doctors are now being trained primarily within the country. It is planned that by 1980 citizens will comprise all but 100 or so of the slightly more than 800 doctors expected then to be in employment. (There are now 500.) Virtually all the national doctors are expected to be working in the public sector. Postgraduate training for the major specialities is being conducted at Tanzania's medical school and close to 200 specialists will have been trained by 1980. Local training in keeping with planned targets is also going ahead for registered and Medical practitioners in Tanzania: Independence to 1980 1961 1970 1971 Training 1972 Train ing 197 3 Training 1974-1980 Planned intake intake intake Planned 1980 annua l train ing intake Graduate doctors 403 1 489 479 48 494 2 48 - 64 64 8003 Assistant medical officers 22 100 115 22 140 - - 24 30 300 Medical ass istants 200 285 289 115 335 146 - 201 2104 1. 200 Rural medical aides 380 473 544 124 578 146 - 338 5604 2.800 --- = not avai lable. 1 Of th e tota l : 35% in government service; 20% employed by th e vo luntary agencies (missions); and 45% in private pra ct ice. Of the 403 medica l graduates only 12 were nationals. 2 Of th e total : 62% in government service; 23% employed by the vo luntary agencies; and 15% in private practice. Of the 494 medi ca l graduates. 195 were national s. 3 Of th e 800 med ical gradu ates, all but 100 or so wi ll be nat ionals. 4 Wastage from training approximately 15%. enrolled nurses, dental assistants and techni- cians, pharmaceutical and dispensing assis- tants and auxiliaries, radiographers and radiographic assistants, laboratory techni- cians and auxiliaries, health education offic- ers and physiotherapists . Traditional medical practitioners are not yet integrated into the organized health ser- vices; however, bilateral aid from a country with considerable experience in the coordina- tion of these two systems is expected soon. Tanzania is spending approximately US$3 per head for health care, or 3 per cent of its gross national product, not including water supply, sanitation, nutrition and other less direct but critical determinants of health . The country's health policy is reflected by the changing pattern of expenditure of the development budget. Health development budget expenditures in Tanzania: 1969/70-1974/75 (in percentages) 1969 / 1970/ 1971/ 1972/ 70 71 72 73 Hospital and anci llary services 63 52 a 52• 27b Rural health cent res and dispensaries 7 24 33 35 Preventive services 9 1 2 10 Training 16C 22 C 13C 18d Manufacturing 5 1 0 10 a About two -thirds in Dar es Sa laam. b Less than 10% in Dar es Sa laam_ c Around 85% in Dar es Sa laam. d Less th an 2% in Dar es Sa laam. 1973/ 1974/ 74 75 15b 12b 33 24 2 8 48d 55d 2 1 From th e table it ca n be seen that during th e three yea rs 1969 -1972 over halfthe development budget had go ne into hospital services (of which two - thirds were spent in Dar es Sa laam). but over the last three yea rs hospita l expendi ture has fallen to only slig ht ly over a tenth of t he budget (and on ly a fraction in Dares Salaam) _ Hospital constructi on has been replaced by expenditure on rural health ce ntres and dispensaries and the bui lding of schools for the tra ining of rural wo rkers. The recurrent budget is also changing in response to the country's new health policies. From 1970/71 to 1974/75 the hospital ser- vices' share of the budget declined from 80 to 60 per cent, while rural health centres and dispensaries more than ·doubled their share from 9 to 19 per cent : preventive services increased from 5 to 12 per cent, and training expenditures rose from 2 to 6 per cent. Al- though the health care system as a whole will cost more with each passing year, it should not rise beyond Tanzania's capacity to finance. The most important decision in this respect has been the one to control the in- crease in the number of hospital beds. Other steps are also being taken to control the costs of drugs and other health service inputs. The system described here is rooted in Tanzania's desire to -provide basic health care to its entire population. This desire stems from a policy of self-reliance that rec- ognizes that no country can be truly indepen- dent while its people suffer from poverty, ignorance and disease. The problems facing Tanzania are enormous, but some critical first steps toward solving them have been taken. Very limited health care resources are being spread thinly so as to maximize the possibility of complete coverage of the popu- lation with minimally required services. This overaJl approach, aimed at increasing the coverage and utilization of primary health care services in rural areas, requires a cut back in the provision of sophisticated and usually expensive but less accessible services. Reorganization of the countryside and mass mobilization are being used as a deliberate political tool to raise the social consciousness of health as the people's own responsibility. The commitment and continuity of Tanza- nia's present health care policies were spelled out in a statement by President Nyerere to the 1973 TANU conference: "We must det- ermine to maintain this national policy and not again be tempted by offers of a big new hospital, with all the high running costs in- volved - at least until every one of our citizens has basic medical services available to him." • 13 revolution in health Cuba's experience in bringing health services to its people was observed for WH 0 by Eilif Liisberg and lraj"Tabibzadeh, interviewed here by Albert Ezban WORLD HEALTH : Dr Liisberg and Dr Tabibzadeh , you have viA'ited Cuba. Could you tell us what the purpose of your mission was ? EILIF LnSBERG : The purpose of the mission to Cuba was to study and describe the health services of Cuba as .part of a WHO/ UNICEF joint study on alternative approaches to meeting health needs of populations in devel- oping countries . We visited the Ministry of Health, at various levels of authority, and health institutions in Havana, in the pro- vinces and in rural areas. W.H.: What struck you most during your visit? KL. :What particularly impressed us was the intensive coverage achieved by the health ser- vices, practically 100 per cent. We went to quite remote areas and we found the same quality of health services there as in the capi- tal. [RAJ T ABIBZADEH: Probably as a result of this wide health service coverage, during the last ten years Cuba has been able to eradicate malaria and poliomyelitis and to reduce the threat of other diseases, so that communi- cable diseases no longer pose a major health problem in most parts of the country. Today the main causes of death in Cuba are heart disease, chronic respiratory diseases, malig- nant tumours, cerebrovascular diseases, acci- dents and other chronic diseases. W.H. : What are the reasons for these sue- . cesses? EL.: Several factors must have played a role. One of them, I think, must be the national will that has made social amenities and health services available to all the people. There is an extraordinary will to implement decisions, good organization of these ser- 14 vices, and excellent programming. One thing which impressed us was the feeling of partici- pation among all the health staff. That human side struck us very much in all the health institutions we visited. LT: We realized that the decision had been taken at the higher, political level that health and education are the primary objectives in Cuba's general social and economic develop- ment. As we understood it, more than 50 per cent of the government budget is allocated to health and education. These aspects, plus the CUBA IN FIGURES Popu lat ion (total) (urban) (ru ral ) Annual rate of popula - ti on increase Crude birth rate (per 1000) Crude death rate (per 1000) Life expectancy at birth Infant mortality per1000 live births Population under 15 yea rs %of deaths < 15 yea rs Number of hospital beds per 1000 popul at io n Sources : WHO. UN . 8657 160 (71) 60.5% (71) 39 .5% (71) 2.3% (72) 28.3 (72) 5.5 (72) 66.8 years (65-70) 27 (73) 36 .7% (7 1) 214% (71) 4. 26 (72) extensive training of manpower, have con- tributed to the successes in health matters. W.H.: In what way i$ community participation brought about? E.L. : Well, the whole country is organized according to different groups and levels of population . For instance, the Federation of Cuban Women, the trade unions, the Corn- mittees for the Defence of the Revolution, are all organized from the national level down to street level ; it is an intertwining system of organizations which coordinate be- tween each other to share responsibilities and actively participate in social and health work . There are regular meetings within the organizations, between the organizations and the administrative services, with the health services and with the Cuban Com- munist Party, and we really got the feeling people were interested. In fact, we joined in a street committee meeting and were told how interested they were in immunization and cleanliness. LT: You can measure community participa- tion by the fact that in most street or rural committees there are one or two persons who belong to the health department. As a result committee discussions tend to increase peo- ple's awareness of health matters. On the practical level , polio immunization, for example, is carried out by street volun- teers and in 1972 more than 900,000 children were immunized in less than three days. W.H.: How are preventive and curative health services integrated? LT: The Cuban health services very success- fully combine preventive, curative and pro- motional activities; there is no separation between these three main components of health activities. In the health centres, the same clinic usually serves for vaccination or A visiting nurse carrying out BCG vaccination . M ore than 90 per cent of the Cuban population is now protected by the tuberculosis programme which started in 1963. The TB mortality rate fell from 19.6 per 100,000 in 1962 to 4.1 in 1973. (Photo WHO/E. Rice)

other disease, prevention activities for chil- dren or infants, but it also administers cura- tive procedures and even promotional work about nutrition and so forth. It is all com- pletely integrated. W.H.: Is the health of the population a govern- ment responsibility? E.L.: Cuba's revolution in 1959 made big changes, one might say from the grass roots. We were told that the leader of the revolu- tion, Dr Fidel Castro, always explained how problems related together - health, educa- tion, nutrition, farm implements, fishing, communications and so on. Thus it was im- possible to make profound changes in the health of the population if there was a high percentage of illiteracy, or if some regions lacked communications. Roads have now been improved and illiteracy wiped out. All the people know how to read and write. Now they are able to educate the people in public health. Moreover it is the stated responsibili- ty of the government to provide health ser- vices for the people. I think this is one of the basic political decisions that have been taken. The leadership invariably describes health as the right of the people and one of the first priorities in Cuba's development, while the whole community is encouraged to participate actively in health work. W.H.: How has the government undertaken the training and redeployment of health per- sonnel to implement its health policy? I.T.: Around the years 1959 and 1960, Cuba had about 6,000 physicians, more than half of them in Havana. In the first ten years of the revolution, about 2,800 of these doctors, for various reasons, left the country. The Cuban Ministry of Health in conjunction with the universities managed within the next ten years, from 1963 to 1973, to train about 5,000 doctors, so that in 1973 their numbers stood at around 8,000. The character of the training has also changed, and there is much emphasis on practical studies, close contact with the community, and an integrated preventive, curative and promotional ap- proach. The approach to the development of health services is pragmatic and gradual, in fact private practice still continues, with 350 physicians. But Cuba's fundamental concept of the physician today is of a man who heals by changing and improving the environment, the working conditions and food. All physicians have to work for two to three years after graduation in a rural health centre, and this is the starting point for career development. The government also trained a consider- able number of nursing staff and auxiliaries of all kinds. There has been total manpower planning in that the government doesn't only think of doctors and nurses but, for instance, of maintenance personnel in all the different specialities, like X-ray maintenance. What struck us was the mobility within the health services structure, how the assistant nurses or the nursing aides were given a general educa- tion by their colleagues in clinics to increase their general background so that they might later on join the nursing school. W.H.: Do the health services use traditional midwives and curanderos ( traditional doc- tors)? E.L.: No, the Cuban system is basically dependent on the physician and they have forbidden the activities of traditional mid- wives or other persons who previously prac- tised without licence. But they have trained them and brought them into the health ser- vice according to their capacity as different types of auxiliaries and under the supervision of the physicians. The curanderos were not allowed to practise. W.H.: In what ways has the government ap- proached rural health problems? LT.: First of all, top priority has been given to rural activities; for example, water supply and sewage disposal is immediately provided in new housing projects in the countryside. In such areas the rate of enteric diseases has usually dropped sharply. In addition , we un- derstood that health institutions now exist even in the most remote areas. After the government started sending out physicians to the rural areas and training auxiliaries, it began a series of pilot pro- grammes on a trial basis to find out how best to provide services for a community. It divided the programme into eight areas: inte- grated care for children, integrated care for women, integrated care for other adults, communicable diseases, environmental sani- tation, food hygiene, occupational health, and dentistry. In this study it was getting results within six months, and from then on it started implementing the results slowly all over the country, but again with emphasis on the remote areas. This is the interesting Opposite page : A teaching hospital in Santia- go de Cuba. Following a one-year internship in a teaching hospital, medical graduates spend two years in the peripheral services and may specialize afterwards. (Photo WHO/E. Rice) Below: A clinic 60 miles north of Santiago de Cuba. Health services have been regionalized in order to make primary care accessible to all. (Photo WHO/E. Rice) point: the Cubans did not start from the centre and work outwards, they started where there was nothing. Today, in most parts of the country, major health programme activities are concentrated along the lines of these eight programmes. W.H.: Could you describe the work being done in the field of maternal and child health? I.T.: Maternal and child health has been given the highest priority among other health activities, and today 93 per cent of all deliv- eries occur in hospital. Most pregnant women have pre-nat:;tl and post-natal care. The coverage is practically 100 per cent. There are often also child health clinics. Usually in each health centre there are three doctors, of whom one is a gynaecologist or obstetrician, one a paediatrician and the third an internist. Immunization of the children and their nutri- tion is arranged on the basis of a planned programme and auxiliaries call at the house at once if the mother has forgotten to bring her child for vaccination, because they keep a file on the family at the clinic. In fact, there are regular home visits on the basis of indi- vidual and family files for the purpose of different programmes. E.L.: Here too, the integrated approach en- sures that social legislation and labour legis- lation all fit in with health needs. Take for example the fact that women who breastfeed their children are given hours off to go home and feed them. A mother may stay home to look after her sick children and still be paid her salary. Pregnant women and women with children under one year old cannot lose their jobs; they have complete job security. There are also kindergartens to take care of chil- dren during working hours. W.H.: What are the main features of the health planning process in Cuba ? LT. : The Cubans' approach is essentially pragmatic; they plan on the basis of epide- miological findings, according to the priori- ties and real needs of the community, espe- cially in rural areas. They have these eight different programmes which have been men- tioned before. Thus each area is set a target not only annually but also monthly, which helps to evaluate their capacity to reach it. Such evaluation enables fresh targets to be set for each health centre, on a national , regional or local level, when next year's plan is being drawn up. E.L. : Remember, it is a total approach. The Cubans don't forget that you need drugs, transport and petrol. We didn't see any X- ray machines broken down or things that didn ' t work because of a Jack of spare parts. We found that the system worked quite smoothly because of this very weB-integrated planning activity. There seems to be very wide participation by a 11 the professional people in the plan- ning, and also a great sense of participation by a 11 kinds of specialists who are grouped into what they call task forces and who Jay down standards and norms which are then published as basic training manuals, for practical daily health work and for imple- mentation of the programmes. W.H.: Ho w have they dealt with the main health problems, for instance the communi- cable diseases ? What are the successes and what are the failures, if any ? E.L. :There has been a measurable success in the fight against the infectious diseases, and this can be seen in the mortality rates, as we11 as in the specific disease mortality rates and morbidity rates. Certain diseases have been, as we said, completely eradicated, like 18 malaria , tetanus, poliomyelitis. For tubercu- losis, to take one example, the morbidity rate in 1968 was 41 per 100,000, and in 1971 it was 17.8, which is a good measure of success. Gastroenteritis is one of the diseases they sti11 have and here they have an interesting ap- proach. They are very keen on early treat- ment of chi ldren with gastroenteritis and lay great emphasis on early case-finding. In fact they often send children with symptoms of gastroenteritis in very early stages to hospi- tal. The philosophy is that clean water and other environmental factors are very impor- tant, but that these cannot be changed over- night, so to attack the disease now they have to treat the cases as they appear, at the ear- liest possible stage. l.T.: The mortality rate from gastroenteritis has dropped from 42.5 in 1957 to 18.4 per I 00,000 in 1970 because of early case detec- tion and treatment in hospital, whi le the morbidity has not decreased so much because of inadequate rural sanitation in some areas. These pockets of poor sanitation in some rural areas wi11 di appear as recon- struction and new housing projects get under way. As reconstruction and housing projects based on the regrouping of scattered houses and vi11ages progress, rural water supply and sewage disposal schemes are simu ltaneously expanding. W.H.: What has been done in the field of nutrition? E. L. : In the field of nutrition the most strik- ing thing is the policy of equa l distribution of available food resources. A11 the population gets a minimum amount of animal proteins or calories and so on. I.T.: Pregnant women, chi ldren and elderly people receive more milk, eggs and some oth- er protein substances than the other groups. This improves a great deal the promotion of health of the population. E.L. : There is also a big programme of sup- plementary feeding in schools, in canteens Above: Clearing a river in the "10 October" region to control mosquito breeding. Malaria has now been eradicated in Cuba. ( Photo WHO/E. Rice) Opposite page : A day-care centre for children of working mothers. In many situations a dis- tinction between health and welfare is mean- ingless. ( Photo WHO/E. Rice) and so on . One daily meal is very often pro- vided free of charge or at a very nominal fee, so that also has had a considerable influence on the nutritional status. In addition, the overall agricultural policy has been geared to the needs of the population so that the fish- eries, the milk and meat production have been increased not for export but to improve the nutritional level of the population. Early detection of nutritional disease is an important part of the maternal and child health services and there is supplementary feeding for children who show signs of mal- nutrition. The authorities set up nutritional rehabilitation centres where difficult cases of mothers who need a lot of training are brought with their children to stay for maybe one or two months, to bring the child up to completely normal nutritional status. W. H.: To what extent can the Cuban example be followed by other countries? I.T.: The Cuban system as a whole can pro- bably not be transplanted to a developing country with a low socioeconomic level because at present the government, we were told, spends more than 50 per cent of the total budget on health and education. Also it has trained a lot of manpower and their basic approach in front-line health services relies on physicians, which could not be achieved for a long time in most developing countries. But there are lessons that one can learn and adapt to different situations in other deve- loping countries. One is the insistence on community participation in health activities and health education. There is the pragmatic planning based on priorities, epidemiological findings and the real needs of the communi- ty. Then the integrated approach to health, which is preventive, curative and promo- tional at grass-roots level , and not restricted to the curative aspect of health. Finally, the system of equal distribution of institutions, giving more attention to the most remote and rural areas rather than emphasizing health institutions for the capital or the big cities, could be profitably studied by other coun- tries. During the last ten years Cuba has devoted more effort to rural areas than to the cities. E.L.: In seeking reasons for Cuba's success I think we have to take into consideration the country's ability to implement political deci- sions and its political will to carry out a programme for the rural areas. This may not always be feasible under other socioeconom- ic systems, so we should consider that proba- bly the Cuban socioeconomic system is large- ly behind the success of what the country has been doing in the health field. • 19 house of health Health assistants and village health workers recruited and trained on the spot are vital to Iran's plan for bringing primary health care to rural communities S ome impression of the task facing Iran as it tries to bring good health to its inhabi- tants can be conveyed by sheer statistics. Its 32 million people live in an area three times the size of France. To cater for the health needs of this huge and fast-growing popula- tion, there are only 11,400 doctors, 5,300 nurses and midwives, and 25,000 other health workers. Like anywhere else in the world, this meagre contingent of medical personnel is concentrated in the towns even though near- ly 60 per cent of the population is rural. The medical staff are also unevenly distributed throughout the country and not always em- ployed to best effect. Iran is therefore on the lookout for new solutions to the problem of giving its people access, all the year round, to an efficient health service. One of the most interesting experiments is taking place in West Azerbai- jan. It involves all the main public and pri- vate welfare organizations which are concerned with health in Iran, headed by the Ministry of Health. Other groups participating in the pro- gramme are the Teheran University School of Public Health and its Institute of Public Health Research, the Imperial Organization of Social Services, the Plan and Budget Organization , the Red Lion and Sun Society. Finally WHO, through the Iran-WHO Health Services Development Institute, is helping to test new approaches in health care delivery. So as to ensure a sound base for the West Azerbaijan project, preliminary studies were made on the spot in 1972. After detailed analysis of the health situation and intensive advance planning, a specific proposal for training health service staff was put into practice. This pilot scheme will be followed by' a full evaluation to see how the lessons learnt from it may be applied to the rest of the country. Rezaiyeh, the capital of West Azerbaijan, stands in the middle of an elongated province framed between the mountainous borders with Iraq and Turkey and the salt waters of a great lake. Like the rest of Iran, it is a land of parched brown earth alternating with moun- tain chains, but wherever water wells to the 20 BY REHANE REPOND surface there is a veritable explosion of vege- tation and farming . Just one of Iran's 21 provinces, its moun- tains offer good pasturage for livestock and the plains are fertile , but the winters are cold and deep snow hinders communications. The IRAN IN FIGURES Populat io n (tota l) (urban) (rura l) A nnu al ra te of popula - tion increase Crude birth rate (per 1000) Crude death rate (per 1000) Life expectancy at birth in yea rs Infant mortality per1000 li ve births Popu lat io n under 1 5 years %of deaths < 15 yea rs Populati on per physi- cian Populati on per profes - sional nurse Number of hospital beds per 1000 population GNP per capita Hea lth bud get as a per- centage of the tota l budg et 30550000 (72) 41.9 % (72) 58.1 % (72) 3.2% (72) 36.7 (72) 5.0 (72) 50 years (65 -70) 100-140 (70) 46.1 (66) 41.4 (7 1) 3 039 (72) 7958 (72) 1.4 (72) US $33 4 2.1 (72) Sources.· W HO. UN. Wo rld Bank. population is 75 per cent rural: about one million of its 1.4 million people are scattered around in some 3,000 villages. The economy is basically agricultural and largescale irriga- tion projects have been started and rural cooperatives developed. The province's birthrate is between 37 and 42 per thousand, and the health picture is dominated by widespread infectious and parasitic diseases. The infant mortality rate is between 100 and 140 per 1.000 live births. The ten or more different bodies responsible for providing medical services are making great efforts to coordinate their work effec- tively, but they come up against the uneven distribution, and the under-utilization of the few available staff. The population is made up of 1.3 million Moslems, of which 500,000 are Kurds, and 100,000 non-Moslems. There are health centres at the provincial and district levels, with less well-staffed ser- vices in some towns and in the countryside. Health workers in general are concentrated in the main owns and in the most developed districts. Preventive medicine, mostly in the form of mass vaccination and malaria con- trol , now reaches virtually the whole popula- tion ofWestAzerbaijan, butonly30 percent- those who live in towns-have access to proper health services. The rest have no med- ical care because they live too far from the health centres. Today, the existing health services are be- ing strengthened and reorganized so as to respond more fully to the real needs of the population, as revealed by the preliminary soundings. The new team Two new types of primary health workers are being trained to bring a basic form of health service within the reach of the en- tire population. They are the health assistant (Behdasht Yar), and the village health work- er (Behvarz). These new personnel are recruited and trained on the spot, and they carry out their work in their own communi- ties . Rezaiyeh, with 150,000 inhabitants, is the headquarters of the research project investi- gating the development of health services. The Director General for Health in Western Azerbaijan is also the administrative director of the programme. He has special responsi- bility for coordinating all the different kinds of health worker operating in the province, who will in due course be associated with the new project. In a Kurdish village in West Azerbaijan. (Photo Ministry of Health of Iran )

The focal point of these actiVIties is the House of Health (Khaneh Behdasht) set up in each main village within easy access of the tiny hamlets and farming communities. The health assistant (Behdasht Yar) is al- lotted a territory comprising the catchment area of two Houses of Health. He is respon- sible for dealing with malaria, tuberculosis and other important endemic diseases, con- trolling infectious diseases and improving the district's sanitation. Maternal and chi ld health also comes under his purview and he may be called on to administer first aid. The village health worker (Behvarz) is pri- marily concerned with the family. She tends pregnant women and nursing mothers, and advises on family planning. She may have to offer first aid in cases of emergency, to give basic treatment and to look after the con- valescent, but she refers difficult cases to a doctor. She has an important educational role to play, particularly as regards nutrition. These two kinds of front-line health workers come under the jurisdiction of a health centre with a doctor in charge. His various teams of health workers send all difficult cases to him, and it is up to him to decide which cases should be admitted to hospital. The initial medical research which prec- eded the new programme showed that in the villages of West Azerbaijan about 80 per cent 22 of cases could be treated with quite simple equipment and a limited range of drugs. It was also proved that the new health workers are almost always able to spot a patient's ailment and are able to take appropriate ac- tion in 60 to 80 per cent of the cases. Green, brown, yellow These new health workers can be recog- nized at a distance, since the young men wear green and the girls wear brown trousers and jackets and a bright yellow blouse and neckerchief. Each morning the Behvarz leaves the House of Health where she lodges with a colleague, or the family with whom she lives, and makes her rounds through the villages in her charge. In the afternoon, she opens up the House of Health and waits for the patients to arrive. They come spontaneously and receive free treatment. As in any other part of the world, the two commonest complaints at the "surgery" are respiratory ailments and stomach-ache. The young Behvarz knows which medicines to dispense. But there is another cabinet for other drugs kept under lock and key to which only the physician has access when he makes his rounds here. Fatemah is the Behvarz at the House of Health in Chonaghlou, which serves seven villages and a population of over 3,000. She Above: An auxiliary health worker calls on a villager in West Azerbaijan. She plays an im- portant part in primary health care. (Photo Ministry of Health of Iran) Opposite page: Teaching primary health workers how to prepare a meal of high nutri- tional value by using local foods. (Photo Ministry of Health of Iran) came top of the class in her training course and, although aged only 19, she does her work with easy assurance. So when a 14- year-old girl arrives with a high temperature and a very sore throat, she knows just what to do. She asks a few questions and, filling a syringe with penicillin, she lets one drop of the solution fall into the girl's eye and waits a quarter of an hour. When the eye shows no irritation and therefore no allergic reaction, Fatemah gives the girl an intramuscular in- jection. The next patient is a three-year-old boy with a bad cut in his foot. Fatemah unwraps the clumsy bandage, cleans up the wound, puts on a new dressing and gives the child a booster shot against tetanus. A woman of about 40 calls next, clad from head to foot in the huge drapes of the "chador" worn here by all the women and even by the girl with the sore throat. Only her eyes are to be seen. She complains of palpita- tions and headache, but proves to have no fever, while her blood pressure is low. Fate- mah notes the paleness of her conjunctiva- a sign of anaemia. Following her instructions, Fatemah gives the lady some medicine and some advice on eating the right food, and advises her to come again if she doesn't feel better. An old man with very high blood pressure needs to be referred at once to the doctor. At last, after about 20 patients, the bench in the corridor which serves as a waiting- room is empty. But the door opens again to admit a beautiful girl of 18 in quest of her next supply of contraceptive pills. She al- ready has one child, but she and her husband have decided to wait for a while before hav- ing another. Family planning instruction is one of the important tasks of the new health workers. The youths talk to the men- who are often reluctant- while the girls always find the wives very willing to learn. This is an aspect of their work about which the village health workers are most enthusias- tic. Too many children, wives anaemic and over-burdened with work- that is the gener- al rule in all the villages. The need to space out the births and limit their number so that their children will have better care and a better education is quickly understood and approved by the women. The House of Health, like the health cen- tre on which it depends, is decorated with lively posters which play an important role in putting across new ideas about family plan- ning and family health. Some of them ex- plain infant care, emphasise the value of cleanliness, good food and clean surround- ings, or describe how to build and look after proper latrines. Sanitation is the particular responsibility of the Behdasht Yar, since there is a great deal to be done in improving water supplies, dealing with sewage and installing latrines in all the villages. Latrines of a simple pattern are built locally and the health assistants ex- plain their use, show how to erect them, dig cess-pits, lay pipes and so on. All the members of the health team work together in the mornings. Census-taking is one job that has to be done, since the pro- gramme is still in its initial stages. The health workers write down in a register the names of everyone in each household, their age and state of health, and take particular note of pregnant women and small children. The young men in green also use this opportunity to make their preliminary enquiries about cases of tuberculosis or malaria, and to take the first steps in improving the local situa- tion. Each visit attracts a crowd of 15 to 20 adults, not to speak of the children of the village- nor of the local poultry which strut and peck around their feet. Everywhere they are greeted with friendly curiosity, and the health workers receive offers from all sides of the traditional welcoming glass of tea. The training course for the new health team is structured and programmed on the most up-to-date lines and lasts for 18 months to two years. It is divided into four parts, each lasting six to eight weeks. After the first part of the course, the pupils go to work in their village, but under supervision. Thus there is no real gap between theory and prac- tice. The pupils are introduced to the basic principles of health protection, with the ac- cent on children and their ailments, vaccina- tion, and the treatment of simple infections. Some of these lessons will have a bearing on patients of any age, but the emphasis is on the child. The second part of the course is centred around the woman of childbearing age, pre- and post-natal care, the new born and family planning. The third and four parts deal primarily with childbirth, since there is a great need for the new health workers to increase village knowledge and skills as the traditional mid- wives are often more skilled in magic than in science. The methodology of this course in preven- tive and curative medicine is very intensive. 23

Latrine building and the laying of drainage pipes in the village square help to create heal- thy surroundings. Male primary health care workers are involved in environmental sanita- tion activities and in communicable disease control. ( Photo Ministry of Health of/ran) Every pupil carries a big file in which a sep- arate page is devoted to each subject or each specific illness. Another appropriate page in the file explains how to act in each case as a result of the questions and examinations in- dicated on the first page. Thus, a page headed "Diarrhoea in in- fants" starts by asking: duration of illness (over three days? over a week?), vomiting (more than 3 times in a day?), presence of blood in the stools? any associated com- plaint of sore throat, ear-ache or skin rash ? Next are listed temperature, weight, dehy- dration and general condition. Each item has a corresponding entry explaining the likely cause and how to deal with it. It is written in simple and concise lan- guage, and in logical sequence explains each step to be taken . The page ends with some educational hints for the family. The mother must learn the importance of the right diet for her sick child and the amount of liquids it must be given ; diarrhoea can be avoided if foodstuffs, cooking utensils and hands are kept clean and if the water is boiled. There is advice on how to keep flies away, and how to get rid of the sick child's faeces. Every detail is clearly explained, with cross-references which appear over-elaborate at first sight but in fact save much space and time, since many of the procedures to be followed apply to various different circumstances, particularly those concerning hygiene and cleanliness. This instruction is aimed at ensuring a constant quality of care, even at the most basic level, with the human and material resources available. The system is flexible enough to allow extra chapters to be inserted according to the special needs of the district where the primary health workers will work ; instead of tuberculosis or malaria, there might be sections on endemic syphilis, trachoma or leprosy. What of the future? From the first year of the experiment, the newcomers have been absorbed and integrat- ed into the local public health services, and even before completing their training course, they have proved capable of carrying out their instructions to the letter. The imme- diate result has been that the doctor at the rural health centre has more time for really serious cases and also for instructing and superv1smg the primary health workers attached to his centre. With this stage well under way, the train- ing courses are starting in other districts of West Azerbaijan, commencing with Khoy and Mahabad. Recruiting presents no problems. There were 100 hopeful candidates for the first training course, of whom 13 girls and seven boys were picked. The trainees have to be at least 16, with not less than six years of schooling, and must belong to the district. The personality, motivation and special abil- ities of the candidates are also taken into account. The youths are generally older than the girls since they have to complete their military service first. Altogether, 350 primary health workers have to be trained for the Khaneh Behdasht of West Azerbaijan. These Houses of Health already offer an essential service of primary health care for thousands of vil- lagers. The experiment here has aroused great national interest, since Iran's Minister of Health, Professor A. Pouyan , is now plan- ning training programmes elsewhere based on the results obtained in this province. He has announced that a health service pro- gramme on a national scale will require the training of no less than 50,000 health assis- tants. • 25 starting from scratch A community health programme in Indonesia which stresses health, not disease, and focuses less on the individual than on the community as a whole F ive years of experience in government service in Indonesia convinced me of the need to review the existing health care deliv- ery system, particularly in the rural areas. The basic aim of providing primary health care had not been fully achieved and it was evident that the costs involved and the effort expended were out of proportion to the results obtained. When I looked at the in- adequacies, the lack of medical and auxiliary staff and of health facilities , the immensity of the health problems and the available bud- get- a mere US $0.32 per capita annually- it seemed essential to consider devising a com- pletely new way of raising the health stan- dards of the people. It remained to be seen how far this could be realized , in the light of the shortages of finance , staff and implemen- tation techniques. Fortunately, in 1963 the government as- signed me and my wife, who is also a physi- cian, to the Foundation for Christian Hospi- tals in Solo, the second largest city in Central Java, with a population of about 400,000. The foundation had existed since 1950, its aim being to coordinate church activities in the health field throughout Central Java. Built on the western outskirts of Solo, the foundation had a small maternity clinic of 20 beds with an outpatient clinic attached. Because of its location, a large number of patients came from the edge of the town and the surrounding villages. Daily management was in the hands of a midwife and auxiliary nurses , under the supervision of a doctor who came at certain appointed times. Occasionally financial sup- port and equipment was received from pri- vate organizations overseas. This was the sit- uation until the beginning of 1963. Drawing on my own and others' ex- perience and attempting as close an adapta- tion to local conditions as possible, I tried to formulate some basic principles that could be used as a new foundation for drawing up a working programme. It seemed to me that the maternity clinic could be used as a base 26 BY GUNAWAN NUGROHO for providing health care activities for the surrounding areas . My programme was intended not merely to serve those people requiring treatment nor merely to prevent disease. The problem of health was not exclusively one of disease alone; health had a very close relationship with all aspects of life, and a health pro- gramme should promote the concept of how to live healthily. At such an early stage this thinking was too far-sighted. INDONESIA IN FIGURES Populatio n (tota I) (urban) (rural) Annu al rate of popula - tion increase Crude birth rate (per 1000) Crude death rate (per 1000) Life expectancy at birth Infa nt mortality per 1000 live births Populati on per physicia n Populati on per profes - sio nal nurse Number of hospital beds per 1000 population GNP per capi ta Health budget as a per- centage of the total budget 118309059 (7 1) 174% (7 1) 82.6% (7 1) 2.0% (61 -71) 47 (71) 19 (71) 47 .5 yea rs (60) 125 (71) 27 380 (71) 25000(71) us $79 (71) 11.7% (73 -74) Sources. WHO. UN. World Bank. I felt strongly that the provision of health services should not always be dependent on overseas experts and aid; somehow a way must be discovered of progressing indepen- dently of outside assistance. In order to achieve this aim, it was essen- tial that the maternity clinic should be reor- ganized as a base and drastically cleaned up. This process was carried out first of all by improving conditions for the staff and in- creasing their wages to an adequate level. By the end of 1965, the staff were now conscious of their respective duties and the feeling had been cultivated that they also shared in the ownership of the clinic. Good teamwork and a sense of commitment had to be developed and carefully nurtured. First the maternity clinic was upgraded to become a maternity hospital where abnormal cases could be assisted . It was also equipped with a children's ward and a family planning clinic. The idea was that the base hospital should also function as a referral hospital for the surrounding health facilities ; it could also be run with greater financial efficiency as a maternity hospital. The improvement in the health care provided by the hospital was accompanied by simplification in all fields. There was no expensive and complicated equipment. In place of an incubator, for ex- ample, a glass box heated with an electric light was used, because most of the auxiliary staff were untrained village girls. Auxiliaries were employed because of the shortage of qualified nurses, but also out of financial considerations. It was also part of the family planning programme to postpone early marriages among unemployed girls by providing job opportunities. Special courses were organized to prepare them for mother- hood and responsible parenthood. Basic standards of cleanliness were observed and the patients' diet and the atmosphere of the hospital were adapted more to conditions in the patients' own homes. From information gathered in the outpa- tient clinic and from local observation it was apparent that the underprivileged group of the community was excluded from the health Thanks to a mini-dam built by the community with village labour and the help of a small loan from the health centre, Sirkandi village increased its rice production by 25 per cent in one year. (Photo WHO/G. Nugroho)

service provided by the hospital, mainly because of the cost. An attempt was made to discuss this problem with the community through meetings organized by the hospital staff in cooperation with the headman of the hamlet and several prominent people of the community. But this gesture was misinter- preted politically, so the first attempt to in- troduce a "community health programme" in which the community would actively par- ticipate failed. The failure was taken as a challenge to find other ways of getting into the community. This was only possible if the doctor could spend more time outside the hospital. It was then decided that my wife would run the maternity hospital so that I could concen- trate more on the community health prob- lems. Begajah is a village with a population of approximately 3,500 inhabitants, 20 kilome- tres south of Solo. It was a poor area which regularly experienced a chronic shortage of food. Each year there were many patients who came to the outpatient clinics suffering from various forms of malnutrition. With no preconceived concept or design a flexible programme, based on what had been learnt from observation and personal con- tact, was drawn up. A village development committee proposed by the clinic staff was set up. The community was involved in the decision-making process through meetings where individuals were free to express their opmwns. The infant mortality rate was around I 00 per 1,000 and many children were suffering from malnutrition, obviously caused by the low food production. In 1966 the average family holding was 0.2 hectares of irrigated riceland and 0.1 hectares of dry land , which could produce 480 kilograms of rice and 175 28 kilograms of other products such as soybean, peanut, cassava, sweet potatoes and corn, if the weather was favourable . This was enough for the average family to subsist on. It was clear that heavy rains or a long drought would be disastrous for the village. By using a demonstration plot, the village development committee was able to intro- duce new rice strains, the use of fertilizers and new agricultural methods in close coop- eration with the government service. Through "food for work" programmes, whereby labour was provided by the commu- nity in return for Bulgar wheat, the irrigation system was improved significantly. By early 1970 the rice production had almost doubled (from 442 tons in 1966 to 854 tons in 1970) and this alone could explain why during an evaluation survey in that year not a single case of malnutrition among the children was encountered. The infant mortality rate went down to 69 per 1,000. Health and nutrition education in con- junction with increases in agricultural yields had accelerated the achievement of the target. It was clear that this achievement would not have been possible without local participation in the community development activities. Viewed from the angle of cost and benefit, these activities were exceedingly cheap yet effective. In 1969, for example, through the "food for work" programme, 9.8 tons of Bulgar wheat were given to the community for improving irrigation canals, and this pro- duced an increase of 31 per cent in the average yield. For the first time it had been proved that a comprehensive approach in raising health standards through community development with community participation could be implemented , and was cheap and appropriate. A similar situation existed in the Klampok district, 200 kilometres west of Solo. Sirkan- di was a poor and backward village in this district, with its main income from palm sug- ar. Money lenders controlled the palm sugar business. No wonder that the average farmer could make only 10,000 to 12,000 rupiahs (around $27.50) a year. The doctor in charge of the nearby health centre developed a comprehensive communi- ty health programme. To provide primary health care for the community, he relied on his cadre farmers from the village, who at- tended a short application course on health matters. The programme also included a pre- paid medical care scheme, as well as home care for a variety of patients, which had results comparable with hospital care. The programme was thus completely run by the people and even paid for by them, under the guidance of the doctor. Because the basic problem was that of food production, the initial steps were not health activities but the improvement of the village's irrigation systems. A " mini-dam" was built by the community with the help of a loan from the health centre. It was finished in about two months and had a tremendous impact on the economy of the village. With an input of 275,000 rupiahs ($700) it in- creased the rice production by one and a half million rupiahs ($3,750) annually. Following the successful completion of these infrastructures, the community became aware of its own potential capacity and the whole programme gathered speed and momentum. In one of the hamlets of Solo, a pro- gramme called Dana Sehat has been started. This is a community-based health insurance scheme of prepaid medical care. After "social preparation" through meetings and Above: A paddy field in the village of Begajah. Comprehensive community development enabled villagers to produce two crops a year. (Photo WHO/G. Nugroho) Opposite page: The irrigation system in the Begajah village was improved significantly through a programme whereby labour was pro- vided by the community in return for Bulgar wheat. (Photo WHO/G. Nugroho) discussions, the community was encouraged to analyse its problems, so that residents un- derstood their situation and their own poten- tial to solve these problems. "Social prepara- tion" is a most important part of any com- munity programme time. It was made clear that the minimum health care the people ex- pected from this scheme was the provision of inexpensive treatment for the sick and the introduction of measures so that the commu- nity could remain healthy. Apparently the situation in this hamlet was not too bad. The community was well organized. The average family income of 5,000 rupiahs ($12) per month for approximately five persons al- lowed them to have at least two meals a day consisting of rice and vegetables. Health problems among the underprivileged were due to poor sanitary conditions, inadequate housing and ignorance of health standards. Each member pays only five rupiahs (one and a half cents US) per month which en- titles him to obtain medical care and, apart from this, there are related activities such as preventive measures, family planning, the weighing of children under five, and health and nutrition education through home visits. The role of the community in this scheme is more than just paying five rupiahs per month. The promotion of awareness and of a sense of responsibility, which essentially costs little, is an important part of the input. An interesting aspect of this scheme was the total cost of the health care provided, including the salary of the staff providing the health care. The cost of preventive care im- plemented through home visits carried out by a qualified midwife and a social worker was about 70 rupiahs (17 cents) per person per year, and the medical care was 60 rupiahs (15 cents) per person. Thus the total cost of health care per capita per year was 130 rupiahs (32 cents), an amount equivalent to that currently provided by the Indonesian government. In this scheme the community paid 46 per cent of the total cost-a signifi- cant proportion. Thus a community health programme which may initially require considerable in- put will in the long run become an increas- ingly less expensive activity which can ulti- mately be borne by the community itself. Health care provided through hospitals, health centres and outpatient clinics is the practice of medicine as applied to individ- uals. It emphasizes the control of disease, which from the doctor's viewpoint is the ap- propriate application of his medical know- ledge. A community health programme, on the other hand, directs its attention to health rather than to di-sease and focuses not only on the individual but rather on the communi- ty as a whole. It is concerned with the total community in its total environment. The well-being of the community can be more quickly attained if all its members unite their efforts so as to create conditions whereby the community can progress towards greater welfare. If such a programme is to be closely adapted to the situation and conditions of the local area, it should be flexible and devel- oped from below with guidance from above. Development from below means involving the community from the very start in the planning and programming. Providing guid- ance means helping to develop the communi- ty members' will and competence to manage their own affairs and, where necessary, to assist with the technical implementation. The next step is to determine how to allow for the great variety of aspirations and desires of the community- which at times may be completely irrelevant to their real needs-so that all parties concerned will be satisfied. Community participation involves a coop- erative effort to create conditions which will enable the community to live a healthy life, and not merely to free themselves from dis- ease or the threat of disease. This does not negate the need for individual medical care; on the contrary this care should be an insepa- rable part of more extensive activities, not standing alone but integrated into the overall programme. With this form of health care, the doctors and auxiliary personnel should not play a dominating role but rather one of guiding the community. They should stimu- late the community actively to promote and raise its own health standards so that it does not have to depend continuously on outside assistance but relies primarily on its own ef- forts to solve its health problems. In essence, the success or otherwise of a community programme in raising people from the depths of poverty and suffering does not depend on outside activities but rather from within, from the people and their desire to awaken and struggle out of the depths themselves. il 29 WORLD HEALTH In many countri es less than 15 per cent of the rural popula- tion and of the underprivileged groups have access to health care of any kind. 1 National Hospital 2 Regional Hospital Only a privileged minority, mainly from the cities, is treated in hospitals like these above . 3 District Hospital 4 Primary Health Centre 5 Rural Health Unit 6 Village Health Unit The rest of the population that receives health care of any kind is attended to in establishments like these. Coming issues of World Health will introduce you to the various members of the health team. This month we present the VILLAGE HEALTH WORKER In remote areas, far from the large cities and towns, sick people turn to the village health worker in his/her hut or room. Village health workers play an essential role in health care because nearly 75 per cent of the world's people live in the countryside. Moreover, hospitals are expensive: a hospital bed (1) costs ten times as much as a rural health unit (5). Who is the VHW? Anyone, man or woman , young or old, provided primary education has given him / her the ability to read and write. The person is selected by the villagers-or with their agreement-to deal with health problems of both individuals and the community. 30 What are his duties? Th ey vary from country to country depending on the local problems. Generally, the VHW should: 1. Care for the health of the villagers and look after com - munity hygiene of the village. 2. Give elementary care and advice in accordance with the instructions written down in a manual or given by the superv1sor. 3. Refer patients to the nearest health centre or hospital in any case not covered by the manual, or in which the manual instructs him to do so. 4. Give villagersadvice on how to prevent disease and learn good habits of hygiene What training is required? At first six to eight weeks with the official health service of the country Then, a regular annual training lasting two to three weeks. The training is always of a practical nature. Where does the training take place? As near as possible to the health worker's village. WHO has prepared a manual, or practical guide, listing 30 health problems which the village health workers deal with. Is he paid for the job? Yes, by the village. Either in money or in goods The job may be full or part -time. Whom does the VHW report to ?The health worker is respon - sible both to the village authorities and to his supervisor/ instructor in charge of the nearest regional health centre. Is there a clinic? No. The village gives the VHW a hut or a room to be used for health activities; but the VHW also makes frequent home visits. What are the working hours? None. The VHW is available any time of the day or night to respond to any emergency calls. He/she does not leave the village without informing the vil - lage authorities. He/ she is, however, encouraged to continue as far as possible his/her other activities, such as farming. QUIZ If you have read this issue carefully, you will have no difficulty in answering these questions: I. Ujamaa: is it an (a) Arabic, (b) Swahili or (c) Bantu word? 2. Tanzania had about 600 rural medical aides in 1972. How many are there expected to be in 1980: (a) 700, (b) 1,500 or (c) 2,800? 3. Rupiah : is it (a) a unit of currency, (b) a drug or (c) the name of a town? 4. Solo: is it (a) a district in London, (b) an Indonesian town or (c) a popular Italian song? 5. Which of these three diseases has been wiped out in Cuba: (a) tuberculosis, (b) gastro-enteritis or (c) malaria? 6. In what country is Rezaiyeh : (a) Indonesia, (b) Iran or (c) Turkey? 7. The Persian word behvarz means (a) a village health worker, (b) a nurse or (c) a doctor? 8. Cuba trained how many doctors between 1963 and 1974 : (a) 800, (b) 3,000 or (c) 5,000? ·;, ·g ~B 'L :q '9 ;;, '5; :q ·p :-r. '£ ; ;, "(: :q '1 :SJ<JMSUV HELP PEOPLE HELP THEMSELVES lP.. There is no single world solution to poverty and .disease. What to do varies according to the type of village, the sort of people, the government, and the problems which need to be faced. People must be asked what they want or need most and helped in all possible ways to do the job themselves. Villagers may ask for help to dig a well or pipe clean water into the village. They can start new village, school or home gardens to proc vide more food for a children's feeding programme. Very simple changes in the way of life can do much to fight disease and avoid premature death. Authors of the month Strengthening of Health Services Dr H. K . Newell is Director of the WHO Division of Strengthening of Health Services Mr 0. Gish is a Fellow of the Institute of Development Studies, University of Sussex. From 1970 to 1973, he served as heal th economist in the Tanzanian Ministry of Health. Dr E. Liisberg is a public health administrator in the WHO Family Health Division. Dr I. Tabibzadeh is a medical officer in the WHO Division of Mrs R. Repond is an infor- mation officer at WHO head- quarters. Dr G. Nugroho has recently been appointed Medical Officer in the WHO Division of Strengthening of Health Services. His special field is community involvement in primary health care. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$ * One year 8.75 Two years 15.75 Three years 21 .- One year: Two years: Three years : £ * 3.75 6.75 9.- Sw.fr. • 25.- 45.- 60.- D D D I enclose cheque/ postal order in the amount of Name: Street: City: Country: • or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland 7 THE SMALLPOX STORY ON FILM he lessons of the eight-year worldwide ctmpaign to wipe the scourge of smallpox off e face of the earth are unlikely to be forgot- ten. But in order to keep ese lessons on record far e future, Wl:fO filmed in colour the prog- AIS$ of the eradication programme as it entered t• closing stages. Cameras recorded the work of surveillance and vaccination teams as they t ned out across Ethiopia, Bangladesh and In- · a, drawing the net ever closer around the last iMatllina pockets of infection, seeking informs- from villagers and local children which would p them to track down every individual .-.. oaa&migbt be a solitary old person, or a 1:1 cleelh m a mudftoored shack or fer frOm afty -tentre of population. ~ nrn.:Jast Sdch a r case, the disease ._. , again kiUing one in of victims and diafiguring or blinding_ ..... e fl ahtliWI hoW the~ shifted from nMion to JJ Jicy of search-and- t; th& WCci n teams tracked ft ,pec;tple sufhtring :f«.tm smallpox and then t.l*4'*' that ~ person who had risked con- tact was protected. The commentator tells us-and we share his hOJ)&-that when the last outbreak has been found,. contained and eradicated we shall have nothing left but pictures like these to remind us of What smallpo)( was. The 15-minute film draws on footage shot in many parts of the world, but particularly two of the last countries where smallpox has been en- demic-Ethiopia and Bangladesh. lt also shows the nerve centre of the whole smallpox eradica- tion operation-the WHO headquarters in Gene- va, where informatkJn arrives from the "battle- front" by telex machines and where a computer hetps the international workers to detect changes and trends in the campaign far away in either Africa or Asia. Copies of the film ,.POINT OF NO RETURN" (18 mm.) can be ordered d irect from t he Film Officer: Division of Public Info rmat ion, WHO, 1211 Geneva 27, Switzerland, price U 10.