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