Study Shows Primary Health Care More Effective in Villages than Previously Thought
Adding to an unfolding debate over the best way to deliver health care to people in poor countries, HSPH researchers have recently published a paper saying that primary health care delivered at the village level may be much more effective than policy makers think.
Allan Hill, Andelot Professor of Demography in the Department of Population and International Health, and his colleagues reported in the February issue of Tropical Medicine and International Health that village-level primary health care can significantly lower the mortality rate of young children when programs are well supported and supervised. The findings differ from previous studies that have suggested primary health care approaches have been relatively ineffective.
Hill and his colleagues analyzed data collected from 40 villages in the central part of Gambia over 15 years. They focused on infant and child mortality rates.
"People have flip-flopped about whether primary health care as a system was a good idea," said Hill. The alternative approach, he explained, is disease-specific intervention for maladies such as malaria and measles.
"Gambia
was a small country that had a reputation for really high mortality rates,"
said Hill. "In the 1950s, more than half of the children died before
their fifth birthday."
In 1978, international leaders met in Alma-Ata in the former Soviet Union at the International Conference on Primary Health Care. The conference spurred efforts to establish affordable, community-based health care systems in poor countries.
As a result, in 1983, Gambia announced its plan for a primary health care system. Health centers and dispensaries were established at the district levels, and community health nurses were stationed in large villages. The community health nurses were paid by the government and were responsible for the people of several villages. These nurses trained and supervised health workers and birth attendants in the villages. The villagers paid for these workers themselves, sometimes with goods such as chickens and eggs.
The new system seemed to work well. Infant mortality rates halved from 13 percent in 1982-83 to 6 percent in 1992-94, and more children were living past their fifth birthdays.
By 1985, more than 2,000 villages in Gambia had access to primary care services. Hill documented that these villagers knew more about the value of health care measures such as vaccines, solid foods for growing children, and oral rehydration therapies to fight diarrheal diseases than their counterparts who did not use the primary health care system.
But the village-level primary health care system was growing in the shadow of disease-specific initiatives, and determining which approach was most effective was becoming increasingly difficult. The determination was important to a government that had little money to invest in health care in the first place. Studies in the early 1990s suggested that broad-based primary health care was ineffective, while "vertical" programs such as the fight against malaria were showing easily quantified, positive results. A political coup in 1994 shook the country, and foreign aid that helped pay for health care halved.
"The flashy, vertical programs have cut across the primary health care initiative," said Hill. "Our study is important because it indicates that village-level primary health care actually makes a difference over and above the vertical health care programs."
The findings come at an important, transitional time in Gambia. Money is now being spent on developing local, private hospitals instead of supporting the village-level system. But as a further sign of an underdeveloped health care system, there are not enough doctors to staff the growing number of hospitals. Gambia is just now opening its first medical school.
"The village health workers are still there," said Hill. "The community health nurses are still there. But they feel that the action has moved elsewhere. They feel undersupported."
Hill said the paper describes a model that seems to work and is affordable and applicable to other poor countries. "This is not a deluxe health care system," he said. "We would not expect the state to provide a nurse in every hamlet, but we can get more out of the community than we give them credit for."
40 villages in the
area of Farafenni, Gambia were surveyed. Villages that use a primary health
care system are starred; those that do not are shown with a triangle.
