(cid:631) 「 |▼ AMREF The African Medical and Research Foundation (AMREFI is an independent non-profit organisation which has been working for more than 25 years to improve the hearth of peopre in Eastern Africa,-mostry in Kenya, Tanzania, southern Sudan and uganda. AMREF runs . *id. variety of innovative pro- iects with an emphasis on appropriate low+ost health care for people in rural aieas' Proiect funds come from government and non-government aid agerrcies in Africa, Europe and North America as well as from private donors. AMREF is in official relations with the world Health organisation. AM R E F's current programme includes: - Primary health care and the training of community health workers Training of rural health staff through continuing education,teacher training and correspondence courses ioumals and health education materials Application of behavioural and social scierrces to healt'r improvement - - Airborne support for remote health facilities including surgical, medical and public health services Ground mobile health services for nomadic pastoralists - Medical radio communication witr more than 1OO t*o-Way radios - Medical research into the control of hydatid disease - Maintenance and repair of medical equipment - Health project development, planning and evaluation Consultancy services in programme areas mentioned above - For further information, please contact AMREF headquarters at Wilson Airport, Nairobi. Postal Addres: AMREF, P.O. Box 30125, Nairobi, Kenya Telephone: Nairobi 5013011213,5OO5O8 Telegram: Afrifoun, Nairobi Telex: 23254 AMREF ・■ :、,F■11 ` 、Albucueralle NM 87冨添 BEYOND THE DISPENSARY (oN GMNG COIIIIUNITY BALNICE TO PRIIIIARY HEALTH CARE) Roy Shaffer Community HeaIth lforker Support Unit African ttedical and Research Foundation This brief work owes a lot to Kingr l{erner, }lorley and Bryan, writers whose personal-experience-based writings ushered in a new era of rationalization and de-mysticization of health eervice and motivated thousands of other connunity health workers, myself included. The writing draws nainly upon the field experiences of nany friends, particularly Geraldine, Janet, GiIl' Davidr Penina, llattie, Dan and Leda; colleagues who pioneered pathways of trust 'beyond the dispensary'. llost important of all have been the CHt{s themselves. When you consider their position you nust agree that in most cases their endeavours are noble. Through their selfless service and'example they are ushering in a new era of lnspired health service- [ the people. January, r9g4 First cdition published and printcd by thc African Mcdical and Rcscarch Foundation tt Rcprintod 1986 English prcss,.p.O. Box 3012?, Enrcrprisc Rosq Nrirobi, Kcoyt R€printed l99r by the African Medical and Research Foundation, Wilson Airport, P.O. Box 30lzs,Nairobi, Kenya CONTENTS SUMMARY Page BACKGROUND l CBHC 。.. ... ●0● 0● ● ●0● ●00」 ●●● ” ４ why cBHc? 。 。.. 。.. 0● ● ●●● ●●● “ ５ Who is lnvolved in CBHC? 。 。.. .● ● 口 ６ Health Committees 。 。.. ... ... ” ６ What is a CHw? . .。 。 。。. ..0 00● ” ７ RecOgnition/Renuneration/Time..。 ... 口 １０ Per●onal Relationships .。 . ..。 。。。 ” １０ Reciprocal RespOnsibilities 。.. :。 ” １２ . Objectives ... 。.● ●●● ●●● ●oo ● １３ Prevalence ... ..● ●●● ●●● ●o● ” １３ How does CBHC start? . ..。 。.. .● ● ” １４ TRAINING .. ... ... ... oo. ... ” 19 Organization ... ..o ... .?. ” 19 l{gthOdS ... ... ... ... o.. “ 20 Check List ... ... ... ... ” 23 'Startersr ... ... ... ... ” 24 tshorgdt .o ... ..r o.. ... “ 25 Objectives .. . .. . .. . .. . 口 27 Training of Trainers (fOT) . .. . ” 28 EVALUAT=ON ... ... 口 29 KAP . ... 。 。。。 ” 29 strunents 。。. ” 29 C=■hanges .. 。 。。。 ” 31 UNCERTAINTIES .。 ... 。。。 ● 33 THienailntgh w it。h.o。u t 。。e。 d ic。i。n.e " 33 ‖ ● 34 Voluntari3m ... ... 35 Governnent 。.. ..◆ “ 36 Politic8 。。。 .。 ● ●●。 " 38 " =HPLICAT=ONS FOR CLINIC=ANS 。.。 。.. ... 39 CONCLUS=ONS 。。。 ... ... ●●● ●●o ooo 40 APPENDICES 41-90 APPENDICES No. Title Page Related to text A AIna Ata Declaration 41 2 B Rec iprocal ?esponsibil ities 43 13 C Programmes 43 14 D How to Start 44 18 E TOT Courses 46 28 F Connunity Survey Forn 47 30 G tsealth Happenings 48 28 H Questionnaire 49 30 I Interactions 51 34 J l,tiscellaneous practical Notes from the Support Unit: (IIST) 51 l. Survey Suggestions 52 31 2. Organization of workshop 54 28 i 3. Evaluation n 55 28 4. Lesson Check List 55 28 5. Teacher Self-Evaluation 56 28 6. "trliss-conceptionst 57 14 7. iWHYi and questions 57 14 "COULD" 8. Guidelines 58 4 9. Six Issues 60 4 10. 'rvlAzro talk topics 63 11. vIAzI, leprosy) 65 "lrloRE ( 12. ltajor questions to CommunitY 66 14′ 31 13. tlinor questions to CommunitY 66 14′ 31 14. Inf ormation 67 4 CIIWSU 15. HeIPer Newsletter 68 28 16. "If OnlY' PlaY 69 18′ 28 L7 . llidwives Exchange 70 7 18. 73 31 'Change CuPboard" Graphics fron the SuPPort Unit 74 \ 1. Arm Circumference 75 31 2. 'Bottle Bunduki' 76 19′ 31 3.- Building Blocks 77 18′ 28 4. DemograPhY CuPboard 78 18 5. First Aid Reminders 79 31 5. 4-Fs 80 31 7. Kibiriti Kit 81 31 8. Latrine Slab 81 31 ・ 9.. LeakY Tin 82 31 10. Malar ia lledicine 83 22 ll. Mix Colours 83 22,31 L2. l-l-l Diarrhoea l{ix 84 31 13. Prevention bY Immunization 85 31 14. Problem Tree 86 29 15. RelationshiPs 86 11 16. to health (modified) 87 31 Road 1?. Snakes and Ladders for TOT 88 28 18. A Good Stool 88 18 I9. Sun-Saf e l{ater 89 31 20. Saf e-Saving llud Stove 89 31 2L. VIP Latrine 90 31 22. Protected SPring 90 31 SUMMARY Public disenchantment and economic constraints related to health services have been approaching the intolerable in all countries of the world.- Hence in 1978 tfHO and UNICEF convened a conference at Alma Ata in Russia to re-think and rationalize health services- The resulting concettsoe thinking bore the label 'Primary llealth Care' (PHC). This p-ia€ Per considers the rarnificatons of the PHC approach as occurs 'beyond the dispensary" aa a Connunity-Based IIeaIth Care (CBHC) development. CBIIC is seen as a practicable way to narrow the widening gaP between health needs and the resources to meet those needg. The key elements are voluntarism, rnotivation and prevention. The key hunan resource people are Eealth Comruittee members and Comnunity Health l{orkers (CHws). The CHI{ is prinarily a catalyst of changed responsibilities, habite and conditions in her (nost CE$s are womenl neighbourhood. The CHW therefore must be permanentt nature, exenplary and a good communicator. Literacy is not a high priorityi Voluntarism and popular selection are of the esssence as is conmunity commitment to moral support of their CBW. The CHt{ts primary focus is on her inmediate neighbours. But she is also involved in a host of other human interre/lationships, both vertical and horizontal. A CHW nust be part of a network of reciprocal responsibilities which inter-relate facilities, cadres, philosophies (particularly the cure,/prevention balance) and modes of approach to people. ThecBHcapproachstrivesfornoredef@'ofresponsibitity for health promotion, better balance between cure and prevention, nore voluntaristic input in6TEiSysten, increased awarene sensitizationand bett6r cross-disciplinarv at CBHCr ES the title implies, should have been born in the ninds and hearts of local people. It should crystalize around a self-help approach to specific preventable problems, not around a dispensary. Traininig of CHWs generally takes place in the local community and does not last more than a week to start with. The curriculum should be felt by the cHt{ trainees to have emerged fron their comnunityrs needs. The nost suitable teaching nethod is the learner-centered-problen-posing nethod popularized by Paulo Freire. A- !"y feature of thla nethod is the rgtarter' or rcode. whlch poses the chosen probrer in i s"-tt"itt"rng-r.i] The well trained cHtf wirl be able to notivate her connunity towa_rds changes Ln r_eeponeiblllty, hanite and eondltiong _invotving notherhood, Eleanlrnesi, i;;e' and dlsease controt. Evaruatlon of her inpact on the cinnonity rs iiiii-roai"."ti"y. There are about thirty speclfrc cni-Jountable changes of habits and-conaition ,ni.rr-.ie erpectable aune uoaultlcyo hnaeg o afn t hinet uCiHtiWvres ngortaivspa toiofn t hoef shteart en eoigf frUouisa.a The CHI| these developnents. The chalrenge is to at"i"e survey nonitorlng lnetrunentg whiih are-r"itrfngrof ana'uansdiiur to her. A number of uncertainties Btill cloud the scene. Iflll GBEC the CEtfrg individual reservolr of voluntarlsn fiit untif le reuarded by neasureable changes in her netghbourii traleithgea Can connunities (and doctors) be reaned off thlir flxatlon on a pi11 for e_very problen and a needle for every need? can- they be_ led to believe oore confidently in .hlalth wlthout nedlcine'? can part-tine voluntarlsn, pronoting prevention becone a cultural .norn, and an optibn for cloelng the needs/resourceB gap? Flnally the paper points out that cBBc is nore conplenentary to than conpetitive rith fornally trained clLnlciane. CBEC helps then to be rather than INBXT-PERTST. BXPERTS ,- BACKGNOUXD Throughout the uorld.there hag recently beon rideepread and lncreising dlsenchantnent rlth health care ln terre of lts a"".e"iUtiity, and affordabiltty. Developing countr-les ln particular aie being forced to re-evaluate their health aystels ln terus of cost and effectlveness. In thig connectlon, WEO and Uf,ICEF ln 1978 at Aha Ata (AA), Russia, launched a calPaign to achleve 'Eealth for tIl by the year 2000' through Prlnary Eealth Car€ (PBC). Prior to AA, -prinary care' to noet peoP1e leant first contact caret J finitLa use of the erpregglon. lhe AA declaration broadened the use of the word 'prinaryr' putting greater enphasis in prlncipte upon the connunity and its 'partlclpationt self-rellance and gelf-deternination.' Baged on the phraseology of the declaratlon, Prinary Health Care stands for essentlal care that ie: accessible - accegtable affordable - all-lncluelve (lntegral) all-together (participatory) at the centre (is the nucleug)and anenable to self-reliant lnltiatlves Furthernore, ln the AA terns of reference, pEC renders the folloring types of servlce: - pronotive - prevantlve curatlve and rehabllltatlve and covers the follorlng problen areass nutrltlon - rater sanltatlon - naternal,/child health furrunlration enderlc diseaseg - education treatnent. The AA erpharla upon connunlty lnvolvclent ra8 not a neu ldea. Shattuckrs Reoort of the Sant.larv Cgnltssto f850 erpha reeponslblllty. But the personar and colluntty erphaals shattuck put forth tn 1850 dld not galn ruch groun-e then, for tro reagoD8o Plrst, an era of rapld devcloplcnt of large corporate rater works was startlng in f,agsachusetts. Th" resulting reduction in prevalence of rater-related diseaEes temporarily took the pressuie off local community health serviceg. Then, at the turn of, the century greal breakthroughs in bacterlology and innunization and, latei, chenotherapy put great enphasis on'the nen in white coatsr.t - There ensued both a popular and professional fixation on the institution- c_entered 'pill for every_ problen and needle foi need' (PENN) approach to heilEh. This (ppNN).xpln"s"tiitvrd r curative- ^donina'.tlil. approach becane eatrenched in the irest, ario iC spieao 'to the Third lforld. There its burgeoning. eosts 6egan to hin-d-e--r and even reverse progress tgwards bltter health in f-ridgll;t independent nations. By the aid l9?0s it was obvioug.that something ras going to have to change. so at Alura Ata the forner comnunity orientation sas revived, re-articulated and -qe-promoted as Fuc, which was to becone ihe nucleus of the health system. see Appendix A for core AA statement. PHC is not a new system as much as it is a nee enphasis and grdering of priorities, with the community beconing nore central in the schene of things. One could say the AA emphasis is upon naking that first contact more peripheral, more participatory, nore personal and more sinple. But the AA declaration did not define 'primary'. Neither did it give specific exanples of the Where, lilho, tfhat, Eow, etc. of PHC. AA did, however, broaden the use of, the word prinary to include nore than its prion meaning did, i.e. the new u6e neant more than just a sickness episoder a single point in tirne/plaee. Regarding the "where', AArs geographical use of 'prinaryi went in theory beyond the nost peripheral establishrnent facility. It went right out to the viJ.lage and the home. Regarding the "who", the title 'prinary worker' uas transferred fron the lowest and least formally trained establishnent worker to the infornally trained-Jlillgger ffieighbours. In answering the question '$Ihat', AA tended to shift the balance of the enphasis slightly fron sicknesa care to health care, i.e. from getting cured to c'taying healthier. As to rllow'PEC was to work, the enphasis in theory 8hifted towards the active (prevention, self-prophylaxis, Eelf-referral) and aray f,ron the passive (being helPed, being referredr being cured, being told). A sinpliflcatlon of the above AA lnferences night be thig: 'Priniry Bealth Care referg to the firet thing an ordinary villagel does for hin/hereelf right in the home to avold getting sick.' 2