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AMERICAN JOURNAL OF Public EcitrisHealth May 1981 Established 1911 Volume 71, Number 5 EDITOR Health
AMERICAN
JOURNAL
OF
Public
EcitrisHealth
May 1981 Established 1911
Volume 71, Number 5
EDITOR
Health for All by the Year 2000
Alfred Yankauer, MD, MPH
EDITORIAL BOARD
Michel A. Ibrahim, MD, PhD
(1983), Chairperson
Myron Allukian, Jr., DDS, MPH (1982)
Paul B. Comely, MD, DrPH (1982)
Sandra J. Eyres, RN, PhD (1983)
Joseph L. Fleiss, MS, PhD (1982)
David Hayes-Bautista, PhD (1981)
Lorraine V. Klerman, DrPH (1983)
Charlotte Muller, PhD (1981)
"Health for all by the year 2000" is the World Health Organization's stated
objective,' and it is also a slogan to mobilize energies towards that goal. It is not bad
as a slogan-but as an objective, is it anything more than wishful thinking? The
article "Low-Cost Health Delivery Systems: Lessons from Nicaragua"2 in this issue
of the Journal does not give much ground for optimism.
An attempt at applying simple health interventions failed. How can we then hope
to implement more comprehensive primary health care programs? The author, Dr.
Heiby, identifies the causes of failure: poor utilization of services because of failure
to recruit patients, and poor delivery of services because of inadequate management
and supervision.
Anita L. Owen, RD, MA (1982)
Ruth Roemer, JD (1981)
Jeannette J. Simmons, MPH, DSc (1981)
Conrad P. Straub, PhD (1983)
Hugh H. Tilson, MD (1981)
The article implies that constraints outside the program's control were responsi-
ble for these problems. This might suggest that the program's failure hinged on very
specific political and organizational obstacles; yet, as the article's title tells us, there
are lessons to be learned here. Especially since we have no structured scientific
methodology to guide us in designing and implementing primary health care
programs, we should look for general principles in this and other examples.3
Joseph Westermeyer, MD, PhD (1983)
M. Donald Whorton, MD, MPH (1982)
First, primary health care
must be appropriate to local conditions. The choice of
STAFF
William H. McBeath, MD, MPH
Executive DirectorlManaging Editor
Doyne Bailey
interventions is inevitably determined by particular local needs, level of develop-
ment, and cultural factors affecting acceptability. But the existing local official and
unofficial health structures are all too often overlooked. Feasible changes in these
structures may substantially improve health services, with little infusion of new
Assistant Managing Editor
resources. On the other hand, as demonstrated in Nicaragua, the structures will not
be amenable to even small changes in organization if the necessary authority is
Michelle Horton
Production Editor
Monica Pogue
lacking. Formal and informal authority is often the crucial factor to be considered.
The tragedy of official technical aid is that the bureaucratic constraints of donor
agencies often exclude the time, flexibility, and initiative needed to understand and
ProductionlAdvertising Assistant
help many local formal and informal authorities promote and maintain appropriate
Richard Carson
changes in the structure of health services. One of these bureaucratic strictures in
Editorial Assistant
CONTRIBUTING EDITORS
donor agencies is a concentration of effort within a single ministry, to the exclusion of
other governmental and nongovernmental structures. It is a credit to the Nicaraguan
William J.
Curran, JD, SMHyg
Public Health and the
Law
Barbara G.
Rosenkrantz,
PhD
program that it identified and recruited a health resource, the trained birth attendants
or "parteras," which was outside the Ministry of Health. It is unfortunate that it did
Public Health Then and Now
not consider the changes in the Ministry's structure that were needed to incorporate
Jean Conelley,
MLS
and support the parteras successfully.
Book Corner
Another constraint is the obsession of many wealthy donor agencies with instant
"national" programs, which precludes testing on a manageable scale before going-
for-broke. This is closely associated with the need to spend too much money too
quickly-the combination of funds and urgency is a steamroller which imposes action
by overpowering the local authority network rather than by improving it.
Second, commitments to the objectives ofprimary health care must be compati-
ble among donor agencies, technical aid personnel, and health authorities at the
relevant levels. Every health organization has many different implicit objectives,
often contradictory. These usually reveal themselves in the workings of the organiza-
AJPH May 1981, Vol. 71, No. 5
459
EDITORIALS tion rather than in official declarations. The most common implicit objectives are better or
EDITORIALS
tion rather than in official declarations. The most common
implicit objectives are better or good health, equity, patron-
age of services, patronage of employment, and bureaucratic
stability-not necessarily in that order of priority. The Alma
Ata Declaration' implicitly includes yet other objectives,
such as socioeconomic development and popular participa-
tion. The description of the Nicaraguan program only men-
tions health but also implies equity as an objective. The
course of events indicates that other objectives were also
important in practice. If these other objectives had been
recognized and taken into account, would the program have
succeeded? Or were they really incompatible with improved
health and equity? Such incompatibility could be recognized
earlier if planning is concerned with assuring the appropriate
support systems to deliver equitable and effective health
services. For instance, if planning sessions can produce no
compromises on the lines of supervision and authority that
are needed to achieve the stated objectives, there is no need
to go further.
whether maximum effect is sought for health or for equity
through the same resources. What is efficient to achieve
equity may not be efficient to achieve health.
The mix of interventions must also be matched to the
persons who will perform the services. The beginning step is
to identify an effective mix and then adapt it to local
conditions. This process is a far more difficult task than
compiling lists of biologically efficacious preventive and
curative treatments8 because it must be done cooperatively
by those providing the technical aid, the authorities, and the
health providers themselves. This adaptation must attain
feasibility without sacrificing the ability to attain the health
or equity targets. If adequate effectiveness is incompatible
with feasibility, one must change the target levels or the
objectives-or scrap the program.
In the Nicaraguan example, achieving any effectiveness
at all required that each partera make a certain number of
patient contacts per year, and this was not realized. Had the
above factors been considered, the importance of patient
contacts would have been recognized and its feasibility
Third, health and other objectives must be translated
into activities with measurable goals. The need for measur-
able indicators is generally recognized, and some of the
necessary characteristics of these indicators have been de-
scribed.4 5 There is less consensus on setting measurable
examined early on.
Similarly, a certain quality of performance per contact
was necessary. The thoughtfulness and care given to the
goals.
Setting such goals requires knowledge of the current
deficits in health indicators (e.g., mortality rates, disease
rates, degree of growth stunting) and knowledge of how
teaching component of the Nicaraguan program reveals the
importance ascribed to task performance. It is therefore hard
to understand why insights about assuring continued learn-
ing through supervision and about assuring the appropriate
structure to motivate adequate task performance came so
much those deficits can be corrected through primary health
late. Fourth, a primary health care system is an organism in
care's mix of interventions. The choice of this mix must
meet various criteria. At least some of the interventions
must be effective in attaining the health goals set.
The evidence for effectiveness in the literature that Dr.
Heiby cites as the basis for the interventions chosen in
which each part must perform its allotted tasks in coordina-
tion with the other parts. Coordination requires an efficient
information system. In the Nicaraguan example, the need for
coordination was recognized for the logistics of medicines.
The existing structure was taken into account and adapted
Nicaragua ranges from the artifactual to the probably valid,
and from major public health significance to none at all.
Unfortunately, in these citations, the better the evidence of
appropriately. It is revealing that medicine logistics is the
only activity in the Nicaraguan example which was mea-
effectiveness, the less important the public health effect.
sured in a continuous fashion. This is because the informa-
tion was needed to assure medical supplies.
The mix of interventions must not only be efficacious-
Similar information systems for supervision and for
capable of achieving biological health benefits-but must
patient referrals depend on a structure that will use the
also be acceptable enough to recruit the people who can
information to take action. Inexpensive and adequate infor-
benefit, so there will be trade-offs between acceptability and
efficacy if a program is to be effective.* Both health and
mation systems9 can be devised if one adheres to two
equity objectives will specify certain sociodemographic and
geographical subgroups as coverage targets, depending on
principles: 1) delegate decisions to the people who will be
most closely involved in implementing them, and 2) collect
*Efficacy refers only to the effect of the treatment when
optimally applied to patients who can benefit from it. Effectiveness
usually refers to health outcomes from programs. If
equity
is defined
only the information that is essential for the decisions. The
furtherthe data gatherers are from a decision and the results
of that decision, the less likely it is that they will collect the
required data in a useful way. Thus, data collection for
patient management and referral and for supervision, logis-
as the availability of efficacious treatment to
those who need it,6 one
tics, and accounting should be an integral part of any
could talk about equity-effectiveness as well. Effectiveness is other-
wise loosely defined in the medical care literature: it is at once any
effect associated with a program, an effect that attains a target, a
ratio between activity or cost and health outcome, a ratio between
an attained health effect and need, and still more ill-defined and
primary health care program.
However, these data are not adequate for determining
need or for assessing progress toward meeting target levels
of health outcomes. This has implications for primary health
often contradictory concepts.6 7 In this editorial, effectiveness is
used to describe a population-related indicator (e.g., deaths averted
per thousand) rather than a cost- or activity-related indicator (e.g.,
care projects where evidence of effectiveness is sought, as
well as for the monitoring of ongoing large-scale public
health care programs.7 10 Systems for evaluating the health
deaths averted per cost or per activity). The latter indicator may rise
as the former falls.
outcomes of primary health care programs are essential-
460
AJPH May 1981, Vol. 71, No. 5
EDITORIALS and such systems must complement the provision of services without compromising them. Too much
EDITORIALS
and such systems must complement the provision of services
without compromising them.
Too much data collection is but one of many extraneous
burdens to be avoided. Once a health care organism exists
there is an overwhelming temptation to assign it more and
more tasks, and smother it. This danger can be averted by
strictly screening every newly proposed activity for its
effectiveness in attaining the objectives of primary health
care, for its appropriateness, and for its effect on the
REFERENCES
1.
World Health Organization and United Nations Save the Chil-
dren's Fund: Alma Ata 1978-Primary Health Care. Geneva:
World Health Organization, 1978.
2.
Heiby JR: Low-cost health delivery systems: Lessons from
Nicaragua. Am J Public Health 1981; 71:514-519.
3.
Gwatkin DR, Wilcox JR, Wray JD: The policy implications of
field experiments in primary health and nutrition care. Soc Sci
Med 1980; 14C:121-128.
4.
Habicht J-P, Butz WP: Measurement of health and nutrition
effects of large-scale nutrition intervention projects; IN: Klein
coordination of the whole. At each step, benefits must be
weighed against what will be sacrificed by implementing the
RE, et al (eds): Evaluating the Impact of Nutrition and Health
Programs. New York: Plenum Press, 1979, pp 133-182.
5.
new activity.
A review of these four principles indicates what can and
Habicht J-P: Some characteristics of indicators of nutritional
status for use in screening and surveillance. Am J Clin Nutr
1980; 33:531-535.
what cannot be usefully extrapolated from one situation to
6.
another: scientific knowledge about biological efficacy and
the process involved in designing a primary health care
program can be; the precise structure and mix of interven-
tions cannot. This insight explains why many successful
Cochrane AL: Effectiveness and Efficiency. The Nuffield Pro-
vincial Hospitals Trust, 1972.
7.
World Health Organization: Measuring the Coverage, Effective-
ness and Efficiency of Health Care: Report of a Collaborative
Study. Geneva: World Health Organization, Document SHS/
SPM 81/1, 1981.
programs are described according to their objectives and
process" and why publication of exact procedures** is
dangerous, because they are too easily adopted unadapted.
8.
Walsh JA, Warren KS: Selective primary health care: An
interim strategy for disease control in developing countries. N
Engl J Med 1979; 301:967-974.
9.
JEAN-PIERRE HABICHT, MD, MPH, PHD
Habicht J-P: Assurance of quality of the provision of primary
medical care by non-professionals. Soc Sci Med 1979; 13B:67-
75.
Address reprint requests to Jean-Pierre Habicht, MD, Division
of Nutritional Sciences, Cornell University, Savage Hall, Ithaca,
10.
NY 14853.
Working Group on Rural Medical Care: Delivery of primary
care by medical auxiliaries: Techniques of use and analysis of
benefits achieved in some rural villages in Guatemala; IN:
ACKNOWLEDGMENTS
PAHO/WHO Scientific Pub. No. 278, Medical Care Auxiliaries.
Washington, DC: PAHO, 1973, pp. 24-37.
I thank Peter Berman, MS, and John Mason, PhD, for useful
11. Maxwell KW: Health by the People. Geneva: World Health
discussions on the content and organization of this communication,
Organization, 1975.
and
Penny Spingarn
for editorial
help.
This is a report of research of the Cornell University Agricultural
12.
Experiment Station, Division of Nutritional Sciences.
Warner D: Donde no hay doctor. 140 Leland Ave., Menlo Park,
CA 1973.
13.
Delgado
HL, Belizan JM, Valverde VE, et al: A simplified
**Individual techniques described as successful by others (e.g.,
health care program in rural Guatemala: The Patulul Project.
12-14
INCAP Scientific Monograph 12, Washington, DC: Pan Ameri-
WHO and INCAP
give a wide range of such techniques) are
can Health Organization, 1980.
often useful as a basis for designing culturally appropriate and
biologically effective programs. None, however, addresses objec-
tives other than health.
14.
The Primary Health Worker. Geneva: World Health Organiza-
tion, 1980.
Do Health Indicators Indicate Health?
Colvez and Blanchet, in an article in this issue of the
Journal, conclude that "
American disability data over
the past decade forestalls any glib talk of a steady, clear-cut
compiled from the NHIS, do indeed appear to support their
conclusions. For example, the reported prevalence of most
chronic illnesses and impairments has risen over the past
improvement in health status, despite arguments to the
contrary based on life expectancy. ' On the other hand, at the
two decades. Even available data from the Center's Health
and Nutrition Examination Survey, in which physical exami-
press briefing, December 5, 1979, at the issuance of Health,
United States, 1979,2 Surgeon General Julius B. Richmond
nations are conducted, fail to show positive changes in
stated that the
health of the American people is better
than ever." Dr. Richmond cited such evidence as decreasing
health status. One of the few areas where improvements
have been measurable is the area of childhood diseases,
especially the recent decline in measles noted by the Centers
infant mortality, increasing life expectancy, dropping mor-
talityfrom heart disease and cancer mortality-all mortality-
for Disease Control. In most other areas we are hard pressed
based statistics.
The disability day and limitation of activity data used by
to cite data-at least survey data-showing improvements in
health status. Yet the recent declines in mortality, improved
access to medical care, improved maternal and child health
Colvez and Blanchet, taken from the National Center for
Health Statistics' National Health Interview Survey (NHIS),
care, improvements in the medical technologies used in
medical care, along with apparent improvements in the
and almost any other time series indicators of health status
health practices of the American people (e.g., quitting ciga-
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461