Compare and contrast the insights into primary health care provided by Dr. Carl Taylor’s lecture with the insights provided from the other assigned lectures, readings and videos during Weeks 1 and 2.
How are these perspectives similar, and how are they different?
Use specific examples from the course materials to back up your arguments.
Clive Durdle Fri 1st February 2013
Dr. Carl Taylor notes that there are various definitions of primary health care, including:
- First contact between an individual and a health worker, and
- Community orientated primary care, “Simply put, community oriented primary care is the merger of front line clinical medicine with public health.”
The Alma-Ata Conference agreed a comprehensive definition:
The Conference strongly reaffirms that health, … is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity,
The detailed definition, see Appendix, includes all matters required to create both healthy individuals and healthy communities. As such, it uses an ecological orientation, whole systems thinking and action research.
Dr. Taylor notes that within a few years this evolving comprehensive, holistic, learning experimental approach had been overtaken by selective approaches. The World Health Organization had become the World Disease Organization.
Dr. Taylor describes the worldwide many millennia long traditions of meeting with and responding to people with complex issues of childbirth, pain, disease, injury and related matters, and how modern methods relate to these.
World Relief writes:
“Vurhonga is only a child in your village — it is less than four years old. But we have been teaching things that are different from the ways that you have lived for many years. How long will it be before you forget what Vurhonga taught and return to the old ways?”
The grannies talked together for a while and then one of them replied. “We have a question for you. A person has been a slave for many years, but somebody buys them and gives them their freedom. How long will it be before they go back to be a slave again?”
Before the work of care groups, the grannies in this village in Mozambique had been captive to an understanding of disease that to them felt like slavery.
They attributed many diseases and deaths of women and children to the work of spirits and curses. Four years later, far fewer of their grandchildren were dying. The young children were thriving not because the spirits had become more kindly but because their parents and caregivers were taking positive, effective action to prevent or to rapidly treat their diseases.”
Arole and Arole note the importance of creating trust.
Future Generations notes:
“Communities need help from officials, who can adjust policies and regulations to facilitate cooperation among factions and channel external resources. Communities also need help from experts who can build capacity by training, introduce new ideas, and help monitor change.”
“When officials and experts show some humility, community enthusiasm becomes contagious. A feedback loop creates new expectations and standards for everyone. As one change supports another, social pressure builds, and those who do not cooperate are generally bypassed or overrun by the community’s momentum. This momentum will eventually redefine the entire community’s collective future.”
The move to systems where health workers are delivering services, arguably driven by market, efficiency, evidence and quality thinking, may have worsened health outcomes. Polio is probably the clearest example. If agencies had been working in gentler ways, winning hearts and minds, there might not have been the damage caused by the superstitious thinking of a very few Mullahs.
The Christian Medical Commission had much earlier found that hospitals were not meeting the needs of people.
“30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis. New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care.
The Dr. Taylor lecture and other sources are singing off the same hymn sheet, with minor differences in emphases.
The core issue is about how the powerful use their resources, expertise and systems to enable, and not towards their own interests, specialisms, time constraints or bureaucracies. The concept of primary health care has not actually been rolled out properly because existing ways of doing things are very institutionalized. There is a huge amount of work also to be done in cities and developed countries using these principles.
I am not certain this is running anymore:
“Recently I met Sam in Bromley-by-Bow. He welcomed me into his surgery and spent an afternoon showing me around his health centre. In addition to team members such as psychologists, nurses, counsellors, and phlebotomists, the centre also houses artists, stonemasons, gardeners, and stained-glass makers. I must say I never expected to find a communiversity and job centre based at a doctor’s surgery.”
Alma- Ata Primary health care:
- …addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;
- includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
- involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;
- requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;
- should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
- relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
Since 2002, we have enabled community development councils and community action groups create self-help projects, such as water management, small scale transportation, home-based literacy and health courses. Communities have established:
- 365 registered Action Groups with 1,936 members representing local communities and working together to improve governance and meet their basic needs, such as literacy, health and hygiene and income generation
- 933 home and mosque-based classes in literacy, health and income generation for 25,597 beneficiaries, 71% being women and girls
- 114 agricultural workshops for 2,470 farmers
- Youth and sports activities for nearly 5,000 boys and girls
- 80 Community Development Councils (CDCs) and Community Development Plans (CDPs) that prioritize local reconstruction projects, such as wells and springs, schools, roads, bridges and improving local capacity for small scale income generating activities.
Future Generations is guided by an approach that builds the self-sufficiency and independence of communities. The real work and activities are undertaken by locally-hired staff who mobilize volunteers and community action groups. By increasing the skills and knowledge of local action groups, Future Generations supports each community’s efforts to meet its own needs, thereby fostering ownership of projects and creating an environment of self-sufficiency and sustainability.
The Four Principles of SEED-SCALE
NECESSARY CONDITIONS FOR CHANGE
Future Generations researchers and colleagues have been monitoring community-based development and conservation programs worldwide to examine why some programs have succeeded and others have failed. This research concludes that in all cases of success, in which the program has been both sustainable and has gone to scale, four determinants can be found. In all these cases, successful community change resulted from a set of necessary conditions, which the SEED-SCALE process has described as four key principles.
PRINCIPLE ONE: BUILD FROM COMMUNITY SUCCESS
People’s energy and creativity expand as they realize that they are capable of controlling the challenges in their lives. One success becomes the stepping stone for subsequent successes and generates community confidence and forward momentum.
Building on community successes is not the customary approach to social change. Professionals, government officials (and indeed the communities themselves) typically focus on the problems, and a long list quickly develops: poverty, the bad roads, poor schools, political, ethnic, or religious factions, etc. Focusing on the problems emphasizes the deficiencies of a community instead of its existing strengths and capacity. The consequence is to beat the community down through what amounts to amassing the evidence that the community is incapable of solving its problems. The ensuing solution is for an outsider to step in and solve this litany of problems, creating a cycle of dependency.
Identifying and then building on successes, however, is an approach that focuses on building upon the existing strengths in a community. This is a forward-moving constructive effort that focuses attention on community assets rather than needs. Action is then based on an assessment of what is possible, rather than what “needs” to be done. Costs of development go down when attention turns to building on assets, rather than attempting goals that require massive influxes of resources from outside.
PRINCIPLE TWO: THREE-WAY PARTNERSHIPS
Community energy seldom mobilizes by itself. Communities need help from officials, who can adjust policies and regulations to facilitate cooperation among factions and channel external resources. Communities also need help from experts who can build capacity by training, introduce new ideas, and help monitor change.
Our long-term studies of community development worldwide show that success results when communities work from the bottom up, when officials work from the top down, and when experts work from the outside in. All three roles are needed. When governments create enabling policies, change can accelerate in a cost-efficient way across entire regions. When appropriate experts are involved, development ideas are up-to-date, and fit the local ecology, culture, and economy. When communities are true partners (rather than simply being manipulated by governments or NGOs) then these communities can act more effectively to redefine their futures.
Relationships between these three partners must be flexible, and need continuing adjustment. Many projects start out working well, but then flounder because participants do not understand that their relationships need to evolve. Initially, entrepreneurial leadership is important. In the middle stages, expert-led training, monitoring, and experimentation guide the process, with appropriate midcourse corrections. Later, structured systems will better help communities expand vision and capacity. And to facilitate this phase, officials and experts must shift their roles from control to support of community action.
PRINCIPLE THREE: EVIDENCE-BASED DECISION-MAKING
Action is effective when grounded in objective data. Lacking such data, participants will make decisions on the basis of transitory opinions. These tend to be most influenced by whoever talks most convincingly, or whoever holds more power at the moment. Lacking data from local situations, decisions are made on information from more distant situations—which may or may not be relevant. Factions polarize around differing opinions, but with accurate local data, and thoughtful guidance from officials and experts, differing community factions can find an objective common ground for working together. While the principle of basing decisions on local data makes sense, accomplishing this goal is often compromised. The SEED process readily adjusts to local capacity, creating an easy-to-do technique by which every community each year can gather data relevant to its needs. Data gathering (especially using the key indicators of a SEED survey) is a process that can start simply and develop great sophistication over time.
PRINCIPLE FOUR: CHANGES IN COMMUNITY BEHAVIOR
People can come together in partnerships; they can agree on objective data; but, to achieve lasting results they must also change behaviors. While changing behavior for the community may start simply by gaining new skills, those in positions of power—community leaders, officials, or experts—face a more challenging requirement, changing their behavior to share power. This means giving up exclusive control, shifting to guidance that empowers rather than acting to foster dependency.
For example, at first community members must be trained how to execute their tasks. But very soon, community members must be allowed to make mistakes as part of the developing process. After that, officials and experts must rapidly let go, and not just pretend to do so. This shift is especially difficult, but it can be brought on systematically if the seven steps of the community action cycle are repeated each year.
When officials and experts show some humility, community enthusiasm becomes contagious. A feedback loop creates new expectations and standards for everyone. As one change supports another, social pressure builds, and those who do not cooperate are generally bypassed or overrun by the community’s momentum. This momentum will eventually redefine the entire community’s collective future.
 For example http://books.google.co.uk/books?hl=en&lr=&id=oSTkb90xof0C&oi=fnd&pg=PA106&dq=rowan+action+research&ots=3o4qn2PEQY&sig=j2PAjCoBuXIB9ZB4U0V_rBp1Yzs#v=onepage&q=rowan%20action%20research&f=false