Table Of Content(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
Description:is in official relations with the world Health organisation. AM R E F's Primary
health care and the training of community health workers. Training of rural .
Questionnaire . prevention becone a cultural .norn, . rbeyond-the-dispensary'.
