PRIMARY HEALTH CARE

SOUTHERN NEW HAMPHIRE UNIVERSITY
AND
OPEN UNIVERSITY OF TANZANIA


COMMUNITY ECONOMIC DEVELOPMENT
ASSIGNMENT : PRIMARY HEALTH CARE (PHC)IN DEVELOPING COUNTRIES.
PROGRAMME : MSC. CED
COURSE TITLE : PRINCIPLES AND PRACTICES OF ECONOMIC DEVELOPMENT

CODE : ICD 533
CENTRE : ARUSHA

STUDENT NAME : KASSIAN SIA
LECTURERS NAME: DR. JUMA KADUANGA
SUBMISSION DATE: 22 OCTOBER









PRIMARY HEALTH CARE (PHC) IN DEVELOPING COUNTRIES

Learning from Structural Adjustment Programe of mid 1980s in Tanzania



Abstract:
This paper aimed at focusing on Primary Health Care in developing countries particularly Tanzania in relation to Structural Adjustment Programe (SAPs) of mid 1980s. Nearly three decades a wide range of health development frameworks have been advocated to improve the health of the population in developing countries. Primary Health Care has been the leading theoretical concept for delivering health services to the vulnerable groups. However, Structural Adjustment Programs (SAPs) through Health Sector Reforms have influenced health service delivery positively or negatively. The paper is organized in five parts namely an introduction, theoretical review, empirical review, policy review and conclusion.


























1.1 Introduction

In 1978, governments around the world signed the Alma Ata Declaration[1] with the aim of achieving Health for All by the year 2000 through the Primary Health Care (PHC) approach (Mahler, 2000). PHC calls on public health systems to meet the needs of the poorest and challenges all sectors to see health as a right. Basically, PHC should be understood in holistic phenomenon because it is a cross cutting issue in which it emphasize on multisectoral, intersectoral, community involvement and appropriate technology upon which the nation/society should rely in order to have a healthier population (ibid).

Dating back from 1950s and ‘60s many developing countries faced an overwhelming task. Economic recession meant that many could not even start to imitate the West’s medical model of health based on hospital medicine and high technology however, different model of care emerged, which recognized that the health of populations was determined by factors other than medical care and that these factors could be controlled by communities themselves, through collaboration with other sectors such as agriculture, water sanitation and education in a spirit of self reliance and self determination.












1.2 Theoretical perspective of health
In order to arrive to the subject mater which is Primary Health Care, it is important in the first place to focus on various model of health which had been put forward by different scholars. Each model was dominant depending on the time framework and environment. The models which have been put forward by different scholars are first, medical model, second, socio-epidemiological model, third, sociological model and lastly political economy (Marxist perspective).

Medical model
This model was dominant in mid nineteen century due to scientific achievement in clinical medicine, scientist discovered how to control and cure disease with penicillin vaccinations and sterile techniques (Macdonald, 1993).It emphasize treating specific physical disease and does not accommodate mental or social problems. The basic argument put forward is that human being is health when he/she is in perfect working order thus the body works like a part of the machine. If the heart does not pump the blood somebody would die.

The medical model was so powerful, in the sense that, it even influences national policy on health in which medical profession maintained a monopoly on knowledge about medicine, health and human body. The medical model was challenged and was seen as not a best model in addressing the health of the people. It favors minority especially those who had financial resources to afford doctors, drugs and health environment.

Socio-epidemiological model
This model advocate that the distribution of disease is related to the structure of social inequalities such as occupational class,socio economic status, gender, marital status,age,ethinicity,area of residence,housing,family structure and employment status.

It advocates that many diseases have social bases and the role of medicine is not of paramount important. Health services and medical provision should not be direct to disease mechanism but to underlying causes of diseases.
Thus, the model suggest the following; medical professional should concern on why disease occur, care should be over and above cure that is care for the individual and not for treatment and environmental and risky factors should be found.

The model was challenged by the medical practioners due to anomality in the sense that while the cause of the disease is within the context of social dynamic, cure and care goes back to medical model i.e. individual taking care of the individual. Also the model differ on the potential cause of the disease their views converge to the individual for instance socio-epidemiological focus on individual lifestyle such as smoking destroy health(victim blaming ideology).

Sociological model
It advocate that social relations (such as social support for individual and social capital or social cohesion for communities play a key role in determining the health of the individual. Some scholars argue that capitalist imperialism influences the presence and distribution of illness in developing nations, through the transfer of modern medicine, industry and technology from the west which is motivated mostly by profit-driven pharmaceutical companies. They argue on the premises in which medical model operates which tends to concentrate on cure and not prevention, individual and not population and physician and medial doctor tends to focus on the disease.

Political economy/Marxist model
The political economy perspective provides a broader political and economic framework, arguing that exploitative relations existing in capitalist class create conditions of deprivation in which some people must struggle to maintain health. It claims that there is a contradiction between the pursuit of health and the pursuit of profit.Diferentials in health can be seen among social classes due to unhealthy work environment of the lower classes.
Illness is seen as a product of exploitation of capitalist society i.e. concentration of economic power, industrialization hence those economically powerfully state exploit the poor. This perspective has been criticized for failing to recognize the substantial health gains that have accompanied capitalist development and for proposing scenario with little opportunity for intervention or change.

Major efforts have been made to identify alternative health care systems where health resources could be used to respond to the needs of the majority of the people (McGilvray, 1969).There have been tremendous efforts to ensure that there are proper health care system which reach the grass root people in a sustainable manner in this case Primary Health Care (PHC) has been taken as a best approach to ensure people have access to health facilities, sanitation measures and the like in an affordable manner.

1.3 Conceptualizing Primary Health Care
Primary Health Care is based on three pillars which are multisectoral approach, community participation and equity (Gilson et al., 1998). It turns the individual, the family and the community into the basis of health system, and it turns the primary health worker as the first agent of the health system that the community deals with into the central health worker.

The multisectoral approach
Health does not exist in isolation. It is influenced by a complex of environmental, social and economic factors ultimately related to each other. Therefore the health of the poor is largely influenced by combination of unemployment, poverty, low level of education, poor housing, poor sanitation and malnutrition. Basing on these facts it is undoubtedly that illness is produced by socio-economic conditions thus there is a need for different sectors to collaborate so as to control the situation.

Community participation
The view that health was the absence of disease which could be realized through the delivery of medical services emerged as a dominant idea in mid 19th century. The view was influenced by the remarkable scientific achievements in clinical medicine because the scientist discovered how to control and cure disease with penicillin, vaccinations and sterile techniques. Priority was placed on complicated scientific research and specialized clinical education regardless of cost.

In mid 1970s peoples mindset began to change and thus health of a person was no longer determined by the medical professional but it rather a response of individual, community or government. Arguments basing on community participation were as follows;

Firstly, most communities, health resources are scarce thus there is a need for resource to be mobilized by communities themselves for example community health workers are needed to increase resources at low cost.

Secondly, health resources are better mobilized and utilized when the community helps to formulate its own plans.
Lastly, it is a process in which community can question and redefine health goals with a view of having health policy determined by the community itself. [2]

Equity
According to Gilson (1998), equity can be defined as fairness, absence of disparity in health or in their major social determinants. This suggest that public resources should be used in funding those activities that do most generate health (promoting allocative efficiency), and that such activities should themselves be undertaken in the way that maximize health gain (promoting technical efficiency).

Equity is judged by assessing the extent to which health care should be cost effective in generating health status of the people, communities are benefiting rather than for individual using them and people are willing to pay at affordable cost.
Those who promote equity agreed that social determinants such as class and income are the major obstacles in bringing health status of the society (Gilson, 1998).
They argue that resources should be distributed equally especially to poor by improving health, education and nutrition. This will enhance the people to sustain their lives and participate fully in normal lives.

1.4 Policy Review
Structural adjustment policies of mid 1980s were concerned with changing the structure of the economy over medium or long term. The policies aimed at economic expansion or expanding tradable aiming at improving the balance of payment (Kanji et al.,1991).

The philosophy underlying SAPs is that African economies have been distorted therefore the solution lies on adjusting the economies. They argue that private sector is able to promote production in a more competitive and efficient manner than the state sector (ibid). SAPs came up with some packages to mention the few, such as reduction of government expenditures in social sectors and introduce user charges in health, education etc. Furthermore, privatization of government enterprises and retrenchment of workers was also advocated.

Many developing countries including Tanzania have adopted SAPs as a solution to solve both social and economic problems prevailing in the respective countries. Since SAPs advocates the countries to undergo reforms in all sectors, the health sector has to undergo reforms as the best solution to ensure effective provision of health service to the people.
Reforms in health sector are likely to be influenced by external changes and the pressure rather than epidemiological and demographic factors (WHO, 1997).However, there is no convincing evidence that these policies have had any beneficial impact on population health (Gilson and Mills,1995,Bossert et al.,2003).

Health sector reforms are based on the assumption that public sector is incapacitated to operate as effective provider of health care. The advocates of health sector reforms such as World Bank, IMF etc tend to focus their arguments within the narrow confines of efficiency and effectiveness. They argue that privatization of health sector will promote competition in health services and the state should only undertake minimal intervention in economy and social welfare.

The health sector reforms are generally characterized by number of changes,
Firstly, most countries undertake reforms in the organization and management of the health system such as organization structure at various level and management style. For example changes could be on staff patterns and health care facilities.

Secondly, reforms are undertaken in the area of health care financing i.e. introduction of user fees, cost containment measures, social insurance and re-allocation of resources.

Thirdly, reforms deal with health care delivery, such as the use of large number of health volunteers and non governmental organizations, increase role of private profit/non profit facilities as well as community facilities.

Lastly, reforms take place as part of changes in civil service structure and administration, such as decentralization, deconcentration and devolution.

1.5 Empirical Review
The quality of life to a great extent depends much on the availability of social services including health as well as education. Prior to the 1980s in Tanzania, the district hospitals, community health centers and other outreach health posts provided medical services and essential drugs free of charge.
During the period characterized by Ujamaa policies, which can roughly be considered as the period between 1967 to the late 1970s, Tanzania attained a variety of successes in social development initiatives. Private schools and hospitals were nationalized; the government began providing free education and health care services.
Through the primary health care development strategy, the government built many rural health centers and many secondary and primary schools. The budget for social services was massive. As a result, literacy rates were high, access to education and health care increased for the majority of the people, and the standard of living improved.
Many people acknowledge that in the period before the SAPs things were relatively better. This is not to say that policies were perfect, but now under SAPs, the government has abandoned those redistribution policies which focused on improving the quality of life for the majority of the people. Expenditure in social services has been reduced drastically thus the majority of the people are having difficulties in accessing good education and health care (Lugalla 1993: Lugalla 1995).

Lack of sufficient budget in most of African governments has made difficult to support the health sector which paralyzed the public health system. There was no money for medical equipment and maintenance, salaries and working conditions declined. In one African country, a medical officer in the public sector was earning only US$ 49 per month. With the emergence of private hospitals, tens of thousands of doctors and health workers fled the public health sector (Cassels, 1994b).
A number of World Bank reports describe the impact of the SAPs among them include Public Expenditure Reviews, Participatory Poverty Assessments and Social Sector Strategy Reviews. Following expenditure cuts during the 1980s, health care centers in Zambia lost qualified personnel and basic health materials (World Bank, Zambia PER, 1992).
In 1985, the government budget for drugs and supplies in Madagascar decreased to 20% of the 1977 level, and only 10% of programmed medical imports were realized. The low level of government expenditure allowed the primary health care centers to cover only 25% of patient drug costs (World Bank, Madagascar PER, 1996).
In Nigeria, capital investments were suspended, and the drastically reduced recurrent expenditures could not support such routine functions as payment of salaries, supply of essential consumables (drugs and instructional materials) or maintenance of facilities. All of this resulted in a significant decline in the quality of services (World Bank, PPA 1996).
In Tanzania, health system performance suffered because of lack of training and poor motivation of doctors and health workers, shortage of supplies, breakdown of transportation and inadequate management. The quality of hospital care declined dramatically, and clinics became increasingly crowded (World Bank, Tanzania PER, 1991).
Reforms in health sector have made women and marginalized groups to suffer the most. The process of privatization leaves large sections of the populations, particularly the rural poor and the majority women depend upon on the shrinking public sector, while the private sector expands rapidly and become more costly and available only to those able to pay. This becomes difficult for Primary Health Care to function which advocate delivering health services at affordable manner.
Many developing countries are facing shortage of qualified medical staff as a result of migration or “brain drain”. In Ghana, for example 12,365 health professionals including 11,325 nurses left the country between 1993 and 2002 for greener pasture. Health professional have no promising future in developing countries in terms of salaries and other fringe benefits. It is very strange in many developing countries including Tanzania that people of high caliber such as medical doctor get low salaries unlike politicians and members of parliament who are better paid.
There has been lack of political will to implement the Primary Health Care, insecurity and lack of resources. Lack of attention has been in the public sector policy such as the impact of services on demand, public sector efficiency and allocation of budgets ( Filmer et al., 2000).However, plans were consistently made according to perceived need of the policy makers and not on the availability of resources (Rhodes,2004,Reidy & kitching,1986).

Structural Adjustment Programmes and Health Sector Reforms have affected the health sector tremendously. Literature shows that these programmes have contributed to the deterioration of the state health care provision and have had negative impact on health (Watts, 1997).
1.6 Conclusion
Majority of developing countries have to learn from others who have achieved a high level of health outcomes despite being poor. It will be useful when African policy-makers are constructing their Poverty Reduction Strategy Papers. China, Sri Lanka, Barbados, Malaysia, Costa Rica and the Indian state of Kerala are ideologically, geographically and demographically diverse, yet they have low incomes and are high health status achievers. These countries were implementing the vision of comprehensive primary health care long before the Alma-Ata Declaration, paying particular attention to system building and intersectoral action for health. The role of public action in demanding health services and better living conditions was also crucial for their success. WHO suggests that countries in the African Region do more than paying lip service to the implementation of the Alma-Ata principles. Development partners in health have a duty to assist in this endeavor.








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[1] Report of the International Conference on Primary Health Care,Alma-Ata,USSR,September 1978 Geneva,World Health Organization,1978.
[2] These arguments of community participation were articulated by Jerry Stromberg of the Division of Strengthening of Health Services, WHO, in private correspondence, September 7, 1979.