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Reproductive and Primary Health Carein Urban Areas Reproductive health care and primary health care are terms and strategies that emerged at different times in different places. Primary Health Care (PHC) emerged first at the 1978 Alma Ata WHO/UNICF conference (WHO/UNICEF, 1978). Reproductive Health Care emerged at the Cairo International Conference on Population and Development in 1994. Though their histories differ, they are close together in espousing better, more thorough and more humane aspects of a fundamental social service, that of promoting health. Thus they can, and perhaps should, be examined together to understand how specific social program can improve the quality of life. For this research design, we first examine the meaning of the two strategies, then lay out specific suggestions for how the can be assessed systematically. Our focus will be on urban areas, but the proposed research design can be adapted to any administrative area or terrain. Primary Health Care (PHC) emerged as a blueprint for a new type of health care system, especially for the Third World, which could provide ghealth for all.h Involving a broad focus on human health that goes beyond the narrow medical orientation that has come to dominate the world, PHC aims to link health more closely to a countryfs economic and social development program. As stated in 1978, PHC gcforms an integral part of the countryfs health
system, of which it is the central function and main focus, and of the
overall social and economic development of In this sense, Primary Health Care has come to have
both ideological and practical aspects. It is built in part in
opposition to what is often called the western medical model that has
developed a powerful technology over the past century or more. That
model is considered a mechanical or engineering model, in which the
body is seen as a machine with parts that can break down or
malfunction, and can be repaired or replaced by technical experts. But
that model is also considered inappropriate for much of the poor world,
where poverty and malnutrition underlie much sickness and death, but
are never seen as part of the health problem. The western model also
implies extensive specialization, both within medical science itself,
and between medical and other sciences. This leads to a narrow
definition of problems, as when medicine fails to see poverty as a
major source of disease and death. It is, finally, a model that is
closely associated with inequality. The providers have all the power
(and acquire considerable wealth), imposing their own decisions and
technology on users who are considered mere passive recipients of care.
This is a system that is criticized for bypassing much of the worldfs
poor. Social acceptability, universal accessibility, and full participation are italicized to emphasize these distinctive and unique aspects of PHC. From this definition, PHC is seen to stand on three main pillars: participation, intersectoral collaboration and equity. Individuals and communities must be actively involved in promoting health. Medical and social sciences must be closely interconnected. Good health and health services should be available to all. While this broad notion of Primary Health Care has
some attractive qualities as aims for the human community, there are
problems with this conception when we come to asking practical
questions about a health delivery system. There have been systematic
attempts to assess national health care systems to see how closely they
come to the PHC model (Fry and Harder, 1994, for example) but these
appear extremely complicated, and the connection of any specific
dimension to actual indicators of health is not clearly established.
What measures of ehealthf are to be used? What do ecommunity
involvementf and eparticipationf mean and how can we assess them?
Furthermore, how do we assess their connection to whatever health
measure we choose to use? These are not mere pedantic questions. They
seek to understand how we can operationalize the PHC concept to find
how when we have more or less PHC. And they ask a most fundamental
question: is PHC in fact related to better human health? In order to examine Primary Health Care in Asian urban settings, we propose taking a somewhat narrower view of the PHC system. We begin with one basic aspect of PHC as defined at Alma Ata, its front line character. PHC is considered gthe first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care processh (Declaration of Alma Ata, VI). In addition, we propose to focus on two aspects that seem especially crucial, quality of care, and people participation. While the PHC movement includes norms of good service, quality of care as a distinctive measurable concept has emerged and been developed more in the area of family planning and reproductive health. In addition, focusing on people participation is based on the recognition that people are both the means and the ends of the service system. Finally, however, in order to undertake a study that will have immediate and direct practical applications, we propose to focus primarily on the medical delivery part of the overall health system. We also believe that it is both important and practical to ask questions about the public health issues arising from environmental conditions. Thus we propose that both the medical delivery subsystem and the public health subsystem of primary health care are areas in which systematic research can yield very practical results. Reproductive Health Care is a term that gained widespread currency in the 1994 International Conference on Population and Development (ICPD), held in Cairo, Egypt (Singh, 1998, Population Council and PRB, 1999). The 1994 ICPD was the third in a series of international conference launched by the UNFPA in its distinguished tenure as the leading International Governmental Organization for population issues. Like the preceding Conferences, this produced a Plan of Action adopted unanimously by 180 countries. But this Plan of Action differed considerably from those of the past. It placed the status of women and the broad issue of reproductive health at the center of the agenda. It gwas a remarkable turning point in that governments formally recognized that the health, rights, and well-being of the individual lie at the core of sustainable development. Reproductive rights, including access to quality reproductive health and family planning services, were established as key to this consensus. (Population Council and PRB 1999, p 1) Many of the elements of reproductive health have received attention in the past and have seen the development of useful operational definition. Maternal and child health care, including immunizations and nutritional services, are a core point of service. Major outcomes can be measured in infant, maternal and child mortality rates. In addition, there are family planning services, with data on the availability of contraceptives, the contraceptive prevalence rates and the total fertility rate as major measurable outcomes. Lying behind these objective measures of outcomes are more subtle, but also more powerful measures of political commitment and the willingness of governments to do what is necessary to provide the good services that implement reproductive health care. II. A Conceptual Design of a Reproductive and Primary Health Care System To develop a research design of this part of the RPHC system involves first the identification of a model of the system. After a model is defined, we can go on to propose ideas for operationalizing the model, or specifying the types of questions and respondents that should be included in the study. One important caveat is in order at this time, however, and we shall repeat it throughout this statement. The model we propose will be a somewhat general one, and the specific questions or data gathering that operationalize the model are only suggestions. They outline a broad framework for research. But in each city, the general model must be adapted to specific local conditions by knowledgeable social and health scientists. That is, the research design is to be adapted to the local situation, not adopted for it. We shall return to this emphasis at many points. The diagram below provides one way to think about a
reproductive and primary health care (RPHC) system. The purpose of the
diagram is to identify a possible system in which the political
commitment of local authorities and the participation of local
communities work together to design, maintain, and render services to
obtain the best outcomes desired. It can thus help to guide research
that will assess a reproductive and primary health care system, and
identify point at which government policy or other interventions might
help to improve the system. The following discussion provides
some details on the elements identified in the system, starting with
the outcomes, but them moving generally from left to right. The basic desired Outcome of the RPHC system is that every family and its members are being given proper health services so that they remain healthy. To measure whether the services reach the intended clients we should have proper prevalence measures. All these indicators should then be compared with various mortality and morbidity rates. The most basic mortality data are Infant and Maternal Mortality rates (IMR and MMR), which are especially useful in examining the large difference between rich and poor countries. For countries with highly productive economies and well-developed health delivery systems, more refined measures should be used. These should be decided upon for each individual case, but usually they will include rates of respiratory and gastrointestinal diseases, or in some cases of excessive environmental degradation, incidence of various carcinogens. In addition various measures of preventive care should also be noted. These include such things as the contraceptive prevalence rate (and one of its main outcomes, the total fertility rate) as well as rates of immunization for common preventable diseases. Affecting these outcomes are two major categories of conditions: broad Contextual factors and more specific Program conditions. In the contextual factors there is another important distinction to be made, shown by the horizontal line in the lower part of the diagram. This divides two subsystems, which we call here the gMedical Delivery Systemh and the Public Health System. While a broad-based primary health care system would normally include both of these sub-systems, they are often separated by agency specialization, which requires deliberate strategies integrate them into an effective overall primary health care system. This specifically speaks to the gintersectoral collaborationh that is one of the main pillars of PHC movement. The Contextual Factors include four sets of conditions. The Political administrative system includes the governmental system, the character of political power, the commitment of political leaders, and the aims or goals that the central political system embraces (Ness and Ando 1984). But it also refers to the administrative capacity to carry out and implement the goals that the government sets out. This set of conditions is addressed largely through qualitative analyses using expert or knowledgeable observers. The second of these contextual factors is the countryfs Socio-economic structure. This includes primarily the wealth of the country and the economic base of that wealth. But it also includes a more subtle set of conditions, such as the character of class divisions, the gap between the rich and the poor, and the extent to which the society can translate its wealth into human welfare. The latter can be assessed quantitatively by the UNDPfs Human Development Index, and especially by the difference in the HDI and GDP ranking of any country (UNDP 1998). This is in large part reflected in the amount of resources a country allocates to health and other social services. The third of the contextual factors is what we call
the Community Structure and Commitment. This includes development of a
community concern for public health measures, conditions of community
organizations for primary health care, and how the community allocates
its resources for primary health care. For the study envisioned here,
the researcher could make use of secondary data available in the
community, usually these data are of a more ethnographic or
anthropological character.. It is the Program Factors, however, that seem most
amenable to direct policy intervention, and which can be a major focus
of this study. These begin with what we call the RPHC Policy and
Management System. In most developing countries government priority
given to social services in general is the dominant force in shaping
all of the program factors. It will be important to identify central
governmentfs aims in its primary health care system, and to assess the
extent to which the government has the resources to implement its
program. Specific questions on this issue are provided below. This
system will be affected by a combination of the political
administrative system, the socio-economic structure, and the community
structure. For example, a strong and welfare-oriented government will
decide on an effective RPHC system. At the other end of this
political-economic spectrum, a weak and repressive political system
will not give high priority to reproductive and primary health care. In
addition, a wealthy economic structure will give the government more
resources to implement that program, and, conversely, whatever the
government does establish might be constrained by a very poor economy.
Finally a community with a strong commitment to reproductive and
primary health care will both push government to provide better
services, and will take fuller advantage of whatever services
government does provide. Client-provider interactions constitute a relatively new arena of research and policy formulation. This is the arena that defines quality of care and what can be called client satisfaction. It has become increasingly evident that quality of care varies greatly in different programs and areas within the same program, and is the most immediate determinant of the health conditions of the society. When patients or clients are treated with respect and kindness, when they are considered intelligent human beings, they respond more positively to treatment and benefit more from it. When they are treated as stupid and below the status of those treating them, they typically withdraw and benefit little from any proscribed treatment. We propose that quality of care is affected both by specific program characteristics, e.g. the kind of training care givers receive, and by the cultural and economic background of the clients themselves. Caldwell has shown, for example, that where women are more independent and have high levels of education, they tend to demand better care for their children, and follow instructions more effectively (Caldwell, 1986) All of the conditions identified in the diagram can be further specified by questions and research methods that constitute the research design of this study. In what follows we suggest various types of questions and sources of information for all of these elements. But two things should be kept in mind, which we shall repeat for emphasis. First, all of these conditions fit together, affecting and being affected by one another. They should be examined as parts linked to one another in an overall system. This is especially important for the design of interventions to improve any of the characteristics of the system. Second, the specific questions to be asked and the specific sources of information will differ in all cases. Individual country study directors must decide what to ask of whom to develop an accurate picture of the reproductive and primary health care system, and a picture that can help government officials take practical steps to improve the performance of the system. Again, the design should be adapted to, not adopted for the in-depth study. Now, however, we must turn to those specific questions and make suggestions about sources and respondents. III. The Research Design: what questions are to be asked of whom? A. Basic Questions and Respondent Selection We can specify five broad questions to be asked in this study of urban reproductive and primary health care. What is the character of the reproductive and primary health care system? Specific questions can be designed to elicit information about each of the boxes in the system diagram above. (Below, we specify further the elements in each of the boxes.) What are the major health problems of the city? Here one can focus on the box called gOutcomes.h How does the RPHC system affect the human health in the cityfs population? Here the attempt is to understand the connections between the boxes, which the diagram shows as arrows, indicating causal connection. What is the perception of the population being served? This concerns the real knowledge, attitude and practices of the people being served. The responses to these questions can be compared with what the system purports to offer to reveal how well system conditions fit with community conditions. How can the RPHC system be improved to provide better for the health of the cityfs population? Are there any plans to expand or improve the system? Are those plans derived from an understanding of both the health problems and how the system works to address those problems? 2. Three levels of research effort We can also suggest three different levels of
research effort, depending on the resources available for the study in
each city. The levels differ primarily in the sample of people who
provide answers to the four questions. Before discussing these levels,
however, we must make a distinction between informants and respondents,
which also distinguishes two broadly different research methodologies.
The three levels of research effort involve different sets and numbers of informants or respondents. They are listed here from the most restricted to the most inclusive. Political, community and technical leaders can be
used to describe the system and its aims, the cityfs problems, and
current plans or ideas for improvement. Political leaders would include
the Mayor and possibly elected members of the city council if one
exists. Community leaders would include the Chairmen of NGO and other
Community Organizations, as well as religious leaders. Technical
leaders would include the directors of the various parts of the health
system. For example, this might include a medical director, a public
health director, and a director of family planning. They would be
interviewed at some length to have them describe the system, the cityfs
health problems and ideas for improvement. The leaders should be asked
about both the public and the private parts of the system. Researchers should examine others reports to determine if studies have been made of the health care system, and can include summaries of these studies in their report. In addition, the researchers should collect whatever objective data are available, including health system budgets, staff and facilities, mortality rates, causes of death, and incidence of major diseases. It would be most useful to collect data for at least the past ten years to note changes that are taking place. Political, community and technical leaders PLUS
system providers, especially at the primary care levels. System
providers includes the medical and nursing staff at the primary clinics
and lay workers, such as family planning workers, who link users with
the system. Insome cases, there are also education workers whose task
is to increase the populationfs awareness of health issues and ways to
improve their own health. Here a decision must be made about including
the private part of the health care system. To reduce costs, it is best
to focus on the public part of the system. Moreover, it is the public
part of the system that is usually most amenable to change and
improvement by government. Nonetheless, it must be recognized that a
private system exists alongside the public system, and the relation
between the two should be considered by the researchers. Above PLUS System Users. In addition to political leaders and system staff, the clients or users of the system can be included if resources permit. This expands the research substantially, but it is especially useful to include the users and potential users of the system. Users can be sampled in a number of ways, but there are two common research tactics: exit interviews and areal probability sampling. The simplest is to use what are called gexit interviews,h asking people who are leaving a primary health care facility to provide responses to a standard questionnaire. In addition to general background questions, respondents can be asked why they came to the facility, how far they traveled, how long they waited and what kind of care they received. They can also be asked for suggestions on how health care can be improved. (Suggested questions are shown below.) Although exit interviews are the easiest and least expensive way to provide user views of the system, they typically miss what might be an important part of the population, those who use the system only rarely or not at all. If people do not use the system because they have had bad experiences with it in the past, the exit interviews miss this important information. The alternative to the exit interview is an areal probability sample, with respondents drawn from households, selected by random sampling techniques. This will provide more information about the system, but it also greatly increases costs, and researchers may decide that the additional information to be obtained may not be worth the additional cost. This is a judgement that must be made locally. B. Suggested questions and information We can suggest types of specific information to
be collected and questions to be asked by using the boxes of the above
diagram. It is especially important for local researchers to view these
as mere suggestions. Each situation will require the development of
specific questions and data collection relevant to that situation. The
questions listed are somewhat general. They will have to be shaped into
specific formats depending on whether they are to be used as checklists
for informants, or standardized surveys questions for respondents. Not
all questions will be equally relevant in all situations, and other
questions may have to be developed for situations not anticipated in
this design. Again, this design should the adapted to local conditions,
not simply adopted. 1. Contextual Factors How strong is the central political system; how
capable is it of making effective policy decisions, and assuring that
those decisions will be implemented? How much initiative does it give
the city government? b. Socio-economic structure How wealthy is the society (the nation and the
city)? What are levels and growth rates of GDP and GDP per capita for
the nation and the city? Are budgets for health considered adequate?
What proportion of GDP is allocated to health? Has this risen or
declined over the past decade? c. Community Structure and Commitment Have communities developed their own primary health care institutions? Are community leaders involved in the process of planning and implementing primary health care services? Are community members paying their own reproductive and primary health care? How much conflict is there in the community: between families, ethnic or class groups? How much solidarity is there in the community? To what extent is the community capable of acting as a single unit in requesting government RPHC services and in making use of the services available? d. Health related environmental conditions Are environmental regulations in place and implemented to control water, sewage, garbage, and polluting water and air emissions? Are medical officials associated with these environmental controls? 2. Program Factors This is the point at which the overall general goals of the system can be described. What are the overall goals of the system? How are preventive and curative goals balanced? What populations is the system designed to serve? What are the front lines of the system, the point at which it first meets the population being served? Is the local community seen as a group whose participation is necessary and useful? Are local community leaders asked for advice on program design and service delivery? b. Program Characteristics What are the numbers and characteristics of the
front line workers: how many doctors, nurses, other paramedical
workers, lay workers? What is the density of workers (i.e. population
per doctors and nurses)? Are doctors available at all times of clinic
operation? c. Client Characteristics What are the characteristics of clients: age,
sex, marital status, parity, reproductive status, literacy, ethnicity,
class or economic status, occupation, etc? d. Community and Family Participation. To what extent is the community involved in RPHC services? Are women and men equally permitted to seek services? Do community leaders take an interest in reproductive and primary health care? Do they encourage members to obtain the services that are available? e. Client-Provider Interactions (Quality of Care) Quantity of contacts: how far must clients travel
to the clinic; how long do clients wait for service; how long is the
normal visit with the provider; how often do clients visit the clinic? 3. Outcomes What proportion of the people receive high quality reproductive and primary health care services? What are the general health conditions of the city's population? Consider typical rates, including IMR, MMR, Contraceptive Prevalence, incidence of respiratory and gastrointestinal ailments, incidence of various infectious diseases; causes of death. Also consider other preventive measures such as vaccination, nutritional education and other educational programs designed to promote health and well being. Caldwell, John, 1986, gRoutes to Low Fertility in
Poor Countries,h Population and Development Review, Vol. 12, No. 2 pp.
171-220. |
