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Hospitals and Primary Health Care


An International Study From the International Hospital Federation

visionary worldwide
health care leadership

by Rufino L. Macagba, MD, MPH A report on world-wide survey on the Role of Hospitals in Primary Health Care Sponsored by the International Hospital Federation and funded by the W.K. Kellogg Foundation of USA

Edited by Melissa Hardie, HA, SRN, PhD

International Hospital Federation 126 Albert Street postage London NW1 7NX England

Hospitals & Primary Health Care


Introduction

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

By its constitution, the aim of the International Hospital Federation (IHF) is to promote improvements in the planning and management not just of hospitals alone, but of health services in general. However, it has to be admitted that in the past many hospitals have not been actively involved either in the formulation of PHC strategies or in their implementation, but the scene is now changing, and changing rapidly. Many IHF members live and work in big cities and in 1975 the IHF started to promote surveys in a number of the world's largest cities to help identify some of the main obstacles hindering the improvement of standards of health and health services. Another objective of these surveys was to identify and publicise some of the more noteworthy initiatives that were being taken to overcome these obstacles. The surveys showed that in almost every city deficiencies in PHC were recognised as being the most critical problem -but at the same time there were reported a number of very imaginative and effective ways in which hospitals were promoting, supporting or providing PHC. Hospitals, like human beings are likely to respond more positively to encouragement to build on what is being done well than to criticism about what is being done badly. On this basis, the IHF felt that it could usefully try to gather from its member associations and hospitals examples of noteworthy innovations and developments in hospital/PHC relationships, in urban and rural areas alike, following the principles successfully demonstrated in the IHF project on Good Practices in Mental Health that started in 1977 and still continues. A number of pilot studies in the late 70's produced promising results, and it was as a result of these that an approach was made to the W.K. Kellogg Foundation of USA for financial support to extend the study on a wider scale. This approach brought a generous response and led to the appointment of Dr Rufino Macagba to undertake the project, which is reported in these pages. With active encouragement and support of the World Health Organization and its Regional Offices, Dr Macagba was able to identify and contact many hospitals all over the world that are actively involved in PHC, and it is of course their efforts that form the basis for this report. It would be fair to say that although the project has shown that more hospitals are more deeply involved in PHC than many people expected, it is equally clear that more hospitals could do more. The project will have achieved its objective if it encourages those hospitals that are doing well to do even better and stimulates those that are doing nothing to do something.

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7. 8. 9. 10. 11. 12. 13. 14.

Miles Hardie Director-General, I H F

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Health Development International

Forward
Over the last twenty years there has been increasing dissatisfaction about the relevance and effectiveness of national health systems in both the developing and the industrialised countries. Many people have been seriously questioning the highly sophisticated -and, it follows, expensive -medical technology, which is widespread throughout the system and particularly in the hospitals. Is it having a real impact in relation to its cost? Many have given voice to an awareness of the need for compatibility between the services provided by the conventional health delivery systems and the most prevalent health needs of the majority of the population. In the industrialised countries the increasing costs of health care had reached a level which no health system -governmental or private -could pay for without falling into bankruptcy; at the same time, people were realising with increasing clarity that they were fast becoming passive objects under a medical care system far beyond their understanding and which they could neither participate in nor control. People were tiring of figuring as numbers on computerised lists, considered as "cases" and not as human beings. Any sense of responsibility for their own health was progressively receding in the minds of individuals, the family and the community. At the same time, in the developing countries people complained that large segments of the national population were not even being granted health care as a basic human right. It is not unusual in developing countries to find between 40% and 60% of the population without access to any form of permanent health care, whilst in the capital city problems just like those found in the industrialized countries were rife and in flagrant contrast to the neglected populations living mainly in the rural areas, the small urban communities and the poverty-stricken belts of the big cities. Many aspects of the health system were questioned. Was there no way to put into practice the old aphorism that "prevention is better than cure"? Were hospitals (enclosed within their own walls and treating advanced stages or sequelae of diseases that could be well prevented outside their walls) the only way of providing an effective _health care? Were physicians the only human resources to be used in all cases, or was there, in fact, a real range of health care activities that could be safely delegated to other professionals, other non-professional health workers and even members of the family, if not the patient themselves? Could other activities be promoted outside the health care delivery system that would contribute, perhaps with more impact in certain cases, to the positive health status of the population? Such activities would be, for example, the provision of clean and safe water; proper sanitation; good nutrition, and even activities concerned with such factors as better education, improved income, proper physical exercise, health habits, etc. Were all the technological developments applied to health care of the same value, equally justified and of the same effectiveness in all societies, or were there serious limitations in their use -financial, economic, cultural, etc? How many of the technological innovations were either "cosmetic" or of very limited, marginal effectiveness, out of proportion to their high cost and fast technical obsolescence?

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Forward (part 2)
All these questions, and many more, challenged the development trends of the conventional health services delivery systems; and all contributed historically to the approach which today we call "Primary Health Care", an approach which is defined in the Declaration of Alma Ata which emanated from the consensus of all countries in the world. The term "Primary Health Care" however, lends itself to a certain degree of distortion and misinterpretation of its real meaning. Primary Health Care is not just the most peripheral level of the health system but the approach to be applied when considering the whole system, up to the level of the most sophisticated and specialised hospital or research institution. Primary Health Care is not a vertical programme, operating on a parallel with but independent from the conventional health services delivery system, with primitive technology, elementary activities and non-professional health workers, oriented to serve at very reduced costs the poor populations in the rural areas, the small urban communities and the marginal belts of poverty in the big cities. On the contrary, Primary Health Care is the way in which the health system -and not only the health services delivery system -can be reoriented to serve the totality of the population of a country in such a way that everybody will have the possibility of access to any level of health care when really needed. Primary Health Care is not a package of activities that has been dreamed up in an industrialised country, at a university or in an international agency for paternal/colonial-style delivery to a passive population. Primary Health Care is concerned, rather, with the way in which the necessary health services are provided. This calls for the active and continuing participation of the people in deciding on priorities; in the selection of technologies that the country and the local communities can really afford; and in delivering the activities as well as in monitoring and controlling the system. Primary Health Care also calls for inter- sectoral action and the coordinated involvement of all those who may contribute to bringing about an improvement in the health situation far beyond the mere treatment of diseases. Finally, Primary Health Care provides a concept through which a given country may equate the most feasible solution for the health problems of the majority of its population with its available health resources -both current and potential. Within this picture, hospitals have a very important role to play in promoting, supporting and providing Primary Health Care not only in developing countries but also in any country, whatever its degree of economic and social development. Dr. D. Tejada-de-Rivero Assistant Director-General World Health Organization Geneva

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Acknowledgements
A large number of national and international colleagues and health care workers have contributed to this review of the roles hospitals play in supporting and developing Primary Health Care (PHC). The project was initiated by the International Hospital Federation (IHF), London, and made possible by a travelling fellowship grant from the W.K. Kellogg Foundation of Battle Creek, Michigan, USA. Strong endorsement of the project came from the World Health Organization (Geneva) and WHO Regional Offices lent their support throughout the world. Special thanks are due to the health workers in the 400 hospitals that took the time to respond to the survey, and to the hospital associations, which conducted their own surveys in cooperation with the study. Dr. Florence M Tadiar of the University of the Philippines Program in Hospital Administration, contributed significantly by visiting and reporting on 10 selected hospitals with innovative PHC involvement in India, Bangladesh, Thailand and Indonesia. Gracious hospitality was extended to the project fellow by many hosts during his visits to hospitals and to special contacts in Australia, Egypt, Hong Kong, Indonesia, Israel, Italy, Kenya, Mexico, Philippines, South Africa, United Kingdom, and the United States of America. To these, and to family and friends who gave much practical assistance, the author offers sincere thanks.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Health Development International

WHY SHOULD HOSPITALS BE INVOLVED IN PHC?

Primary Health Care (PHC) is a strategy now internationally accepted as the most important means of meeting the health needs of people in communities around the world. To implement this strategy and improve the general level of health amongst populations and in individuals, cooperation and efforts must come from all quarters of the organised health care field, the public and social services, and from people themselves in their communities. Hospitals, usually looked up to for leadership in the total health care effort, cannot do the job alone but ideally can contribute to the comprehensive plan of attack. Why should a hospital be involved in PHC? The answer is in the mounting crisis in health care in the world today. In industrialised countries, people over-eat, oversmoke, over- drink, over-drive, and over-stress themselves. There are the poorly educated who have problems in nutrition, and infectious and parasitic diseases; and in knowing how to utilise the health services available to them. In some developing countries, up to 80% of the people have no access to decent health care, and 75% of health budgets may be spent on doctors and hospitals providing curative care for a small minority. In the meantime, one person in" two may never see a trained health worker, one in three drinks unsafe water, one in four have an inadequate diet, and there are one billion instances of acute diarrhoea occurring in children under age five each year. The consequences are millions of premature deaths. Hospitals can and must play an important role in helping to overcome this crisis. PHC became widely publicised after the WHO/UNICEF International Conference on Primary Health Care, held in Alma Ata, USSR, in 1978. The Conference issued the famous Alma Ata Declaration, which defined PHC and declared it to be the main vehicle for the attainment of Health for All by the Year 2000.1 The Declaration recognised the failure of conventional professional health strategies in improving the health of communities around the world, and especially of the poor in developing countries. In 1981 a WHO report stated that: "There appears to have been little or no progress in recent years in reducing either the incidence or the prevalence of the many diseases that plague the less-developed countries. The need for anew approach to meeting people's basic health requirements grew out of more than a simple dissatisfaction with the basic health services. There was and there continues to be growing concern about the low health status of the majority of the world's population, especially the rural poor. ---------------------------------------------------------------------------------------------------------------1. An extract from the Alma Ata Declaration appears in Appendix 1. Health systems are characterised by a medical orientation, no attempt being made to develop mechanisms that take into account the important contribution other sectors can make to health. For instance, few ministries of health are in a position to promote health by working with ministries of agriculture on improved food and nutrition programmes."2

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

WHY SHOULD HOSPITALS BE INVOLVED IN PHC? (part 2)


It had become imperative by 1978 for health professionals to be questioned on what they were doing about the long- standing inequities in health care. That which could be seen was in one sense admirable, but in many others distressing, because of its inadequacy in preventing malnutrition and disease. Health workers were, and still are being trained in sophisticated, expensive and institutional patient care. In most cases, they have too little orientation and interest in health issues in their communities while most health problems are in communities, not in hospitals and clinics. Too many are working in, and strongly prefer, hospitals and clinics in cities and large towns where they can have higher earnings and a more comfortable life, and more easily obtain professional advancement. Too often health professions resist attempts to permit non-professional workers to diagnose and treat patients, even in places where the professionals refuse to go. In many rural areas of developing countries, where 50-80% of people live, professionals are too sophisticated and expensive to serve. It often appears that their main desire is to make hospitals and clinics better and better equipped to take care of the minority who go to them. PHC, alternatively, is a return to basics in order to serve the majority. It attempts to reverse the tide of more sophisticated health care for a privileged few. This attempt is being made in the developing as well as in the industrialised countries, where unhealthy lifestyles are affecting the physical, mental and social health of the people. PHC is a new philosophy as well as a strategy to take health care to the people; it promotes the diagnosing and improvement of health status for whole communities rather than for single patients. It means re-orientation and reorganisation of health services to add comprehensive care for the community to traditional curative care for the individual. PHC requires the use of new management skills in planning, organising, leading and controlling the results of PHC programmes. Practical management principles and techniques can be learned in short workshops and can be supplemented by reading and continuing education programmes, seminars or workshops. It means involving the people themselves in their own health care through better diet, proper exercise, simple remedies for common minor ailments, and general improvement in lifestyle. ----------------------------------------------------------------------------------------------------------------

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2. World Health Forum, The World's Main Health Problems, 2 (2): 264-280 (1981).

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

It also means that mass communication and marketing skills must be used the maximum, so that other disciplines outside the organised health care field can contribute to the total care effort. It means involving agriculturists, public workers, business establishments, legislators, and other leaders at all levels.

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5

Health Development International

WHY SHOULD HOSPITALS BE INVOLVED IN PHC? (part 3)


HOW PHC WORKS
In developing countries: In developed countries:

Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Community education programmes Stress control and crisis management Added training to traditional midwives Encouraging and training community health workers Teaching nutrition Maternal and child welfare Clean water and provision of sanitation Immunisation programmes Weight control and dietary improvement Life-style modification Special access programmes for disadvantaged groups Family-oriented ambulatory care, in hand with emergency care Health screening Care of adolescents and elderly

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PHC is therefore a response to the health needs of today, and even of to-morrow, until a better way is discovered. With certainty the professional and institutional approach has failed to provide effective PHC. The hospital of to -day can learn from this failure and re-orient itself to support and implement new trends in health care, for the sake of the people to whom all institutions owe their existence. The aim of this report is to try to show what hospitals can do, and in increasing numbers are doing, to promote, support or provide PHC.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Health Development International

DESCRIPTION OF INTERNATIONAL STUDY

The purpose of the international study on the role of hospitals in PHC was primarily to help develop the partnership between hospitals and the communities they serve. Focus was put on what health care activities hospitals generated, or took part in, beyond traditional in-patient and outpatient care. How are hospitals responding to unmet health needs in communities? How do they keep themselves abreast of these unmet needs? Are there good examples of successful programmes and partnerships in health care, which could be adopted or adapted for use by other hospitals in other countries? Initiated in 1981 by the International Hospital Federation (IHF) in London, and with the collaboration of the World Health Organization (WHO), a Travelling Fellowship was created to carry out the study. The W.K. Kellogg Foundation of Battle Creek, Michigan, USA, generously funded the project over a three-year period. The Project Fellow completed the study, and submitted his report in 1983, his findings forming the basis of this report. Survey forms and techniques used within the study, however, are still being employed in several countries, where the collation of information and good ideas is thought to be useful and stimulating to greater involvement of hospitals in PHC. Scope of study The emphasis within the general programme of visits and reports was placed upon developing countries, although some examples of innovatory projects were included from developed countries. The aim was to include examples of PHC involvement by hospitals in each of the six WHO regions, from urban and rural hospitals, government and private, and from large and small. Such aims and emphasis necessitated correspondence with hospital associations, ministries of health, WHO regional offices, and many other related organisations and people. From them some outstanding PHC programmes in their respective countries or regions could be identified. Survey methods A simple but useful method for obtaining, describing and-analysing hospital-related PHC innovations were devised. A major worldwide statistical survey was not projected as this would not be appropriate to the descriptive, case-study approach, which was wanted. Co-operation from the recommended hospitals was needed, so that much information could be gathered prior to selected visits for further study. When visits were made, the purposes of the study were furthered by encouraging appropriate organisations, usually hospital associations to continue the collection, analysis and dissemination of information on hospital-related PHC innovations. Such communication and review would inculcate the partnership, which the project was established to promote, and act as spring- boards to continued efforts.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Health Development International

DESCRIPTION OF INTERNATIONAL STUDY (part 2)


Over 800 survey forms were distributed by post in 105 countries. Over 400 hospitals responded to Form I, which is a checklist of hospital involvement in PHC. From that primary survey, it was learned that hospitals were involving themselves in the following activities in various combinations: Health promotion Preventive health care Family planning Health education Curative health care Physical rehabilitation Integrated hospital/community care Training Administrative support Research/surveys/studies A fuller explanation of these categories is included in the next chapter. A second questionnaire (Form II) was completed by over l00 hospitals, giving a much more detailed description of the hospital's PHC programme. On the basis of these two questionnaires, and subsequent visits to selected hospitals, an extensive descriptive report was written. In summarising that report, this handbook does not attempt to provide all details of every hospital's involvement in PHC activities. Instead, the general themes, as listed above, are discussed in the light of some of the practical ways in which they have been introduced in specific places. Fourteen outstanding examples of PHC participation, as selected for the full report by the project fellow, are included in greater detail. It is hoped that these examples of ideas and programmes may stimulate other hospitals to adopt, adapt or study a wider range of PHC activities. If so, this study will have gone some distance towards achieving its ambition of promoting the closer partnership of hospital and community in the health care field. Special awards may be given to outstanding efforts by hospitals, which involve themselves in PHC. The Australian Hospital Association, for example, has such a scheme and widely publicises the work of the winning hospital each year. Inter-hospital visits and exchanges are also to be encouraged, because health workers have much to learn from each other's experience in PHC. Ministries of health, hospital associations and universities can review, publicise and even reward out- standing hospital PHC programmes to encourage increased support. One conclusion of this report is that PHC needs this kind of support if it is to succeed.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Health Development International

DESCRIPTION OF INTERNATIONAL STUDY (part 3)


A brief summary of project statistics Method By Mail By Visit 13

Countries 105 surveyed Hospitals surveyed Asia & South 334 Pacific Africa, Middle East, 54 Europe The 36 Americas Total 424 Hospital association survey set

19 11 6 36

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A practical outcome of this study, as briefly mentioned above, was the preparation of a set of survey documents. These were provided to national hospital associations, which stated an interest in carrying out a PHC review project in their own countries. The set consisted of the following components: a) A personalised covering letter outlining the purpose of the project. b) An introductory letter from the IHF. c) An endorsement letter from WHO. d) Sample covering letter for use or modification within the relevant country. e) Questionnaire (Form I). f) Optional one-page questionnaire (Form II) on noteworthy features of PHC work. : g) A form letter for confirmation of intention to participate in survey h) Addressed return envelope. Sets were made available in English, French and Spanish. It is expected that some of these documents will continue to be used in follow-up projects, so some of them have been included in Appendix 2. The questionnaires were designed to be short and simple, hopefully avoiding the waste of valuable health care time for the respondents.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

DESCRIPTION OF INTERNATIONAL STUDY (part 4)


It is of special interest to note that a number of organisations in various countries have already made use of the survey set, or have stated their intent to do so. Amongst those who have conducted their own surveys are the Costa Rican Hospital Association, the Indian Hospital Association, the Voluntary Health Association of India, the Korean Hospital Association and the Philippine Hospital Association. Several associations have indicated their willingness to under- take their own studies and these include the Indonesian Hospital Association, the Hospital Boards Association of New Zealand, and the Brazilian government hospitals of Sao Paulo State, The American Hospital Association and the University of Washington for Health Services Research provided information on US hospitals with innovative PHC involvement. The latter is in the final stages of a six-year study of hospital-sponsored primary care group practices in the USA.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses
Worldwide, 424 hospitals participated in some way in the project. Because of the thorough and excellent study of their own hospitals by the Philippine Hospital Association, 200 of the total respondents were from that country. Also conducting their own studies in order to contribute more substantially were the Voluntary Hospital Association of India (39), the Costa Rican Hospital Association (7) and the Korean Hospital Association (17). These figures included both governmental and non-governmental hospitals. Those hospitals, which completed the survey Form I as their mode of participation in the project numbered 207 (leaving aside the special tabulations from the Philippines and Korea). Of the 207 responses made direct to the study project, 71 were from government hospitals and 136 from nongovernmental hospitals. For the purposes of exploring the general themes of PHC, which were found in the study, a brief review of categories included follows, for the 207 hospitals only. 1. HEALTH PROMOTION goes beyond the prevention of diseases to actively improve physical, mental, social and even spiritual health. Considered within this category were activities such as lifestyle change or improvement programmes, physical fitness, dental care, nutrition, education, stress control, dental care, youth counselling, and marriage and motherhood preparation. The most frequent type of health promotion done by the 207 hospitals being analysed was nutrition education. Sixty three per cent of hospitals had such programmes within the hospital; 48% supporting programmes in the community; and some 31% giving help to other projects being sponsored in the community. The target groups for nutrition education were of wide-ranging and specific nature in type, such as for pre-natal patients, hospital visitors, and other special groups such as diabetics. Lifestyle improvement programmes dealt with promoting good health habits and healthy living, covering topics such as smoking, sleep patterns, drugs and alcohol, eating habits and stress control. Approximately a quarter of hospitals were involved in activities relevant to these topics both within the hospital and in the community. A quarter of hospitals also supported physical fitness programmes, mainly with exercise projects to promote muscle tone, joint flexibility and cardiovascular integrity. The second most frequent health promotion programme among the 207 hospitals was dental care. Support was given, for example, to regular brushing, care and inspection of teeth, topical fluoridation of the teeth, water fluoridation and attention to calcium intake. The least-conducted programmes amongst the 207 hospitals are those devoted to stress control. They are more frequent in industrialised country hospitals, since for example there are over a million deaths annually from stress-related diseases in the USA (heart attacks, hypertension, strokes, etc). Stress control programmes are rapidly becoming one of the most important and most frequently conducted health education activities in business corporations in the industrialised world. This study found 11% of hospitals sponsoring programmes within hospitals, and 7% sponsoring them in the community, with about 4% giving help to other projects.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 2)


Youth counselling programmes include both counselling and other mental health projects directed to adolescents and teenagers. These may also include pairing adolescents with elderly people who live alone, and health career guidance programmes, as in the CREATE and SHADOW projects of the North Central Bronx Hospital, New York City. About 15% of hospitals in this study had such programmes operating within the hospital and 12% in the community, with 9% contributing help to other community projects. A quarter of hospitals sponsored marriage and motherhood preparation programmes in the hospital, 21% in the community and 16% contributing to other projects. Other health promotion programmes included school health, geriatric advisory service, family welfare, clubs, assertiveness training, social skill training, drug and alcohol control programmes, care groups, eye care, health screening, and mother and child care, and about 12% of hospitals supported or participated in these activities. 2. PREVENTIVE HEALTH CARE is another broad-based category of activities related to general health status in the community. Activities included within this category for the study were the following: safe drinking water, waste disposal, vector control, immunisation, supplemental feeding, and food production (family gardens). Immunisation was the most frequently reported preventive health care activity among the 207 hospitals analysed. The great majority of children in developing countries are not immunised with the standard vaccines, which have proven themselves to be effective against serious diseases such as poliomyelitis, pertussis, tetanus, diphtheria, measles and tuberculosis. Measles is the Number One killer of children in Africa. Another important need is tetanus immunization of pregnant women in developing countries, because of the high incidence of tetanus neonatorum among the newborn delivered without aseptic precautions by indigenous and often untrained midwives. Of the hospitals in this study, 69% had immunisation programmes at the hospital, 53% in the community, with 33% aiding other community projects in this work. Diarrhoeal and other water-borne diseases remain one of the most frequent causes of morbidity and mortality in developing countries. The diseases are usually caused by unsafe or contaminated drinking water. , Teaching or helping the people to obtain safer drinking f water can be one of the most effective PHC activities in these countries. A third of the hospitals in this study had safe drinking water programmes within the hospital, 32% sponsoring projects in the community, and 22% giving help to other projects. Related to safe water programmes are waste disposal methods. Thirty per cent of hospitals gave special attention to this problem in the hospital, 24% having programmes in the community and 20% aiding other projects for the purpose. The range of activities included the promotion of safe disposal of garbage and human waste, which remain major causes of enteric, fly and vector-borne diseases in most developing countries. Rural areas and urban slums especially face acute problems with waste disposal.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 3)


Vector control programmes deal with control of flies, rats, mosquitoes, etc, including the drainage of stagnant water. The importance of these is seen when it is realised that 200 million cases of malaria, 200 million cases of snail fever (schistosomiasis) and 40 million cases of river blindness (onchocerciasis) exist around the world (1976, USAID report to Congress). One-fifth of hospitals in this study reported programmes within this category, with one-sixth reporting special programmes in the community. Food programmes include those for supplemental feeding of c special groups, as well as programmes devoted to food production. The supplemental feeding is usually for children under five, accompanied by nutrition education of the mothers and those taking care of the children. Poor families may also benefit from these programmes, which 34% of hospitals reported having. Thirty per cent sponsored feeding projects in the community, and 21% gave help to other sponsors. Approximately one-fifth of hospitals were involved in some way with food production. In the hospital, food production projects can be for the patients, the staff or even for the community, using vacant land that hospitals sometimes have. One major cause of malnutrition in developing countries is lack of food. Even farmers may lack food for their tables because they need the money they get from selling their produce. Small-scale home gardens, poultry and small animal projects for home consumption can make a significant difference in the vitamin, mineral and even protein intake of the family, especially of the children. The distribution of seed or seedlings for home gardens, and education concerning protecting produce from loose animals, can do a lot for nutrition improvement. Fishing villages often have little food during the rainy season, and can benefit from this sort of project. Training farmers to increase their production can also result in more food for the table and improved family nutrition. Other preventive programmes reported by hospitals included pre-school projects, health talks, care groups, special clinics, breast examination and stop-smoking clinics. In addition hospitals have been active in the encouragement of zoning regulations.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

3. FAMILY PLANNING is one of the most effective tools in combating the continuing problem of the 'population explosion'. Without family planning, improvement in the effectiveness of health care only aggravates the struggle. On the survey checklist, family planning activities were classified as the following: reorientation of community leaders, education, services, supplies, sterilisation, and other. Education was the most frequently reported activity, with 64% of hospitals running in-hospital projects, 46% sponsoring programmes in the community, and 38% giving aid to other family planning projects in the community. The target group, naturally, was young men and women and eligible couples within the childbearing age range, because they would actually practice family planning. Nevertheless there was also some educational support needed amongst older generations who would through tradition and culture influence family planning practice. Education for grandmothers and grandfathers is probably also necessary!

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 4)


Family planning is a delicate and controversial issue in many societies, even today. Opposition from respected community leaders can be a major barrier to the effectiveness of family planning projects. Enlisting support and hence the 'reorientation of community leaders' took some part in 18% of hospital programmes, in 17% of community family planning projects, and in 20% of hospitals which aided other community endeavours. Actual family planning services were sponsored by 60% of hospitals in the survey, and 31% of hospitals provided services in the community, cooperating also with other groups doing the same (23%). About 40% of hospitals provided family planning supplies with 25% providing them through community services as well. The other types of activities reported within this category were mobile clinics, training programmes for sanitarians, adolescent sexuality projects, pregnancy termination (abortion), and the training of government and other family planning health workers. 4. HEALTH EDUCATION METHODS were many and various with some ideas having only limited or regional appeal. There is much room for innovative programming within this category of activity, and the following table shows an interesting range. Method of education Hospital projects Community projects 41 27 69 18 23 62 31

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Radio 12 programmes Television 8 programmes Posters 94 Comic books 19 Newspapers 26 School 31 programmes Clubs 7

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Amongst the methods listed in the table, posters were the type of health education practice, which was most widespread. In different parts of the world, however, other ideas were employed. In Asia, for example, mobile units with films were used, as were group talks, a puppet theatre, a monthly bulletin, and person-toperson links. In Africa, filmstrips were also reported, along with health magazines, dramatic presentations and story telling, songs, cooking demonstrations, and teaching cards. In Latin America, teaching cards were also mentioned, and in USA and Canada common methods were health education courses on various topics, films, health fairs and newsletters. Much support and help for PHC can be contributed by hospitals involving themselves in extending their health education activities. Such visible participation in PHC activities for the whole community emphasizes health care commitment on the part of hospitals, and not just their role in curative medicine.

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 5)


5. CURATIVE HEALTH CARE obviously is a primary focus for hospitals, through its in-patient and outpatient facilities. For this survey, emphasis was placed on primary care programmes for diagnosis and treatment of first-contact patients, i.e., where the patient's contact with the hospital was not through some other professional referral. Therefore, the survey looked at the following range of activities; emergency/accident services, ambulatory care, crisis centres, home care projects, and other similar service&. Within hospitals emergency and accident services were the most frequently mentioned of curative care programmes, followed closely by ambulatory care programmes. In the community the most frequent type of curative care was home or domiciliary care, through various types of community health workers. Special projects sponsored by hospitals or participated in by hospitals along with other agencies were described for the purposes of the survey as curative health care programmes. These included: mobile clinics, teachers' training programmes, projects for sexually transmitted diseases, primary care drop-in clinics, care groups, First aid training, and the provision of village health workers. As well as being curative in emphasis, many of the same projects could be described as rehabilitative, and showed the involvement of hospitals outside their own walls. 6. REHABILITATION PROGRAMMES dealt with the rehabilitation of individuals and communities in all spheres of physical, mental and social activity. In-patient, outpatient and rehabilitation programmes in the home were described by some hospitals. As might be expected, many more projects were described as occurring within the hospital than in the community, and this is perhaps an area for increased attention if PHC is to succeed. Some rehabilitation requires equipment and facilities, which possibly are best provided and housed in hospitals, but certainly not all. Rehabilitation carried out within hospital walls necessarily 'medicalizes' ordinary activities, which then must be practised or 'lived' in the community. In-patient rehabilitation programmes were reported by just over 50% of the hospitals surveyed, whereas ambulatory out- patient programmes were mentioned by 46%. Of the latter, 15% of hospitals had ambulatory projects in the community and 8% gave help to other agencies working on the problem. Home rehabilitation projects employing the use of hospital- based teams or community-based teams of 'rehabilitators' were few. Slightly more of the non-governmental hospitals used this method than did the governmental ones. In all, 19 hospitals reported having hospital-based teams engaged in the work of rehabilitation, with 37 hospitals mentioning community-based teams. A further 22 projects engaged in rehabilitation were described, and these included: leprosy or polio rehabilitation, day care centres, rest homes, alcoholism rehabilitation, nutrition rehabilitation, ophthalmic programmes and recovery after cardiac incidents. 7. INTEGRATED HOSPITAL/COMMUNITY HEALTH CARE. What forms does PHC take, where it is already a stated aim? How does integrated hospital and community health care work? These were the interesting questions, which were surveyed within this section of the study.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 6)


The most frequent type of integrated care was hospital responsibility for total health care in a designated geographical area. It was of special note that 31% of the total 136 non-governmental hospitals surveyed reported total responsibility of this kind. As a method, this assignment is not uncommon in Africa, where mission hospitals in rural areas are given this type of responsibility along with government funding. Overall, 79 hospitals surveyed took total geographical responsibility for health care and based that PHC in the hospital. Seventy-one hospitals also participated in PHC based in the community on a special programme basis, and 39 hospitals helped community-based PHC programmes of this type. There were other ways, however, for integrated care to emerge, and the following table lists these. Method Combined preventive & curative for specific population groups Comprehensive hospital/PHC for industrial/commercial firms Comprehensive hospital/PHC for insured populations Mobile clinics & services Hospital/community staffing Exchange, rotation, secondment Collaboration with educational; agricultural & other sectors, also mass media In hospital 34 12 27 35 58 In community: 41 12 19 100 62

4. 5. 6.

36

88

7. 8. 9. 10. 11. 12. 13. 14.

Other types of integrated hospital and community health care were mentioned in specific geographical areas. For example, an inter-agency health referral council operates in Asia. Domiciliary care and meals-on-wheels were reported as integrated care in Australia and New Zealand. A family life-training centre is supported in Africa and a re-forestation project jointly supported in Latin America. A variety of shared services were described by USA and Canadian respondents.

8. TRAINING is a major factor in the re-orientation of attitudes and practices, which can make PHC work. Within hospitals , the orientation of health professionals in that specific direction and the training of community health workers were the types of programmes most often reported. In the community, training programmes focussed on community " volunteers, community leaders as well as the health workers. The following table illustrates the range of PHC training.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Survey Responses (part 7)


Programme for Family first aiders Community volunteers Community health workers PHC project staff PHC management training Health professionals Community leaders Others* In hospital 38 46 65 51 43 69 36 21 In community 46 91 117 64 54 69 85 19

*Other programmes reported were for training laboratory workers, government workers, traditional midwives and healers, medical, nursing, midwifery & other students, community nurses, residency programmes in family medicine, and paramedics for emergency care. 9. ADMINISTRATIVE SUPPORT FOR PHC is also an essential ingredient in its success, because of the make-or-break effect that management skill and attitudes can have. One third to one half of the responding hospitals were active in providing administrative support for PHC programmes already in operation. Such help included: providing planning and management assistance, providing office accommodation for PHC staff, providing supplies (pharmaceuticals, sterile supplies, etc) and equipment maintenance, providing transportation to PHC project locations, providing medical records assistance, storage or analysis, and then the provision of a range of other types of administrative support. In the latter category were included laboratory services, X-ray, surgery, maternity support, ECG, maintenance of food supplies and the provision of a nutrition unit. 10. PHC RESEARCH, SURVEYS OR STUDIES were being undertaken by up to a fifth of the hospitals surveyed. Nutrition and health status studies were the most common within the hospital, but investigations were also being made into PHCrelated clinical areas (for example, leprosy and other clinical epidemiological topics). A break- down of topics under study includes, health status (of populations),nutrition studies, dental status, high- risk groups, disadvantaged groups and the 'under-served' , health perception, potential health resources, facility utilisation, health programme evaluation, PHC-related clinical topics, and others. Other general topics being researched were community diagnosis methods, adolescents, attitudinal subjects related to health and various epidemiological questions.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Summary & Conclusions


Hospitals, large and small, urban and rural, governmental and non-governmental, are actively involved in PHC in various and innovative ways. Many have gone beyond traditional out- patient and in-patient care to respond to unmet health needs in the communities that they serve. They respond not only to physical needs but in various environments to mental, social, economic and educational needs of people as well. This study has shown that hospital innovation in PHC is not confined to developing countries, but extends to big city hospitals in industrialised countries. Health needs are not always the same in these different environments, however. Mental health needs appear more prevalent in industrialised countries, whereas physical health needs take precedence in developing countries. It is hoped that the many interesting hospital innovations in PHC found by this study will encourage more hospitals in all countries to become interested in PHC needs in their own communities, especially among disadvantaged and high-risk groups of people. It is well known that most hospitals around the world are still involved primarily in traditional in-patient and outpatient care. The study reported here is not an attempt to show what percentage of hospitals around the world are involved in PHC. The purpose is rather to show how some hospitals have become convinced of the need to reach out beyond their walls to participate in the total health care effort, and to help to correct inequities in care and in the delivery of services. The roles of the hospital are many, but basic to them all is the need to know and understand the community that it serves, and to whom it owes its existence. This community may be geographically defined, occupationally defined, or in many other ways determined -as for certain age groups, disease groups, or treatment groups. Nevertheless, the actual process of identifying its 'community' and assessing their needs, is an essential ingredient for successful PHC. A hospital can collaborate with others to identify disadvantaged groups in any community where health needs may be largely unmet, whether these be physical, mental, social or even spiritual needs which affect total health. Physical needs include nutrition, exercise, immunisation, sanitation, in-patient, ambulatory and emergency care, home care and rehabilitation. These overlap with emotional and mental need for stress control, education, improvement of attitudes and selfconfidence, assistance to the mentally handicapped, and counselling for the bereaved and the dying. Social needs to which hospitals can contribute some solution are preparation for parenthood, prevention and treatment of drug and alcohol abuse, and help with lifestyle improvements in general. Hospitals can involve themselves with the problems of poverty, ignorance, poor transportation and communication, and thereby contribute significantly to abetter environment for their community. In the following pages, more detailed case studies give a sound idea of how integrated PHC programmes operate across the world. Good ideas on how some of these programmes can be accommodated in other communities will undoubtedly emerge for readers. By now, there may be many more in operation

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Summary & Conclusions (part 2)


and therefore hospital associations may feel that perhaps more local studies would be profitable and encouraging. Based on this international study, a number of lessons may be considered in relation to PHC. The following short sections summarise these lessons. The home is the basic unit of effective health care The importance of health care practice in the home was seen again and again in the successful programmes in the current study. Especially it was shown in those programmes, which documented significant reductions in infant and other mortality rates. It was therefore crucial for the nearest health worker, health centre or other contact point to be aware of every home in which there was a significant health care need whether that be immunisation, family planning, malnutrition, tuberculosis, or some other significant complex of problems. For the health care system the importance of home health practice means that an efficient follow-up mechanism, including reminders to health workers, must be in operation. Family members can also be the most effective implementers of health practices if they are motivated and taught in ways they can understand by people they know and trust. Specifying 'manageable' groups of about 2000 people makes the provision of effective health care easier Defining a population for care service, educational purposes or social support, engenders a sense of responsibility and respect in both the care workers and the community people among which they work. Community volunteers come forward more readily and find it easier to assist the health workers, nursing aides, and other regular professional workers assigned to the area. Community maps and community mapping are practical As was seen in Mexico and Costa Rica, a map of the community is made by the local health workers, showing the location of every house and health care facility in the community. Symbols or coloured pins are used to mark the houses according to the health and social priorities that need attention. This is more easily done if the community served is limited to about 2000 people or less, as mentioned above. Disadvantaged groups suffer also from defeatist attitudes A 'can't do' attitude, or even a passive one, is a strong deterrent to the solution of problems. As seen in Bihar (India) the Achievement Motivation Course used by the Holy Family Hospital is a most encouraging method. It seems to have changed people's attitudes from 'can't do' to 'can do' well enough to help people in three villages successfully to control alcoholism. This is an exciting development, which may need much wider application in PHC.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Summary & Conclusions (part 3)


Non-professional health workers are a basic element in the success of PHC The training and employment of less than fully professionally trained workers, be they paramedical or volunteers, appears essential not only in developing countries but also in industrialised areas. On the whole, professionals will not live and serve in the village; trained but not wholly professional health workers do live in the community and are available to serve people where they are. They are much less expensive to train and support than professional health personnel, and provide a sensible link between family care and professional care. Citizen committees are vital to successful PHC The successful PHC programmes in this study were provided with feedback and community input into health planning. This could ~take different forms, but the citizen 'committee' made it : possible for health providers at the professional level to consider what people were thinking, feeling and saying about the health care they received. Successful businesses use this fundamental method and it is one that hospitals and health providers of all types can learn and use. Hospital associations can do much to encourage PHC In this study, hospital associations reported varying ways in which they supported PHC innovations and activities among their member hospitals. Several hospital associations had conducted their own surveys of hospital involvement in PHC in their own countries, sometimes using (very successfully) postgraduate students of different disciplines as information-gatherers and report-writers. Some publish their results. One association gives national awards to hospitals with outstanding hospitalsponsored PHC programmes. Another produced a policy on the hospital's responsibility for health promotion. These were two of the ways in which associations created increasing awareness among hospitals on the importance of hospital involvement in PHC. There are other means and these might be ? creating a regular section on hospital innovations in PHC in the official journal of the association ? giving annual or special awards to outstanding programmes ? promoting association visits to hospitals with innovative programmes ? holding special sessions on hospitals and PHC during association meetings ? promoting 'hospital and PHC' weeks within the country. The possible roles for hospitals in PHC are many There need not just be one or two ways in which "hospitals do PHC", so that one way is considered right and another wrong. There are many ways to contribute to PHC initiatives, no matter where they arise. It may be that one appropriate beginning is in the creation of a Community Health Department or Industrial Health Department within the hospital to act as a focus for collaborative efforts with the community. If the hospital identifies the geographical or other population, which it can serve, then it is easier to form or collaborate with the group of organisations already interested in participating in PHC activities in the locale, and with local government workers.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Summary & Conclusions (part 4)


The hospital management and employees can participate in studies to identify and understand community health needs. The hospital can participate in information-giving exercises to inform officials, professionals, and business leaders, about pressing health needs and opportunities in the community. The hospital can provide management expertise to train leaders of local PHC programmes in using management principles and techniques. The hospital can utilise the various specialties within its walls (medical, nursing, laboratory, physiotherapy, dietary) in training programmes for primary health workers. The hospital can use modern marketing techniques and innovative approaches in health education to support healthier lifestyles. The above suggestions are general in nature, and can be carried out in many very specific ways. In the preceding pages and in the case studies following, specific ways are apparent whether through newspaper columns, radio programmes, 'health fairs' or in the training of high-school students to carry out simple screening. Local organisations, which previously may not have taken health care as a primary focus, have other ways to contribute to the overall healthier lifestyle, which we all want for our communities and for our home and family environments. PHC is for all and for everyone

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

FOURTEEN OUTSTANDING HOSPITAL/PHC PROJECTS

From urban centres to remote rural areas, there are health needs and health demands of individuals and groups, some of which are met, many of which are not. Those hospitals, which reach outside the confines of their walls into the communities surrounding them, appear overall to serve most effectively. And there is hard evidence that the general health status of the community is affected positively and increasingly. PHC works, often against the odds and the prejudices of health professionals, and of lay people who have become enamoured of the exciting developments, which high-level technologies seem to promise. Again and again it is found that wellness and improved general health facilities and attitudes depend on people, their willingness and ability to cooperate. This thread of argument runs through the following tapestry of 14 outstanding case studies of hospitals working in PHC. The examples have been chosen to represent the range and variety of projects found through this study. Each region of WHO is also represented by one or more projects. Large and small hospitals are described along with both urban and rural hospitals in contributing to the broad strategy of PHC. All details of every programme cannot be included here, so in every case one or more contact persons is listed who will be willing to share further information about the implementation, problems and progress, of their active programmes. Good ideas and experience breed better ideas and experience, therefore sharing these case studies should be stimulating to further innovation.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 1 Dr. CARLOS LUIS VALVERDE HOSPITAL San Ramon, Costa Rica

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact person Dr. G. Ortiz Guier Director Community Health Programme

125-Bed District hospital 'HOSPITAL WITHOUT WALLS'; COMMUNITY MAPPING; HEALTH EDUCATION; AUDIT OF INFANT DEATHS; COMMUNITY DEVELOPMENT Hospital Dr. C.L. Valverde This hospital serves a rural population of 92,000 people and pioneered the 'Hospital without walls' concept, which enabled it to decrease infant mortality from 50/1000 in 1971 to less than 10.5/1000 in 1982. The hospital PHC programme has the following innovations: 1. Integrated Health Care organisation The hospital developed and organised an integrated system of health care that includes four cantonal health centres supervising 46 health posts, each post regularly visiting every home (at least 2-3 times a year, sometimes 1-2 times a month) in its area of about 2,000 people. The health centres are manned by a medical team, but each health post is run by a paid health aide and volunteer community health workers, and supervised by a local health committee. The hospital sends help to the health centres in the form of specialists (i.e. paediatricians, dermatologists, gynaecologists, psychiatrists) and social workers; moreover, general practitioners and laboratory technicians are sent to health posts. 2. Community Mapping Basic to the health system is the development of a "patch working" system for the preparation of a "community map" for each area or community. The health map of each area shows every dwelling-place and other building, accompanied by simple statistical and other information about the type of housing, sanitation, social conditions, and so on and listings of the main causes of death and morbidity for that particular community. From this basic information there is prepared for each community a programme of priorities or targets for improving its standards of health and social welfare, with particular emphasis upon the promotion of health and prevention of illness. Essential to the whole system is the recruitment from and by the local community of "health promoters" or community health aides, one of whose main initial tasks is the collection, by house-to-house survey under professional supervision, of the information for the community map. Most of these health promoters/aides are women aged 18-30 who have had basic education but hold no professional qualifications. They receive a one-week initial training, followed by further periodical in-service training. Being chosen by the community, they all appear to be very well accepted by the working teams from the health posts and health centres; and all are linked to the referral hospital. Costa Rica was one of the countries that pioneered the practice of community mapping, which is now used in quite a number of countries. (Extract from "Hospitals and Primary Health Care" by Dr Rufino
Macagba. Published by the IHF. December 1984.)

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 1: Dr. CARLOS LUIS VALVERDE HOSPITAL (part 2)


3. Health Education Each health post conducts health education discussions in its community a1 least once a month. There is also an annual Health Education Week, which runs for seven days in each community. Mornings are for school children, lunchtime for teachers and community leaders, and evenings for the entire community. Slides and filmstrips, movies, health food displays, dramatisations, discussions, contests, and the "magician of health" are the attractions of the week. The people are given opportunities to discuss their health problems, to choose their leaders and new members of their committees. A popular feature of the evenings is the appearance of the "Magician of Health" - a local person who was taught to perform magic tricks with a health education message. One example is puncturing a white balloon representing an unhealthy infant -the balloon bursts (the infant dies). Then a red balloon representing a healthy infant is punctured -it does not burst (the infant lives). Other tricks promote the eating of eggs for health and the dangers of alcoholism. 4. Audit of every infant death Every infant death in the area is investigated by a team, including a physician, a social worker, a complete interdisciplinary team, local health leaders and others. The team interviews the family, neighbours and local leaders to gather information on the causes of death. Medical records are studied and medical personnel interviewed, even if the death was in a hospital outside the hospital's district. Autopsy records are often available. The findings are summarised in a report and discussed at a general assembly of people from the hospital, the community and interested organisations. The child's family is kept out of these sessions to keep their anonymity and to avoid upsetting them. At the assembly, the people attending learn about the socio-economic background of the community and family, the family's medical history, the child's medical condition from the prenatal period to the death, the mother's and the community's opinions of the death. They see the family's living conditions from slides taken by the team. The discussion then deals with what happened, why, and what can be done to avoid similar deaths. These audits and discussions deal with a very delicate matter, but they serve to educate both the professionals and the community. The physicians become aware of the importance of socio-economic factors in their "medical" patients. A bond is developed between the providers of health care and the people. This gives them a common goal -- to prevent more infant deaths and control disease in the community. 5. Community Development and participation The experience of the programme has convinced its leaders of the importance of socio-economic factors in the causation of disease and of the need for the hospital to become highly community-oriented. However, this process cannot be effected overnight. It is necessary to have as an aim a functional integration between the hospital and other levels of existing services, and also to work in close association

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 1: Dr. CARLOS LUIS VALVERDE HOSPITAL (part 3)


with an organised community. In this respect the Canton of San Ramon was the first to have the health programme incorporated in the community. All this is a process that takes several years, but very significant results can be obtained, as is shown by the following details and statistics. A. Projects generated in the "Hospital without walls" programme, which have national repercussions: ? Treatment of alcoholics as a social problem, with support of the hospitals and community for their recovery; ? Treatment of psychiatric patients in local hospitals, without obligatory reference to specialised hospitals, with significant reduction of hospitalisation. ? The first health post in the country was established in the San Ramon area. Since July 1975, community promoters have been working in the San Ramon area. They strive to detect health problems and develop methods of improving health conditions in the area. The health post nurse helps promote community health meetings. There are 800 elected community promoters in the San Ramon area, and in addition 2,500 have been prepared and sent throughout the country. B. Provisions which help to increase community health by improvement of living standards through: ? Drinkable water (100% supply of pipes, at intra-domicile level); ? Housing (promotion of building projects); ? Environmental sanitation (house to house promotion by committees and health authorities); ? Electrification and telephone (90% electrified zone); ? Highways and roads (specially for the most distant communities); ? Land holding (promotion of rural holdings); ? Food and nutrition (promotion of fruit gardens and distribution of food to needy families); ? Employment: with the collaboration of community leaders, a milk co-operative was created that integrates milk producers from four Cantons to have the machinery and capability to pasteurise milk, and they now supply milk to people within and even outside the area. The programme also organised three coffee cooperatives in this coffee-growing area, a door and window factory, and a tourism co-operative. It promotes local crafts through expositions.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 1: Dr. CARLOS LUIS VALVERDE HOSPITAL (part 4)


Mortality rates for Costa Rica and the Canton of San Ramon 3-Year periods 1970-71-72 and 1982 Canton of San Ramon 1970-71-72 Rates of Mortality First Month Infant Mortality % of Deaths in First Year Deaths First Month Mortality 1 -4 years % of Deaths Less than 5 years Over 50 years General Mortality * Data 1980 23.8 54.0 44.0 2.98 35.4 48.4 5.0 Costa Rica 70-71-72 24.36 57.5 42.4 4.75 38.7 43.3 6.05 1982 Canton S.Ramon 8.2 10.1 81.8 0.9 11.6 69.8 3.2 Cost Rica 11.0 18.8 58.7 1.01* 17.02* 61.0* 3.97

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 2 THE DHAKA SHISHU HOSPITAL Sher-E-Banglanagar Dacca Bangladesh

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person : Prof. Tofayel Ahmed Dept. of Rural and Community paediatrics

215-bed, non-governmental, teaching, special (paediatric) hospital in urban area NETWORK OF COMMUNITY CLINICS; HEALTH-BASED COMMUNITY DEVELOPMENT; EXTERNAL EVALUATION OF COMMUNITY DEVELOPMENT PROGRAMME The Dhaka Shishu Hospital was established (in 1977) to serve as a base for paediatric health care in the country, but in practice its location limits its services to the children in the capital city of Dacca and environs, while 90% of the population, including 40 million children, live in the rural areas of Bangladesh. The hospital decided it must do something about the health of children in rural areas, even though there is only 1 paediatrician for 1 million people in Bangladesh and the general practitioner ratio is 1 doctor per 0.5 million people. The hospital has an active Rural and Community paediatrics Department and at the start had 2 full-time doctors. Junior hospital doctors rotate through the department and its rural clinics for 4 weeks each year, and in 1983 the Department had 8 doctors and there were 29 junior doctors doing residency training, 10 consultants and 8 visiting professors in the entire hospital. In mid-1983 the Bangladesh Institute of Child Health was inaugurated, with the hospital's doctors serving as the nucleus of the Institute's staff. It is planned to be the national training centre of doctors, nurses, midwives and paramedics in the field of child health, and eventually hoped to be a comprehensive, all-purpose organisation for child health in Bangladesh. The Palli Shishu (rural child) Foundation was created in 1976 to do something about the health care of village children. Its philosophy is based on villagers being able to take care of the health of their own children. Though the main objective of the Foundation is prevention, curative care and medicines are provided to attract people to come to the clinics. Here they are taught the importance of prevention and what they can do about it. The PHC programme of the Dhaka Shishu Hospital is carried out mainly through the Palli Shishu Foundation, which has a direct relationship to the Rural and Community Paediatrics Department of the Hospital. The Foundation organised people from the villages and brought them to the hospital for practical training. A rural child clinic was established in each Union Council (about 15 villages with a population of 20,000 people). From each union, 6 village health workers (3 males, 3 females) were invited to the hospital for 2 weeks' training in child care and prevention of the 10 most common diseases in the communities (after a socioeconomic survey of 120 villages in 1977). The Foundation also provides the village health workers with some orientation on the socio-economic aspects of childcare before they are sent on to the hospital.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 2: THE DHAKA SHISHU HOSPITAL (part 2) The Dhaka Shishu Hospital is the only hospital in Bangladesh with an extensive network of community clinics in rural areas. The PHC programme is a partnership of several components: the Foundation, the hospital and the villagers, the latter who carry out the work, whilst the former provide finance, training and special diagnostic and treatment services. PALLI SHISHU (RURAL CHILD) CLINICS Each clinic has 3 male and 3 female village health workers, 12 traditional birth attendants, 1 supervisor (paramedic) and 1 local doctor (unlicensed or licensed medical practitioners, or practical physicians who were medical auxiliaries). Recently a new 1-year course was approved which will produce 'primary doctors' for Bangladesh and these doctors are given additional training by the Foundation and the hospital to fit them for clinic assignment. Each clinic is set up and managed by a Village Committee, which is elected by villagers (who also have deposing authority). The clinics are open 2-3 days a week, 2-3 hours per day, and monthly reports are sent to the Foundation. By mid1983, 88 rural health clinics had been established. Since 1981 some clinics have been involving themselves in social and economic activities as well, because of the importance of these to health maintenance. Some 20-30 clinics are doing one or more of the following: providing sewing machines, backyard gardening, fish raising, carpentry, tailoring, latrine making, all with the help of villagers, and seed money from the Foundation. By raising family income, the villagers will eventually be able to support their clinic, paying for their own health staff and medicines, etc. The target date for being self-supporting is 1990.

4. 5. 6.

Health worker training Training is of three main types: 1. The programme has trained 840 village Health Workers (VHWs), and focuses on preventive measures against communicable diseases, dispensing drugs, doing home visits and identifying health-related problems of children at home or in the family, and referral measures for these problems above their level of competence. Female VHWs must be mature with their family small in size, and male VHWs must be able-bodied and experienced in village leadership. 2. The programme has trained 557 village 'Dais' or traditional birth attendants in pre-natal care, improved home delivery procedures, post-partum and post-natal care. 3. The programme has trained 758 primary school teachers to promote child hygiene and nutrition to their pupils, and this teaching is on going. Outreach This has gone forward in several ways. With the help of VHWs, over 200,000 health education pictorials and leaflets were distributed about sanitation and nutrition. These are displayed in schools, dispensaries and government offices.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 2: THE DHAKA SHISHU HOSPITAL (part 3) Again with the help of VHWs successful immunisation campaigns with BCG and smallpox were conducted in 810 villages. DPT and oral polio vaccines have been administered in a more limited way. Family planning clinics are held weekly, supplying contraceptives to eligible couples.

Finance A number of international organisations contribute money and medicines to the Foundation. At present the Foundation is trying to raise funds locally and also from international organisations. In addition, patients are charged a small amount when they come to the clinic, which serves as the honorarium of the VHW and the doctor's transportation expenses. Efforts to charge more from the patients have been proved counter-productive owing to low per capita income of the patients, 90% of whom are from the landless group. Evaluation This is undertaken by the Foundation staff periodically. At an annual conference activities are discussed and plans for the next year presented. Each clinic keeps a yearly record of all activities and the health programme portion is completed by the doctor. Each child has a health book with basic data about the child and family and this is used for follow up. COMMUNITY DEVELOPMENT PROGRAMME The Palli Shishu Foundation, in collaboration with World Vision International, started and managed a health-based community development programme in Sreenagar Thana from September 1977 to September 1982. A socio-economic survey was undertaken with the help of an experienced consultant in community development, resulting in the Sreenagar Thana Outreach Community Development project (CDP). The survey showed that 45% of children 15 years and less were malnourished and had frequent episodes of communicable and preventable diseases. It was evident that the health problems were due to environment, sanitation, hygiene, low caloric and unbalanced food intake and contaminated drinking water, all features related to the social and economic status of the people. The resulting CDP attempted to cover 200,000 landless and marginal-farming people, composing more than two-thirds of the population of the Thana. The CDP was formally evaluated by an independent agency in its 4th year. One conclusion was that to make a dent in the massive health-related problems in the developing world there should be more efforts like it.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 2: THE DHAKA SHISHU HOSPITAL (part 4)

Programme components Specific objectives were set out and are grouped here under 'Projects'. Project 1: Health care for 129,600 children, 11,600 families needing safe drinking water, and 662 couples needing family planning supplies: 1. Establish 14 rural clinics, one in each Union; 2. b) Recruit 28 family planning leaders and train; c) Indigenous midwife training; d) Borehole latrine system. Project 2: Food production for landless and marginal farmers: a) Training for farmers, seeds, equipment and starter farm animals; b) Training in home economics, nutrition and improved cooking for one woman from each union to act as teacher to others; c) Reclamation of 14 derelict ponds and re-stock with fast breeding fish by fifth year. Project 3: Social and economic improvement for families: a) Agricultural extension training for 360 young (3 from each of 120 villages); b) Cottage industries, strengthening existing handloom and pottery industries and beginning new ones; 3. Training and credit for inland fishermen.

4. 5. 6.

Programme organisation A Chairman and four Field Officers, one of whom acted as the programme manager, formed part of the Central Management Committee of seven members to provide overall guidance to the Sreenagar programme. A programme headquarters was set up in Dacca, and a Sreenagar sub-office linked up with it (3 hours away by car or boat from Dacca). Thana level government officers and their departments were involved in setting up and running the programme, and 15 clinics, as already described in the previous section, were set up. VHWs were recruited and trained with a physician, local midwives were trained and family planning leaders selected from the local communities. Programme evaluation In the 4th year of the 5-year programme an outside organisation, Rapport Bangladesh Ltd., a firm of management consultants, trainers and publishers, carried out a formal evaluation on the basis of meetings, site visits, and interviews. The results were presented in a large report giving statistical data as well as attitudinal information. Their findings are summarised generally as follows:

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 2: THE DHAKA SHISHU HOSPITAL (part 5)

Improvements 1) Sanitation attitudes had changed; houses were cleaner. 2) Supply of safe drinking water was increased. 3) Awareness of prevention through vaccination widespread. 4) Family planning practice increased. 5) Incidence of major children's diseases decreased. 6) Increase of fruit trees and vegetables despite inadequate supply of seeds and saplings. 7) Improved care of expectant mothers. 8) Greater interest among women in voluntary outdoor activities. 9) Greater interest among girls for income-generating activities. 10) Increased interest in community activities and substantial contribution in cash and kind from local people. 11) Increase in female involvement as midwives and voluntary health workers. 12) Improved diets. 13) Free treatment at rural clinics to children of disadvantaged groups. 14) Much increased purchase and installation of latrines. 15) Some landless have purchased small tracts of land. 16) A trend from labour to trade among the landless. 17) A trend toward mutual co-operation. 18) The decrease of some wasteful social customs and old superstitions (such as role of women, pregnancy and childbirth taboos, dietary taboos, and prejudices against family planning). Some failures and problems 1) The idea of a community kitchen was not implemented, though there is some interest. 2) The reclamation of derelict ponds had limited success because of low topography. 3) Limited success in horticultural training because local government officers would not be convinced of the need to give talks in local dialects. 4) Trained birth attendants tend to fall back to their old practices, perhaps due to low level of education, inadequate motivation and understanding. There is a need for continuous education. 5) Village people are suspicious of the motives of the clinics, and do not come until they see benefits. 6) Initial motivation of the people as well as sustenance of their interest in the programme is a difficult job. 7) Communication between donor agencies and local people is not easy to establish. The 88 Palli Shishu clinics are covering only 1,200 villages out of the 68,000 villages of Bangladesh where 48% of the population are under 16 years. A major problem is how to extend similar services to more people. Seventy-five per cent of rural children are malnourished with vitamin deficiencies, and require more food. Vaccines and drugs that need refrigeration cannot reach remote villages as it may take 3-5 days of travel to reach them. A chain of cold storage is needed, and 80% of clinics have no electricity. In addition, many more specialist pediatricians are needed.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 2: THE DHAKA SHISHU HOSPITAL (part 6)

The lessons learned from the above project are many. Motivation, and awareness raising of people on their health, is very important at the start of any PHC programme and also for a few years until it takes root. The programme should not be imposed from outside, the achievement of the programme should not be expected to be of the same level everywhere, because awareness varies greatly from place to place. It should not be manned by outside people, as the community must develop a sense of ownership. Immunisation and preventive care of children should be included in any out-reach programme of each hospital, and all hospitals should be involved in community outreach through a network of relationships and services in rural areas. Health professionals, students and paramedical personnel should be acquainted with day-to-day rural health problems, gaining some experience in a rural area. Continuing education of the public on the expanded role of hospitals should be done by every hospital, taking advantage of the mass media and any special celebratory occasion.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 3 LADY HARDINGE MEDICAL COLLEGE AND ASSOCIATED HOSPITALS New Delhi India

Contact Person : Dr. Mrs. Santosh Chawla Principal & Medical Superintendent

600-bed governmental urban teaching hospital COMMUNITY MEDICINE ORIENTATION OF MEDICAL STUDENTS AND MEDICAL STAFF IN A LARGE TEACHING HOSPITAL

This hospital is owned and run by the Central Government of India and is the main training institution of a government college of medicine for women. The teaching hospital has all the general health care facilities with special emphasis on the health care of mothers and children. Even with the requirement of the Medical Council of India for medical students to go into the community (1958), the students at Lady Hardinge were reluctant to be sent to the villages. It was decided that it would be best to work in those rural healthtraining centres of the Ministry of Health and Family Planning, which had an attached hostel. (Students are all female.) Starting in 1959, students were sent to a village 30 kilometres away with this kind of a centre. Two other centres were later selected for this purpose, so that medical students will be exposed to community medicine for three months during their last year of training. The PHC programme is planned, organised, directed, and controlled by the Department of Community Medicine of the Lady Hardinge Medical College. The department is staffed by the following : 1 Professor (Medical doctor with an MPH from Harvard) 1 Associate Professor 5 Assistant professors 2 Public Health Nurses 1 Health Educator 1 Statistician 1 Social Worker 1 Laboratory Technologist with two assistants 1 Senior Social Scientist, and 1 Demographer They work in one urban centre and three village centres in the more rural areas. Students are required to stay in a village centre with 15 beds. The other two village centres have 10 beds each. Each centre has medical and para-medical staff paid by the Ministry of Health and Family Welfare or by the Lady Hardinge Medical College. Medical students are assigned to the department for three months at a time, and spend some time in the community centres of the college. Student nurses from the Delhi University College of Nursing also receive some training in the department.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 3: LADY HARDINGE MEDICAL COLLEGE (part 2)

The medical students, with guidance from the Department of Community Medicine, render basic health and obstetrical services. Each student is trained in family approach to medicine with the emphasis on promotion of health and prevention of disease, and not on illness. The students learn about the socio-economic status and problems, emotional difficulties, and other aspects of family life in the community, which affect the health and illness of the individual and their families. They give advice on how to cope with these problems. They participate in the activities of community organisations, in health education, home care and other activities. Serious medical cases are referred to the Associated Hospitals of Lady Hardinge Medical College. Clinical specialists visit the community centres as needed, or patients are brought to them in the hospital. The hospital is also active in rendering primary care in its outpatient department. In addition, the following are operating in the hospital: Family welfare Nutrition education Health education Immunisation Medical students are taught principles and concepts in social science and biostatistics during their first year by the Department of Community Medicine. Environmental sanitation is learned during the second year, while epidemiology is taught during the third year. These are in preparation for the practical training in community medicine that they undergo during their fourth and last year in medical school. A 3-year residency training (post-graduate) programme in community medicine is also offered which gives the title "Community Medicine Specialist". No formal evaluation has been done on the programme. However, studies to find the indices for improvement in various fields are done by the students, under the guidance of the senior faculty. Funding of the PHC programme comes from the budget of the medical college. Community participation is in the following forms: 1. Construction of centres by villages (or buildings are sometimes donated). 2. Health committees are established in the villages by the programme staff and students. The health committee members suggest the type of health services needed in the community and they support the health programmes being implemented. 3. The Associated Hospitals of the Lady Hardinge Medical College conduct a camp 4-5 times a year, wherein a mobile health van manned by hospital staff (with specialists and students from various departments) go to a certain area to render health services.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 3: LADY HARDINGE MEDICAL COLLEGE (part 3) The community provides food and lodging, takes care of arrangements to enable the camp to be established, and is in charge of registration of the patients. The health committees are responsible for leadership in the community. The mobile clinic stays from 5-15 days in one place and provides family planning services, surgery, and other specific programmes as needed. 4. Community leaders, civic organisations and volunteers from the community seek donations for drugs and other aids to be given to indigent patients. Problems and obstacles A lot of convincing had to be done: 1. For people to accept the programme (explanations had to be made in their own language and curative medicine had to attract the people first); 2. For the hospital to go out (compliance was first made mandatory), although later on the faculty, and students started to see the value of the programme as they were exposed to the field; 3. For the government to give support to the programme, for petrol, travelling allowances, drugs; 4. For the approval of the flexible schedule which the staff had to follow (the department has to fight for its programme repeatedly). Communications and transport are also problematic. At times there are no roads or vehicles for patients and supplies or staff to be transported. A modest budget has made this problem difficult to solve. The midwife at the sub-centre and the staff at the health centre have to be able to communicate with the centre or hospital in urgent situations. A telephone or radio system had to be installed. Shortage of staff in the hospital is a problem, particularly of specialists. Because of negative attitudes towards the programmes, department staff had to start with the few who were more receptive of the idea. Due to shortage of staff, serious patients or complicated cases had to be brought to the hospital for proper referral, diagnosis, or treatment. Specialists go to the centres only once in awhile. For staff willing to go to the centre, there is not much incentive to stay. No food allowances are given for going out. This remains a problem but the department is asking for funds for this. Lessons learned A positive attitude among the faculty, dean and principal is very important to the successful implementation of a community medicine programme. Since the principal of the college is also the medical superintendent of the hospital, it was not difficult for the programme to be started and maintained.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 3: LADY HARDINGE MEDICAL COLLEGE (part 4)

Government support is necessary. The policy of requiring medical colleges to have a Department of Community Medicine, helped push the programme. Since the hospital is government-owned and operated, it is easy to get the co-operation and collaborative participation of other government agencies in the communities. 1. All hospitals should change their training programme orientation from the hospital to the community. If they want medical and nursing students to be involved in PHC, they should all go as near to the periphery as possible. 2. The hospital should define a definite catchment area and population for which it is responsible in terms of health promotion and maintenance. The teaching hospital itself should be the referral centre for this region and, preferably, should not have an out-patient department for primary cases. The health care system should be regulated and the hospital assigned its place in the system. 3. Specialists should go to the community centres only when needed. But they should go occasionally for community orientation. 4. Medical colleges should also be located outside cities so medical education does not become too city-oriented. 5. Students should be trained more in the district hospitals, which are under regional hospitals (specially hospitals with medical colleges). District hospitals should supervise and be referral centres of the primary level care centres. 6. Hospitals should educate patients where and how to move about the health care system. 7. There should be close co-operation between medical colleges and the health service system. The training of medical students and lady health visitors should be closer to each other, and if possible this should be handled by one organisation. 8. Private hospitals are not contributing much to PHC due to the policy that the government is responsible for the health of the people. But private hospitals should be encouraged by the government to participate in PHC. 9. The role of hospital associations in PHC should be to facilitate communication among agencies dealing with health, and with universities too. The Hospital Association should encourage relationships to develop between hospitals and other levels of health care serving the same geographic area.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 4 WAD MEDANI CIVIL HOSPITAL Medani Sudan Hospital

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person: Dr. Awad Mohamed Ahmed Director Head, Dept. of Obstetrics & Gynaecology)

850-bed governmental general teaching hospital COMMUNITY-BASED TRAINING OF TEACHERS OF PARAMEDICAL WORKERS; INVOLVEMENT OF POLITICAL LEADERS IN COMMUNITY HEALTH PROGRAMMES; CURRICULUM DESIGN; TASK ANALYSIS FOR PARAMEDICAL PERSONNEL

Sudan is the largest country in Africa with 1 million square miles, and a population of 18 million, giving a population density of six persons per square mile. The government's meagre resources are committed to the free delivery of health services but there is also an acute lack of doctors and paramedical personnel. Given these geographic, economic and manpower considerations, it is the para-professionals who form the backbone of the country's health care services. The development of the PHC strategies therefore inevitably involves the increase and support of larger numbers of paramedical workers, and the eliciting of help from political leaders in encouraging community health programmes. The Wad Medani Hospital is engaged in several activities supporting PHC initiatives and these include: a unique teacher training programme for teachers of paramedical workers, where part of the training deals with gaining experience in the community; a paediatric department study of maternal and child health and family health in a village over a six year period; and involvement in the design and teaching of programmes in the nursing school, the theatre attendants' school, the midwifery school, the village midwifery school and the health visitors' school. Described here is the training programme for teachers of the various paramedical workers. The general objective The general objective is to train teachers of health workers, health visitors, medical assistants, community health workers and other personnel already in service positions in the community so that they can plan, implement and evaluate an effective and efficient training programme leading to improved maternal and child health care and family planning. The specific objectives are to upgrade trainee technical knowledge in the field of maternal and child health care and family planning, as well as in environmental health, educational skills and knowledge of community problems. Also, the ex-trainees should be assisted in developing their own activities after the course, by involving the community in the programme to ensure their active participation in their own health care. Implementation This was achieved by forming an advisory committee, assisted by a WHO consultant in educational methodology. The committee selected villages for the courses, reviewed and altered the instruction, reviewed feedback from students, and translated into Arabic any relevant material from medical periodicals and books. A work plan was made, outlining the steps to be followed and target dates. Two minibuses were provided for the project and a room set aside in an existing health centre for training sessions.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 4: WAD MEDANI CIVIL HOSPITAL (part 2)


Involvement of government officials This involvement was important and contributed to the success of the programme in at least three ways: a) Most of the government officials are laymen as far as medicine is concerned. The informal consultation with them may have been the first time they had come in contact with a health programme. The experience allowed them to see the health needs of their province, and the understanding, which they gained, made them more co-operative in offering help to the programme. b) In learning that the Governor was involved in the programme's services, local people took the programme more seriously and also co-operated in its activities. c) The politicians could solve many problems, which had an indirect impact on health in the village situation both socially and economically. An example of the latter political contribution was support by one governor of a fund to build two classrooms, for 5th and 6th year students, so that girls, previously excluded due to social and religious custom, could continue their education separated from, but equal to, that of the boys. Task analysis for paramedical personnel -This was found to be the most difficult part of the programme. Making decisions about which type of health worker would carry out what tasks within a given problem, and to whom they should refer patients, is always difficult. But, the analysis, such as it was, had to be distributed to the teachers on the first day of the course so that it could be worked with over the period of the training programme. This task assignment is not included here because it is reinterpreted and adapted locally. A community workshop A workshop is held three days before the start of each course for paramedical workers, and the community leaders, the advisory committee, and the students are invited. Programme objectives and methods are explained, their questions answered, and a questionnaire is distributed, to be filled in for each village household volunteers from the village are selected by village leaders and students, and preference is given to housewives and mothers because of their easy access to the family and their motivation to learn new approaches to improve the health of their own children. These volunteers will become the local paramedical workers, and learn from the students how to make weaning foods for babies, rehydration fluids from local ingredients, and how to teach other mothers in group sessions to make these. She also helps bring children and mothers to the clinic during the practical phase of the teaching programme.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 4: WAD MEDANI CIVIL HOSPITAL (part 3)


Details of the training programme The details follow along with the specified First course: 1 October -31 December Second course: 1 February -30 April PHASE I: (4 weeks) a) Community workshop (explained above) b) Lectures on: -Educational methodology -Simple medical vital statistics -Environmental health -Study of task matrix for different paramedical categories -MCH/FP with stress on at risk pregnant women -Start preparing individual manual and curriculum Start preparing for stay in village. PHASE II: (3 weeks) a) Ten days in the village to: -collect information and check questionnaires filled by village leaders; -observe and record day to day activities of villagers in the village (i.e. habits, mode of living and their effects on health); -survey health status of villagers and health services in the village; -appoint volunteers; -treat minor ailments (they are supplied with drugs for common ailments); -deliver babies if there is no village midwife (health visitor it; provided with a delivery kit); -give health education lectures in the evening. b) Back in school for more lectures on the following: -MCH/FP -Vaccination -Weaning food and rehydration fluid ; -Analysis of information from questionnaires and prepare a report on health survey -How to hold a workshop for village leaders and discuss the

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 4: WAD MEDANI CIVIL HOSPITAL (part 4)


PHASE III: (3 weeks) a) Put up work plan for next stay in village. b) Preparation of resources and supplies for work in the villages. c) preparation of posters. d) Continue technical lectures and answer questions from students. e) Continue work on manuals and curriculum design. PHASE IV: (2 weeks) Ten days stay in village, carrying out the following activities under the supervision of consultants: a) Antenatal care and family planning. b) Child health activities: -Vaccination (Triple Vaccine, Polio and Measles) -Teaching mothers and volunteers how to make weaning food and rehydration fluid -Treating children. c) Environmental health: -Cleaning of 'village -disposal of garbage -Screening of slaughterhouse and water supply - health education. Back in school at the end of this period, the curriculum plan and teacher manual are finalised, comments and evaluations of the course are collected, and finally there is the graduation ceremony. Usually there are some problems or obstacles in carrying out the total programme. These can be summarised as due to budget modifications and inflation, bureaucracy, climatic conditions which limit the number of 3-month courses to only two a year, problems in fuel, spare parts and electricity, as well as lack of reference material in Arabic. Programme outcomes have been the following: a) The students developed an understanding of community health problems and a commitment to being actively involved in their solution. b) They apparently gained considerable knowledge and skill in assisting communities actively to promote their own health improvement programmes. c) They gained some competence in training others, particularly village volunteers, to take responsibility for and participate in health care activities. d) They developed educational materials to be applied in their own teaching functions. e) They developed new technical competence in MCH/FP care.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 4: WAD MEDANI CIVIL HOSPITAL (part 5)


f) On the part of the village selected for the training, people have taken steps to improve their health status, particularly in the area of MCH/FP. g) The staff of the hospital and the public health department have made a commitment to continue follow-up activities in the village. h) The staff of the programme itself have developed their competence in educational planning. i) The resource personnel participating in the programme have developed a new consciousness of community health problems and their possible solutions. j) Political leaders and leaders in other sectors have developed new perspectives in community health and their responsibility with respect to its maintenance.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 5 THE SSA HOSPITAL City of Netzacualcoyotyl State of Mexico Mexico

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person: Director Dept. of Public Health

Urban, governmental teaching hospital HOSPITAL-BASED PUBLIC HEALTH; PUBLIC HEALTH TRAINING FOR PROFESSIONALS & AUXILIARIES; COMMUNITY MAPPING; COMPREHENSIVE PAEDIATRIC DENTAL PROGRAMME; PERFORMANCE STANDARDS & HEALTH TEAM REVIEW

Owned by the Secretariat for Public Health and Welfare of Mexico (SSA), this hospital is a part of one of the three main health care systems, which serve the country through their own sets of hospitals, family medical units and health centres. While other systems provide both curative and preventive services to the employed and their families (31% of the population) and the employees of the State (8%), the SSA is responsible for providing health services to the masses (57%), mainly the poor and the unemployed. Additionally, the SSA is primarily responsible for the country's health policy and activities related to public health, and medical care. The city served by the hospital is crowded with 2 million people, and has tripled its size in the past decade. The SSA hospital is both a general hospital and a specialist one with a staff of 950 in total, encompassing departments of public relations, social work, administration, nursing (training), public health amongst other standard specialties. An innovative programme of curative and preventive dentistry and oral hygiene is one special feature. The three most common causes of hospitalisation are conditions relating to pregnancy, infections of the respiratory, gastrointestinal or urinary tracts, and trauma from accidents or violence. Several interesting features of how this hospital promotes PHC are worthy of description, and may serve as models that other hospitals might adopt, adapt or study. In order to put the innovations into a framework, a brief summary of the health care organisation is helpful. The basic community health units are related to a so-called 'micro-region' (of up to 500 families/3,000 people) belonging to a larger 'sub-region'. Several sub-regions compose a Region of 100,000 to 400,000 people. A region is served by a Health Centre led by a physician who graduated from a residency programme in public health within the system. The seven Regional Health Centres are directly supervised by the Department of public Health based in the hospital. A sub-region has a medical consultation office manned by a physician, and the micro-region is served by a non-physician professional such as a public health nurse. Altogether the basic health team is composed of a physician, a nurse, and a health promoter (described in more detail later). They are expected at regional level to take care of 85% of the health problems in the community, referring 15% to the hospital.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 5: THE SSA HOSPITAL (part 2)

HOSPITAL-BASED DEPARTMENT OF PUBLIC HEALTH

Based at the hospital, this department co-ordinates the public health work of 7 health centres, 3 childcare centres, a paediatric dental centre and a family planning programme. It organises this work with the headquarters of the Co-ordinated Services of public Health in the State of Mexico. It sponsors a one-year residency training programme in public health, graduating 238 workers (mainly physicians) in the 6 years before 1981. The department provides back-up studies as part of its co-ordinating and epidemiological functions. One departmental study of stool examinations, for example, showed that 60-70% of the stools were positive for amoeba. Related to this finding 85% of households lacked adequate drainage, and at least 41% lacked toilets. The major causes of morbidity in the city are respiratory and gastrointestinal infections, intestinal parasitism, diabetes and obesity (due to affinity for foods rich in carbohydrates). Over 50% of the population have varying degrees of malnutrition. Cardiovascular diseases, cancer, hepatitis, alcoholism, cirrhosis and degenerative diseases are also major problems in the city. In the planning guidelines developed by the larger SSA organisation, which owns this hospital, the principle of foresight in planning health programmes was stated and elaborated on. Forecasting, and who should do it, and in what particular time sequence, are all subjects, which have been covered. Goals are established to meet local conditions in accordance with the guidelines; the latter are contained in the following documents: 1. Organisation manual 2. Guidelines for programming 3. A guide for the diagnosis of the health situation 4. An information system 5. Supervision and evaluation manual 6. Basic formulary of drugs & medications 7. Technical procedure manuals The Department of Public Health works with population units of up to 500 families, through the regions, sub-regions and micro-regions as outlined above. A community health worker or 'health promoter' is trained from the community to serve that community. The community group of 500 families is organised to have a local leader, matron or committee to serve as a link between the department and the group of families. This health promoter is usually a woman, aged 18-25 years, with at least an elementary school background. Around this health promoter, her training and her eventual capacities to contribute to the drawing up of a community map for the purposes of making a 'community diagnosis', are clustered a number of innovatory tools for PHC.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 5: THE SSA HOSPITAL (part 3)

1. Training manuals in Spanish for health auxiliaries These have been drawn up by-the Co-ordinated Public Health Services and facilitate the training of health promoters. There are 15 simple training manuals in Spanish the spoken language -covering the following topics: a) The disease phenomenon and the role of the health team in the country b) Community mapping c) Family health diagnosis d) Working with families and community groups e) Community health education f) Vaccinations g) Pregnancy h) The birth experience i) Family planning j) Under-fives care k) Basic medical attention (emphasis on diarrhoeal & respiratory disease) l) First aid and accident prevention m) Nutritional vigilance and orientation n) Intra-family and community environmental measures o) Oral health. These manuals are available from the Co-ordinated public Health Services, Independencia 1009, Toluca, Estado de Mexico, Mexico. 2. The community map and diagnosis This is both a training method and a diagnostic tool for PHC. Health Promoters live in the area that they serve, and work with one or two volunteers, forming a type of volunteer brigade, serving as a link between the health system and the community. They are trained in modules in basic techniques of hygiene, immunisation, infant care and other methods of prevention. Their training also includes the making and use of community maps, house-to-house surveys through interview, all contributing to the community diagnosis. Community diagnosis is a recognition of the prevailing health problems in the community, which they are taught to recognise and record through home visits. The diagnosis is summarised in a rough map of the locality. By means of signs and symbols, information is recorded visibly on the maps by the promoters. Based on the picture of the health situation of the locale, the next training module is carried out. By the end of the module, the health promoter should be able to participate, for example, in the immunisation campaigns in the community relating to the diseases she has helped identify. Based on her findings, therefore, she is taught the diagnosis and treatment of these diseases, and the conditions which must be referred to the nurse or doctor. She is taught the use of about 13 drugs that she can employ.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 5: THE SSA HOSPITAL (part 4) The resulting community map is marked to show the status of health priorities, such as: the number of pregnant women, women of fertile age, children fully immunised or not, and family planning participants. The surveys take about 3 months to complete depending on the target population group of families. 3. Family health records This is based on a home-orientation were developed to assess both the family and community health. The data collected also serve as a guide to detailed programme planning and control. 4. Mass immunisation The Department found that house-to-house vaccination efforts in the community are more effective than asking the parents to bring their children to a health centre or the hospital for immunisation. This approach has resulted in immunisation of over 90% of children-under-five years. With careful planning and organisation, the department has utilised the services of over 500 people, mostly volunteers, to vaccinate 68,000 children in a two week period. PAEDIATRIC DENTAL CENTRE The techniques of industrial management and engineering were applied to the design of the dental health unit constructed beside the main hospital building. The "total system" approach included the design of the building, its rooms, the design and arrangement of furniture and equipment, instrument lay-out, hand movements, team composition and roles, work-flow and patient-flow, and the scheduling and mix of preventive and curative dental activities. The result is a superb system of preventive and curative dental and oral hygiene services for adults and children of the community. One section of the building is set aside for dental health education of the children enrolled in the programme. They are taught how to brush and care for their teeth. MONTHLY REVIEW OF STANDARDS OF WORK The SSA has developed a set of standards of work expected of each basic health team in serving each population group of 3,000 people or 500 families. It is expected that each health team submits regular reports on its monthly activities in relation to these standards, for example: 1. Vaccination 0-1YR 1-4 YRS 5-14YRS 15YRS+ 9 doses 34 doses 29 doses 27 21 27 20 34 To groups at risk, at discretion of team To pregnant mothers at doctor's discretion

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

BCG DPT Sabin (polio) Measles Typhoid Tetanus Toxoid

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 5: THE SSA HOSPITAL (part 5)

2. Nutrition pre-school children: 3,000 rations pregnant and lactating mothers: 900 rations 3. Out-patient Consultations 0-1 yr. old 1-4 5-14 15 yrs old or older .TOTAL Family planning 4. Dental Consultations 5. Health Education Sessions 772 GROUPS TALKS 6 1 1 20 5 8 44 visits 83 147 158 462 visits 54 visits

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15 years or older pregnant and nursing women Family planning 6. Communal Basic Sanitation Work

Workshops: according to detected problems Water, food, and sanitary inspection & referral: 1x15,000 inhabitants 7. In-service Training Talks to personnel: 2 Talks to community leaders: 1 8. Home Visits: 40

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9. Physician's Community Visits: 15

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 6 NORTH CENTRAL BRONX HOSPITAL Bronx New York 10467 U.S.A.

Contact Person: Dr. Mutya San Agustin Director Dept. of Ambulatory Care

500-bed city government general hospital REORGANISATION OF AMBULATORY CARE FOR PHC; COMPREHENSIVE COMMUNITY OUTREACH PROGRAMMES

The North Central Bronx Hospital was opened in 1976 to replace Morrisania City Hospital and Fordham Hospital both in the Bronx, New York, USA. It serves a socio-economically deprived population composed of 50% blacks, 45% Hispanics and 5% whites. The area has about 300,000 adults. The Department of Ambulatory Care Services at North Central Bronx Hospital is an outcome of the reorganisation of the Outpatient Department at Morrisania City Hospital. The hospital has about 190,000 outpatient visits each year adult primary care 48,257, paediatric primary care 37,397, obstetrical/ gynaecological primary care 40,112, medical subspecialty consultations 11,314, surgical specialties 62,520 and 83,186 emergency service visits from 55,109 adults and 28,077 children. City hospitals have become primary providers of medical care in many of today's urban centres, where community residents are economically dependent, socially isolated and have no easy access to private medical care. The rising costs of medical care and inadequate or absent health insurance makes increased demands on teaching hospitals to find ways to serve local populations more effectively in the area of ambulatory care. Morrisania City Hospital reviewed its outpatient services in the early 1970s to find them fragmented, episodic, disease-oriented and without adequate follow-up of patients. There was over-specialisation and lack of patient care co-ordination. In 1973, Morrisania City Hospital unified its outpatient departments into a Department of Ambulatory Care with a full-time director who became responsible for planning, implementation and co-ordination of the programme, including the integration of all ambulatory care components: medical & paediatric clinics and sub-specialties, specialty units of surgery, obstetrics and gynaecology, otolaryngology, ophthalmology, dentistry, adult & paediatric emergency services, a home care unit and the employees' health service. The Director began and has continued liaison with chiefs of all clinical departments concerning the planning and staffing related to their disciplines. The functional independence of the Director facilitated the establishment of priorities for different care components while minimising conflicts of interest. Described here are some of the innovation programmes for ambulatory care, which have grown out of the reorganisation for PHC.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 6: NORTH CENTRAL BRONX HOSPITAL (part 2)


The Neighbourhood Family Care Centre (NFCC) The NFCC, begun in 1973, was organised to provide integrated first level care in the district, with family rather than disease orientation, and including home visits. The Centre offers and advertises the following: health services for infants, children, adolescents and adults; family planning, prenatal care, speech & hearing care, nutrition advice, dental service, mental health service, laboratory and pharmacy services. The NFCC is open from 9 am to 5 pm, four days a week, from 9 am to 8 pm, one day and 24-hour telephone coverage is provided. General medical and paediatric clinics and their sub-specialty clinics were phased out, and five primary Health Care Teams were established. Each team (of 26-28 members, as listed below) is an independent unit responsible for provision of comprehensive care to a specific population group in the district who are registered as families to that unit. Teams are composed of the following: 2 full-time internists 4 internal medicine residents 1-2 full-time paediatricians 2-3 adult nurse practitioners 1-2 paediatric nurse practitioners 1 community health nurse 5 family health technicians 1 social worker 2 social worker technicians 4 nurses' aides 4 clerks Adult family members are seen by the internist and/or nurse practitioner, while paediatric patients are seen by the paediatrician and/or nurse practitioner in the same primary care unit. Specialty services are available for referrals in surgery, dentistry, obstetrics and gynaecology, ophthalmology and otolaryngology. A surgeon may also be called in when necessary. Dentistry and medical specialty residents are assigned periodically or on rotation to the teams, and this enhances the quality of care by promoting a beneficial exchange of information between the team and visiting specialist residents. The community health nurse co-ordinates family health care as a whole and supervises the work of family health technicians who provide most of the home visits and outreach programmes. Also in 1973, a full-time Director of the Adult Emergency Services was employed and new positions designated as 'ambulatory care residents' were created. Spending half their time in the adult emergency services and half in the primary care units, the residents' hours are arranged so that they follow up patients that they see in emergency rooms in the primary care unit. Programme Evaluation was able to show that despite an increased number of ambulatory visits, total admissions to the adult medical service were reduced after the ambulatory care reorganisation. Diseases which had represented 23% of all admissions (diabetes mellitus, hypertension, cerebrovascular accidents, congestive failure and asthma) were significantly reduced, and financial savings ensued.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 6: NORTH CENTRAL BRONX HOSPITAL (part 3)

Community outreach programmes These have developed in several ways since 1965, when it was known that 40% of the population were under 18 years, the area had one of the highest rates of juvenile delinquency in the city, 80% of children were receiving public assistance and of 2,345 seen as patients, 71% had conditions related to malnutrition. Anaemia from poor nutrition was found in 83%. A. The Comprehensive Child Health Project was organised to provide a multidisciplinary approach to the total health care of children in the community. The essence of the project, the Health Team, is composed of the paediatrician, the public health nurse and the community health assistant, and serves from a central clinic in the community. The paediatrician provides continuous, personal medical care not unlike a private physician and sees about 20 patients a day. The public health nurse visits the homes of new patients and follows up with clinical and counselling services, also instructing special groups in the clinic (parents, family planning, nutrition, etc). Specialist support systems are available to the Team, and an inservice training programme for community health assistants is run to provide help for public health nurses and social workers with transport, referral and follow-up problems at home. Increasing community acceptance has been measured, and the project maintains close working relationships with the hospital's paediatric department and other agencies where referral may be necessary. A 2-week camp for children, a day care centre and recreational programmes and meetings with local leaders are some of the outreach activities for which the project is known and it has been used as a demonstration project in training public health and other project workers. Evaluation showed also that the project's cost effectiveness improved at a rapid rate with expense per child treated decreasing by 40% over three years. B. The "Shadow" Programme, operating since 1970, enabled high school and college students who show interest in dentistry or medicine to 'follow' the dentist or doctor in their work at the hospital. The primary purpose is to motivate volunteers (who are generally black or Hispanic) to stay in school and know that they could become doctors and dentists too. The student is a 'shadow' in the literal sense when the health provider is very busy. When things ease up, there is time for questions and learning. Each participant, assessed according to interest, is assigned to a specific health professional, and instruction is arranged in basic clinical skills (taking vital signs, resuscitation, etc). Primarily assigned to ambulatory care clinics, in time they may be transferred to emergency rooms or medical/surgical wards. They attend lectures, grand rounds, discharge rounds, and are permitted to be oncall for 24 hours with their teams. Individual files about the student's participation in the programme are kept along with recommendations, so that counselling and information can be given when the students make applications for professional training. Of 101 students in the programme from 1970 to 1974, and who were followed closely thereafter, 58 showed definite potential and pursued professional careers in health care while 39 of the remaining 43 pursued non-professional careers in health care.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 6: NORTH CENTRAL BRONX HOSPITAL (part 4)


The Shadow programme has received much publicity and a number of national and state awards, as well as the Mayoral Award from the City of New York. C. The "Barefoot Doctor" Programme was inspired by the visit of the Director of Ambulatory Care at the North Central Bronx Hospital to China, when students listening to her experiences there, wondered if they could be "barefoot doctors" too. Since 1975 this programme has become an integral part of the hospital and its outreach programmes. Its particular importance in the beginning was because of the unchecked rise in incidents of venereal disease, and the lack of any effective methods for getting the 'message' across to the teenage population where it thrived. Initially 20 students were trained, selected from the trouble- makers, predelinquents, truants and other disruptors. They were shown how to do health screening, which included a check on temperature, pulse, respiration rates, blood pressures, vision, hearing, urine analysis and gonorrhoea cultures. Dental screening was added later on. After their training, the students raised funds to purchase jackets, and a science room in the school was converted into a clinic run by students for students. By 1982 the programme had trained 350 students. About one third went into the armed services, with a strong preference for health services. Of the remainder 182 have progressed to college, the majority studying X-ray or laboratory technology. Twelve are in pre-med or dental programmes. Students are 15-18 when selected and the training they receive is part of their high school education. The course outline is varied and practical, including: a) The World of Work; b) The Health Care Industry; c) Health Services & the Health Team; d) The Patient's Well-being; e) Anatomy and physiology; f) Nutrition and Food Service; g) Nature of Ageing; h) Care of the Dying, and i) China (Health Care). D. Project "CREATE" stands for 'Community Respected Elders and Teenage Exchange' and is a programme that matches 12-15 year olds with lonely elderly people. The hope is that both will learn from each other, and that young students would also be exposed to health careers, helping the social workers in hospital by giving feedback on the elderly they visited in their homes. The peer support and friendship that the students, often problematic and difficult previously, have received is an important part of the programme. Some elders have even 'adopted' their CREATE students and new dimensions are brought into their lives through visits, walking and talking together with the young.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 6: NORTH CENTRAL BRONX HOSPITAL (part 5)

The programme activities include extensive training in the understanding of older people, working at the hospital and in various hospital, home and community settings, visits to various departments of the hospital and orientation to their work through workshops, group sessions in various types of therapies and 'dynamic' situations, and practice in the techniques of doing oral histories. The students keep daily records of their work with the elderly, and analyse their feelings about it. They are tested by teachers on the scientific and social information from the workshops, and they evaluate each others progress in group sessions. Examination by essays also assesses the students' knowledge of the work. Follow-up counselling for students and families, as well as parental and alumni involvement in the project are special features which make this a PHC project of consequence in the community. Parents also tour the hospital and visit the teachers involved in the programme. Recent graduates of the programme are involved in a follow-up programme. They are contacted to see if they need any help in being placed in the right programmes for them and in adjusting to their new schools. Several CREATE alumni have expressed interest in giving time and support to the new CREATE students. CREATE students may join the Barefoot Doctor programme or the Shadow Programme of the hospital. In addition to what has already been mentioned, CREATE students have participated in conferences as panellists and the programme has received a lot of publicity from television and in a number of school publications. The programme received a Mayoral Award in 1980.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 7 ADI HUSADA HOSPITAL 40-44 Undaan Wetan Surabaya Jatim Indonesia

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person: Dr J B Djuanda Director

320-bed teaching semi-urban non-governmental hospital SCHOOL HEALTH PROGRAMME -ACCIDENT PREVENTION - COMMUNITY DEVELOPMENT THROUGH A WOMEN'S ORGANISATION -HOME CARE The PHC programme used to be called the hospital's extramural programme. PHC became a formal programme in 1976. The hospital started the health centre, which had been promised. It was a pilot project to help determine how to accelerate community participation in the prevention and simple curative treatment of diseases. Before this the extramural programme's objective was to help people. With the establishment of PHC, the goal was changed into facilitating people to help themselves. The government challenged the hospital on how to increase the health status of the people by helping them to attain self-reliance. This has led to a combination of various programmes, which are allocated 30 million Rupiahs out of the 1.5 billion Rupiah budget of the hospital. The director decides where the 30 million is to be spent among the projects. The staff of the community health programme is composed of doctors, dentists, nurses, social workers, sociologists and psychologists. SCHOOL HEALTH The Child Health Competition project of the hospital is composed of three parts: a. The child representatives of the schools were asked questions like the meaning of health and what health habits they practise. They demonstrate how they eat and how they brush their teeth. b. Vaccination data of all the children were obtained. c. The weights and heights of all the children were taken by the hospital and school staff. Prizes were given to the best school whose children were in the best of health. There are now 16 schools with 6,441 pupils (from Kindergarten to High School), which are participating in the School Health Programme. Two medical doctors, four dentists and three nurses are responsible for this programme. The two doctors rotate around the schools while the dentists are in the school clinics in the morning. They serve in the hospital in the afternoons. All staff members are on full-time employment by the hospital. The hospital psychologist and social workers from the hospital also help in the programme. The service component of this programme includes examination of all students twice a year, psychological tests (including IQ) yearly, and social work handling of those with home and emotional problems (including home visits). Teachers are also examined yearly with chest X-rays.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 7: ADI HUSADA HOSPITAL (part 2)


The hospital director was able to convince schools to participate in their health programme when he showed them in figures how much cheaper it is for a child to pay 200 Rupiahs a month for one year and get the services offered, than for the child to go to a private doctor. Consent of parents for the care of the child by the school physician is always taken. Each school teacher also pays an equal amount. Indigent pupils do not pay. If a member of the school health programme is hospitalised, he or she does not pay for doctors' fees or routine laboratory or x-ray examinations. Only the medicines and accommodations are not free. Indigent patients are given all of these free. The student organisations are involved in the programme. The chairman and two representatives (one girl, one boy) when interviewed by this reporter, knew about the programme, their responsibilities, and expressed satisfaction with the services rendered. The chairman said he was responsible for motivating his friends to pay attention to their own health and to have a clean environment. The child-to-child programme seems to be more successful than the child-to-home programme. The latter is better implemented in the schools located in the poorer villages. The child-to-child programme involves the pupil teaching his younger brothers and sisters health practices, which he has learned. The child-to-home programme includes projects such as banana and papaya tree-planting demonstrations by the school headmaster, and usage of boiled water and toothbrushes in the school. These are expected to be done at home by the pupils. ACCIDENT PREVENTION PROGRAMME The hospital participates in a programme together with other hospitals in the city. This is the Emergency Care programme, designed to deal with the many traffic accidents in this area, and it involves: a. helping traffic accident victims on the streets; b. helping various institutions (hospitals, police, insurance companies, etc) to coordinate their efforts and activities for reducing/correcting the accident problem; and c. educating the masses to prevent traffic accidents. The various functions and responsibilities of each sector are defined and these are coordinated together. The lead hospital here is the government city hospital, whose director is the vice president of the local federation of hospitals. This is possible because all hospitals in East Java, whether governmental or private are working side by side on the basis of mutual co- operation and mutual benefit. VILLAGE DEVELOPMENT PROGRAMME This is a project of the hospital together with the women's organisation in a village. One local woman organises others to form the Dharma Wanita (Dharma means devote or donate, and Manita means woman). Dharma Wanita is then used as the vehicle for the government programme of PKK (literal translation: Education, Welfare and Family), and so is a semi-official organisation.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 7: ADI HUSADA HOSPITAL (part 3)


The programme has 10 major concerns: 1. Basic philosophy of the country (pancasila). 2. Gotong-royong (mutual co-operation). 3. Food. 4. Clothing. 5. Housing and home administration. 6. Education. 7. Health including Family planning. 8. Development of co-operative life system. 9. Conservation of healthy living environment. 10. Planning towards healthful living. This project was submitted by Adi Husada and assisted by WHO in 1978 for a 5-year period. An offshoot of the successful community development project stimulated by Dr Nugroho (now with WHO, Manila). It was believed that the best way to make the project a success was to work through a woman's organisation, which is a part of the village development programme. Adi Husada embarked on a series of training programmes in the following: ? Trainer training ? Health education ? Family planning and demography ? Women's activities ? Voluntary health workers ? Local executive training ? Nutrition ? Family planning motivators In one village (Klampis Ngasem), the leader of the women's organisation has been quite active, supported by chairman of the village committee on social and health affairs. With the stimulation, guidance and support of Adi Husada, the 300 members of the village women's organisation developed a strong and active organisation with many accomplishments. Their leader has the ability to present these achievements of their programme before groups of people. Because of this, she has been invited to conventions and meetings in Indonesia and is scheduled to start attending international conferences. She has also been appointed as the provincial agricultural contact of the government with the farmers. There are 1,214 families participating in the village development programme of Adi Husada Hospital, involving 5,258 people in Klampis Ngasem. The village women are now running the programme themselves (after the end of 5 year programme in 1983). Besides that, programmes are still going on in six villages. Programme activities include the following: a) Monthly weighing of children under five years of age.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 7: ADI HUSADA HOSPITAL (part 4)


The village built a small canteen where they do this and their other activities. The organisation members do everything except vaccinations, which are done by Adi Husada staff. Cooking demonstrations are held here for the mothers. The children are given the food cooked by the mothers as supplementary feeding during the weighing sessions. b) Housing project and water filtration Here, the women apply their "gotong royong" concept of helping each other. The women agree that whenever someone wants to improve her house, she must give some help in kind (like constructional material, roof tiles, etc.) or money, to a neighbour for the latter to also upgrade her house. There is no limit (minimum or maximum) for this help. c) Workshops or courses are held to enable the villagers to understand the 10 concerns of PKK mentioned above, and to train youth leaders in the village in what they could do to help. d) Village women must help implement the school programme. The village development programme provided opportunities for the hospital nursing and medical students (affiliates from the College of Medicine) to do their required community work. Paramedical workers were also given training here in learning about community needs. The medical students are required to stay 2 months in a community during their pre-clinical years. It is also compulsory for them to have field training in community health.

4. 5. 6.

Financing The villagers participating in the programme contribute 50-100 Rupiahs each month. The village head is knowledgeable about who has money and when, enabling him to collect at the proper time for the village central fund. The village social affairs committee together with the women's organisation decide what to do with their money. Once a month, the hospital used to meet with these leaders. At this time, they were informed about donations for their programme and where the money goes. Some problems and obstacles I As a private organisation, Adi Husada had difficulties finding an entry point into the village. The people were suspicious of the hospital staff's presence. It took one whole year for the first village to accept and cooperate in the programme. It was a good thing that the hospital staff enjoyed going to the village. But some of the staff members also asked why - the hospital had to do all these tasks when they should be considered as I the government's responsibility. The co-ordinating organisation for all women's organisations in various villages is the BKOW. One problem is the lack of coordination among the higher authorities in village intersectoral programmes, even among various health agencies. Since the hospital programme staff left the area, the women have felt abandoned or left alone in their problems. However, Adi Husada staff plan to visit them periodically.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 7: ADI HUSADA HOSPITAL (part 5)


In some villages similar programmes can be hampered by disharmony between the head of the village and that of the women's organisation in the villages. Or the wife of the village head may not want to become actively involved in the programme. HOME CARE PROGRAMME This was initiated 6 years ago for the benefit of three types of patients: a. Low-income patients who need hospitalisation, but are unable to afford hospital fees or expenses for their relatives to come and help take care of them in the hospital (a practice common in developing countries). b. Those who need hospitalisation when the hospital is full, so that there is no space for them. This need started the programme in 1976. c. Those who refuse to be hospitalised for various reasons, although hospitalisation is indicated. There have been problems to face in this part of the PHC programme. All the staff members running the programme are women, so it is difficult for them to go out at night when required by a patient's need. A security guard had to be employed for this reason. Since the nursing schools opened their doors to male students, there are now male nursing graduates who can attend to outside calls at night. Transportation can be a problem for certain areas. The family has to be trained to take care of the patient. The presence of student nurses helps to solve this problem because they have more energy to travel. Lack of water in some homes can make home care difficult and unhygienic. Summarising the lessons that have been learned, however, they have been found to be valuable. Intersectoral co-operation is important, and the hospital plans to do more of this. Motivational efforts directed to the staff of the programme are likewise very important. Their attitudes can do a lot to help or hinder the programme. Social workers in the hospital, with guidance from a sociologist, can develop a very active mental health and. educational programme for children admitted to the hospital. In the hospital's paediatric wards, the social workers help with the children's homework, direct recreation, handicraft, and play activities, aid in attaining improved communication between mother and child, and prepare the children psychologically before operations. The professional medical and nursing staff and medical and nursing students need orientation to community health needs and PHC. Once they are made personally aware of these needs, and ways to meet them (including promotion and prevention), they can be very valuable leaders or members of the team. Health professionals must not just wait for patients. They need to go to the people in the community. They must be aware of this responsibility.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 8: THE SOROKA MEDICAL CENTER University Center for Health Sciences (UCHS) Ben Gurion university of the Negev P.O. Box 653 Beer Sheva 84105 Israel

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Persons: Dr. Reuben Eldar Acting Chairman Dept. of Health in Community Boaz porter, M.B., Ch.B Acting Head Primary Care Unit

Teaching hospital with associated community health clinics, home care programmes & public health services COMPLETE INTEGRATION OF HOSPITAL SERVICES, MEDICAL EDUCATION, AND REGIONAL HEALTH SERVICES; HOSPITAL-BASED GERIATRIC HOME CARE

The Negev region is known for its arid land and sparse population. It encompasses 60% of Israel's territory but has only 10% of its population. Amongst its 400,000 people, spread out in 177 towns and settlements over 17,000 square kilometres, are 46,000 Bedouin. Beer Sheva has been known since biblical times, as the place where Abraham dug wells. In 1949 it was a village of 2,500; the university was established in 1969 and the city now has a population of 130,000. The Soroka Medical Center is owned by the General Federation of Labour's Sick Fund, which also owns and operates most community health services on the primary and secondary level in Israel. In 1974, it merged in Beer Sheva with the Ben Gurion University of the Negev into the Faculty of Health Sciences to put into action a new philosophy -emphasising the relevance of medical care to community needs and the development needs of the region. The university has a most interesting mix of faculties and research institutes, all geared toward the long-term development of the Negev. Its Applied Research Institute has made a breakthrough in teaching farmers how to turn once-barren plains into verdant fields of wheat and vegetables for export. Other research products include tomatoes that stay fresh without refrigeration for 3 months, a water-saving dual-flush toilet, and a formula for making instant yogurt. The Faculty of Health Sciences comprises four schools: medicine, allied health professions (including nursing and physiotherapy), health administration and continuing education. In 1974, with the vision of the Founding Dean of the Medical Center, four institutions and services were merged: the Soroka Hospital, the public Health Services of the Ministry of Health, the Kupat Holim (workers' health fund clinics) and the Faculty of Health Sciences, to form a consortium: the University Center for Health Sciences. The purpose was to integrate medical education with health and hospital services, and make the medical faculty full partner in the design and administration of comprehensive health services -preventive, curative and rehabilitative -for a large region. The medical school, the medical centre and the health services for the Negev Region are all under one head, who is responsible for the co- ordination and integration of the work, education and services through specific division and department heads.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 8: THE SOROKA MEDICAL CENTER (part 2)


The heads of medical specialties in the hospital are also responsible for the quality of care in their respective specialties in the region. This means that the chief of paediatric medicine is ultimately held accountable for the quality of medical care of children in every town and settlement of the Negev. Faculty and students therefore are active in the total health care programme in the region, including PHC.

COMMUNITY-ORIENTED MEDICAL CURRICULUM Israel has one of the highest doctor/patient ratios in the world, yet finds itself with a health care delivery system inadequate to meet the health needs of its population. Its doctors are concentrated in specialist departments in hospitals, while out-patient and primary care clinics lack well trained physicians, especially in the less-developed parts of the country. Highly specialised medicine has been encouraged by its other three medical schools, which offer conventional systems of medical education centred on the teaching hospital. Doctors are more comfortable in the cities, and have little orientation to the interplay of factors that influence health and disease in the community. The School of Medicine in Beer Sheva is the first in the country to devise its curriculum to become community-oriented from the first week of the first-year class. The students are exposed to 'normal health' in factories, nurseries, homes for the aged, etc. They also see patients in the clinics, and are encouraged to see complete individuals rather than cases. A major emphasis in instruction is public health. The students learn how to identify community health problems, develop and implement measures for their solution and evaluate results in the community. "To teach is to serve, to serve is to teach". Following this motto, many of the faculty members are practising physicians from various communities in the region. They know, first-hand, the prevailing health problems and conditions in the area. From their first day at the university, medical students receive instruction in clinical practice, visit the hospital wards, accompany physicians in primary care clinics and work in emergency rooms. Because of this the students take their oath of medicine upon entering the university and not after they graduate. Students also visit and gain experience in geriatric centres, private homes and in Negev development towns, agricultural settlements, and Bedouin encampments. Working with a special health care team (family physician, nurse and often a social worker or psychologist) the student acquires a much broader perspective about illness and wellness in the community. Teaching is based on systems correlated with what the students observe in real life, as they progressively see these people in their normal state as well as in their diseased or abnormal state. The spiral principle of teaching gradually adds details and refinements to each personal health system each year. problem-solving skills are emphasised, using problems of increasing complexity. The total medical school curriculum is made up of seven years, after high school, including internship, and this adds up to 19 years of education to provide a doctor. After each of the major courses, all teachers involved, together with student representatives, participate in a de-briefing session. These are frank discussions during which course content and teacher performance are assessed. Courses are subsequently revised or refined as necessary.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 8: THE SOROKA MEDICAL CENTER (part 3)


Medical student selection An undergraduate university degree is not a prerequisite for admission. Fifty students are admitted yearly to the first-year class. Before admission, the student is interviewed by a committee that includes ten physicians and ten laymen from the community. Community-orientation is looked for in attitude, behaviour and experience of the applicant. Empathy is valued along with the ability to communicate with people from various social backgrounds. Motivation to work within a developing community is essential. Results to date By 1983, two graduating classes had been produced, 18 graduates continuing to work in community medicine. The quality of medical education under this integrated system was found to be as good if not better than at other medical schools in the country. In addition, the graduates have better community orientation, more familiarity with primary care, and have the ability to work in an integrated system. They are capable of being agents of change. The Health Sciences Center has been designated a Collaborative Institute of WHO, because of its innovative and far-reaching approach. There is a steady flow of medical experts from abroad who visit the Center to share their expertise as well as learn from the experiences there. ADMINISTRATION OF HEALTH SERVICES FOR THE REGION Behind the landmark decision for the Dean of the Faculty of Health Sciences to serve as the Director of Health Services of the Negev was the desire to avoid wasteful duplication of services and resources, and to improve the region's health care system in line with its growing population. This made the UCHS in charge of thousands of health care personnel in scores of communities. The planning and co-ordination of health care for the region is conducted by the Regional Committee for Health Services, composed of various heads of health services and members of faculty. It meets now once a month, although originally it met twice weekly, and it has a number of sub- committees that meet as needed. An independent unit for epidemiology and health services evaluation also exists, headed by the professor of epidemiology, which serves the region. Its findings serve as feedback in the assessment of facilities and needs. PRI MARY HEALTH CARE Primary health care is available through clinics belonging to the health maintenance organisation/health insurance group, called Kupat Holim. Medical records in the clinics are organised according to families, to facilitate analysis of health problems. Referrals to hospital must be accompanied by a card from the clinic and patients are referred back to the clinics when they leave the hospital.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 8: THE SOROKA MEDICAL CENTER (part 4)


Community health centres, staffed by the Ministry of Health, provide preventive services by performing routine baby check-ups, -including immunisation, pre-natal care and health care for elderly patients. They keep complete medical records with past and present medical histories, nutrition records, immunisation charts, etc. Sick patients are referred to the Kupat Holim clinics. Each specialty department in the hospital schedules regular visits by its specialists to clinics and health centres in the region. Each clinic is visited 2-3 times a week by a consultant and this is where problem cases are raised, and in-service training given by staff. Health education classes are held regularly in hospital for patients and visitors, with special attention to the Bedouin who are basically nomadic and have special needs. There is also a mobile service that visits Bedouin encampments regularly, and especially to follow-up on hospital admissions. Bedouins suffer from malnutrition, gastroenteritis in summertime and respiratory infection during winter. The mobile clinic has begun an oral rehydration training programme amongst Bedouin women. Computerisation of health information has begun for the region's residents. This should be a useful source of future information to analyse disease patterns and assist in planning of services. In 1983 the Center sponsored an international symposium on PHC for medical educators. They debated the type of doctor, internist or paediatrician, that was especially needed for PHC. THE GERIATRIC PROBLEM Only 8.5 per cent of the total population in the Negev are 65 years of age or older, and live under fairly good conditions, as compared to 13% in other parts of the country, particularly in big cities. The criteria for involvement in the geriatric care programme of the Centre are three: 1. Need for rehabilitation after CVA, fractures and amputees; 2. Need for health maintenance (severe congestive heart failure) with clinical problems beyond the capacities of the family physician; and 3. Need for nursing in such cases as severe dementia, pressure sores, catheters, etc. The Center's programme includes a 20-bed geriatric department, a home care unit, 3 day-care centres, and a home for the aged. The hospital-based home care programme This works with family physicians in the community to follow-up 200 geriatric patients. High but not exclusive emphasis is on care for the home-bound and bed-ridden elderly. The home care unit is staffed by 2 senior geriatricians, 1 family medicine doctor, 4 nurses, 1 1/2 physiotherapists, 1 occupational therapist and a 1/2 time social worker. The team has links with community services such as family physicians, domestic help, meals on wheels, day centres, volunteers, etc. and has a permanent schedule of visits to patients in other regional towns, providing advisory services to local authorities as well. Family counselling is a main focus and instruction is given on diet and drug regime compliance.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 8: THE SOROKA MEDICAL CENTER (part 5)

Day care centres These are manned by volunteers and supervised by social workers. They are open from 0730 to 1300 hrs and transport to them is provided by the city. Each centre has a director, instructors and helpers for its various activities. Medical care for those attending is provided by the home care unit of the hospital's geriatric department. THE FUTURE An issue the Center is planning to resolve is how to improve public input into health policy and strategy decisions. 'It may be easy to start a revolution', said the founding Dean of the Center, 'but difficult to keep up the momentum.' Resistance came originally from established university groups of medical educators but appears resolved. The dichotomy between the services of the Kupat Holim and the Ministry of Health services was also not easy to overcome, but the official merger under the Regional Director of Health Services has eased that problem. The conclusion, however, is that hospitals can do a great deal for PHC. Hospitals can become familiar with the communities they serve, include community orientation and training for medical, nursing and other staff. Additionally hospitals can merge, collaborate and co-operate with other health institutions in the area for total health care, with the emphasis on PHC.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 9: GONOSHASTHA YA KENDRA Via Dhamrai P.O. Box Nayarhat Dhaka District Bangladesh

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person : Dr. Zafrullah Chowdhury Projects' Co-ordinator

15-bed lying-in hospital', general, in rural area, as part of a community development programme complex CURATIVE & PHC PROGRAMMES; DRUGS FACTORY; AGRICULTURAL EXTENSION PROGRAMME; SCHOOL & SKILLS TRAINING PROGRAMME

Gonoshasthaya Kendra -The peoples' Health Centre -Trust includes : curative and primary health care programmes, Gonoshasthaya pharmaceuticals Limited; agricultural extension programme; women's vocational skills training centre; primary school and adult education programme, and "Monthly Gonoshasthaya" and other publications. The hospital in GK is an integral part of the primary health care and rural community development programme. During the 1971 Liberation struggle, a team of doctors and medical students established the 'Bangladesh Hospital' for freedom fighters and refugees of Bangladesh (then East Pakistan). They trained volunteers and refugees, most of them women, to treat the wounded and the problems of malnutrition, disease and public health in the camps. During this period those experienced doctors learned for the first time of the health problems of the poor and how existing systems fail them. After liberation they re- established the centre and began experimental work in an alternative health system. The objective: to provide primary health care for the majority of the population of one area. The 15-bed hospital for emergency admissions plus its operating theatre, out-patient clinics, pathology laboratory, X-ray department and pharmacy, provide vital back-up. Primary health care first Pioneering work was done in training people with little formal education as paraprofessional health workers. Training women is a priority, so women in the community have full access to facilities. The health programme employs 76 paramedics of whom about 60% are women. Paramedics are based in the main Savar centre and four other sub-centres, or in their own villages. They serve a total population of 120,000. Bhatsala GK is an independent centre 120 miles from Dhaka, carrying out the same programme and it has its own sub-centre. In Bhatsala and all the sub- centre hospital units, admission wards for emergency patients are available, plus operating theatres, pathology labs and pharmacies. Senior paramedics have gained the specialised training necessary and also assist in theatre and undertake, independently, minor operations. There are three full-time doctors on call in Savar GK and one in Bhatsala on a part-time basis. In Savar there are also one qualified pathologist, a surgeon and an anaesthetist. Patients are admitted into the hospital for short periods, returning to the village as soon as possible, to keep costs to the minimum for tile patient. The staff of the hospital are paramedics given training in nursing skills. In Savar there are two big rooms, which serve as wards for all the patients, with minimum essential facilities.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 9: GONOSHASTHA YA KENDRA (part 2) Health care alone is not enough Paramedics faced with people suffering from malnutrition because they are poor, or recurrent diarrhoea because of unsanitary conditions, can do little. To tackle the underlying causes of death and disease GK developed its other projects. Agricultural extension groups of the landless and marginalized farmers work for increased food production and income from new sources: the aim is economic solvency and self-help organisation for men and women. Nari Kendra -the women's centre -provides vocational training and employment in metal work, carpentry, jute plastic production, sandal- making, jute and bamboo handicrafts and tailoring, laundering and a bakery. Poor rural women are the most exploited class of society suffering oppression, both as peasants and as women. Nari Kendra promotes women's education, training and employment. The education programme consists of adult literacy training and education in the centre, and village schools and a primary school for the children of the poor. Gonoshasthaya pharmaceuticals Ltd is a commercial venture under the Trust. We produce low-cost, high quality, essential drugs, as listed by the World Health Organization. We support the Government's drug policy and promote good marketing practices for generic drugs. "Monthly Gonoshasthaya" provides up-to-date medical and scientific information for doctors and health workers and covers a range of social and political issues. Getting started -finance Support came from inside Bangladesh to start with, individuals donated land and funds and set up a charitable trust to administer them. Foreign agencies, for example, Oxfam, NOVIB, War on Want and Christian Aid gave support and still do. One principal aim is economic self-sufficiency, our programme should be replicable throughout the country without heavy reliance on foreign aid. A health insurance scheme pays for part of the health programme. The poorest receive insurance free and pay only a token price for treatment, including hospitalisation fees. Above those unable to provide two meals a day from any source, patients are divided into two categories depending on their land holding, income and economic solvency. They pay insurance fees and treatment costs at two rates according to their means. Profits from the productive sectors of GK, including Gonoshasthaya Pharmaceuticals Ltd, are limited by the charitable charter to 10-15% and fund the health and education programmes. Obstacles and problems met Workers have been murdered. "Health is a political issue. Those enjoying care do not want to share this care." The work and the philosophy of GK is a threat to the selfinterests of the privileged and often corrupt minority.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 9: GONOSHASTHA YA KENDRA (part 3) Finding people ready to commit time and energies to this work at a much lower salary than they could get in foreign-run organisations is a problem. Daily village rounds are physically as well as mentally demanding, change is slow and involves risks. A tragic waste of women's skills, because of prejudice against working women, is a huge problem. The project is showing women and men the possibilities for all" women to work outside the home. Lessons learned 1. Positive discrimination in favour of women's employment and education is essential to change the economic, health and educational condition of the poor and to enable women to use their skills for community development. 2. Preventive medicine, curative medicine and family planning must be integrated. More importantly, health and development efforts must be integrated. 3. Government health care is more costly, especially in matters of medicine. One bottle of 60ml of antibiotics is insufficient for a series of treatment. packaging two bottles is costly where packing them in quantities of 100ml (syrup/suspension) saves money. 4. This programme is easy to replicate. All one needs is commitment to health for all. 5. The programme workers must understand the situation of poor people by daily experience of their lives and listening to them. Evaluation The projects regularly measure and assess the following: 1) Mortality and morbidity rates 2) Acceptability of immunisation (70-90% in 1983) 3) Number of people employed, especially women. 4) People attending programmes

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 10 RAMATHIBODI HOSPITAL Community Medicine Centre, Faculty of Medicine Mahidol University Community Health programme Bangkok Thailand

Contact Person: Dr. Prem Buri Adviser (Former Director)

700-bed government urban teaching hospital PREPARATION FOR LEADERSHIP; CURRICULUM DESIGN FOR PUBLIC HEALTH

When the hospital was opened in 1969, the faculty was already aware that community medicine was important for its students. However, they also knew that this would be difficult to introduce because of the urban trained and oriented specialists who wanted to build their own empires. Inspired by the visit and ideas of Dr. Robert Loeb, representing the Ford Foundation, which was about to grant money to the hospital, a group of doctors planned and introduced public health into the curriculum of the new college. A later Fellowship from the Rockefeller Foundation to one doctor allowed him to visit different public programmes around the world, and this armed him with many stimulating ideas. Back in Thailand, people from 11 different departments and disciplines in the hospital were brought together, and five short-term consultants were obtained from the USA. Together they formulated the concept of Community Medicine, organised the programme and curriculum design, and solicited financial and moral support. The group began with brainstorming on how to teach students who would become responsible for integrated and comprehensive care to a large ii population (50,000 to 100,000 per district). It soon became clear that the t' doctors who would assume the role of district hospital chief would need the qualities of a competent practitioner (for individuals and families), a competent manager of a health team and others: a teacher with basic knowledge of the science of education and setting objectives, and a supervisor and consultant for PHC. On the basis of those four roles, the objectives of the PHC programme were established. The primary objectives of the teaching activities in community health are: 1. To offer an integrated and progressive sequence of learning experiences which will give students the knowledge and skills needed for : a. a critical examination of the health care needs of a defined population group, and for b. the design of health care programmes to meet those needs. 2. To prepare students and interns to perform effectively as First Class Health Centre Physicians, giving the best possible comprehensive and integrated health care (curative, preventive, promotive) to the people of the district, using the limited resources available at such health centres.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 10: RAMATHIBODI HOSPITAL (part 2)


Training in the community The programme has chosen the district of Amphur Bang Pa-In, mentioned above, with a population of 46,000 people. It serves as a realistic setting for teaching community health care and brings the CHP's teaching objectives in line with the Ministry of Health's actual operating policies and future plans for meeting rural health care needs. The field programme also provides an opportunity for innovation and operations research into methods of health care delivery to a defined population group. TEACHING PROGRAMME The teaching programme in community health includes a sequence of 3 courses. The course is given during years 3, 5 and 6 of the 6-year medical curriculum. All courses are taught by the CHP staff, with other faculty members also participating when appropriate. Ministry officials help to teach in several of the courses. Course I. Health and demographic survey; Analysis of community health problems and Community health planning This is a combination of three courses. It is compulsory for all Year 3 students during ~e second semester of the third year. This course is designed to introduce the students to community health problems in a population of 50,000 living in a rural district. It includes field survey, techniques, community approach and community diagnosis. It is analogous to the study of "anatomy, physiology and pathology" of the community. Basic sciences such as epidemiology, statistics and behavioural science are stressed when opportunities arise during the course. Students study specific health problems of Thailand as a whole and of particular population groups within the country, and they learn a rational problemsolving approach to these problems. Then the principles of, and exercise on, health planning are introduced. The primary objective is to lead students through the complicated steps of planning for integrated health care activities with very limited personnel and resources. What health and disease problems should have priority? How can the various health workers spend their time most effectively? How is "effectiveness" evaluated? Obviously, there are no clear-cut answers to such questions, but the issues behind them are illustrated and discussed. Other topics include the community's view of its own problems; the importance of health education; health care resources available in Thailand; and a comparison of Thailand's health care system with those of other countries. Course II. Clerkship in Community health All Year 5 students (in groups of 20) are required to spend six weeks living and working in Amphur Bang Pa-In. Facilities there include anew government community hospital (with examining room, small laboratory, surgical suite, conference room and 30 in-patient beds) and a dormitory Teaching building built by the CHP (with lecture and seminar rooms, library and sleeping accommodations for over 40 people). In recent years another district hospital in Amphur Sena was included in our training programme. Of these 20 medical students, half of them will stay at Bang Pa-In, and the other 10 students will join the training programme at Amphur Sena."

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 10: RAMATHIBODI HOSPITAL (part 3)


Students are expected to further their understanding of the health demands made by the community, by working in the hospital out-patient clinic, and in-patient care. More importantly, they learn more of the health needs of the population by participating in regular home visits and in student field projects, which are completed during the six weeks. By working with the health team and the guidance of the CHP staff, students demonstrate the ability to use administrative and managerial principles in designing and carrying out health programmes. Course 111. Externship in Community hospital (Year 6) This course of one month is compulsory for students in Year 6, groups of 2- 3 students are assigned for a period of one month in four community hospitals: pakchong, Soongneon, Choompong and Pimai District Hospital in Nakornratsima province. The overall objective is to have each student learn how the official health care system is organised and administered, and to see the system in operation at different levels. They also study the role of the community hospital in the health care system. This course provides the important opportunity for the student to study the role of the doctor in supporting PHC. The students spend one week in the village. By discussion and promotion of community participation, they develop useful innovations and programmes for that village. In summary, the major goal of the CHP is to develop in students the ability and motivation to think of health care not just in terms of doctors practising curative medicine with individual patients, but also in terms of "community health care" which is defined as the provision of comprehensive, integrated health care (curative, preventive and promotive) to a defined population group by a team of health workers, led by a physician. OBSTACLES, PROBLEMS AND LESSONS Medical specialists have no background or orientation in community medicine. So when they rotate in the CHP, they are not able to answer community-related medical questions from the students. This problem was minimised by developing one or two sympathisers with the programme in each specialty department. They become more interested and involved after they are exposed to the community and the students' feedback and questions. The issue is also raised during faculty meetings and executive board meetings. Not being a Department, the CHP had only borrowed staff and office space. Without full-time leadership, the programme was slow in getting started. Promotions in academic rank depended on the specific departments where the staff belonged, so they would rather concentrate their efforts in their own departments. The CHP was directly under the Dean's Office for 13 years. Now, the CHP has become a Centre with the status of a department. Once its department status was approved by the government, it was able to receive funds which allowed the recruitment of a core staff. Other departments contribute their expertise to supplement the regular CHP staff. As a Centre, the CHP is more than a department, giving it the ability to get funds from the government Budget Bureau and various government Ministries such as Agriculture, Co-operatives, and Education, thereby making an intersectoral approach to health care more possible.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 10: RAMATHIBODI HOSPITAL (part 4)


Rapport and a common understanding between the Faculty of Medicine and the Ministry of Health was not there in the beginning and had to be developed by frequent dialogue and a two-way communication. There remains the difficulty of placing the female medical students in district health centres away from their families, which they do not want to leave. This problem is not easy to solve. It took the visit of the consultants from abroad and attendance at international meetings to make some of the leaders in the hospital more aware and convinced of the importance of adjusting the medical care system to the needs of the people. Feedback from the graduates revealed that what was being taught in medical school was not relevant to the community. There was too much specialisation in the hospital. The graduates have now' formed a very influential political body -the Rural Doctors' Association (from government district hospitals). They talk about their difficulties in real rural practice and make recommendations to the Finance Ministry, Ministry of Health and Medical Council (where many of them become members). In order to have success, the people in the programme must have guts, determination, sincerity and they must enjoy working in it. Co-ordination is very important within the hospital, and between the hospital and the university, various government Ministries (particularly Health, Agriculture, Education, Finance), other medical schools, the National Medical Council, the provincial Teachers' Association and the Rural Doctors' Association.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #11 GRACE CHILDREN'S HOSPITAL Crusade Against Tuberculosis #38, Delmas 31 Boite Postale 1767 Haiti West Indies

Contact Person: J. Howard Teel, Ph.D. General Director of programs Port-au-prince Haiti

80-bed, non-governmental urban paediatric hospital for tuberculosis LARGE SCALE EXPANDED PROGRAMME OF IMMUNIZATION (EPI ) AND TUBERCULOSIS CONTROL PROGRAMME (CAT)

Health standards for the Haitian population are the lowest in the Western Hemisphere and, as in most developing countries, tuberculosis is a major public health problem. TB prevalence in Haiti is one of the highest in the world. Studies show approximately 3% of the population suffer with active tuberculosis. This, however, is only part of a much larger problem of the debility and dependency upon society that TB creates. A paucity of doctors and nurses, especially in rural areas, poor communications and conditions of travel, predominantly curative services, high infant mortality and a high birth rate all contribute to health problems which are too large for the government health sector and its public health agencies to control. Private hospital and organisational involvement in PHC is, therefore, very important and much needed. Grace Children's Hospital is financed and operated by International Child Care (ICC), a Christian service organisation whose central programme objective is to enable Haitian health service personnel to control tuberculosis in Haiti. Over a 17-year history, and stemming originally from a 200-bed hospital for tuberculous children, ICC has evolved a wide variety of services promoting PHC. These include: a) A teaching centre/TB out-patient clinic seeing 2,200 patients each month. The clinic provides the training ground for health agents sent by rural dispensaries for a 3-month course on TB and general health. b) A central sputum laboratory, giving training to TB agents in bacilloscopy, and handling control analyses on slides from 110 co-operating centres throughout Haiti; c) A BCG vaccination programme covering over 2 million children (0-20 years) with annual campaigns to vaccinate newborns {0-11 months); d) An extensive programme of TB education for all levels of the medical and general communities; e) A programme of technical and material support to 110 independent TB treatment centres to up-grade and strengthen case-finding, treatment and education methods; and f) An 80-bed hospital for in-patient treatment of acutely ill children.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #11: GRACE CHILDREN'S HOSPITAL (part 2)

PROGRAMME DESCRIPTION The Department of Health, with substantial support from USAID, has trained 450 of the 1,500 health agents who are expected to be the backbone of Haiti's health delivery system. ICC participated in the TB training of these community health workers, who form the backbone for the TB control programme. They perform the following activities: a) TB case-finding, treatment and education (CFTE) activities throughout Haiti, with 115 TB agents trained and working in over 110 health centres. b) Education and training programmes, providing health professionals, paraprofessionals and the general public with TB and primary health care information through a variety of health information forms (classes, seminars, literature, posters, radio, television, direct mail, etc.). c) The mass BCG vaccination of persons 0-20 years of age since November 1975, systematically conducted throughout Haiti. Over 2,100,000 persons were vaccinated (over 80% of the eligible population). This was done one country zone at a time, with funding for each zone coming from a speci5ic set of donor agencies. d) Two mini-mass vaccination campaigns with BCG and DPT for newborns. Newborn vaccinations are now administered annually by motorcycle teams which visit each post established during the mass vaccination campaign. e) The Out-patient Department at Grace Children's Hospital which handles about 2,200 paediatric and adult visits per month. It is a centre for education, training and research activities. PRIMARY HEALTH CARE In 1979, there started a growing consciousness of the health system as it exists in Haiti and the need for a "downward push" on the priorities: to focus more attention on primary level interventions. One problem has been the difficulty in motivating community leaders to participate in these efforts. Without this motivation from within the society, development of PHC cannot take root. Several workshops on PHC were conducted in Creole to increase awareness in the country on the importance and application of PHC principles to Haiti's realities. PHC information was disseminated through: a) A mailing programme to all medical establishments, providing ICC publications as well as copies of Salubritas, Contact, and Sante du Monde; b) A modest book sales activity (Where There is No Doctor, Helping Health Workers Learn); c) Various publications in the ICC resource centre made available to the medical community in Haiti.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #11: GRACE CHILDREN'S HOSPITAL (part 3)

As an organisation, ICC has completed a phase of consciousness-raising for PHC. It is at a critical phase of trying to translate theories into more critical actions. This is the most difficult part of the process. For example, how does one actually alert the community to an awareness of its own health problems and of its own capacity to do something about them? ICC feels that the initiative must come from organisations with sufficient knowledge of PHC principles, but who, nevertheless, have one foot already in the community. ICC's rural health programmes have taken it to every corner of the country, have required close collaboration with local government, church and development leaders, and have developed the confidence and respect of local communities. TRAINING FOR PHC An Education and Training Department has been established. Besides developing the overall philosophy and strategy for education outreach, the department sponsors metropolitan and national seminars, responds to speaking requests, develops TV and radio programmes, publishes the quarterly CAT bulletin, and prepares written materials that are needed. The head of the department supervises staff who manage the library, literature processing and distribution, monitoring of sales of promotional items, development of visual aids and other educational aids, patient and parent education, and regional education co-ordination. The programme puts a lot of emphasis on training of community health workers, giving both initial and refresher courses. It helps support and strengthen the intercommunity referral system. It facilitates the provision of supplies and equipment, and helps to determine the ways in which those supplies are being used. RESULTS TO DATE As of the end of 1983, the programme has achieved the following: a) 80% of people under 20 years of age have been vaccinated with BCG vaccine. b) The TB drug distribution programme has enabled about 30,000 people to receive medication for tuberculosis. In 1981, the sales volume for TB drugs doubled to about US$2S0,000 per year. c) Case finding, treatment, and education activities are going on in about 110 establishments monitored by the Crusade Against Tuberculosis programme. Approximately 6,000 active TB patients are treated annually in these clinics. d) The hospital out-patient department currently takes care of 2,200 patients per month with active TB. Less than 10% need hospitalisation.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #11: GRACE CHILDREN'S HOSPITAL (part 4)

SOME BARRIERS/OBSTACLES Professional resistance is a major obstacle. professionals are generally unwilling to work in the rural areas where health services are most needed, while, paradoxically, they resist the delegation of responsibilities to paramedical and auxiliary personnel. This may need correction through changes in the curriculum for medical education. Many auxiliaries and non-professional health workers are fearful that upgrading their skills and broadening the scope of their work would involve II them in responsibilities which they consider those of the physician. Many people still believe that only physicians can provide good health care, and so they resist going to the nonprofessional PHC workers. An exception II would be the traditional healers, which attract the rural population because of tradition and convenience. Community participation is difficult to achieve because of a generally passive community attitude. The people have been on the receiving end so long that they can only think in terms of receiving aid, and not in terms .of helping themselves. It will take time and strong continuing II motivational and awareness programmes to turn this around. Over- centralisation of decisions in the health care system has prevented effective and adequate delivery at the periphery. Very often, the decision makers may not be aware of the real health problems at the community level. Poor communication and transportation systems have been mentioned as obstacles to reaching the people, and also their reaching the providers of health care. LESSONS LEARNED 1. Community health workers need continuing supervised training and followup if they are to be effective in PHC. 2. There is a need to experiment with an intermediate level of health worker, similar to the medical assistant level, to serve in rural areas. This level is between the community health worker and the professional levels. 3. Vigorous and continuous efforts are needed to reverse the passive attitude of the people into a more active participation in improving their own health. 4. Decentralisation of decision-making in the government health II care system can contribute significantly to improving the relevance and appropriateness of health care at the periphery. 5. A functioning referral and logistical support system is necessary to the achievement of success in PHC.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #12 HOLY FAMILY HOSPITAL Mandar, P.O. 835214 Administrator Ranchi , Bihar , India

Contact Person: Sr. Agnes Panikulam,

150-bed rural general hospital, mission-operated STUDY IN COMMUNITY ACHIEVEMENT MOTIVATION, A FARM DEPARTMENT FOR COMMUNITY DEVELOPMENT
The hospital was built in a forest in 1947, by the Medical Mission Sisters, on land donated by the people. Management gradually transferred to Indian hands and 98% of employees are from the local area. One of the 14 departments of the hospital is the Farm Department, whose head is a College of Agriculture graduate. They raise animals (cows, pigs, chickens, bulls for breeding and ploughing, rabbits) vegetables and fruit trees; all for hospital consumption. Biogas is produced from manure, with the gas piped directly into the kitchen for cooking. The hospital has seven acres of land with seven wells and a pond that collects rain water for irrigation. Outside the hospital is a hostel, owned and operated by the staff, with rooms rented out at very inexpensive rates to relatives of patients in the hospital. Reasons for PHC involvement and getting started In the early 1970s the Medical Mission Sisters who run the hospital, heard about the community development work of a priest, Father Heredero, a psychologist and economist. He had also written a book about his "Achievement Motivation Course" which he conducts for 4-5 days among village people in India . Sister Germaine, the head of the hospital's public health programme, and some of her staff attended this course of which the general concept is motivation of participants from "I cannot do it" to "I can". In 1974, the hospital created a Community Health Department led by Sister Germaine. The department initiated this development approach among the tribal people in the villages surrounding the hospital. Some of the villagers who took the course learned how to conduct it and eventually joined the staff of the department. The Community Health Department has a staff of eight led by an agricultural worker. The team has 3 auxiliary nurse-midwives, 1 adult education worker, 1 vehicle driver, 1 tractor driver and 1 Medical Mission Sister (in charge of the day care nursery for hospital employees' babies). ACHIEVEMENT MOTIVATION COURSE Father Heredero discovered that people can be transformed, if they are helped to first develop positive attitudes about people and themselves. They can then be motivated more easily to learn what they need to solve their own problems and implement the solutions themselves. He dealt only with groups because individuals can find it too difficult to introduce new things that others are not doing in the community.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #12: HOLY FAMILY HOSPITAL

(part 2)

His best results came from training people from the same caste or social group, especially if they were the decision-makers in their community. Once they got over their long-nurtured doubts about their ability to help themselves, it was relatively easy for them to get things done in their own community. They had the strength of a group that has gone through a period of self-examination and self-discovery, and found that they can indeed think more creatively together and find effective solutions to their problems. Father Heredero wrote a book about his experience in experimenting with this course in rural India . The book is entitled, "From rural development and social change, an experiment in non-formal education". (Fr. J.M. Heredero. Manohar publications, 2 Amari Road, Darya Ganji, New Delhi, 110002 India. 1977). The achievement motivation concept was derived from McClelland's theory of motivation, modified and applied to the needs of rural India . The book came to the following conclusions: 1. Development has to do more with people than things. 2. Train groups rather than individuals, stressing the idea of community, accepting members from the same community, from a similar social group or caste. 3. The main aim of the training is personal development of the individual-in-thecommunity. Needs and feelings of the individual are taken into consideration above socio-cultural values. 4. Training is best given outside the village in a retreat setting, where the "learning community" can gain a sense of perspective away from their daily associations. 5. During the training process, the trainer's warmth and support is a very necessary element to communicate faith and courage to the participants. Faith and courage make the educational process a creative act, leading to meaningful behavioural changes. 6. The whole training course is geared to help the participants understand themselves and other people, and to give them opportunities to discover and discuss their problems together and seek creative solutions that they themselves can apply to those problems. They are given time to reflect on these things together and gradually come to the conclusion that they do not really need to depend too much on the government or the outside for solutions to their problems. 7. Follow-up is very important, but only to act as catalysts or advisers to the people who have organised themselves to solve their own problems. The hospital conducts its achievement motivation course for groups of at least 30 family heads per class. Each group should sign a letter asking for help from the Community Health Department (CHD). If there are more than 30 families, the extra heads have to get others to make a group of 30 for them to go through an achievement motivation course.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #12: HOLY FAMILY HOSPITAL

(part 3)

During the discussions they try to solve one problem at a time, selected according to their own priority. They complete a project to solve, minimize or avoid the problem before starting another one. Leaders and committees are elected by each class after completing the course. These help to ensure successful follow-up action when they get back to their community. After the achievement motivation course, the people decide on a priority problem which they think they are able to tackle with their available resources and with the help of CHD. The department staff consider themselves as catalysts and provide only encouragement and assistance in creative thinking and problem solving. They find this developmental approach very practical, useful and effective. Twelve villages have participated in this developmental approach. The department has been helping the people in 69 villages. The rest have been helped mainly with immunisation activities and health education, with the help of village health workers trained by the hospital. VILLAGE HEALTH WORKER TRAINING 74 Village Health Workers (VHW) have been trained so far. These were chosen by the villagers and not one has left their village. They are given a 6-day course, after which they receive their certificate. Each village usually sends one male and one female, with little education, to be trained. Their graduation will be held in their own village where they are formally accepted by the community. Usually the village pays them according to whatever agreement they have. Villagers may contribute something like 6 cents per family per month. A treasurer collects the money and gives the honorarium to the VHW. Each VHW is given a box of medicines. They do not deliver babies but they may help the village midwife. The latter are given training separately by the hospital. Every first Friday of the month, the VHWs come back for refresher courses. The auxiliary nurse and midwives of the CHD also follow-up their work in the villages. Usually, the traditional village healers disappear from the village where a VHW has been trained. COMMUNITY DEVELOPMENT The Farm Department has used its experience in its own food production programmes for hospital use to share its expertise with people in the villages. Its activities include: a) A short training programme in agriculture for villagers, conducted with faculty from a local agricultural college; b) Seed distribution and supervision of plants by staff; c) Demonstrations in grafting; d) Advice and assistance in poultry, piggery, dairy, bee-keeping, depending on the desire, resources and priority of the villagers; e) Advice and assistance on how the villagers can obtain government help in their agricultural projects.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #12: HOLY FAMILY HOSPITAL


Evaluation

(part 4)

Villages evaluate the CHD staff and their programmes and give continuous feedback to them during regular meetings. The CHD staff evaluates the programmes monthly and plan their subsequent activities based on their programme assessment. They also do an annual evaluation and planning. II After 4-5 months of .working in a village, the CHD staff looks at the following: a) How mothers keep their children - cleanliness, growth, immunisation; b) How drinking of alcohol is controlled; . c) prevalence/incidence of scabies, malar1a and mosquito dens1ty (mainly by approximation). Results (from Annual Report, 1982) Drunkenness has been eliminated or greatly reduced in three villages. Many villagers had been disturbed by the drunks; the problem was discussed in the meetings. They realized that money was wasted on alcohol. They decided to impose penalties for excessive drinking (drinking at home during festivals is allowed, but not to the point of being drunk). Those who found this difficult at first would go to another village to get drunk. Gradually, however, drunkenness ceased. One village got rid of their stagnant water, cleaned the village and conducted health education classes. Their morbidity rate decreased. Obstacles and problems encountered 1. It takes time for the people who have low levels of education to see their problems and think of possible solutions. It needs a lot of patience and hard work. 2. It is difficult to identify people who are really interested in community work. Once these people are recruited and trained, many of them stay. 3. Before the introduction of the achievement motivation course, a food supplement distribution project distributed food to all the villagers in participating villages. There was no control over whether these people ate or sold the commodities. Since the course was introduced the villagers themselves manage this project and make sure that the appropriate people eat the food supplements. 4. In the past, there was resistance to immunisation. After the motivation course plus training of VHWs, this programme became more successful. 5. Problems with the caste system in India are well known. However, these seem to have been minimised in the villages where the motivation course has been conducted.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT #12: HOLY FAMILY HOSPITAL :

(part 5)

6. Non-Christians initially warned the villagers that the hospital was interested only in Christianising them. After they saw the successful projects being done in other villages, these people also started to co-operate and desire for participation in the CHP initiated programmes. 7. Court cases separate the group's cohesion. After the motivation course, the villagers now try to settle their problems at the community level and avoid going to court. Lessons learned 1. People must be aware of their weaknesses as well as strengths, and become motivated to improve their situation before any project can be started and succeed. They must be convinced about their project and this must emanate from them. Sometimes, they are not aware of their real needs, so the CHP staff must help them realise this and the resources available. The people must make their own decisions so that they will feel that any successful project is mainly because of their own efforts. 2. The support from the hospital staff and the governing board is very important because the work is not easy and needs a lot of patience and perseverance. 3. The staff must be very committed and stable so that there is continuity and more success. They must be flexible in their schedule and willing to serve 'rain or shine'.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 13 SERABU HOSPITAL Via Bo, Sierra Leone West Africa

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact person: Sr. Denise Dorr SRPHN

123 bed, non-government rural & general teaching hospital COMMUNITY HEALTH PROGRAMME PLANNING AND EVALUATION IN WEST AFRICA

A community health programme was begun in 1975, three years before the Community Health Department was formally established. The reasons for the programme lay in the recognition of the following facts: there had been no improvement observable in the health of the local people after 30 years of hospital services; patients returned again and again with recurrence of the same disease, such as tuberculosis, worms, etc; mobile clinics had become very expensive to run in terms of petrol, personnel and medicines, with little or no signs of effectiveness. The programme serves communities of 500-1,500 people in the 11 sections of the Bumpe Chiefdom. Mainly the people are subsistence farmers and petty traders, and often poor and illiterate. The total population of the Chiefdom is 30,000, and the section towns are the centres of local administration for the Chiefdom. The surrounding villages look to these centres for help. The overall goals of the PHC project is to create in the villages an awareness of their own potential for personal intervention in health and to mobilize community resources of all kinds to promote and achieve health. The purpose of these goals is to enable local communities to take responsibility for their own health by being in control of their own situation, through promotion of specific healthy practices and perceptions, through preventive work and through appropriate use of medical facilities .at chiefdom and district levels.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

The special features designed to promote the new programme were that it should be completely community-oriented, as opposed to being hospital-based and healthprofessional-determined, that community members would show their greater interest and faith in the hospital (there has been increased appropriate use of the hospital since 1976), and that community resources, as opposed to drugs, should be used to raise local awareness of community responsibility for its own health status. A list of objectives were set out to help in achieving goals, and in order to refine this list along with the community, health committees were formed. Getting started In 1975, some hospital staff visited a village community and carried out a small survey on what the people saw as their health needs and what actions they took in times of illness. Certain health needs were obviously being catered for already by a small village group, and the idea of educating this group evolved. They were named the village Health Committee and the members of the first committee included the local midwife, the local medicine man and a clerk (for registration of births and deaths, and to write referrals).

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 2)


A list of 12 specific objectives was achieved in the overall programme, and there are specific objectives evolved for each year to contribute to the overall plan. Three of the specific objectives have been chosen as the most sensitive indicators of changes in health status for the communities, and these are the first two listed below, in addition to the known indicator, the infant mortality rate. 1. 80-90% of all under-5 children to be fully immunised (OPT, BCG, Measles, polio, Smallpox -excluding booster doses) in Bumpe Chiefdom 2. Adequate nutrition for all under-5 children (i.e. gaining weight for age on 'the road to health' chart). 3. Reliable referral system from the community to the hospital for prompt care in time of acute illness for all community members. 4. Comprehensive ante-natal care to ensure health of the mother and baby. 5. Comprehensive care during delivery and in the post-natal period for all mothers. 6. Adequate environmental sanitation (i.e. one latrine per dwelling, etc) for all members. 7. Health education for all members of the community - to promote positive health behavioural changes. 8. To ensure referral and follow-up of patients with chronic illnesses. 9. Identification of specific disease conditions in the community (i.e. orthopaedic, glaucoma, etc) and implementation of case finding measure for same. 10. Annual physical examinations of all school children. 11. To reduce the TE defaulter rate and improve case finding ability. 12. To increase the utilisation of land resources so as to promote health. Programme activities The following excerpts from the programme's 1981 annual report yield some insights on this most interesting programme: "At the beginning of 1981 the community health staff had many in-depth sessions to sort out our priorities, problems and direction ...Then over the year we have tested and rethought the outcomes or compromised or leaped ahead to new approaches." "As always, the philosophy of the department is to endeavour to tap the potential that lies in each person, family and community for some control over their own lives and health."

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 3)


"Our four community health nurses strive to motivate the people and communities represented through a village Health Committee. They encourage the comm1ttee to be self-directing and hopefully in the foreseeable future to be self-supporting for some basic health care services. Some of the committees have come a long way in this over the year." "Much effort has gone into the Health Committees this year to 'teach them to teach'. Health Committee members teaching in family clinic, in schools and on home visits. They are also beginning to extend their new ideas on health to surrounding villages. Only some Health Committees were ready for this and four have made overt approaches to a village. A message would be sent from a section town saying representatives of the Health Committee members would go with a nurse to explain the background and ideas of the programme. The villagers are in the process of responding to this." "What we all need to know is -are we getting anywhere? Neither ourselves nor the communities can continue to work with enthusiasm unless we know if we are effective. A volunteer village clerk has a lot to do with keeping records, making hospital referrals, taking minutes of meetings and weighing all the under fives in family clinics. One clerk proudly showed me his birth record for the year saying 'You know these women are really trying for us. This year we have had 43 births and only 2 infants died.' When a community has this kind of positive information, the enthusiasm builds." "The communities have helped us to find out a lot about them by members joining us in a yearly house-to-house survey done in 1979-80, in 34 section towns and villages, and 1980-81, in 13 section towns and villages. The results of these have been compiled in a report ...Throughout the year we repeatedly feed back this information to community members. While sitting on the low stools on the back veranda of the Women's Society Bundu house, we review with the midwives the number of births last year, any maternal deaths and whether there were any tetanus deaths. The midwives themselves are telling us that they don't see as much tetanus as before. Even if it is witch-caused, maybe boiling the blade and the string and tetanus toxoid injection are keeping the witches away. It is hoped that it is this realisation -that it is possible to battle the forces that seem to have always been omnipotent -that will promote change in attitudes and behaviour." "A few figures emerging from these community health assessments follow: 1979-80 305/1000 births 24% of all infant deaths 1980-81 171/1000 births 7% of all infant deaths 55% 23%

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Infant mortality rate in 11 villages Infant deaths due to tetanus reported by mothers

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Immunisation (% of children 37% 1-5 years old, with all vaccines) Nutritional status (% under27% weight for age on under-5 card)

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 4)

Village midwives programme "Miss Barnes has been able to develop a more coherent approach in this valuable area of our work with the setting of goals, teaching a regular progression of lessons, information gathering and in-depth reporting." Home visits "This activity has such potential -from being totally ineffective to being a gratifying learning experience for both the nurse and family concerned." "This is a very delicate issue. Is a nurse, rather than a neighbour more acceptable in asking a woman what she has fed her child that morning? or, is a fellow villager more knowledgeable of the intricacies of relationships therefore more able to get at the real reasons of a problem such as one (neglected?) Kwashiorkor child in a household of otherwise healthy children." Family clinics "Even when committee members had their full quota of basic lessons they lacked a focus for their (new) skills and the community tended not to recognise these new positions and skills. We were also not satisfied that the immunisation status was coming up fast enough -perhaps the leaders -husbands and fathers -would help us more if they felt involved and that we were concerned about their health also." Transportation "The programme's four community health nurses and numerous pupil nurses use four motorcycles that enable them to visit 4 different sections of town at the same time, at less cost and more convenience than other means." Annual health status surveys "Each year for five years (from 1976), the programme, using maps, has measured a number of health status indicators in 3 of the villages, using physical examinations, examination of stool, urine and blood samples, infant mortality rate, crude mortality rate, immunisation status, and weight for age." Organisation and staff 1 Community health department supervisor (State registered nurse with public health) Roles: Staff supervision. Liaison with other hospital staff

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 5)

4 Field staff (state enrolled community health nurses) Roles: Work in the community 3 nights a week Run under-fives clinics and ante-natal clinics in 3 main centres on Fridays 1 Village midwifery assistant Roles: Educate traditional village midwives and mothers of young children Assist in above clinics. Part-time consultants (subject-matter experts) e.g. in planning, evaluation, etc. Some problems and obstacles 1. The re-orientation of hospital staff - both doctors and nurses is still an uphill process. 2. Re-orientation of the community from dependency on drugs and injections to promotion and prevention for health in the community ...gradual success being experienced. 3. Re-education of government health workers - 3 years of training sessions with little success. Villages without government workers show greater improvements. 4. Co-ordination of government workers as a team at village level is desirous but next to impossible because of lack of supervision from their own supervisors. 5. Problems of cooperation with and motivation of village community where there is poor leadership e.g. very old or ailing chief or "bush" disputes. Lessons learned 1. The more homogenous the population the easier it is for the health committee to function. 2. Health committees seem to function better in smaller communities such as those with a population below 1,500. 3. Communities with poor leaders - for one reason or another - do not get very far in the functioning of the health committee or in community efforts for health. 4. Progress takes time and patience but good planning and active involvement of the people themselves in the programme pays off well with good results.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 6) COMMUNITY HEALTH PROGRAMME EVALUATION
Early efforts When the first pilot project was started in 1976, the plan for evaluation was to conduct an annual physical examination on all community members over a period of five years. Objectives were also set against which the pilot project's results would be measured. It was found that these were not easy to accomplish. Second assessment Three years later (1979), a second study was undertaken to determine the effectiveness of the village health committees in changing villagers' practices and perceptions towards health in the 3 pilot villages. Three control villages were selected for comparison. The results of this study showed a significant improvement in attitudes and practices in preventive health (e.g. immunisations, and use of under-five and antenatal clinic, etc.). There were also significant improvements in the treatment of common complaints such as diarrhoea, fever, constipation, etc. Ongoing assessment In 1978-1979, an ongoing method of evaluation was designed, which was less expensive less time-consuming, and required more active community involvement than annual physicals. This method is a process of community assessment which is undertaken during the initial visits to any community and carried out annually in the section towns and survey villages, with the help of the health committee and community members. 1. Objectives a) To determine the existing health problems and health related practices in selected villages in Bumpe Chiefdom. b) To determine changes in health status and health related practices in 'those villages with health committees in Bumpe Chiefdom. 2. Methods Both objective and subjective data are collected, compiled and then presented back to the committee and community members for discussion and planning purposes. This assessment helps determine whether or not the programme objectives are being met. All villages regularly visited by community health staff have been assessed. This includes the 3 survey villages, 9 section towns, and 26 other villages which were visited as part of the TB programme in 1980. The 3 survey villages and section towns, where there are health committees are assessed annually. All households in every surveyed village were visited. If household members were not at home, the interviewing team returned on subsequent days. Because of time constraints, individual household members were not always found.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 13: SERABU HOSPITAL (part 7)

3. Results Population 31.5% are under 15 years of age 53% are male and 47% female Infant Mortality Rate (1979) = 332.2/1000 4. Analysis a) The reduction in infant mortality rate by 44.8% in one year is admirable. The most significant decrease in causes of infant deaths was a decrease in the number of deaths from tetanus and measles. The drop in the number of reported deaths from neonatal tetanus may reflect the extensive training of Traditional birth attendants during this period. They were taught the causes of tetanus, the importance of tetanus immunisation, aseptic technique in de11very and cord care. b) The fact that 77.9% of all under-five children had under- five cards helped the programme to monitor the nutritional status of these children. c) The largest percentage of underweight children were between 0-1 and 1-2 years of age" 26% and 33% respectively of the total number of children in each of these age groups. d) Three health indicators: (1) infant mortality rate, (2) immunisation status of under-five children, and (3) nutritional status (weight for age) of children from infants to 5 years of age, all showed improvements which are encouraging to the staff and the people involved in this programme. The foregoing is an example of a practical approach to monitoring and measuring the progress and the results of a community health programme. The reporting system that was designed automatically yields most of the data needed in the evaluation of the programme. It tries to measure subjective as well as objective components. A regular review of these reports, coupled with what the staff gather from site visits and informal talks with various kinds of people involved in the programme, would yield considerable information upon which to base their evaluation of progress and results of the programme. This they have done and they used the information gathered in replanning their programme for each succeeding year.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care


PHC PROJECT # 14 SILLIMAN UNIVERSITY MEDICAL CENTRE P.O. Box 49 Dumaguete City

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

Contact Person : Dr. Laong Laan U Garcia Hospital Director Philippines

125-bed general urban church-related teaching hospital .. RURAL OUT-REACH; VILLAGE HEALTH WORKER TRAINING; FINANCIAL INCENTIVES; COMMUNITY DEVELOPMENT; PROGRAMME EVALUATION

The medical centre has a philosophy of total health care, 'thinking first of education and prevention, second of cure'. Developing this idea in response to the low income of most of the people, the centre provides high quality medical and hospital care but emphasises prevention as the least expensive way to improve and maintain health. Based at the 83-year old Silliman University, a Christian Foundation, the medical centre began as a hospital in 1923, and extended clinics to rural villages in 1925. A province of 700,000 people is served. The Extension Service Department of the centre supervises two major clinics or 'family life centres' outside the city. Each clinic serves as a base for teams that go out to eight remote villages for health and development activities. In these villages ('barrios') family clubs have been formed for planning, discussion, education and community action. Barrio health aides have been trained for volunteer service, as well as volunteers in food production, nutrition and sanitation. Village Health Worker training Because of the inevitable slowness of change in rural peoples' attitudes toward health care, when only weekly visits could be made to the barrios, a training programme for health aides was devised. Individuals were needed to deliver simple medical health care and to serve as contacts for the medical staff and the village people. The shortterm programme goals, therefore, were to make trained health workers available in rural areas, to provide a link between the professional and the village through a system of referral, and generally to promote effective health work. These aims would meet the long-term goals of the extension of an effective health care system into peoples' homes and the perpetuation of these services through appropriate section and training of personnel and through community organisation of parents. Based on repeated evaluations, a profile has been drawn up and subsequently revised, of the type of person who should be selected to be a Barrio Health Aide. Basic requirements are the following: A trusted and respected member of the local community; having leadership qualities shown through participation in community programmes; one who is able to speak, read and write basic English and the local dialect, and is able to fill out simple reports; one who is over 25 years old, preferably married and settled down in the community; if a woman, then to have no children requiring attention. Maturity is preferred over formal education and it is important that the Aide is intelligent, resourceful and sensitive to the needs of the community. The functions of the Barrio Aides These are twofold, and include primary health care and the promotion of self-reliance and self-sufficiency among the families in the community.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 14: SILLIMAN UNIVERSITY MEDICAL CENTRE (part 2)

Primary health care functions are: 1. First aid for accidents and emergencies; 2. Medication for simple and common ailments; 3. Follow-up treatments as prescribed by supervising health workers; 4. Referral to agencies for more serious conditions; 5. Liaison work between development groups and the community; 6. Immunisation; 7. Supplier of contraceptive materials for regular users; 8. Identification and referral of malnourished children; 9. Campaigner for improved sanitation and hygiene.

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The major roles that health aides play in promotion of self-sufficiency are to work for improved food production, and to promote community involvement in various projects. The training course The course was initially set up to cover a three-month period but this has increased to 6-10 months on the basis of two days' training per week. The emphasis is on training rather than education, and the methods are practical rather than theoretical. Programme financing came from international funding agencies, though a unique feature has been some modest funding for paying the Barrio Aides has come through the community itself, through income from village stores run with the help of village committee members. The training contains approximately 16 elements, and covers the following: Introduction to the aims of the Extension Service Department; the role of the Aide; human and public relations; community development and communication; structure and function of the human body; the idea of 'caution' in relation to health, and disease; recognition of illness and abnormalities; the symptomatic treatment of fever and diarrhoea; the simple treatment of wounds; general environmental health and sanitation; health education; family planning; simple epidemiology and statistics; , surveying the community; maternal and child health; immunisation and relationships with government health personnel.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

PHC PROJECT # 14: SILLIMAN UNIVERSITY MEDICAL CENTRE (part 3) Lessons learned Lessons which have been learned from the Barrio Health Aide Training scheme I have been many, some general and some specific. A formal programme evaluation takes place every 18 months to two years, and includes surveying opinions of the aides, professional health staff, the government health services and the village communities themselves. Evaluation results have been very positive in all aspects and are also shown through increased agricultural production and income of the people. Mortality and morbidity statistics at village level, however, have not been monitored as yet. Summarising the lessons learned may be of use to others, therefore the following must be mentioned in relation to the village Health Aide programme: a. The cheapest way to deliver health services is through preventive measures such as sanitation, nutrition and immunisation. b. Most health services can be given by auxiliary health workers supervised by a doctor or a graduate nurse. c. Permanent effects may be achieved through health education of the people and community support of the Extension unit. Through experience it is found that intermittent visits to the community even by highly trained professionals is not effective, because there must be continuity between visits, and a local auxiliary worker is needed. Trained traditional midwives are used more by the community because they are available and well accepted locally. Health may not be the priority that a community feels it needs, therefore it is important in conducting basic surveys that 'felt needs' are determined and it is known how villages want to be helped. The underlying principle of any community work is self-help, and dole-outs, which are unjustified do not help any community. Working through local organisations, or if there are none, organising these, is very important. Mothers' clubs were a first target group, but parents' clubs also evolved so that fathers would also be included. Specific recommendations that can be made are the following: a. Two health workers should be trained in each village because they need mutual psychological support and continuity of services. b. Trainees should be selected by local residents. c. Attitudes of trainees are more important than academic achievement. Even illiterates can be trained to be proficient by continuous training and retraining. d. The Aide must be supported by the village served, so he/she should be only a parttime worker, with partial self-support. e. The community will have to be developed and socially educated to support the health programme. f. Indigenous midwives should also receive training to improve their own results and to help in family planning activities.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

APPENDICES The Alma Ata definition of PRIMARY HEALTH CARE*


APPENDIX 1

"Primary Health Care is essential health care based on appropriate and acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain in the spirit of self-reliance. It forms an integral part both of the country's health system of which it is the central function and of the overall social and economic development of the community. It constitutes the first level of contact of individuals, the family and the community with the national health system. Primary health care: 1. Reflects and evolves from the economic conditions and social values of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; 2. addresses the main health problems in the community, providing promotive preventive, curative and rehabilitative services accordingly; 3. includes at least: 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; education concerning prevailing health problems and the methods of preventing and controlling them; appropriate treatment of common diseases and injuries; and provision of essential drugs;** 4. involves all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works and communication; 5. requires and promotes maximum community and individual self-reliance and participation in the planning, organisation, operation and control of primary health care, making the fullest use of local, national and other available resources; and to this end develops through appropriate education the abilities of communities to participate; 6. should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all; 7. uses health workers, including physicians, nurses, auxiliaries and traditional practitioners as applicable, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community." * Extract from the 'Declaration of Alma Ata' issued at the conclusion of the WHO/UNICEF International Conference on Primary Health Care held in Ala Ata, USSR, between 6- 12 September, 1978. ** In the recommendations of the Alma Ata Conference, although for some reason not in the Declaration itself, the promotion of mental health was included in this list of the elements of PHC.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

APPENDICES (part 2)

FEDERATION INTERNATIONALE DES HOPITAUX INTERNATIONAL HOSPITAL FEDERATION HOSPITALS AND PRIMARY HEALTH CARE W.K. Kellogg Foundation Travelling Fellowship 126 ALBERT STREET. LONDON. NW1 7NX TELEPHONE. 01-2675176 TELEGRAMS: INTHOSP London NWI

FEDERACION INTERNACIONAL DE HOSPITALES Project Fellow: DR RUFINO L MACAGBA JR WHAT ARE HOSPITALS DOING IN PRIMARY HEALTH CARE (PHC)? As you may already know, the International Hospital Federation, in collaboration with WHO, is conducting a world-wide project to study and help develop the role of the hospital in primary health care (PHC). In connection with this study, we are encouraging hospital associations to conduct their own survey of what their member hospitals are doing in PHC. You may know that the Australian Hospital Association and the Ontario Hospital Association recently did their own surveys on this subject, and came up with very interesting and encouraging results. We under- stand that the Philippine Hospital Association is currently doing its own survey. As PHC is gaining in worldwide acceptance as the most practical and effective means of improving the health status of the people, the timing seems to be right for hospitals to reconsider their role in PHC. Enclosed is a simple form that we developed for this purpose, together with a sample cover letter that a hospital association might consider using for its own survey. The form can be completed in a few minutes and it provides useful information that tells at a glance what a hospital is doing in PHC. Please feel free to modify or change the form as you wish. Enclosed is a response form that we hope you will fill up and send back in the enclosed self-addressed envelope. I hope very much that you will be able to help us in this project. Sincerely, Dr R L Macagba, Jr, Project Fellow

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

APPENDICES (part 3) The IHF is an Independent non-political body whose aims are to promote Improvements in planning and management of hospitals and health services WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE From Dr D. Tejada-de-Rivero To Dr A.H. Taba, Regional Assistant Director-General Director. EMRO

Subject: INTERNATIONAL HOSPITAL FEDERATION STUDY ON INNOVATIVE APPROACHES TO THE HOSPITALS ROLE IN SUPPORTING PRIMARY HEALTH CARE' As you may learn from the enclosed copy of a letter from Mr M. Hardie, DirectorGeneral of the International Hospital Federation. and the accompanying documentation, the International Hospital Federation - supported by the Kellogg Foundation of the USA - is within the next three years undertaking a study specifically concerned with 'The role of the hospital in promoting, supporting and providing PHC in developing countries'. Dr Rufino Macagba has been designated by the IHF 88 leader of this study. Since the issues related to the role of hospitals in the support of PHC become of increasing interest to WHO and Member States. the IHF' s complementary role in this field should be welcomed and encouraged. Dr Rufino Macagba, former executive of the World Vision International, designated by the IHF as project leader, is known to us as a knowledgeable and reliable person. In 1980/81 he participated in WHO preparatory work related to the 34th WHA Technical Discussions on 'Health System Support for Prim3ry Health Care'. Bearing the above in mind. I request your utmost support in enabling Dr R. Macagba, through relevant officers of the Regional' Office and the WPCs, to identify and approach those countries in your Region which are currently involved in re-defining and strengthening the role of hospitals in promoting, supporting and providing primary health care. Thank you in advance for your positive cooperation in this matter. Dr D. Tejada-de-Rivero Assistant Director-General ENC: as mentioned above A similar memorandum has been sent to: Dr Comlan A.A. Quenum, Regional Director, AFRO Dr Hector R. Acuna, Regional Director, AMRO Dr L.A. Kaprio, Regional Director, EURO Dr U. Ko Ko, Regional Director, SEARO Dr H. Nakajima, Regional Director, WPRO

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

APPENDICES (part 4)

FEDERATION INTERNATIONALE DES HOPITAUX INTERNATIONAL HOSPITAL FEDERATION FEDERACION INTERNACIONAL DE HOSPITALES

President PROF. DR. SIGURD HUMERFELT Director-General/ MR. MILES HARDIE MCH/AWL

126 ALBERT STREET. LONDON. NW1 7NX TELEPHONE. 01-2675176 TELEGRAMS: INTHOSP London NWI

August. 1981

HOSPITALS AND PRIMARY HEALTH CARE W.K. Kellogg Foundation Travelling Fellowship Dr Rufino Macagba has been appointed by the International Hospital Federation to undertake this Travelling Fellowship, the purpose of which is to study and report upon innovations and developments in the role of the hospital in promoting, supporting and providing primary health care, within the context of WHO's strategies for achieving Health for All by the year 2000. I hope that you will be prepared to give Dr Macagba such help and advice as you can to enable him to carry out this work most effectively. It is our intention that the results of this Fellowship should be published in a report that we hope will be of value to any hospitals interested in improving standards of primary health care, so any assistance that you can give to Dr .Macagba will be greatly appreciated.

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Miles Hardie Director-General International Hospital Federation The IHF Is an independent non-political body whose alms are to promote Improvements In the planning and management of hospital. and health service..

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

REFERENCES

Several of the 14 hospitals gave references to other publications about their work. Details of these references are given below. For further information, please get in touch direct with the contact-person for each hospital.

Dr. Carlos Luis Valverde Hospital, Costa Rica 1. Mills, A. Hospitals and primary health care. World Hospitals, Vol XVI, No 2, May 1980, p 27. 2. Ortiz Guier, G. Hospitals without walls: Costa Rica. World . Hospitals, Vol XVII, No 4, November 1981, pp 21-23. 3. Mohs, E. Article in Paediatric infectious disease, 1982, 1:212. 4. American Public Health Association. Community participation in primary health care. January 1983, p 56. 5. Ofosu-Amaah, V. National experience in the use of community health workers: a review of current issues and problems. WHO offset publication No 71. World Health Organization, Geneva. 1983. Dhaka Shishu Hospital, Bangladesh 1. Tofayel Ahmed and Razaul Karim. Rural paediatrics in developing countries. 1981. 2. Rapport, Bangladesh. Evaluation report of the Sreenagar Thana Outreach Community Development Project. 3. Planning Commission, Government of Bangladesh. Second five year plan (1980-85). May 1980. 4. Ministry of Finance, Government of Bangladesh. Annual budget, 1982-8~.. 5. Bangladesh Manpower Planning Centre, Government of Bangladesh. Seminar report on population and human resources development (unpublished). 6. Siddiqui, AM A H. Education and manpower training. Paper presented in the seminar on human resources planning, organised by ILO/ Planning Commission, Dhaka. 1982. 7. Palli Shishu Foundation. Proceedings of annual conference; minutes of the meetings of executive committees; and other records. 8. Asia Foundation. Proposal for family planning project, with Palli .Shishu Foundation. 9. Bangladesh Manpower Planning Centre. Study on supply of medical professionals in Bangladesh. 10. Bangladesh Manpower Planning Centre. Manpower Bulletin, Vol I, No 1, Apr1.1 1982. Wad Medani Hospital, Sudan This program has been described in World Health Forum, Volume I, Nos. 1980, pp 4551, in a paper by Awad, MA, Edstrom, K and Katz, F. Sudan: teacher training gets out of the rut.

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7. 8. 9. 10. 11. 12. 13. 14.

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

REFERENCES (part 2)

SSA Hospital, Netzacualcoyotl, Mexico 1. Macagba, R L. Hospitals and primary health care in Mexico. World Hospitals, Volume XVIII, No 2, May 1982, pp 12-16. 2. Washington, DC. Population Reference Bureau statistics, 1980-81. 3. Morris, R. Mexico's first aides. Health and Social Service Journal, March 25, 1982. 4. Morris, R. What can Mexico teach us about health care? Report on International Hospital Federation (IHF) Special Study visit, 1981. 5. Johnson, S. An approach to primary health care in the state of Mexico: the coordinated public health services' experience. IHF Yearbook, 1984. North Central Bronx Hospital, New York City 1. San Agustin, Goldfrank, Suberman et al. Reorganization of ambulatory health care in an urban municipal hospital. Archives of internal medicine, Vol 136, November 1976, 1262-66 2. San Agustin, M. Primary care in a tertiary center. Annals of the New York Academy of Sciences, Vol 310, June 21, 1978, pp 121-128. 3. San Agustin, Sidel, Drosness et al. A controlled clinical trial of family care compared with child-only care in the comprehensive primary care of children. Medical care (J B Lippincott Co), Vol 19, No 2, February 1981, pp 202-. 4. San Agustin, M. The Montefiore-Morrisiana comprehensive child care project. Postgraduate Medicine, Vol 48, No 4, October 1970, pp 235-239.1 5. Health Care Education Department, North Central Bronx Hospital. Shadow, 1 barefoot doctors and CREATE programs. Unpublished paper. 6. Goldfrank, L, San Agustin, M, Dash, Sand Samms, T. Linking emergency room and ambulatory service. Urban Health, July/August 1978. 7. San Agustin, M, Goldfrank, L, Bloom, R, Grossman, S, Lloyd, W, Smith, D, Ulrich, R, Uribelarrea, M, Bihari, M, Kindig, D, Warshawsky, N, Gardner, H, Martin, E, Endicott, K. Primary care conference Part I: Delivery of services. Journal of Ambulatory Care Management, Vol 2, February 1979. 8. San Agustin, M, Kuperman, AS, Hamerman, D, Boufford, J, Bloom, P, I Belmar, R, Erlbaums M, Harris, N, Alpert, J. Primary care conference II Part Education Journal of Ambulatory Care Management, Vol 2, No 2, May 1979. 9. San Agustin, M, Starfield, B, Bass, M, Morehead, MA Kindig, Smith, D; Zarate, C, Adler, R. Primary care conference Part III. Research Journal of Ambulatory Care Management, Vo1. 2, No 3, August 1979.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

REFERENCES (part 3) Soroka Medical Centre, Israel 1. Prywes, M. Community medicine: the 'first-born' of a marriage .between medical education and medical care. Health Policy and Education, 1980, pp 291-300. 2. Prywes, M. Reconciling the educational role of the teaching hospital with its commitments for health care in the community. Unpublished paper. fr 3. Galinsky, Cohen, Schneiderman et al. A programme in undergraduate geriatric education: the Beer Sheva experiment. Medical Education, 1983, 17: pp 32-36. 4. Galinsky, Schneiderman and Lowenthal. A home-care unit: geriatrically oriented and hospital-based with the family physician actively " involved. Unpublished paper. 5. Porter, Cohen, Kobliner et al. Differences in the use of emergency room and hospitalisation in relation to primary care paediatric services. Israel Journal of Medical Sciences, 1981, 17: pp 119-121. 6. Prywes, M. News from Israel: the Beer Sheva experience. JAMA, Vol 238, No 14, October 3, 1977, p 1571. 7. Antonovsky, Anson and Bernstin. Interviewing and the selection of c med1.cal students: the experience of five years at Beersheva. PLET, Vol 16, No 4, November 1979, pp 328 -334. 8. Segall, Prywes, Benor and Susskind. University Center for Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel: an interim perspective. Public Health Papers No 70, World Health Organization, Geneva. 1978, p 111. 9. Ben-Gurion University Center for Health Sciences. Medicine for the community. 10. Ben-Gurion University of the Negev. Catalogue. 11. San Agustin, M. Visit to the University Center for Health Sciences, BenGurion University of the Negev, Beer Sheva, Israel. Unpublished paper, October-November 1980. Serabu Hospital, Sierra Leone 1. Ross, D. The village health committee -a case study of community participation from Sierra Leone. Contact 49, February 1979. 2. Ross, D. A village health project in Sierra Leone -evaluation of a new basic health care system. MA thesis, 1979. 3. Finch, F. Feedback on the village health committees. Serabu Hospital private publication.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

ABOUT THE IHF

What the IHF is


The IHF is an independent non-political organisation. supported by subscribing members in some 80 countries. It aims to promote improvements in the planning and management of hospitals and health services through international conferences, study tours, training courses, Information services, publications and research and development projects. The official languages of the IHF are English, French and Spanish. The IHF has five categories of membership: "A" National hospital and health service organisations, governmental or nongovernmental, including national associations of public or private hospitals, Ministries of Health and other organisations concerned with hospital and health services at national level. B Any other organisations, associations and institutions whose alms or activities are directly concerned with hospital and health services, including professional organisations, regional or local health authorities, groups of hospitals and individual hospitals. "C" Individual members from all disciplines and occupations concerned with hospitals and health services. "D" Professional firms (e.g. architects, engineers) interested in hospital and health services, and commercial or industrial companies involved in the health care field, including publishers of journals. The names and addresses of "D" members are listed in every issue of the IHF quarterly journal WORLD HOSPITALS. "E" Honorary members, who are elected by the General Assembly for special services rendered to the IHF or to the health care field in general. The combined membership forms the General Assembly of the Federation which normally meets every second year during a Congress. While every member has the right to speak at meetings of the General Assembly, only the " A " members can vote and it is they who elect the Council of Management. The Council has 21 members, each holding office for six years, one third retiring every two years. The Council in turn elects from within its number an Executive Committee of seven, who are responsible for conducting the affairs of the IHF between the Council's meetings. Thanks to the help and support of the American Hospital Association, the IHF has an office in Washington, and the IHF also has close contacts with other international organiisations in the health care field, and especially with the World Health Organization, with which the IHF has an official link as a non-governmental organisation (NGO).

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

ABOUT THE IHF (part 2)

What the IHF does


The International Hospital Federation publishes an annual YEAR BOOK of reference information and a quarterly Journal, WORLD HOSPITALS, both of which are issued free to members. The journal has supplements in French and Spanish, and contains authoritative articles and reports on various aspects of international developments in the planning and operation of hospitals and health services. Particular attention is paid to reporting on on IHF congresses, study tours and other activities. organizes international CONGRESSES and regional conferences and seminars at which representatives of all branches of health services can meet their colleagues from other countries and discuss common problems. These meetings are open to all, but members of the IHF pay a reduced fee. . ..arranges STUDY TOURS of hospitals and health services to give members firsthand knowledge of health service work in different countries. ..maintains an INFORMATION service for members on hospital and health service matters anywhere In the world, and offers advice and assistance to members over personal study tours and other matters. In the field of information, the IHF works in collaboration with the King's Fund Centre of King Edward's Hospital Fund for London. sponsors an annual 10-week COURSE, which is organised jointly .with the Health Services Management Centre of the University of Birmingham, for senior hospital and health service administrators from overseas. Over 600 people from some 80 countries have attended this course sInce It started In 1961. ..sponsors PROJECTS and study groups on different aspects of hospital and health services. Amongst current and recent projects have been ones concerned with health care planning in urban areas; good practices in mental health; health auxiliaries; hospitals and primary health care.

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If you wish to have further information about the IHF and details of subscription rates, etc., or if you know of an organisation or individual who you think might be interested to have such details, please complete and return the form on the next page: To: IHF, 126 Albert Street, London NWI 7NX, England Please send information about the IHF to: Name: Address: Country:

Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

Hospitals & Primary Health Care

Health Development International

Introduction page 2 Forward pages 3 - 4 Acknowledgements page 5 Why Should Hospitals be Involved in PHC? pages 6 - 8 Description of International Study pages 9 -12 Survey Responses pages 13 -19 Summary and Conclusions pages 20 -23 14 Outstanding PHC Projects pages 24 -89 1. 2. 3. Dr Carlos Luis Valverde Hospital, Costa Rica Dhaka Shishu Hospital, Bangladesh Lady Hardinge Medical College and associated Hospitals, New Delhi, India Wad Medani Hospital, Sudan SSA Hospital, Netzacualcoyotl, Mexico North Central Bronx Hospital, New York City, USA Adi Husada Hospital, Surabaya, Indonesia Soroka Medical Centre, Beer Sheva, Israel Gonoshystha Kendra, Bangladesh Ramathibodi Hospital, Bangkok, Thailand Grace Children's Hospital, Haiti Holy Family Hospital, Bihar, India Serabu Hospital, Sierra Leone Silliman Medical Centre, Philippines

ABOUT THE AUTHOR

Dr Rufino Macagba, MD, MPH (1984)

Dr. Macagba was born and educated in the Philippines and graduated MD from the University of the Philippines Medical College in Manila in 1957. After three years of surgical training at the Philippine General Hospital Medical College, he went on to become hospital director and chief surgeon at Lorma Hospital in La Union Province in the Philippines, a private 150-bed hospital with a school of nursing. In 1975 he gained his MPH at the Department of Health Services and Hospital Administration of the University of California at Los Angeles. From 1975- 1980 he was associate director, health care delivery systems, with World Vision International (WVI) a Christian humanitarian organisation with over 400 relief and development programmes and over 1500 child-care projects in over 70 countries. Between 1980- 83 he acted as consultant and visiting lecturer in international health. During this period he carried out the hospital/PHC project on which this report is based, and also participated in 1980/81 in WHO preparatory work related to the 34th World Health Assembly technical discussions on 'Health system support for primary health care'. In 1984 he rejoined WVI and is currently working in Indonesia on health care management training and community development. His previous publications included Health care guidelines for use in developing countries published by WVI Press in 1977 (111 pages) in English, French and Spanish, as a basic guide to health programme planning, implementation and evaluation; and How to have a healthy family, also published by WVI Press in 1978. This is a comic-book-style health education aid for families, schools and community health workers in developing countries. It has 32 pages, with editions in English, Chinese, Filipino, Indonesian, Korean, Spanish and Thai. Dr Macagba is married (to a doctor), and has four children.

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Appendices & References pages 90 -96 About the IHF pages 97 -98 About the Author page 99

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