Hospitals and Primary Health Care

Transcription

1 visionary health care leadership worldwide Hospitals and Primary Health Care An International From the International Hospital Federation 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 Edited by Melissa Hardie, HA, SRN, PhD e-book version thanks to International Hospital Federation 151 Route de Loëx Bernex Switzerland

2 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 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. Miles Hardie Director-General, I H F

3 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?

4 (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

5 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,. 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 Program in Hospital Administration, contributed significantly by visiting and reporting on 10 selected hospitals with innovative PHC involvement in India,, 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,, 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.

6 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 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 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 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

7 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 World Health Forum, The World's Main Health Problems, 2 (2): (1981). 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.

8 WHY SHOULD HOSPITALS BE INVOLVED IN PHC? (part 3) HOW PHC WORKS In developing countries: In developed countries: 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 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.

9 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,, 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.

10 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.

11 DESCRIPTION OF INTERNATIONAL STUDY (part 3) A brief summary of project statistics Hospital association survey set Method By Mail By Visit Countries surveyed Hospitals surveyed Asia & South 334 Pacific 19 Africa, Middle East, Europe The 36 6 Americas Total 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.

12 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.

13 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 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 (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.

14 (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.

15 (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, ID 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. 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!

16 (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 Radio programmes Television programmes 8 27 Posters Comic books Newspapers School programmes Clubs 7 31 Community projects 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 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.

17 (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.

18 (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 In hospital In community: Combined preventive & curative for specific population groups Comprehensive hospital/phc for 12 industrial/commercial firms 12 Comprehensive hospital/phc for insured populations Mobile clinics & services Hospital/community staffing Exchange, rotation, secondment Collaboration with educational; agricultural & other sectors, also mass media 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 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.

19 (part 7) Programme for In hospital In community Family first aiders Community volunteers Community health workers PHC project staff PHC management training Health professionals Community leaders Others* *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.

20 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

21 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.