First Level Care in Developing Health Care Systems

First contact care in developing
health care systems




In important ways, all health systems suffer from
under-development, not just those in ‘developing’ countries. If equity of
access is not guaranteed, the most affluent health spending will not result in
improved health for all. Equitable opportunities for improved health have to be
built in at the point where help is most needed. In this chapter we focus on the
situation in the poorer, or developing, countries and examine the range of
persons who are consulted at ‘first contact’ by a sick person, where the
primary medical practitioner is only one of a range of likely contacts.
Since developing countries are far from homogeneous, and vary
dramatically in their social structure, the health systems that grow out of them
also vary. Further, these countries are in a state of unprecedented flux, and
these fundamental changes influence disease, health and health seeking in a
multitude of ways. Nevertheless, some broad patterns are common, and it is these
we try to draw out in this chapter. This involves some preliminary
generalizations, with specific examples drawn from several widely different
developing countries. Our purpose is to add a sense of the diversity of these
societies, and some human colour and pathos.
This chapter has four sections. The first outlines the social and
economic features of Third World societies. In particular, it involves
consideration of what is meant by ‘developing societies’, and how and why
these are changing so rapidly. The second section looks more specifically at the
health improvements that some, and not other, poor societies have experienced.
Thirdly, we look more closely at a case study of what happens when the poor get
sick. Finally, the chapter examines some of the barriers—local, national, and
global—standing in the way of better health, and better primary health care
services.

Developing countries: what are they?
The term ‘developing’ is often used interchangeably with
‘Third World’, or ‘South’ or ‘Non-Western’. We use the term
‘developing’ here to mean poor, with an emphasis on the problems of those
most poor residing in the poorer countries. This qualification of the word
‘developing’ acknowledges the serious consequences of ‘development’ to
the ecosystems on which our whole species depends.
To sketch the context, let us jump backwards to Africa, nearly half
a century ago; it was then that David Morley, a young British paediatrician,
took up a post in the hinterland of Nigeria. As well as clinical duties, he led
a small research team that followed up all the babies born in a local village.
The experience changed the way he understood disease and the services designed
to combat it—within a poor and ‘emerging’ country.
Fifteen years later in 1973, he wrote Paediatric
Priorities in the Developing World,(1) which set
out the essential facts about the developing world, its health, and the role and
limitations of doctors and health services. He concluded that medical
services—primary, secondary, and tertiary—were largely inappropriate, and
needed radical restructuring. Much of what Morley had to say then is relevant
and challenging now, and a useful starting point for an examination of primary
care in the developing world.
He began by describing the salient social, economic, and
demographic characteristics of developing countries, noting that these
factors—which govern not only the prevalent pattern of illness, but also their
health services—had been strangely neglected by planners. ‘Poor, rural, and
young’ were the features that stood out as distinguishing the peoples of
‘developing’ countries from those more affluent. Health services designed
for populations that were wealthier, older, and mainly lived in industrial
cities, as is the case in the West, were simply out of place.
Morley placed the health problems of developing countries clearly
into a global context. With nearly 80 per cent of the world's (then) population
of 4.5 billion living in the developing world, he noted mortality rates
particularly among the young were further skewed, with deaths for under fives in
developing countries accounting for over 95 per cent of global under fives'
deaths.
Almost 30 years later, and after many changes, how poor, rural,
young, and burdened by disease are the developing countries now?
Twenty years on, McMichael wrote Planetary
Overload,(2) which marks a watershed. In 1993, with
the world population rising to about 5.3 billion, about 820 million or 16 per
cent could be called rich, with an average income of about US$20 000. The very
poor, with an average per capita income as low as US$330, mainly reside in the
huge regions of South Asia or Sub-Saharan Africa. Those classified as middle
income, with average annual incomes ranging from US$1800 to 2400, are those
mainly in the Middle Eastern, Eastern European, or South American regions.
Overall the world's population had risen, and so had its wealth,
with some developing countries rising from poor to middle-income status. But
many countries had not moved forward. McMichael notes that, while the number of
persons living in ‘absolute poverty’, defined as an annual income of less
than US$370, had shown a slight relative decline over the previous 20 years,
actual numbers had risen. In the developing countries, which then made up 3.7
billion or 70 per cent of the world's total, about 30 per cent could be
classified as living in absolute poverty. This means that about one in five of
the world's inhabitants still lived in conditions so degraded by poverty to
remain—in the words of former World Bank President McNamara as quoted by
McMichael—‘beneath any reasonable definition of human decency’.(2)
By 2002, the world population has risen further to 6.1
billion.(3) However, the number of the poorest amounts to
1.2 billion, and has changed little.(4) Not only does
poverty remain the biggest problem, but the relative youth of developing
countries has also not changed: for those very poor, almost half of those living
in absolute poverty remain less than 15 years old.(5)
However, important changes have occurred. The poorest of the poor
are not as ‘rural’ as they were when David Morley left Lagos for Nigeria's
hinterland in 1956: they are in Lagos itself, and the dozens of vast cities
sprouting in other developing countries. The last 30 years has been marked by
massive migrations of communities from the countryside to the city. This process
of urbanization now means that while the majority of the populations of
developing countries can still be classified as rural, the proportion is
falling, and many of the poorest—fleeing poverty, famine, and war—are now to
be found in vast cities like Lagos and Dhaka. Lagos has grown by 6 per cent, and
Dhaka by 7 per cent per year since 1975, so that the population of Lagos has
increased fourfold, and Dhaka sixfold, so that by 2000 both had populations
exceeding 10 million, so joining the class of mega-cities.(3)
While some migrants have ‘made good’ in the cities, whole
generations of slum dwellers remain, inheriting many of the unhealthy conditions
of their rural cousins—poor food and water, and little medical care. Adding
problems more specific to the city, including those arising from overcrowding,
and the stresses of drugs and violence, increases the disease burdens on the
poor. The attenuation of older and more traditional social structures also means
it may be harder to pass on limited but useful indi-genous healing and support
practices. Work too is different: the new city dwellers—or the more fortunate
of them—can now find work in factories making clothing, textiles, or
machinery, as global capital moves in search of cheaper labour.(6)
Morley's other distinguishing characteristic of the people of the
developing world—their overwhelming share of the burden of disease—remains.
Table 1, showing some representative data on several
selected low, middle, and high income countries, indicates not only the much
lower life expectancy in the poorer countries, but also their peoples' even more
greatly reduced chance of a life—as measured as a ‘healthy
life’—relatively free of disability and disease. Note also the higher
proportion of the older population, and lower fertility rates of the richer
countries.

Continued from above.....

Looking beyond the figures, let us now consider what they mean in every day terms for the 1000 million living in ‘absolute poverty†in ‘developing countriesâ€. It is these people that carry by far the greatest burden of the world's disease, and the greatest challenge to health planners and practitioners—just as Morley concluded in 1973. Further, while an increasing number fill the slums of the great conurbations of the Third World, more than half of these people still live in rural areas, in thousands of villages scattered across Asia, or Africa and South America, living a hand-to-mouth existence as subsistence farmers or landless labourers.
The multiple burdens consist of fitful and insufficient disposable income, poor and unhygienic living conditions, food deficient in quantity and quality, large family size, low education, and poor access to basic health services. These combine to produce a web of direct and indirect forces which together create the conditions where disease is fomented. Preventive and curative responses to disease are also hindered: thus such persons cannot, to quote the recent WHO jargon,(7) join the ‘rising curve of health†that others more fortunate are joining, both in their own countries, and in the West.

Changing patterns of health and disease in developing countries
Despite the dismal picture for the majority of the poorer populations of the world, it is clear that for some, health has improved greatly. This section examines reasons for this.
In the broadest and simplest terms, health status can be measured by life expectancy, and by mortality rates; in particular the infant mortality rate (IMR) has often been used as a way to measure the relative level of prevailing health between countries, and within countries over time. As indicated in Table 1, in general life expectancy rises, and mortality rates tend to fall as income rises. Fertility rates follow the pattern of mortality rates.
The demography of most poor countries can be characterized as being high mortality, high fertility, low life expectancy; in richer countries the pattern is the opposite—low fertility, low mortality, high life expectancy. We now know that the change from one pattern to another, now called the demographic transition, has already occurred in western countries over the period from about the mid-nineteenth to the mid-twentieth century. In many of the poorer countries, the process is occurring much later.
It is only recently that the shape of this transition process, and the underlying reasons for it, are becoming understood. Such an analysis is not just of academic interest, it is vital for understanding the influence of health care, and of the key role of primary care within it.
Figure 1, taken from the 1999 WHO Annual Report(7) links time, income, and IMR: it complements the relatively simple picture arising from Table 1.



Figure 1 shows that in both the upper curve for 1952, and the lower curve for 1992, IMR falls as income rises. However, for any given level of income, in the 40-year period between the curves, IMR has almost halved, indicating that factors other than income are playing a major role in mortality reduction. The report goes on to draw on this and other evidence now available, indicating that however important income may be, these other factors—including access to health technology, and female education—are crucial.
In understanding this transition process, a further area has recently come into prominence. Marmot and Wilkinson( highlight the emergence—or more accurately the re-emergence—of key social determinants of health. This research is now beginning to establish that after the earliest stages of the health transition, human autonomy—individual and community—and equitable human relationships are fundamental to human mental and physical health: without them, we are almost as badly off as if we had nothing to eat.
In summary, the health transition, which follows the demographic transition, now appears to arise from several inter-related factors. Rising income is essential to lift the poorest from their dreadful base, so they can join ‘the rising curve of healthâ€. But it is capacity building—'social capitalâ€â€”investments in education, in public health and housing, in equitable distributions and services—including basic health services—that then builds the fertile conditions that make sturdy those millions of little plants, our human lives. And in particular, researchers such as Starfield have defined how medical care, and especially primary medical care, influence patterns of health and disease.(9)
Against this backdrop, how do the primary care systems of the developing world fit into a process of health system development?

Continued from above.....

First contact: what happens when the poor get sick
We now move from the big picture to an individual human story—the story of a woman we call Kulsum, and as recorded by a researcher, Dr Amatul Uzma,(10) investigating the health care seeking behaviour of post-partum mothers living in a slum in Dhaka, the capital of Bangladesh.
The reader should first try to picture the slum: a swampy plot of about 2 ha containing over 5000 squatters, packed into over 700 flimsy structures with no running water or power, ranging from a few bits of tattered cloth, to a tiny shack of tin and boards. In the case below, our own comments are added in square brackets.


Kulsum had spent the first 13 years of her life in a poor rural village; her father was a landless farmer, and she was one of seven living children. Before puberty she was married off to Suruj Mia, and two years later, a thin 15 year old, she gave birth to her first son.
Eventually her husband reported, ‘She was too thin to be a wife. I thought she would get big after having kids but it was the other way round. The more she had children, the more she became thin.’ Suruj Mia stated that Kulsum was ill for all of her pregnancies, and could not adequately undertake her domestic tasks.
Her fragility became worse with each pregnancy. Said her husband: ‘My mother told me that there is an asor (bad spirit) with Kulsum, and we did everything to get rid of it. You won't understand this. You are town people. There are lots of bad spirits. We treated her with kabiraji (herbal medicine), and used the mowlanas (spiritual healer). (But)… she had a strong asor.’
(During her first four pregnancies, all in the rural village, she never consulted either a doctor, or a ‘western care provider,’ relying on her family, and the local healers, here the herbalist and spiritual healer. Together they provided care at delivery and various herbs, potions and rituals.)
At aged 20, (escaping rural poverty and natural disaster), the (nuclear) family moved to Dhaka, and the slum. Three further pregnancies followed. There she visited the local TBA (Traditional Birth Attendant, who practises a mixture of traditional and some western care, and conducts most of the births in the slum for a small fee). Further, during the sixth of her 8 pregnancies, for the first time she had consulted a western doctor: escorted by a (government) health worker from a local clinic, she had attended a government hospital, and received tetanus toxoid. And, further, she had been told she had a serious disease, and needed urgent treatment.
‘The doctors said that she had jokkah (local dialect for tuberculosis),’ said her husband, ‘and that she had to take medicines for 18 months, and should never get pregnant again. They asked her to deliver the baby in hospital, and they would do something to make her sterile. They wanted me to take her to another hospital (Dhaka Chest Hospital). I have never heard of a disease for which you are supposed to take medicine for 18 months and for which you should not get pregnant. Pregnancy… is controlled by God… I think she was responsible for what had happened…. She never listened to me or my mother… her movements during her pregnancies were wild… She attracted evil spirits…’
(As a result of these beliefs, and also because of cost, despite her own apparent willingness, Kulsum did not attend the chest hospital, and did not receive treatment for her tuberculosis). During her eighth, and final pregnancy, despite further herbal and traditional treatments, she became increasingly ill. Eventually she went into labour, but became distressed, and the TBA was called. Soon after her arrival, the patient collapsed into coma. She was transferred by ‘baby taxi’ (motorised three wheeler) to the local government hospital, but died in hospital immediately after the birth of a live baby.
Kulsum was then 26 years old. She left 7 living children, including the newborn, a husband Suruj Mia, a rickshaw puller, in their one room shack in the slum of Dhaka.



This single case history illustrates many of the characteristics of developing societies outlined above: Kulsum is poor, and young, a rural migrant to the great city, and cut off by poverty, lack of knowledge and personal autonomy from care that could have saved her life. Her poignant trajectory illustrates clearly the nature of ‘first contact’ care as experienced by many of the world's poorest.
Influenced by a host of inter-related factors, Kulsum seeks care from a wide variety of persons. These include: proximity and availability; cost; gender and appropriateness to her (and crucially her husband's) understanding of her illness; and the severity and stage of her symptoms. ‘First contact care’—the first set of persons chosen by the patient and their family to attend them in their illness—is an intricate, dynamic and individualized process. While complex, it can be understood, and we now have a better picture of the way it works.
Helman's approachable text(11) reminds us that any society's health system is an integral part of the society itself: it grows from it. Landy(12) points out that a health system has two inter-related aspects, cultural and social. The cultural includes basic ideas, normative practices and shared modes of perception; the social includes the specified roles of carer and cared, and the rules governing these settings in different places, such as the home, health centre, and hospital.
In the West, our example might be reduced to ‘the natural history of a case of TB’. Yet essentially Kulsum moves through a set of cultural and social encounters as she, and those around her, pursue a response that might help them, and one that matches their understanding of the problem, and the resources available.
Another way of building an understandable model of this experience is offered by Kleinman.(13) He suggests that in any system, three overlapping and interconnected sectors are operating: the popular, folk, and professional. Here, we see the first group to which Kulsum turns is the popular sector; this is the lay or non-professional domain. The dominant options here are self-treatment, or advice or care from relatives. While Kulsum herself did not engage in much self-treatment, or appear to make use of medicines from the thriving bunch of drug stores on the edge of the slum, Uzma's research(10) demonstrates their crucial role in the ‘medical system’ of the slum, a point of far-reaching importance explored later.
Kleinman's second domain, the folk sector, at one stage seemed to dominate only in developing societies, but now is re-emerging strongly as ‘alternative medicine’ in Western countries. Here individuals specialize in forms of healing that are either sacred (Kulsum's mowlanas) or secular (the kabiraji). These folk healers form a heterogeneous group, with extraordinary cultural variation in style, outlook, type of payment, and rules of entry and training.(11)
But essential in understanding the pluralism of newly emerging service providers is to note how many groups—particularly the folk healers—are beginning to fuse ‘alternative’ components to their more traditional treatments—including key allopathic medications rising from Western bio-medicine. This has been called the ‘indigenization of Western medicine’,(14) a process potentially fertile for outcomes both useful and harmful to health.
The following example, taken from the early work of one of the authors,(15) and as quoted by Helman, provides a case that illustrates a striking version of this process as seen in a country emerging from centuries of isolation. ‘An example of a… secular (folk) healer, is the sahi as described by the Underwoods in Raymah, in the Yemen Arab Republic. These healers have only appeared… in recent years, and their practice consists (almost entirely) of giving injections of western drugs. They have little training… and limited diagnostic (or) counselling skills. To the inhabitant of Raymah, however, the sahi practises what is considered to be the quintessence of western medicine—'the treatment of illness by injections.’(11)
The original description went on to note that the recent arrival of the sahi is a mixed blessing for the poor Raymis. While some individuals benefit from the injections, particularly injections of antibiotics, the service is not only expensive but often actually dangerous. It also diverts understanding from the actual causes of ill-health.(15)
Helman notes the growing popularity of injections (and injectionists) in many other Third World countries. In Kenya, for instance, ‘untrained bush doctors administer medicines and injections’, and ‘street and bus-depot doctor boys’ hustle antibiotic capsules.(11) In a useful recent description from South Africa, Cocks and Dold(14) report the use of indigenous and indigenized Western medicine integrated into the local and ‘traditional’ amayeza system.
Kleinman's third sector—the professional––represents those persons organized and legally sanctioned as medical and paramedical members of the system. As Kulsum's story shows, even in a country as poor as Bangladesh, the government-sponsored health system does have outreach to the poorest. At one stage, the sick woman reached a local health centre worker, who referred her to a hospital and eventually to an allopathic ‘Western’ trained physician. There she received a crucial piece of information—a diagnosis of a serious but treatable disease. However, fatefully, this life-saving knowledge was not acted upon.
The professional sector has until recently been the focus for health planners, as they seek to combat the terrible health indices of the poor in developing countries. Yet a growing recognition of the pluralism of the health system—and particularly of the burgeoning growth of the ‘private sector’ in both the folk and professional sectors—has led many to revise this emphasis on the professional sector in general, and that part of it sponsored through government in particular.
An example of this approach comes from the work of Berman.(16) He argues that many people—not just the poor like Kulsum, but many more fortunate in wealth and education—‘vote with their feet’. They attend a bewildering range of private healers who vary from private Western allopaths, to the drug stores of Dhaka's slums, the amayeza practitioners of South Africa, or the sahi of Yemen. This private sector provides something like half the health care of the sick of the developing world—and so can no longer be neglected by planners and researchers.
Despite appearances to the contrary, there is a consistent logic in this: like Morley 30 years before, Berman is saying—let us see what is there, and where the problems are, and direct our scarce resources accordingly. Such an emphasis should not be seen to allocate special privileges to the ‘hidden hand’ of the ‘competitive market’—for it ‘assigns priority to social development, not to the consumption-driven throughput of energy and materials.(6)

Continued....

Summary: overcoming barriers to improved health services in developing counties
In this chapter, we began by outlining the distinguishing features of developing countries, and of the health problems they face. We cited evidence to indicate that the poorest still share an overwhelming burden of the world's disease, and that they require basic economic improvements to lift them onto the ‘curve of rising healthâ€. Nevertheless health services, as one of several key investments in ‘social capitalâ€, can contribute significantly to move the poorest people along the curve, and so towards a longer, and a healthier life. It is now becoming clearer that it is primary care—providing the crucial interface with most of the sick—that offers the best returns from investment in health services. The miasma of poverty, a diseased environment, lack of education, and personal powerlessness, build insurmountable barriers between the sick person and what Schumacher(17) called so powerfully, ‘the useful knowledge†that can preserve life.
What then can be done to lower some of these barriers to improved health for the poorest of the world's poor? Schumacher outlined the ingredients of a way forward at the same time Morley published his Nigerian prescription. He described the importance of questioning conventional economics and principles of growth, sought small-scale structures and solutions, promoted intermediate technologies, and taught reverence for the earth: these, we feel, are now even more relevant as the social basis of health is understood better.
Finally, we present three recommendations designed to focus the issues for readers of a textbook of primary medical care: they are not narrowly medical, drawing on the larger context that has been the emphasis of this chapter.
First, in every forum, as health workers we must speak up for the big issues, for it is they that make the biggest difference to health. A society whose wealth is evenly spread, that is fair, and peaceful, and in which all members play a respected role, and whose institutions are robust, participatory and accessible, will build healthier individuals and communities. Systems built on these core principles will be ‘cheaper†to run, less invasive and more sustainable.
Second, within our clinics, health centres, hospitals, and teaching and research institutions, we should work at reforming the health sector so that it should be—as both Morley and Schumacher recommended so long ago—distributed better to where the people, and particularly the poorer people, are. That means systems that are more ‘generalized†to address the basic and common and treatable health problems of the many. It also implies trade-offs within health systems to make them less specialized towards the rarer and less treatable conditions of the few, and more focused on prevention and care. This recognizes the central contribution that primary care—still so often the poor relation of health services—can make to improvements in health.
Third, while professional medicine has developed many effective therapies, it does not, nor should it, own them. First contact care has a rich range, of which ‘professional†Western-based primary medical care is only a part. Improving the way the parts work together needs increased research and investment. We now know something of the therapies that work; many of these are already in the private and folk sectors which provide half the care to the world's sick. If primary health care is to become the core of the system, not just the entry point to a conduit into specialized and expensive interventions, it needs greater attention. Despite difficulties great and small, primary care for the poorest can be made more accessible, appropriate, participatory and sustaining of human community, itself the wellspring of physical and mental health.

After these recommendations comes the warning.
Here, we have emphasized the importance of recognizing the burden of ill-health that, in a global sense falls on the world's poor. But, since it threatens the whole species, the environmental crisis must also be recognized as the biggest issue. In reference to McMichael,(2) we used the term ‘watershedâ€. The turning point it marks is the recognition that not only are the ecosystems of the earth—on which we all depend—‘overloadedâ€, but much of the cause is not the poor, but the minority of the rich who produce three quarters of the planet's pollution. His further analysis in 2001 recommends a ‘more far-sighted approach… (where) efficiency, fairness and sustainability should become the joint and interdependent goals of our social and economic policies.(6)
Thus, in an ironic twist, while in the shorter term it is the poor that are over-burdened with disease, in the longer term it is the rich that are burdening, indeed making sick, the very planet which provides us all with our sustenance. And it is ‘developmentâ€â€”particularly that coarse version that is dependent on the exhaustion of the planet's reserves and the pollution of its systems—which is largely responsible. Globally, the pursuit of health should best start with those humans most in need. Yet while this is necessary, it is not sufficient—and so the focus must be widened beyond her children to include the well-being of Mother Earth herself.
We conclude that the examination of ‘first contact care in developing countriesâ€, our vital starting point, should encourage us to work also at improving our contact with the Earth. Nurturing both this Earth and those humans who are poor and marginalized is not simply being kindly, it is practical good sense, and good public health. And is a true investment, paying off manifold for all of us.(18)