Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Village Level

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The most successful programmes are those that have effective local leadership, decent training, some curative potential, and powerful political will. They are also those that combine health with other developmental efforts, so that health, nutrition, food provision, and economics are interrelated and supported by common efforts [8; 9].

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In this context, however, it is probably unwise to generalize from one region of the world to the next. A programme that works with volunteer women community health workers in Africa, which has a strong tradition of respecting women as workers and community leaders, probably would be less effective in another area where no such respect exists and where people are sufficiently enmeshed in the cash economy to expect monetary compensation for their time.

In short, the combined public health, medical, political science, sociological, and anthropological studies suggest no "cookbook" solutions as to what exact set of factors will make any programme successful. Moreover, they appear to illustrate the effectiveness of flexible regional or local policies as opposed to global ones.

For many years, anthropologists have commented on the problems in the organization of primary health care programmes from the points of view of folk cultures and medical and bureaucratic cultures. For example: "Medical and public health programmes in developing countries will be successful in design and operation if they take into consideration the social, cultural, and psychological characteristics of the target group" [3]. Another typical comment: "The most successful medical and public health programmes in developing countries require knowledge about the social, cultural, and psychological factors inherent in the innovating organisations and their professional personnel" [3].

In attempts to understand why people in developing countries under-use Western health services, uncongenial atmosphere in clinics and unfriendly service by clinicians have been documented in the ethnographic literature since the s and s [2; 10]. In addition to the better-known issue that patients and doctors, operating from folk and Western medical perspectives respectively, might not view illness and its treatment alike [11], anthropologists have noted that the treatment clients receive is often abusive.

A dramatic example is doctors' refusing to treat sick children on days set aside for preventive care if their mothers have not registered them on well-baby days. Such an assignment of priorities may appear incomprehensible and outrageous to mothers, especially those who have travelled some distance to a clinic [1; 12; 13]. Another example is doctors' indicating their cultural distance superiority by ridiculing patients' health beliefs and practices. Social distance between foreign physicians and patients which is often the case in Asia and Africa or between doctors and their compatriots of lower socioeconomic class as in Latin America may cause communication problems on either side.

Studies have indicated that some doctors do not even speak the language of those they treat [14] and that they use insulting and rough language toward patients rather than polite terms of address [13; 15; 16]. Correspondingly, nurses and other clinic workers rudely assemble patients into queues, then rush them through their short procedures. Another problem is that of physicians not understanding or caring to comprehend patients' descriptions of their complaints, which is not restricted to one region of the world.

Finally, illness always affects social relations beyond the sick individual, and logistically involves relatives or others to accompany and care for the person. Particularly where nursing care is in short supply, however, rules usually control visiting [17] or inconveniently restrict who may attend a patient. Patients often perceive those who work in the clinic as not only unfriendly and insensitive but also incompetent. In Latin America, national rules dictate that first-year graduates of medical schools serve in public clinics, but patients often do not trust these neophyte physicians [6; 18; 19; personal communication, M.

Zeitlin and K. Johnson, ]. People prefer to consult the more experienced and trustworthy, although more expensive, private physicians. These practitioners have established good reputations, perform reliable therapy, and often have a good understanding of local illnesses or at least of the terms in which people express complaints.

In addition, primary care clinics seem to have irregular hours, and patients cannot count on doctors being present with any regularity or having the proper medical supplies when they are there. In India, it has been noted that doctors in public service sometimes provide poor service to make sure that few people will come to the clinic, thus giving them more time and drugs for their paying clients.

On the other hand, they may provide inadequate service so that patients will have to return again and again [9]. Surveys indicate that throughout India primary health care is insufficient and inadequate: doctors lack drugs as well as motivation and training to serve the poor [20]. In addition, medical and housing facilities for doctors are unsatisfactory [21]. In Nepal, physicians may depart from their rural posts for months at a time without being replaced. Problems of lack of facilities and low pay, which shatter the will of the more idealistic young physicians to practice medicine, have been noted in Africa as well, where doctors may even turn to other occupations in order to support a middle-class life-style [4].

Overall, both medical personnel and clients recognize that inadequate facilities, lack of supplies, and insufficient medical and logistic back-up make effective care difficult or impossible. From the perspective of the patients, the numbers of clinic hours and personnel may be insufficient for them to be cared for without long waits or even at all. From the perspective of health providers, it makes little sense to keep the clinic open if it is not supplied. Once the patient is inside the consultation office, the examination may be brief: in the Dominican Republic examinations were timed as lasting 2 minutes and 50 seconds on the average 19], in Mexico 2 minutes [22], and in India less than 1 minute [23], or 2.

Such short consultations rarely involve physical examinations or even measuring vital signs [24]. In Saudi Arabia, baseline data on three health centres showed that the mean length of time physicians spent with each patient was 3. The time spent explaining a patient's illness and medications seemed to be minimal.

Fewer than one-third of the patients interviewed after consultations understood their diagnosis or how to take their medicines [25]. In the Sudan, for two clinics and one hospital outpatient clinic, the average consultation time was 2 minutes In addition to a long wait and a brief consultation, drugs may be a problem, as both clinics and mobile units have been documented to be undersupplied in all parts of the world, including Mexico, Central America, Haiti, Peru, India, Bangladesh, Burma, Kenya, Ethiopia, and Tanzania.

Aggravating the endemic shortage of supplies may be corrupt use of them. Mexican ethnographic studies report suspected plundering of health and nutritional supplies [27], and in India drugs were reported to find their way into the private practices of physicians. Contributing to shortfalls in supply is the attitude of those served by public clinics that they "deserve" medicines, which leads to wastage, as people go to the clinic to "get their money's worth" or fake symptoms so that they can obtain strong drugs [19; 28].

Use of pharmacists, local curers, or private physicians in the countries mentioned is based on speedier treatment and better supplies, as well as the usually greater sensitivity of these care providers than patients can expect from primary health care professionals. If a trip to a primary health care facility includes the time and expense of a trip elsewhere to purchase medicine, people will choose to go elsewhere in the first place. In addition people may value the medicines provided by the alternative care givers more highly.

Pharmacists usually carry brand-name medicines with which patients are familiar through the media or prior illness in small quantities that patients can afford and that better fit their cultural preferences, expectations, and pocketbooks [29]. Pharmacists are usually nearby, are open every day and for long hours, and explain illness and treatments in terms that clients can understand [30].


Even where drugs are available, however, they may be too expensive. Furthermore, clients may not purchase or take recommended dosages, they may not get better, and thus they may conclude that the health services are worthless [14; 31].

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Beyond, but also related to, appropriate drug availability and physician attitudes are issues of the quality of the diagnostic and medicinal treatments. The general conclusions in reports from the Dominican Republic [19], India [20; 24; 32], Bangladesh [33], Ghana [34], and other countries is that the quality of primary health care is poor and that is why people do not use the services. Studies in Tanzania, Saudi Arabia, Ghana, and Bangladesh showed that, when drugs were available, physicians tended to overprescribe or use dangerous agents indiscriminately [25; 33; 35].

Part of the problem may be that patients use medicines incorrectly because drugs often are supplied without sufficient explanation of how often and how long to take them. In combination, insufficient or improper consultations by clinic or health staff and unavailable, in appropriate, confusing, or overly expensive medicines lead potential clients to evaluate primary health care as useless and to seek medical help elsewhere.

This is particularly true when people calculate the time and expense of the visits against the prospective benefits. Many studies show that it is not cultural factors but inadequate access that accounts for the under-use of Western-style health services in general and in some instances those that are supposedly free as well.

Clinics are not always conveniently located, so that time and expense, including consultation and medication fees for the supposedly free services, may be considerable [6; 18; 36]. Catchment areas seem to vary by practitioner [36]. People in the closest proximity seem to seek health care more frequently, particularly when the services are free and involve no extra cost [28; 37].

Beyond that, people will reckon the likelihood of effective care against the time and cost of seeking it, taking into consideration the probability of being treated by a skilled practitioner usually a physician and receiving appropriate therapy.

Helping Health Workers Learn: A Book of Methods, Aids, & Ideas for Instructors at the Village Level

Given the shortage of physicians and nurses in most developing countries, many health programmes have been designed to deliver basic services to the rural and urban poor by means of medical auxiliaries. Such programmes are intended to transfer the management of health from the hands of the medical profession to those of the community.

However, political problems, poor medical quality, and logistic failings plague them as well. As certain classic health projects have shown, projects that are especially sensitive to the socio-cultural context and health and illness beliefs of the recipient population can still fail if they neglect the sensibilities of the medical culture.

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Definitions of tasks, relationships of authority, and respect among doctors, nurses, and medical auxiliaries were inadequately considered and thus doomed an otherwise culture-sensitive project [38]. The social stratification and the culture of medical society are significant factors contributing to or detracting from programme effectiveness. Also important are the cultural beliefs of the recipients when health programmes introduce new categories and mixes of health workers without consideration of the clients' own perceptions of needs and their own health practitioners [39].

Several problems arise in programmes staffed by auxiliaries. The role of physicians must be defined vis-a-vis the rest of the health care staff. The literature shows that it is the presence of effective, experienced doctors that draws people to health services: patients are unlikely to take the time to seek services if they feel they are being inadequately cared for [40; 41]. In the view of the health care providers, however, trained medical personnel should be used exclusively to direct the programmes and health teams and to provide curative care. Therefore, as providers define the services and tasks of other personnel, health auxiliaries often feel they are being treated like servants, which results in poor staff morale [33].

Where no team is in place, or where it consists of mobile units, medical backup may be inadequate, resulting in poor care. Such problems are not easily overcome without major changes in structuring.

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The relationship of the health care team to the clients must be considered as well. Are health workers to be local villagers, or non-local, often more highly educated personnel? From the recipients' point of view, local health workers are able to speak their language and understand the clients' health concerns, but they may lack credibility since they know little more than the average villager.

More highly educated outsiders may command respect; on the other hand, they may be too socially distant and insensitive to culturally expected or appropriate behaviour to encourage the population's participation in health programmes. From the medical providers' point of view, the trade-offs are educational can villagers, if under-educated, handle the tasks of record keeping? Although some preliminary attention to existing ethnographic literature on the area to be served and additional ethno-medical surveys could alleviate potential problems of understanding the cultural contexts of health and illness, such initiative is apparently rarely taken.

Even where information on local cultural conditions hampering health delivery exists, it is often ignored for programmatic reasons [40; 42]. Governments tend to accept the dictates of foreign donor organizations in order to add employment, whether or not it fits their local conditions [42]. Yet another issue is that of how indigenous health practitioners might be incorporated into primary health care efforts. Although directives have tried to improve the effectiveness of reaching the people through consultation with and incorporation of indigenous practitioners, selecting these individuals to work with may be difficult [3].

In addition, "some programmes which aim to incorporate the traditional healer have undermined the healer's status by relegating the healer to the bottom rung of the Western health service and converting him or her from an indigenous expert to a marginal health aide" [39; 42]. An oral rehydration therapy ORT programme for children with diarrhoea in Brazil is one example of the successful joining of local beliefs and practices with the provision of modern treatment by traditional healers [43].

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The healers skillfully incorporated ORT into their routines, provided the patients with good psychological as well as medical care, and assured follow-up. In this case, national health authorities were willing to include these practitioners in the ORT programme after they had satisfied themselves that the healers did not compromise the level of care. The programme, it should be noted, followed a detailed socio-cultural survey of local beliefs and practices relating to diarrhoea and probably carefully built up respect for and rapport with local healers.

We have looked at educational, economic, and cultural issues with respect to local versus non-local personnel.