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Finance & Development, September 1980
Article

Community health care in developing countries: An efficient and low-cost method of providing greater health care, but one that is underutilized

Author(s):
International Monetary Fund. External Relations Dept.
Published Date:
September 1980
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Fredrick L. Golladay

Few developing countries have formulated health policies based upon detailed assessments of the socioeconomic costs and benefits of different approaches to health care. As a result, expenditures for health care in many cases are not as effective as they could be. This realization has produced renewed emphasis on the need to evaluate health care policies and programs in the developing world in order to make them more appropriate to the prevailing needs and resources. Studies, conducted by the countries themselves and agencies such as the World Health Organization (WHO) and the World Bank, have concluded that health care systems need to be expanded and improved at the community level in order to reach the great majority of people who presently do not have access to adequate health care.

Although countries differ in their level of development and in the magnitude of their investment in health, health care systems in many developing countries share certain major characteristics:

• Government expenditures on health in low-income countries are very low.

• The overwhelming majority of people, especially the poorest, cannot easily reach a modern health care facility.

• Most spending is for curative medicine, high-cost hospitals, and highly trained medical personnel.

• Existing programs of health care are frequently inefficient in their use of financial and human resources.

Government expenditures on health in low-income countries seldom exceed 2 per cent of gross national product (GNP). Almost half of the 86 developing countries for which data are available spend less than $2 per capita a year on health care; 22 countries spend less than $1 per capita. By comparison, in 1976 the average per capita government expenditures for health were $550 in Sweden and $171 in Japan. There is an emphasis in developing countries on high-cost, individual, curative medicine—for example, the operation of expensive, well-equipped hospitals staffed by highly trained medical personnel—and these facilities are concentrated in urban centers. In Ghana, for example, 62 per cent of physicians in 1969 resided in urban areas, where 15 per cent of the population lived. The limited data available suggest that private expenditures for health in developing countries are often considerably greater than the amount spent by governments. In fact, the ratio of private expenditure on health to government expenditure is generally far larger than that in the developed countries (see the table). However, much of the private expenditure is for the services of traditional healers and for drugs of controversial value.

The health problems of developing countries are typically those associated with poverty. However, they are generally more severe than those in industrialized countries and often occur in the form of multiple diseases because the tropical environment encourages the growth of disease-carrying insects and the transmission of disease among the population. In addition, the inadequate housing, clothing, and public hygiene add to the problems of health maintenance. Undernutrition frequently makes people more susceptible to disease and lessens their chance of recovery.

Health expenditure as percentage of gross domestic product1
Developing countries (1970)Developing countries (1973-75)
GovernmentPrivateGovernmentPrivate
Ghana1.12.9Australia5.01.5
Honduras1.93.2Belgium4.20.8
India0.42.1Canada5.11.7
Pakistan0.91.5Netherlands5.12.2
Philippines0.41.5Sweden6.70.6
Sri Lanka1.81.2United Kingdom4.60.6
Sudan2.21.5United States2.43.9
Source: Richards, P. J., Some Distributional Issues in Planning for Basic Needs Health Care; A World Employment Research Working Paper, Provisional Draft, Income Distribution and Employment Programme, International Labour Office, Geneva, June 1979, p. 3.

These figures must be taken as approximate, since major items may be missing from the public and private side. Comprehensive and accurate data are rarely available; there are often numerous, disparate, and not easily quantifiable sources of finance for health care services within a country. Sources may include the central government, state and local governments, insurance plans, private households, voluntary organizations, employers, lotteries, etc.

Source: Richards, P. J., Some Distributional Issues in Planning for Basic Needs Health Care; A World Employment Research Working Paper, Provisional Draft, Income Distribution and Employment Programme, International Labour Office, Geneva, June 1979, p. 3.

These figures must be taken as approximate, since major items may be missing from the public and private side. Comprehensive and accurate data are rarely available; there are often numerous, disparate, and not easily quantifiable sources of finance for health care services within a country. Sources may include the central government, state and local governments, insurance plans, private households, voluntary organizations, employers, lotteries, etc.

Inadequate coverage

An estimated 70 per cent of people living in developing countries do not have easy access to a modern health care facility for a number of reasons. Lack of roads and public transportation prevent vast numbers of rural patients from obtaining health care. Pregnant women and small children—those whose needs are greatest—typically find travel especially difficult. An Indian study showed that the proportion of the community attending a dispensary was found to decrease by 50 per cent for each additional half mile between the community and the facility. (H. Frederiksen, Maintenance of Malaria Eradication, World Health Organization, Geneva, February 1964.) Research in Africa has concluded that utilization there declines by half for each two additional miles of travel. Where health services are available, supplies of drugs, pesticides, and other essential materials are often unreliable. The resulting interruptions in the services frustrate patients and discourage them from relying on local health facilities. In many cases, the services provided are not adequate. Charges for services or drugs are often not affordable, and people in the subsistence sector frequently do not have the cash to pay for them. Even where care is consistently available, costs of transportation to a health facility and the loss of income that results from absence from work frequently exceed the economic resources of many of the poorest people.

Providing health services nationwide will not be easy for any government. Even the most developed countries find that assuring ready access to care is typically too costly and difficult. Developing countries have an acute need for low-cost, self-sustaining, and effective health care systems that can be established and operated within scattered communities.

The state of health

The urgent need for better health care is quite obvious from a review of the state of the health of the developing world.

About 16 million children under five years of age died in 1979 in developing countries. Five million of these deaths could have been prevented by immunization against the six most common diseases of childhood—measles, polio, tetanus, diphtheria, whooping cough, and typhoid. Nearly 6 million children—all under the age of one year—died as a consequence of the mother’s undernutrition during pregnancy. In addition, those who reach adulthood in the poorest countries sacrifice up to a third of their potential working lives by succumbing to fatal diseases.

Much greater human and economic costs are imposed by nonfatal illnesses. Reports are very sketchy, but, even so, the numbers are staggering. At least 5 million children are blinded or permanently crippled in the developing world each year—most of them as a result of polio, a disease for which safe, effective vaccines are available. The WHO estimates that 2-3 million children are severely retarded each year by readily preventable diseases.

The tragedy of disease in developing countries is that many of the most serious health problems are either preventable or curable by simple, inexpensive, and safe methods. For example, a recent World Bank study of health conditions in Mali, West Africa, found that 90 per cent of infant deaths resulted from faulty care of pregnant women and insanitary delivery practices. Similarly, infant “weanling diarrhea” is a major killer of children in most of the world, yet its prevention or cure is inexpensive and simple. The problem can be avoided by good hygiene and adequate nutrition. Alternatively, body fluids lost because of diarrhea can be restored cheaply at home by administering a solution of boiled water, salt, and sugar by mouth. However, in much of the developing world, ample supplies of safe water and adequate facilities for the sanitary disposal of human wastes are not yet available. Where clean water and sanitation are provided, poor hygienic practices often negate any potential reduction of diarrheal disease.

Community health services

Since on the whole it is the poor and neglected, living mainly in the rural areas in the developing world, who lack essential health care and an understanding of the importance of nutrition and hygienic practices, the problem becomes one of how to serve them best. Many countries are responding by establishing community-level health care facilities that make use of community health workers rather than doctors. But the practical difficulties of too few and too hastily trained health workers, of limited transport, and of inadequate and erratic supplies are compounded in most countries by widespread reluctance to rely upon community health workers. These problems do not mean that the approach itself is incorrect, but rather suggest that in most countries sustained efforts to adapt and strengthen it are required. A large number of developing countries are now implementing a second generation of community health programs that incorporate the lessons of experience from the first.

In order to bring health care closer to people who have been underserved in the past, a three-tiered pyramidal approach to the provision of health services is being used (see Chart 1). The first level is the community health center, the second is the rural or urban polyclinic, and the third is the referral hospital (often at a district level). Community health facilities are being constructed all over the world. These facilities are usually described as health posts, dispensaries, mini-posts, or community health centers. They are typically staffed by locally recruited persons who have been given six months to two years of training. The buildings are typically of local design and materials and are very modestly equipped. These facilities are intended to extend the coverage of the health care system rather than to supplant it. They rely upon existing polyclinics, district hospitals, and health centers for logistical support, supervision, and, in many instances, training. They seek to provide two thirds or more of health care, including supervision of pregnancy, midwifery, care of newborn children, immunization, treatment of endemic diseases (such as malaria), and emergency care for injuries. Tasks requiring complex equipment, such as laboratory diagnosis and surgery, are conducted at higher levels after referral of patients by community health workers. Health and hygiene education are also major responsibilities of community health workers.

Chart 1Organization of a community based health system serving about 1 million people

Source: Health Sector Policy Paper (World Bank, 1980).

Nearly a decade of experience with low-cost health care—in countries as diverse as Botswana, Brazil, the People’s Republic of China, India, Iran, Jamaica, and Sudan—is now available. This experience shows that the achievements at recently constructed local health facilities have often been disappointing. One problem has been matching the supply of their services with demand for them. Particularly in Southeast Asia, rural health centers and community health posts are virtually unused—by-passed by patients who prefer to attend larger, more sophisticated facilities. In other areas of the world—most notably sub-Saharan Africa—large numbers of people use community health facilities but receive only minimal attention from staff. In East Africa, many village health workers see up to 90 persons an hour.

Efforts to provide accessible low-cost care have also been frustrated by lack of supplies and personnel. Drugs, dressings, and other materials are often exhausted a few days after receipt. This is sometimes due to poor planning; however, more often the quantities ordered are adequate for several months, but run out because of improper use—patients may hoard drugs at home or medical officials may overprescribe, for example. Such activities waste funds and may even injure, rather than promote, health. In addition, the sale of drugs on the black market is a common problem. Because dispensers, nurses, medical assistants, and even physicians are ill paid, they may supplement their government salaries by illegal sales of drugs.

A number of countries—especially the smaller, poorer countries—confront severe problems in financing salaries and purchasing drugs. Health budgets are too small, and workers most distant from the capital are the least likely to be paid. Because pharmaceuticals often must be purchased from abroad, foreign exchange constraints are also serious. One Saharan country has been forced to turn to increasingly expensive suppliers as its credit rating with pharmaceutical manufacturers has declined.

The performance of community health workers, too, has often not been as effective as expected. The need for health care in some countries has put so much pressure on health workers that they are almost prohibited from providing careful diagnosis and precise treatment. Many health workers prescribe three or more drugs to patients when in doubt about the cause of illness, hoping to cover the most common ailments. This practice not only wastes the drugs and supplies but also promotes resistance of disease organisms to drugs such as penicillin, which are widely available at low prices. The type of training given to these health workers also causes problems in many countries. Patients expect health workers to render instantaneous diagnosis, and they distrust the systematic approach of Western health care. Rural health workers are sometimes influenced by community leaders and traditional healers to abandon the practices they have been taught. Since these workers are typically young and of modest social status, they are often unable to resist such social pressures.

Yet another reason community health workers are not as effective as they should be is that they are not trained in the diagnosis and treatment of locally important diseases. This undermines a community’s confidence as well as the workers’ own confidence in their professional ability. In-service and continuing education, and referral of difficult problems to more sophisticated facilities can minimize this problem. New methods for training health workers are being devised to improve their competence (see Chart 2).

Chart 2Sample diagnostic flow chart for use by community health workers

Source: World Health Organization (1978). Flow charts developed by Dr. B. Essex.

Improvements

Experience from these early efforts in community-level health care provides a basis for improving the second generation of programs now being initiated. Many of the improvements center on the relationship between the health worker and the community he serves. If the health worker is to gain the respect essential for him to be effective, he must be given sufficient training, equipment, and supplies so that he is not forced to refer more than a minimum number of patients to higher levels. Very high referral rates undermine the community’s confidence in the health worker and also increase the probability of patients’ bypassing him. For the same reason, the health worker should be mature enough to enjoy the respect of the community. Early programs exaggerated the importance of formal education for health workers; it is now clear that it is more important for them to have had children themselves and personal experiences with the health crises experienced by the people they will be treating.

Other improvements to existing rural health systems concern supervision. It has been found that, if at least part of the health worker’s salary is paid by the government, the operation is more susceptible to discipline than it would otherwise be, since a government salary increases the possibility of sanctions from health officials. Only a very few countries (including the People’s Republic of China) have succeeded in making the community responsible for the salary of the health worker without sacrificing efficiency. Moreover, relying solely on local finance tends to favor high-income communities.

Frequent supervision of the community health worker is essential—both to provide in-service training and to ensure that performance meets minimal standards. The isolated, modestly trained health worker is rarely confident of his or her skills and often confronts problems for which he was not trained. Each health worker should be visited regularly by staff from neighboring dispensaries, health centers, and hospitals, as well as from the office of the regional medical officer. Written reports should be used sparingly, but the information that is collected should be promptly analyzed and followed up. Supervision should provide numerous contacts with supervisors to compensate for the inevitable breakdowns in transport, to ensure that a broad range of issues (from clinical care to drug management) is considered, and to reduce the crisis character of visits from the outside. Establishing standards for the use of drugs and supplies and then carefully monitoring the demands of individual health workers are necessary to avoid misuse and/or misappropriation of drugs.

Further, health workers must be made accountable to the community, especially through recognized organizations, such as the local council or village development committee. The community can monitor such aspects of performance as the hours of service, the use of drugs and materials, and the care provided. But how far the health worker should be made formally accountable to the local authorities has to depend on the local situation. In some cases, supervision can be successfully exercised by the community. In others, program directors argue that complaints are resolved most rapidly and effectively if health authorities at a higher level deal with them.

Priorities

Building effective systems of low-cost health care will require sustained efforts, continuous modification of approaches, and experimentation. However, the gains in human welfare are potentially dramatic, and the financial costs are relatively modest. The overwhelming importance of good health to individual well-being and to economic performance implies that governments should assign high priority to improving services that contribute to the control of disease.

A simple infrastructure for local health services employing community health workers is important. This primary health care approach would not only extend the effective coverage of basic health care but would also afford a mechanism for surveillance of disease, health education, promotion of family planning, monitoring of sanitation, and targeting of disease control programs. The acceptance of community health workers hinges on their ability to meet a substantial part of the needs of the community. Thus, they must be integrated into a system of supervision, logistical support, and referral. These parallel, supportive programs must be introduced concurrently with the program of community health care.

But community health services should only be part of a wider system. Perhaps the most basic step for most countries is to strengthen programs to control endemic, vector-borne parasitic diseases—especially malaria, sleeping sickness, and schistosomiasis (bilharzia). These programs can be made efficient and be effectively operated without significant changes in the habits and practices of the people who benefit. The basis for such disease-control programs already exists in most of the affected countries.

A second priority is to expand the coverage of childhood immunization programs. These activities require very little effort on the part of those who benefit and generally may be organized without an extensive local infrastructure. Sierra Leone, for example, does this well by employing teams of recruiters, who enlist the assistance of local leaders in gathering together immediately before the vaccinators arrive in a village, all persons who should be immunized.

Improvements in nutrition, hygiene, and sanitation are also necessary in order to reach the full health potential of most communities. Major investments in these areas will generally be required to improve the quality of services significantly. Moreover, the benefits of greater availability of nutritious foods and safe water will be realized only with marked improvements in the practices of individuals and households. In view of the large investments necessary to improve services, it seems preferable to coordinate these outlays with the expansion of effective primary health care.

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