World Bank Document

are more expensive and less critical compared with 490 per physician, reliance and partnership betweento health. (Latrines, septic tanks 80 per hospital bed, and 260 per communities and government.and other lower-cost alternatives nurse in the Federal Republic of The concept has achieved widetoconventional sewerage are less Germany. (Some of the middle- spread intergovernmental support,likely to contaminate water sup- income countries, though, have especially from the 1978 Internapliesif the water is centrally treated almost as many physicians per tional Conference on Primary Healthand distributed under pressure in person as the developed countries Care.ThishasbeennomeanpoLiticalpipes.) But water supply systems do.) achievement; but in most countriesmust be maintained-something For many necessary but simple the rhetoric stiDl must be translatedthat is frequently neglected. A medical tasks, paramedical workers into more money and reorganizedWorld Bank review of village are likely to do a better job than health systems.water supplies found two coun- physicians, who may be dissatis- A key element of primary healthtries in which systems were fail- fied with their work in rural areas care, or of any health care systeming faster than they were being and so turn to private practice. that attempts wide coverage atconstructed. In many countries, however, there relatively low cost, is the use ofAlthough heavy investment in are even fewer nurses than there are community health workers (CHWs)water supplies is often warranted doctors. with limited training both to proasa means of raising living stan- In many developing countries, vide front-line services and to referdards, it is unlikely to produce people typically live in scattered, seriously ill patients or specialquick or dramatic improvements often small villages and cannot cases to larger dispensaries andin health-and is expensive for travel far. They are therefore hospitals (see box overleaf). Thelow-income countries. Even public unwilling or unable to seek out potential duties among whichstandpipes and yard taps, while modern health facilities in urban their time must be allocated aremuch cheaper than conventional areas, except in extraordinary maternal and child health care,house connections with internal emergencies. Moreover, where midwifery, family planning, treatplumbing,can cost more than $40 rural health facilities are available, ment of injuries and helping toper person (in 1978 prices). In they are usually far too small to move seriously injured people tocontrast, immunization against all employ a physician full time-and referral facilities. In addition, theycommon childhood diseases costs certainly too smaLL to make efficient may organize immunization andat most $5 per child. use of equipment and auxiliary mass treatment programs, providestaff. Although occasional visits guidance on nutrition, family plan-Aby traveling doctors and nurses ning and hygiene, and monitor epi-The amount spent on health care can help, they are obviously unable demics, water quality and sanitation.varies widely throughout the to provide services at short notice. Although several examples (indevelopingworld, though it is They may also not develop suffi- cLuding China-see box on pagetypica:lly very low. Government cient individual rapport with 74) have shown that effective prihealthbudgets in low-income Africa patients. mary health care is feasible evenand Asia are usually less than $5for low-income countries, it makesper person a year (and frequently Primary health care fairly heavy administrative demuchless). Private outlays are often The widespread provision of basic mands. An effective coordinatedlarger--in Bangladesh, for example, preventive and curative medical approach is needed-involvingindividuals spent an estimated $1.50 services is essential. But in an careful selection and training ofeach in 1976, or three times what attempt to tackle both the broader CHWs, thorough supervision,the government was spending. But causes of health problems and referral of serious cases to betterthe combined total of $2 compares administrative, political and other trained and equipped people, andwith about $700 in the Federal implementation problems (see adequate (but controlled) availa-Republic of Germany. This gap Chapter 6), the WHO and UNICEF bility of drugs and other supplies.would remain huge even if allow- have recently sponsored a concept Without this, CHWs are likely toance were made for differences called "primary health care" that become demoralized, discreditedin prices. It is thus not surprising goes far beyond these services. It and inefficient-and their recomthatin the mid-1970s in Bangla- is an integrated approach to health mendations for curative and predeshthere were 9,260 people per that also spans food production, ventive care disregarded.physician, 5,600 per hospital bed, education, water and sanitation; Moreover, the emphasis thatand 42,080 per nurse or midwife, in addition, it emphasizes self- this Report (and others) gives to57