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Chapter 10. Providing health care

In any community, people become ill and require access to health care facilities and treatment. The problem may be physical, such as diarrhoea, fever or injury, or mental, e.g. psychosis, epilepsy or a learning difficulty. Women have special needs related to pregnancy and childbirth, and children require immunization against common diseases. Regardless of the nature of the health issue, the health outcomes depend to a large degree on individuals' ability to access health care services. Unfortunately, health services are often planned without consulting the community members who use and pay for such services, particularly in rural areas. To counter this, and to meet community demands for accessible, affordable services, community members should be actively involved in their planning. Health centres should attract the community (see Figure 10.1).

Figure 10.1Rural health centre

The way in which people deal with illness is also an important factor in health care. Most people initially treat ill-health within the home and seek outside help only when the problem continues or becomes severe. Such help may not necessarily come from qualified medical personnel; it can also come from local pharmacists or medicine sellers, traditional healers, religious leaders and friends. Often, seeking medical advice from qualified personnel is the last resort. This can happen for many reasons, such as that an individual does not consider the problem to be severe or "medical" in nature, or that the value of medical advice is not appreciated. Sometimes, there is simply mistrust of the medical profession.

Consequently, when planning health care interventions, it is important first to understand current health practices, as well as community needs: which health care services are available, what type of service the community wants and where health facilities should be located. This can be achieved through community discussions using participatory learning techniques with different community groups - defined by age, gender, wealth and ethnic/religious affiliation. The purpose is to generate a reliable picture of community needs and ensure that the services provided will be equitable, accessible and affordable.

Providing health care services

Health care facilities (rural clinics, health centres) should be within easy walking distance of the community, particularly for women and children.

Outreach or primary health care workers, such as health visitors and promoters, can be valuable front-line community health workers if they are provided with adequate training and support, particularly if they come from the community itself.

Other health service providers (pharmacists, medicine sellers, traditional healers) can provide additional health advice and care if they are given adequate training and support, and are supervised by medical staff.

Referral systems between different levels of health care (primary, secondary and tertiary) should be clear and comprehensible to both users and providers. The reasons for referrals are often unclear to the users, which can provoke anxiety and lead to non-attendance. In addition, many primary- and secondary-level health care workers may not understand how to refer a patient to higher levels of service, or may not recognize symptoms of more severe illness, which leads to dangerous delays in referral.

10.1 Establishing community health care programmes

When community health care services are established, it is essential that the primary health care be effective and efficient. Community members can lobby local service providers to put primary health care workers in the community, as well as identify community members who could be trained to provide health advice. Other people who can provide health advice to the community, such as pharmacists or medicine sellers, birth attendants and traditional healers, should also be identified. Local service providers can be lobbied to provide additional training and support for these people if necessary. To be effective, health care workers should be acceptable to different community groups and have unrestricted access to the population. Women, for example, may not consider male health care workers to be acceptable for certain issues, and vice versa. Primary health care workers should also have sufficient knowledge and support to recognize illnesses that are beyond their ability to treat, and be able to refer patients to higher-level health care facilities for expert advice and treatment.

The role of pharmacists and medicine sellers in malaria treatment

In south Asia, WHO has promoted the use of local pharmacists and medicine sellers to provide treatment for malaria. They have been trained to recognize malaria symptoms, to prescribe the correct drug dosages, and to advise patients on whether they should seek expert advice. The programme has proved popular with communities, and with the medicine sellers and pharmacists, and it has reduced the burden on over-stretched health services.

The following questionnaire can help community members to determine whether current health services are adequate. If the community lacks adequate access to health services, a strategy for improving the services should be developed and presented to local service providers. Presenting a concrete plan for improving health services, rather than simply complaining that they are inadequate, will enable service providers to plan the necessary services better.

Are current health services adequate?

Where is the nearest health centre to the community? Can women and children walk to it within one hour?

Do trained health workers visit the community? What treatment and health advice can they offer?

Do health workers provide health education by visiting households and schools, or by attending community meetings?

Is there a pharmacist or medicine seller in the community or in a nearby community? What medicines can be obtained and what advice is provided? Do the pharmacists or medicine sellers receive supervision or support? Do community members consider them to be helpful in treating disease?

If community members become sick, do they have access to drugs and other treatments?

What sort of health service provision would the community like to have?

10.2 Factors that influence the type of health care that people seek

When people are sick many cultural and societal factors influence whether and where they seek health care and from whom. For example, it may be difficult for women to approach male health workers for certain problems. On the other hand, individuals in the community who are perceived as wise, or likely to have the required information, may be trusted by most community members. Too often, traditional ways of treating health problems are discounted by people outside a community who try to impose "western" or orthodox models of health care, with their emphasis on medication. However, if the illness is ascribed to angry gods or bad spirits, for example, this approach may not be perceived as effective and community members will be unlikely to seek orthodox health care; indigenous healers or religious leaders may be consulted instead.

The societal context of a disease, too, can affect whether people seek medical advice. In communities where communicable diseases are common, diarrhoea may not be viewed as a major problem unless it is severe. Frequent mild cases of malaria may not lead the sufferer to seek medical assistance, even though malaria can be a life-threatening disease. As a result, people often do not seek treatment and continue to have poor health.

For many reasons, therefore, it is important to work with a community to find out where individuals go for health advice and why. By understanding what help can be provided by different health care workers and how different people can work together, the best possible health care can be provided. This can be accomplished either by formal discussions or in more informal settings. By working with community members it will be possible to set up a referral system that includes all community health providers and to ensure that all providers have standard codes of practice.

Who provides community health advice?

Are there any traditional healers or birth attendants in the community?

What sort of advice do they provide?

Do any problems arise from using traditional healers?

Are there any health workers in the community?

What services do they offer?

Where do men mostly go to seek advice about their health or treatment?

Where do women usually go to seek advice about their health or treatment?

Where do families usually take their children when they are sick?

Are boys taken to different people from girls?

10.3 Encouraging and sustaining the use of health services

For the cultural and societal reasons discussed in section 10.2, it can be difficult to change the way people seek health advice. To accomplish change, health care services must be easily available, since people are less likely to use good health services if they are distant from the community. If the community has been actively involved in planning and selecting the health services, it is also more likely that community members will use them. All community members should therefore be involved in the planning process, not simply community leaders. Community leaders may desire a certain level of health service, but if the rest of the community feels the service does not meet their needs, the result may be expensive services that are not used.

To sustain the use of health services, continuing campaigns in the community and in schools may be required. Educational messages through posters and the mass media can be part of larger campaigns within the community. Regular community meetings can also be held between outreach workers, influential people within the community, and community groups or households. A key strategy is to allow people to express their concerns about the health services. It may be, for example, that families do not use the available service because service providers have been rude or aggressive, or because the facility is not open at convenient times. Service providers and communities should therefore maintain a dialogue and find compromises that meet community demands but also reflect the capacity of the service.

10.4 Immunization of children

Vaccines are available for some major infectious childhood diseases, including measles, poliomyelitis, tuberculosis, diphtheria, tetanus, whooping cough (pertussis), mumps and rubella (German measles). However, all children in a community should have the full course of immunization for these diseases. If a child contracts a disease it is not just his or her health that is at risk: there is a risk of an outbreak within the community, and these diseases can be fatal or cause complications such as blindness, infertility, partial paralysis and stunting.

For the majority of the childhood diseases, it is most effective to immunize children at a young age (preferably under 1 year), usually by means of a series of injections or oral vaccines as shown in Figure 10.2. Most countries make immunization programmes available to communities at no cost through local health centres, although some may offer immunization services only on certain days. In other cases, mobile teams visit communities on certain days to carry out immunization. It is important that community members know where and when immunization services are available.

Figure 10.2 Nurse immunizing a child

10.4.1 Overcoming barriers to immunization

Immunization generally requires babies or young children to be injected and many parents have fears about this. The fears result from several factors, including a dislike of needles, and concerns about the transmission of HIV/AIDS or other health problems arising from the use of contaminated syringes and needles. Immunization injections can also cause reactions, such as a mild fever or pain in the injection site, and make the child cry. Mothers and families may thus be reluctant to follow the full course of immunization, or even to begin immunization, if other families have had bad experiences. However, such reactions are not harmful to the child and the full course must be taken to ensure that the child is fully immunized. Many rural families may feel they do not have the time to take children for immunization, particularly if immunization services are available only during periods of intensive work on the farms.

To overcome these barriers, immunization services should be available at times convenient for community members. Community leaders and health staff should also provide full information to families before immunization is started and ensure that everyone has an opportunity to ask questions and voice concerns. If immunization is to be effective, all children should complete the full course and obstacles to this must be overcome. Community meetings with health staff should help in overcoming such problems.

Checklist for immunization

Are immunization services available at the local health centre?

When are these services offered and who provides them?

Are special arrangements required (e.g. do people have to make appointments; are there restrictions on how many immunizations can be done in one day)?

If mobile teams offer immunization services, when will the services be available?

Where will the immunization sessions be held?

How many people can attend?

Who is responsible for providing the community with feedback from immunization programmes?

Has this information been provided?

While immunization should be carried out by trained health staff, the community itself has an important role to play in ensuring that this is done properly and that everyone has access to immunization services. It is important that the community receives information about how many children were immunized on each visit. A community health worker can be given responsibility for identifying families that have limited access to services or that do not use the services that are available. The health worker should then lobby for improved access and work with the families to persuade them to use the services available.

10.4.2 Making immunization safe

Immunizations are normally (and should be) carried out either at health centres or by mobile immunization teams. Immunizations requiring an injection should be carried out by qualified medical personnel, such as doctors or nurses; immunizations that are given orally (for instance poliomyelitis) can be given by other health staff under the supervision of a doctor or senior nurse. In all cases, the vaccines should be used before their expiration date. If disposable syringes and needles are used for vaccinations they should be safely discarded after use. A new type of safe, disposable syringe is now available, called the AD (auto-disable) syringe, which is much safer because it locks after a single use. Disposable syringes and needles are intended for a single use only and are highly dangerous if they are used more than once. If sterilizable syringes and needles are still used, they must be properly sterilized after each use to avoid the transmission of pathogens such as HIV, viral hepatitis B and hepatitis C. All used syringes and needles MUST be disposed of safely and not be left on the ground or in waste bins in the village, since they represent an extreme health risk, particularly for children who may find them and play with them. Preferably, needles, syringes and other medical waste should be taken away by trained staff and disposed of at properly designed facilities. If no such facilities are available, the waste should be incinerated or buried in the village but only if there is a secure site.

Several safety issues about which health staff need to reassure communities are listed in the text box below. Community members have a right to know the answers to these questions - they are important for establishing confidence in immunization services.

Safety issues for immunization programmes

Do the people carrying out immunization have the necessary training?

Are nonmedical staff supervised?

Are the vaccines used by their expiry date? (Vaccines that have expired may lose effectiveness or become dangerous.)

Are disposable needles used only once?

Are sterilizable syringes and needles properly sterilized between injections?

Are AD syringes available?

How will used syringes, needles and other waste be disposed of?

10.5 Groups with special health care needs

Certain groups within a community will have special health care needs because they are more vulnerable to infectious or chronic noncommunicable diseases than the general population. These groups include the very young, the very old and pregnant women.

10.5.1 Pregnant women and infants

Local health care centres and village health care workers should provide advice and specialist care to infants and pregnant women. For infants, regular check-ups are necessary to ensure that they are not malnourished and are gaining sufficient weight. Children are particularly susceptible to infectious diseases that cause diarrhoea and extra care should be taken to ensure that water and food for children are hygienic. Parents, and particularly mothers, should actively encourage children at an early age to develop good hygiene practices, such as using latrines and washing hands.

Key checks far pregnant women

Measure the growth and position of the baby.

Test blood pressure.

Test the urine for proteinuria.

Perform blood tests for diseases such as HIV, syphilis and malaria, and to assess whether the mother is anaemic.

Screen for women who will be at high risk for health complications and refer them to local hospitals for further checks and treatment. Those at high risk include women pregnant with twins, women who have previously had a caesarean section and women in their fifth (or greater) pregnancy.

Health care for pregnant women would usually be offered through a health centre or mobile health team. Antenatal and postnatal care are both vital for ensuring that mother and child remain healthy, and pregnant women should visit their doctor regularly for health checks. If basic antenatal and postnatal care are not available in a village, the community should lobby for such services to be provided. In areas where malaria is endemic, pregnant women should be given mosquito nets impregnated with insecticide as early in the pregnancy as possible.

10.5.2 The elderly

As people age they become more susceptible to ill-health, both from infectious diseases and from noncommunicable diseases, such as cancers or degenerative diseases. The risk of infectious disease is often increased by chronic disease, particularly when treatment involves treatment with certain drugs that can suppress the immune system and render it less effective. Some disabilities in old age may result from an earlier lifestyle and work, or from malnutrition and repeated infection in formative years. These disabilities can be prevented only by healthier lifestyles at a younger age.

Key illnesses that affect older people include heart complaints, strokes, eye problems (e.g. glaucoma), respiratory problems, deafness, arthritis, and problems with urinating and sleeping. If an elderly community member has eye or heart problems, he or she should visit a health centre and obtain treatment at an early stage of the disease. Many chronic health problems faced by the elderly either require long-term medication or have significant potential for recurrence. Planning for health care within the family and community may therefore require careful budgeting. Furthermore, many older people are sceptical of "western" or orthodox drug-based health care and it is important to make sure that they take their medication regularly.

If a community has a significant number of older people, it should lobby to ensure that the nearest health centre has someone with a particular interest in the care of the elderly and runs regular clinics dedicated to older people. Health education programmes that target the problems of the elderly and provide information on healthy ageing are often an effective way to improve the health and well-being of the elderly. Many older people also suffer from depression or anxiety as their physical abilities (such as eyesight and hearing) decline and they feel they are unable to contribute fully to the life of the home and community. To counter this, they should be encouraged to retain an active role in the community. While older people may not have the energy or strength to perform all the roles they used to, this should not mean that they are no longer asked to undertake important tasks. Indeed, their health and well-being may depend on being actively involved within the community. Developing a positive attitude towards ageing, among the young and old alike, will help people to remain active in later life and develop better support for the elderly.

10.6 Risky behaviour

Some people engage in behaviour that poses a high risk both to their health and to the health of their family. For example, if a person has sex with multiple partners and does not use condoms there is a high risk of contracting HIV/AIDS and other sexually transmitted diseases. If the person is married or is in a relationship, he or she can then pass on the infection to their spouse or usual partner. This can have devastating consequences: infection with HIV can lead to the development of AIDS and to premature death, and other sexually transmitted diseases can cause infertility, problems during childbirth and stunting in babies.

Risky behaviour in a community

Do people in the community engage in high-risk sexual behaviour?

Do people in the community use drugs or drink too much alcohol?

Is information about these problems available in health centres, schools or community centres?

Is support available for people with drug or behavioural problems?

Are community health workers aware of the health risks associated with these behaviours?

The abuse of substances such as alcohol, cigarettes and other legal and illegal substances, to the extent that an individual becomes dependent upon them, can also lead to severe physical health problems, such as liver dysfunction or cancer, and may make the person more vulnerable to heart disease and other health problems. Long-term use of such substances may lead to mental health problems or worsen existing problems. Dependence on a substance can also cause a person to neglect their normal social and family duties and take less care of their appearance. In some cases, people dependent on substances commit crimes in order to fund their habits.

10.6.1 Changing risky behaviour

People who engage in risky activities do so for many reasons, some of which may relate to other problems in their life or in their society. People who abuse substances or drink too much alcohol may do so not only to get a "buzz" or "high" but also because they have problems in their personal or family life or because they feel marginalized in their community. This behaviour can be a means of trying to cope with these problems. People who engage in high-risk behaviour do not always consider the impact of their behaviour on their own health and well-being, or on the well-being of their families and communities.

A first step in changing risky behaviour is to encourage people to talk about the impact that their behaviour has on themselves and on their community. This requires that they have access to information and support. Encouraging people to change risky behaviours takes effort and time, and may require working with individuals, households and the whole community. While it may be relatively easy to change a person's behaviour initially, sustaining such changes can be much more difficult. If a person reverts to the risky behaviour, it is important to continue to work with them and help them to stop the behaviour again.

One approach is to form a community support group with support from counsellors or other health personnel. Those engaging in risky behaviour can discuss the problems associated with their behaviour in terms of financial cost, losing respect, disharmony in the home and difficult interactions with neighbours. It is also important to identify the problems a person faces in trying to change their behaviour and to discuss factors that might encourage them to overcome these problems. This may require working with people to develop strategies for dealing with personal and family problems, and to develop other social and occupational activities in place of the risky behaviour.

Many people will need ongoing support and encouragement not to go back to risky behaviour. It is important not to penalize people who revert to risky behaviour; they should be helped to understand why they went back and encouraged to change. Such relapses can be used as a learning experience, helping the person to understand which situations trigger a return to risky behaviour. Eliminating this behaviour completely may not be possible and it may be more effective to keep it within limits that do not harm the person or their family. For example, drinking could be reduced to non-harmful levels. In some cases, the individual or community may need support from medical personnel or mental health specialists. Sometimes, when a person has become dependent on a substance, he or she will need medical assistance to stop using the substance. This is sometimes called "detoxification". Care should be taken to ensure that this process is properly supervised as it can pose a risk to health.

10.6.2 Health education

In addition to working with people who engage in risky behaviour, it is important to work with communities to develop strategies and knowledge for preventing it. As with many health issues, prevention is much better than trying to treat problems after they occur. Many of the techniques discussed in the previous chapter can also be used to raise awareness about risky behaviours. The whole community should be encouraged to participate in defining the impacts and problems associated with risky behaviours, and to discuss how they can be reduced or prevented.

It is especially important that children have access to information about the impact of risky behaviour on their health and on the well-being of their community. In this respect, health education in schools is very important and should be carried out in a way that allows children to openly discuss these difficult problems. In many areas, encouraging less risky sexual practices has proved to be an effective method for promoting better sexual health. In addition to school programmes, health centres and clinics should also be encouraged to provide information about the impact of risky behaviours. The information should be communicated in terms that are easily understood by the whole community, rather than in complicated medical terms, and community members should be provided with an opportunity to discuss issues with health staff. It is important, however, that such messages are not too harsh or strict. For instance, some consumption of alcohol may not be harmful and discouraging all use may be neither necessary nor helpful. It is more important to emphasize the need to keep consumption at levels that do not represent a risk to the person's health.

10.7 Mental health problems, learning difficulties and epilepsy

10.7.1 Mental health problems

Mental health problems are mental, emotional and behavioural difficulties that disrupt relationships and may impair the ability of a person to play a full and active role in the community. In some cases, mental health problems result from brain diseases, while in other cases they may be reactions to bad experiences. People with severe mental health problems often need to be given drugs to treat symptoms, but these can have side-effects that make people feel unwell or drowsy. As a result, some people stop taking their prescribed medication and feel they can cope without it, which can cause the illness to recur. People with mental health problems should therefore be encouraged to continue taking any medication that has been prescribed.

An important way to help people with mental health problems is to engage them in counselling or enrol them in mental health services. However, mental health specialists may not be easily accessible to community members, since there are usually relatively few of them, and they work at higher levels of service provision. To overcome this, community members should lobby for access or referral to mental health specialists or other health staff who can provide assistance, both in treating patients and in identifying support for the individuals and families. Assistance does not necessarily mean financial aid and often includes social support and health education. To help them feel valued within the community, people with mental health problems should be encouraged to take up employment and social opportunities.

10.7.2 Learning difficulties

People with learning difficulties have limited intellectual capabilities and may seem "slow", yet there are many ways in which they can play a meaningful role in their community. However, these people will often need support from their community and will benefit from input from health care and other staff, who can help them to develop their abilities and skills.

10.7.3 Epilepsy

People with epilepsy suffer from fits that can be alarming to themselves, their families and other community members. Epilepsy can be caused by head injuries during infancy, or result from maternal infections such as meningitis or syphilis. Epilepsy is not an infectious disease and there is no risk of catching it from someone else. Epilepsy can be treated and controlled with suitable medication, and when people with epilepsy are stabilized on medication they can play a full role in the community.

10.7.4 Social inclusion

People with mental health problems, learning difficulties or epilepsy are often stigmatized by the community because of ignorance about the nature of mental illnesses. This only compounds the problem by making those suffering from the illnesses and their families feel like "outsiders", and can lead to discrimination. Community members and health workers should work to overcome stigmatization and value the sufferers as full and useful members of the community. Often, this can be accomplished through education and by providing support services for these individuals. Encouraging them to undertake activities that are useful to the community, and that make them feel part of their community, can reduce the level of stigma and increase social inclusion. Schools should also include education about mental health to encourage greater understanding of the problems and of the ways in which sufferers can be supported to enjoy a full and productive life. Addressing problems of this nature with children often helps prevent stigmatization and other social problems, which are usually fuelled by ignorance.

Community mental health

Are there people in the community suffering from mental health problems?

Are there people in the community suffering from learning difficulties?

Are there people in the community suffering from epilepsy?

Are community health workers trained to provide support to these people?

Does the community have access to mental health workers?

What is the attitude of the community towards people with mental health problems, learning difficulties or epilepsy?

Are educational materials about mental health problems, learning difficulties or epilepsy available to the community?