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Viswanatha, V. and Narayan, T. Year of Publication: 2008

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Synthesis of grey literature from select Asian countries about Comprehensive Primary Health

Care (CPHC) experiences

1. Introduction:

This paper provides a narrative synthesis of literature pertaining to Comprehensive Primary Health

Care (CPHC) experiences in select countries of Asian region. Totally 77 studies (See Annexure.No.1.)

pertaining to CPHC experiences of 12 countries (Bangladesh, India, Indonesia, Iran, Lebanon, Nepal,

Oman, Pakistan, Philippines, Sri Lanka, Thailand and Vietnam) including 2 studies pertaining to

CPHC experience of multiple countries of Asia that met the inclusion criteria of our research analytical

framework are included in the review process. Out of the allotted 14 Asian countries, the present study

does not cover experiences in 3 allotted countries (Bhutan, Malaysia and Palestine) and includes a

study on one country (Oman) which was not in the original list of allotted countries.

1. Methodology for the review process:

The studies for the review and narrative synthesis were drawn from two sources and undertaken by two

different teams:

1. Grey literature review undertaken by team at Community Health Cell (CHC) based in

Bangalore in India

2. Published and indexed literature review undertaken by the team at Flinders University and

South Australian Community Health Research Unit, Australia

2.1. Search strategy:

The CHC had agreed to undertake a review of grey literature on CPHC experiences in 14 countries1 in

the Asian region. Information was collected about health programs and projects in the 14 countries that

used or were using “Comprehensive Primary Health Care (CPHC)” approach in their work using the

following methods:

1. Review of the books, articles, academic and non-academic periodic and non-periodic

publications and unpublished materials in the library of CHC

2. An inventory of contacts of people and projects working on CPHC was prepared based on more

than 25 years of rich and long networking experiences of Dr.Ravi Narayan and Dr.Thelma

Narayan. An e-mail request was sent out to the organizations and individuals with a request for

materials from their projects for the review process. Remainder emails were sent and follow-up

telephone calls made to non-respondents thrice during the study period (June 2007 to May

2008). Leads on further contacts provided by the originally contacted people were also

followed up.

3. An e-mail request for literature on CPHC experiences was also sent out to people who had

agreed to be regional/country resource people for the project and listed in the project proposal

as researchers, research users and institutions.

1 India, Bangladesh, Bhutan, Nepal, Pakistan, Sri Lanka, Lebanon, Palestine, Iran, Philippines, Indonesia, Malaysia,

Thailand, and Vietnam


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The team based in Australia undertook the published and indexed literature review using the database

provided by the University of Ottawa (912 references).

2.2. Inclusion and exclusion of the studies in the review and narrative synthesis:

The grey literature review till date includes materials obtained from the above mentioned process, no

later than May 2008. During the Level-1 of grey literature review process, the title and abstract

(whenever available) reviews was undertaken using the research analytical framework provided by the

University of Ottawa. The final selection of the articles for full review was based on the information

obtained from the abstracts/title depending upon the set criteria. The studies/documents identified as

meeting the research inclusion criteria in Level-1 were included in the full text review process i.e.

Level-2 of the literature review process. Finally, 35 studies were included in the full text review (See

Annexure No.1.)

From the original published and indexed literature database of 915 articles, a total of 42 articles met

the set criteria of Level-1 and were included in the Level-2 of the literature review process. 11 of these

42 were commentaries and did not qualify for inclusion into narrative synthesis. (See Annexure No.2.).

In total, 77 literary pieces covering CPHC experiences of 12 countries (see Table No.1.) were reviewed

using analytical framework of the project. 66 of the reviewed 77 studies contributed to this narrative

synthesis and 11 studies that were commentaries were excluded from the narrative synthesis (See

Figure No.1).

Table.No.1. Country of studies included in the review

Country Grey Literature

Review Indexed

Literature Review Total

Studies

Bangladesh 4 2 6

India 15 11 26

Indonesia 3 4 7

Iran 4 2 6

Lebanon 1 0 1

Multi-country -- 1 1

Nepal 1 3 4

Oman 1 0 1

Pakistan 3 8 11

Philippines -- 2 2

Sri Lanka 1 0 1

Thailand 1 5 6

Vietnam 1 4 5

Total Studies 35 42 77


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GREY LITERATURE REVIEW INDEXED LITERATURE REVIEW

Level 1

Review of titles and abstract using

research analytical framework

Studies not

matching set

criteria

Studies

matching set

criteria

Level 2

Full review of the literary

papers using research

analytical framework

(n=35)

Level 1

Review of titles and abstract of

published and indexed literature

database using research analytical

framework (n=915)

Studies not

matching set

criteria (n=873)

Studies

matching set

criteria (n=42)

Level 2

Full review of the

studies using research

analytical framework

(n=42)

No further

analysis

No further

analysis

Studies

that are

commentaries

(n=11)

Studies

other than

commentaries

(n=31)

No further

analysis

NARRATIVE SYNTHESIS (n=66)

Figure No.1. Steps of literature review


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2.3. Limitations of the reviews undertaken:

Any research into the effectiveness of CPHC is a monumental process owing to the diversity of the

understanding and practice of CPHC and we are certain that we have not included all relevant and

appropriate literature on CPHC in this review process. The practice of CPHC is more common than

that is reported. Formal documentation of the effectiveness of CPHC programs is not very common

and many of the published literature are not widely available. Furthermore, many CPHC programs are

more practice oriented than research oriented, evidenced by their reporting mechanism. In addition,

many reports are published in local languages which further limit the already meagre number of

studies on CPHC initiatives available for review process. Moreover, many CPHC initiatives have been

reported as “slices” rather than “whole” posing immense challenge in integrating the various reports of

the same initiative to obtain the whole picture compromising the process of drawing lessons learnt.

Also, there are no databases containing a comprehensive documentation of CPHC publications limiting

the review process. The whole review process is further complicated by the immense complexity of the

interventions involved and the dearth of research methods to adequately conquer the complexity of

both the process and outcomes of CPHC initiatives.

Besides, grey literatures on CPHC do not exactly qualify as research studies with rigorous study design

and systematic analysis. Hence, they are more qualified to be known as reviews. Even though many of

the country studies are classified as “narrative synthesis”, they do not fit exactly into the framework of

“narrative synthesis” in the way it is defined currently. At the same time, it appears that there has been

a dearth of research studies on CPHC post 1980. In addition, it looks like most of the studies have been

undertaken in severe resource, time and trained human resource constraints leading to compromise on

study methodology. As a result of all these factors, the robustness of the evidence and therefore the

interpretation and the analysis vary. Additionally, full review of all the CPHC literature available with

CHC team was limited by time and human resource constraints.

Moreover, the indexed literature review was faced with the challenge of finding relevant articles on CPHC

within the scientific literature database, as most of the interventions reported were highly selective PHC

(SPHC) interventions. The articles that had some relevance to this research project seem to be published

mostly in the period from mid 1990s to now. We speculate that the relative absence of scientific articles

describing the whole CPHC programs seem to have been limited due to the constraint of word limit and

absence of a dedicated journal for reporting CPHC.

As a result all the drawbacks mentioned above, the literatures that have been included may possibly

provide a partial view of the available evidence. Nevertheless, we are confident that this review has

been able to capture a relatively comprehensive and robust evidence of CPHC effectiveness within the

limitations mentioned above.

However, it should also be borne in mind that there are varied forms of knowledge generation and that

grey literature chronicles real life experiences in a rich text format from which there are important

lessons to be given to the world.

It as also appears that there is lack of adequate development of research methodologies on CPHC and

lack of political will and financial resources that have hampered the full implementation of CPHC also

have affected the development of research methodologies. We dare say that the practice of CPHC has

moved far ahead compared to the research of CPHC. One of the roles of research to inform policy and

practice can therefore be questioned. This provides an opportunity to develop newer research methods


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and also closer links between practitioners, people, policy makers and researchers. This may improve

the potential synergy between research implementation that would help accelerate the achievement of

the “health for all” goal. There is a vast research gap between policy and practice of CPHC and

research into this important area. Lack of research funding and low priority by policy makers and

national research bodies may also be a reason for the limited research conducted in CPHC in the Asian

region.

Our grey literature review experience of CPHC in Asian region has some important lessons for us

namely:

It is a time consuming, labor intensive but worthwhile process to collect widely scattered and

little known but important studies and reports that are not indexed

Persistence and rich networking are of prime importance in collecting grey literature

The studies and reports in the grey literature arena often use a mix of methods and analysis

process in field conditions and hence may not follow rigorous scientific, quantitative evidence

collection methods

Many of the valuable experiences regarding CPHC, especially the experiments by

NGOs/CSOs as well as overview of country experiences, that have not still entered the indexed

literature domain or internet domain, have rich and valuable lessons to inform the practice of

CPHC in the world. Hence, grey literature review must be an integral part of any exercise in

synthesizing evidence on CPHC

There is a need to further develop and refine research methodologies to study CPHC as a

strategy to work towards “Health for All”

Grey literature offers better possibilities for reporting “whole CPHC” initiatives since it is not

constrained by the “length limit” and “evidence only” policies of peer reviewed journals. We

found that grey literature is much more comprehensive than journal articles in terms of

covering CPHC initiatives in their “wholeness” including contextual factors., full description

of the CPHC intervention including experiential narration which id often very rich and

valuable but by-passed in the peer reviewed journals

3. Brief history of CPHC in Asia:

The Asian region has a long and rich history of efforts to develop pro-people and community based

health care systems which relates to freedom struggle of Asian countries from their colonizers. There is

in a way an aspiration of Health for All as articulated in Bandung Conference in Indonesia in1936,

Sokhey Committee report (a sub-committee on Health of the planning committee of Indian National

Conference formed in anticipation of Independence from colonizing British) in India in 1939 and

Bhore Committee report in India in 1946. Furthermore, many NGO programs like Deenabandhupuram

project started in South India in 1946 were fired by similar aspirations and tried to actualize it locally.

In addition, NGO led Jamkhed Comprehensive Rural Health Project (CRHP) in the Maharashtra state

of India started in 1970 and one Indonesian project in central Java run by Dr Gunawan Nugroho were

featured in “Contact”, a bimonthly publication of the Christian Medical Council of the world council

of churches based in Geneva, in the 1970s as pioneering community health projects. The Jamkhed

CRHP was also featured in the landmark publication “Health by the People” edited by Dr Kenneth N.

Newell in 1972, which greatly influenced the 1978 Alma Ata conference and declaration.

The early articulations (e.g. Bandung Conference 1936, Bhore Committee 1946) were broad in scope

and aspirational. They linked health to development, saw the gaps in health care and saw the need for

community based care. They evolved in response to the situation with severe resource constraints


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(human, material and financial) and were based on the available knowledge and technologies at the

time.

4. Synthesis of data and analysis:

(to be provided by Ottawa ‘hub’, this then can be complemented by us)

5. Results:

The CPHC practice over the past three decades had been as diverse as its understanding and it is

difficult to capture the various facets of the same in one single paper. However, the review of the

effectiveness reports of CPHC, especially its contribution to the improvements of communities’ health,

can be analyzed broadly under two categories:

1. National and regional CPHC programs: Study of national public health systems, modeled on

CPHC principles to varying extent, undertaken by national governments covering the entire

population of the nation or large populations spread across large geographical areas within the

countries.

2. Local CPHC programs: Study of CPHC programs undertaken by NGO/CSOs covering a

defined population usually within a small, defined geographical area.

5.1. Characteristics of the included studies:

5.1.a. Study settings: Of the 66 studies, 17 studies pertain to national CPHC experiences belonging

to Bangladesh 1 , India 2;3 , Iran 4-6, Indonesia 7;8 , Lebanon 9 , Nepal 10, Oman 11 , Pakistan 12 , Sri

Lanka 13 , Thailand 14;15 and Vietnam 16;17.

8 studies reviewed CPHC programs with sub-national coverage within large countries in India 18-20,

Indonesia 21;22, Iran 23 and Pakistan 24;25.

The remaining 41 studies pertain to local initiatives taken up either by Non-Governmental

Organization (NGOs)/Civil Society Organizations (CSOs) covering smaller populations or evaluation

of Government led nationwide CPHC programs in defined geographical areas covering smaller

populations.

5.1.b. Timeline of studies: The time-period (range of the starting time of studies: 1946 to 2005) and

the time-length (range of time-length covered by studies: 50 years to 2 months) of the CPHC

experiences covered by the studies reviewed are varied.

15 of the studies have a time-line starting even before the Alma Ata declaration of 1978 (See

Table.No.2). The break up of the timeline of reviewed studies is shown in Figure.No.2.

Many programs have had a long experience of work in CPHC area and their studies cover the entire

time-length or a part of it (e.g. Deenabandhpuram project in India for 62 years with the study covering

the initial 38 years, Jamkhed Comprehensive rural Health Project in India for 38 years with the study

covering the initial 26 years, etc.) 7;26;27 and some of them are operational as on 2008.

The CHC team decided to capture the historical trend of CPHC initiatives and hence did not take a cut-

off period for excluding grey literatures for review. However, we were not able to review few


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literatures on CPHC due to time constraints and suggest that the collection of literature and analysis of

the same should continue at least until the start of the training of the selected research triads.

Table.No.2. Studies with start of timeline pre-dating Alma Ata Declaration of 1978

Sl.No. Title of the study Country Study

Period

1 We learn through our failures: The evolution of a community based

programme in Deenabandhu India 1946-1984

2 A community health programme in rural Tamil Nadu, India: the need for

gender justice for women India 1956-2006

3 Primary Health Care in Indonesia Indonesia 1960-1990

4 Bucking the trend: How Sri Lanka has achieved good health at low cost:

Challenges and policy lessons for the 21st Century Sri Lanka 1960-2000

5 Evolution of primary health care in Thailand: What policies worked? Thailand 1965-1986

6 Jamkhed: A Comprehensive Rural Health Project. India 1970-1996

7 Country report Oman: Successful National Policies in Primary Health Care Oman 1970-2006

8 An Iranian experience in primary health care, the West Azerbaijan Project Iran

August

1971-

April 1983

9 Acheiving the Millennium Development Goal on Maternal Mortality.

Gonoshasthaya Kendra's Experience in Rural Bangladesh Bangladesh 1971-2007

10 With the people...For the People Bangladesh 1972-2001

11 Mallur health cooperative and evaluation of primary health care. India 1973-1979

12 Primary Health Care System, Narrowing of Rural–Urban Gap in Health

Indicators, and Rural Poverty Reduction: The Experience of Iran Iran 1974-2000

13

A critical assessment of the health status of population after four years of

health services provided through medical college in villages of Mehrauli

block of Delhi

India 1975-1979

14 Participation- A problem in a semi-urban community health programme India 1975-1979

15 Comprehensive health project, Rangabelia India 1976-1979

1514

18

109

Before-1978 1978-1989 1990-1999 2000 and after Unknown

Starting year of studies

Nu

mb

er

of

stu

die

s


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Figure No.2. Number of studies sorted in the order of their starting year

5.1.c. Key Questions/Design/Methods of studies:

Design Indexed Lit Grey Lit Total

Case Study (Multiple) 1 0 1

Non-randomised control studies

0 1 1

Rapid evaluation 0 1 1

Cost Analysis 0 1 1

Cluster Randomised control trial

1 0 1

Cohort (Retrospective) 1 0 1

Cross-section with control 2 2

Not Specified 0 2 2

PAR/CBR 2 0 2

Narrative Synthesis 0 3 3

Case Study (Single) 2 2 4

Cross-section without control 4 2 6

National Health Policy and Program Reviews: Analysis, Temporal tracking of health indicators, Case Studies, Literature Review

0 7 7

Mixed 6 7 13

Quasi Experimental 12 9 21


Method Indexed Lit Grey Lit Total

Analytical Commentary 0 2 2

Narrative Synthesis 0 6 6

Qualitative 4 3 7

Quantitative 12 5 17

Mixed 15 19 34


The design and methods used the studies reviewed are as diverse as the studies themselves. The key

questions addressed by the reports were more implicit than explicit. Frequently, a line of enquiry into

particular theme/s of CPHC was more easily identified than a key question per se and such objectives

or aims of the study often determined the design and the methods adapted.

The key themes/objectives addressed by the studies of national and sub-national CPHC programs fell

under three broad areas and the study designs and methods incorporated by them are as follows:

5.1.c.1.a. The first type of studies (9/25 national & sub-national CPHC studies) are reviews of national

health policies and health systems and the strategies adapted by them to promote and strengthen CPHC


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in respective countries with a view for generating recommendations for future action. These studies

address heterogeneous questions; are often more descriptive; and attempt to give an overview of the

organization of PHC systems and their functioning, historic overview of national health activities, the

impact of policy decisions and socio-political-economic contexts (local, regional and global) on such

systems, the extent of congruence of field realities with policy statements, the major achievements in

the past and the future challenges faced by the systems in the respective countries. These studies often

take a theoretical perspective and adapt mixed design and methods for elaboration. (See Table.No.3).

All reviews/studies in this category were derived from grey literature review and adapted a narrative

review/synthesis approach except for two studies: one reporting the experiences of West Azerbaijan

project in Iran23 which was quasi-experimental in design and one published study in peer reviewed

journal which relied on case study approach 14. All the narrative reports and the quasi-experimental

studies adapted a mixed methodology (both quantitative and qualitative) and the lone case study was

mainly an analytical commentary constructed on the basis of secondary qualitative data.

The narrative reviews relied primarily on qualitative review of documents (review of government

documents like policies and legislative orders over a period of time, research articles, country reports,

evaluation reports, and any other documents pertaining to CPHC experiences in the respective

countries) for critical health policy analysis. For describing the health system infrastructure and

national health gains, these studies used secondary data from various sources (e.g. Sample Registration

Survey, National Census, Health departmental statistical reports, etc.). Most studies analyzed

secondary data for tracking temporal trends in national population health indicators as proxy indicators

for impact of health systems.

Only three reviews/studies commissioned primary research including focus group discussion with

multiple stakeholders; exit interviews and cross-sectional surveys with PHC users/communities and

providers; and key person interviews with multiple stakeholders (providers, policy makers, ministry

officials, NGO health workers, and academic experts) to supplement secondary data to answer some

unanswered questions 9;13;16. For instance, Kronfol’s review of CPHC in Lebanon undertook surveys to

assess the attitudes and opinions of clients of Primary Health care centers across the country, the opinions of

health care providers in those centers; focus group discussions with professionals from the various sectors

involved in the practice of CPHC in Lebanon; and interviews with officials from the NGOs, academia and other

stakeholders to assess the convergence/divergence of CPHC understanding among multiple stakeholders 9. Only

two studies captured communities’/users’ perceptions and attitude towards Primary Health Care

system/centers primarily through focus group discussions and exit interviews 9;16.

Narrative synthesis, though not in the exact way it is understood currently, appears to offer a wide

scope for reporting rich textual details regarding critical analysis of national health policies and

programs and analyzing longer term trends and contextual factors. It also seems to offers space to

integrate fragmented and widely heterogeneous studies reporting on slices of CPHC into one whole

study. However, the underdevelopment of research methods to capture the effectiveness of broad based

programs of CPHC in terms of estimating its absolute and isolated effects on population health (if ever

it is present in real life situation) appears to limit drawing conclusions on effectiveness of CPHC. In

addition, the routine health information systems in the region to track the overall and disaggregated

national health indicators appear to be inadequate or not reflected in the literature barring Iran,

Thailand and Sri Lanka. Furthermore the non-inclusion of many country reports on their health

systems (the existence of which is known) due to difficulties in accessibility suggests the need for a

database on country research studies/reports on CPHC in the region. Also, many researchers have


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explicitly mentioned about the time and resource constraints compromising the research process

validating the low priority for CPHC in general and CPHC research in particular.


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Table.No.3. Summary of key questions/objectives, design and methods of national & sub-national CPHC studies primarily adapting a national

health policy and system review approach

Sl. No.

Title of the study/report

Country Key

question/Objective of the study

Design Description of the methods

1

Country report Oman:

Successful National

Policies in Primary

Health Care

Oman

The report reviews the National

Health Policies of Oman in the

context of its health development

under the framework of Alma Ata

declaration and PHC Principles

Analytical review of health

policies and tracking of

temporal trends in national

health indicators

Mostly qualitative with the review focusing on the strengths of the

Omani National Health policies in promoting the health of the people

of Oman. The study tracks the trends in the health status of people

over a period of 36 years from 1970 to 2006 and attempts to look at

the gains in health status of the population with National health

policies in place

2

Primary Health Care

System, Narrowing of

Rural–Urban Gap in

Health Indicators, and

Rural Poverty

Reduction: The

Experience of Iran

Iran

What are the contributory factors

for the temporally, narrowing gap

in the health status indicators of

urban and rural population?

Narrative synthesis of

existing literature

Case study approach where the researchers look at the trends in health

status indictors of urban and rural population in Iran over a period of

26 years and critically analyze the possible contributors for the

observed changes

3

Primary Health Care

Policy Review -

Vietnam Profile

Vietnam

Review of national efforts towards

achieving Health for All through

national PHC Program involving

narrative, analytical and contextual

review of national health

programs, health policies and

practices.

Narrative synthesis and

Case study (single)

involving analytical review

of health policies and

tracking of temporal trends

in national health indicators

Mostly qualitative methods involving interviews of a range of

stakeholders and analysis of reports and secondary data. The review

focuses on the strengths and weaknesses of the National Health

programs, systems and field realities of health sector in promoting the

health of the people of Vietnam. The study tracks the trends in the

health status of the people of Vietnam over time from 1978 and

attempts to look at the gains in health status of the population with

National health programs in place and identifying challenges for

action

4

Primary Health Care

In Lebanon:Ten

Years Later- A

review of

developments and

Evaluation of

achievements in this

sector

Lebanon

Evaluation of the strategies that

have been followed to promote and

strengthen Primary Health Care in

Lebanon, with the view of

proposing recommendations for

future action. The evaluation

report aims at assessing the quality

of the services delivered, the

acceptable and sustainable cost,

the ease of access and the extent of

coverage of PHC.

Narrative synthesis and

Case study (single)

involving narrative,

analytical and contextual

review of the National

health programs and various

health-related policies and

practices under PHC

banner.

The methods consist of primarily of a review of materials and

documents appertaining to Primary Health Care (PHC) in the country;

discussion and meetings with various stakeholders; surveys to assess

the attitudes and opinions of clients of Primary Health care centers

across the country and the opinions of health care providers in those

centers; focus group discussions with professionals from the various

sectors involved in the practice of PHC; and interviews with officials

from the NGOs, Academia and other stakeholders.


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5

Bucking the trend:

How Sri Lanka has

achieved good health

at low cost:

Challenges and policy

lessons for the 21st

Century

Sri Lanka

Can there be a well equipped

health system established at low

cost at the country level?

Narrative Synthesis and

Case Study (Single)

Primarily qualitative involving narrative synthesis of CPHC literature

complemented with a multi level survey and assessment by different

researchers simultaneously in different levels of the public health

infrastructure and functioning.

6 Primary Health Care

in Indonesia Indonesia

An attempt to capture the

comprehensive history of

evolution of PHC in Indonesia

describing the development and

progress of community health up

to 1990

Narrative Synthesis

Primarily qualitative methods used including systematic study of

about 60 available documents on PHC in Indonesia, interviews with

several knowledgeable persons and detailed examination of the

development of PHC in Indonesia

7 The PHC experience

in Iran Iran

Planning and operationalisation of

a national health system based on

the PHC model for more efficient

service delivery and equitable

health improvements of the

population

Case Study (Single) and

narrative synthesis

Mainly qualitative with sharing of in-depth and first hand experience

of the author (who was involved in the evolution of the PHC network

in Iran from the beginning) of CPHC initiatives in Iran that is

supplemented with quantitative secondary data supporting the claims,

made in the book, about the effectiveness of PHC in Iran

8

Evolution of primary

health care in

Thailand: What

policies worked?

Thailand

Describing the successful

implementation of policies in PHC

in Thailand

Case study Primarily descriptive backed by quantitative data of nutrition and

access to basic needs like clean water, etc.

9

An Iranian experience

in primary health

care, the West

Azerbaijan Project

Iran

The project coming out of a need

to look for more effective ways to

provide holistic efficient health

services, focus was to develop a

multi-sectoral methodology that

provides alternative approaches to

health policies and development

that could be used by other

member WHO states

Situational Analysis using a

mixture of qualitative and

quantitative survey data

(field observation) and

Quasi-experimental with

control.

A mixture of quantitative (primary data and secondary data) and

qualitative methods (participant observation, unstructured interviews,

an in-depth sociological study in 4 villages) used to measure, analyze,

plan, implement and evaluate the primary health care in West

Azerbaijan

Viswanatha, V. and Narayan, T. Year of Publication:

2008

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5.1.c.1.b. A second group of studies (12/25) concentrate on analyzing one “slice” of the CPHC

based national health systems (See Table No.4).

Nine of the eleven studies explore Community Health Worker(CHW)/Community Health

Volunteer (CHV) (both of them referred to as CHW henceforth) experiences undertaken on a

mammoth scale covering entire national or sub-national population by national health systems in

India 2;3;20, Indonesia 8;22, Nepal 10, Pakistan 25, Thailand 15 and Chhattisgarh state in India 19.

Two of these studies are evaluation reports 2;19 to examine the characteristics and program and

institutional mechanisms of a national CHW system which is also compared with CHW

experiences in the voluntary sector. These studies also assess the performance of national CHW

programs in terms of performance of CHWs (coverage, range, quantity and quality of services);

processes (selection, training and support); perceptions of stakeholders (community members,

CHWs, health functionaries) about CHWs; outcomes and impact of interventions of CHW and

their work and effectiveness of administrative aspects of the programs. Four studies 3;8;10;15 are

analytical reviews of national experiences of CHW programs over a long period of time (starting

form as early as 1950s up to 1989) attempting to measure the effectiveness of the CHW

programs and drawing lessons on operation of CHW programs on a national or sub-national

scale by the governments. These studies have incorporated contextual factor analysis in their

narration and one study 8 also looks at financial costs and implications of national CHW

programs. Many of these studies also address questions of challenges of scaling up the

Community Health Worker program from a small program catering to a small population to a

state wide program and the necessary changes it calls for in the health system.

Three studies 20;22;25 from India, Indonesia and Pakistan explore the effectiveness of using

women CHWs for the promotion of family planning program in rural communities to assess the

changes in family planning uptake when it is linked to CHWs. Berman et all 21 look at the issue

of financing CPHC and attempts to obtain national and provincial estimates of the total and

average costs of some of the specific public health programmes and government per capita health

expenditure to analyze national governmental health spending pattern. One evaluation study 18

assesses the effectiveness of health empowerment training to women from rural areas with an

aim of encouraging informed health seeking behavior and better access to health care facilities.

Another study reports on the innovative appropriate technology of a community based, national

health information and management system maintained by CHWs and institutionalized under

national CPHC system in Iran 4.

Four studies 3;8;10;15 which explored national CHW programs over a long period of time for

lessons on processes and effectiveness of the programs used a narrative synthesis design, which

is inferred and not mentioned explicitly in the reports. Three of the four studies assessing CHW

performance 2;19;20, two of which are evaluation reports, were cross-section studies without

control population and one study was a cross sectional study with control population 25. While

Berman et all 21 have used cost analysis design to study CPHC costing and financing, Jandhyala 18 has used cross-sectional study without control population to evaluate a women’s health

empowerment training program. Yet another group of researchers have adapted multiple designs

of community based participatory research, cohort study without control and qualitative survey

while assessing the impact of female health volunteers on acceptance of family planning in

Indonesia 22.

Viswanatha, V. and Narayan, T. Year of Publication:

2008

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The narrative reviews relied primarily on qualitative review of documents (research articles,

program reports, evaluation reports, and any other documents pertaining to CHW programs in

the respective countries) for critical analysis of national CHW programs and used quantitative

data from secondary sources to contextualize study findings (age, gender, socio-economic status

and such others composition of population under study) and to present impact of the programs

(mostly indicators of physical health like Infant Mortality Rate- IMR, Maternal Mortality Rate-

MMR , Vaccination coverage, etc.). The studies assessing CHW performance were cross-

sectional studies and adopted mixed quantitative and qualitative methods. Qualitative methods

were the main methods for assessing the processes of the programs and included focus group

discussions with the communities, CHWs, health system functionaries; semi structured and

structured interviews; documentary analysis; case study documentation and participant

observation. Quantitative methods were the main measures for assessing the impact of the

programs; almost all studies relying on a mix of primary and secondary data sources.

Quantitative demographic indicators included age, gender, and socio-economic status which are

often intertwined with the qualitative data to incorporate and contextualize study findings.

Specific quantitative methods for measuring impact included coverage of services by CHWs;

infant mortality rate and other mortality and morbidity indicators of physical health; health

service usage indicators; percentage of target population reached; costing and cost-efficiency

analysis of services; and KAP studies of CHWs and communities.

Mixed study designs and methods are most commonly used in the studies that attempt to capture

both the processes and impacts of CPHC programs since they offer flexibility of

comprehensively capturing the contextual factors and processes of CPHC through qualitative

methods and combining them with the quantitative indicators of program outcomes and impact.

Qualitative methods of focus group discussion and interviews seem to be the preferred method

than self-administered surveys in collecting community members’ perception, sometimes even

the CHWs’ perceptions, in the region where illiteracy is still high and oral tradition and story

telling is more common. In addition, the high frequency of cross-section studies without control

group in national CPHC interventions is a necessity of the situation given the nature of

interventions where groups of people cannot be denied PHC when it is taken up by national

governments due to political and ethical reasons in the real life situations. However, it seems that

a well planned strategy of timing the research at the end of an initial phase of a national CPHC

program before it goes into an expanded phase can offer situation for cross-section study with

control population as demonstrated by Douthwaite,M et all 25. Most of the national health

programs have inbuilt midterm and end term evaluations but most often they do not as yet enter

even into grey literature. The heavy reliance on secondary quantitative data highlights the issues

of constrained resources for research in CPHC and practice oriented CPHC over research

oriented PHC. In addition, lack of explanatory modeling for the changes observed can either be

due to limitations of research methodology of CPHC or paucity of data and non-introduction of

research component into the programs right from their initiation. Furthermore, many anecdotal,

observational and personal critical reflection data find prominent place in the studies reflecting

the lack of systematic research processes and reporting of CPHC initiatives compromising the

validity of the studies. However, this may also be the only method of data collection in the

absence of research funding and research expertise justifying their inclusion in the research

process.


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Table.No.4. Summary of key questions/objectives, design and methods of national & sub-national CPHC studies of one aspect of CPHC practice

Sl. No.


Country

Key question/Objective of the study

Design Description of the methods

1

Repeat evaluation

of the community

health volunteer

scheme.

India

Evaluation of the Community Health

Volunteer (CHV) scheme introduced in India

in 1977-78 to answer following questions:1.

Perception, reaction, degree of satisfaction of

community with CHV; 2. Performance of

CHV- Range, quality and quantity; 3. Assess

Processes – Selection, Training; 4. Interaction

between and understanding of the scheme

within Health system and CHVs; 5. Assess

effectiveness of administrative aspects –

Honoraria, medicine and Kit availability,

problems of coordination

Cross-section survey

(without control

population) and case

study (multiple)

Primarily qualitative methods with quantitative data from

secondary sources used to answer the key questions with the

following types of methods: Interviews (Semi-structured) with

various stakeholders selected through stratified, random

sampling ; Analysis of quantitative secondary data available

from different sources like Primary Health Center and CHV;

and Case study

2

Community-based

health programmes

in Indonesia: the

challenge of

supporting a

national expansion

Indon

esia

Review of the characteristics of the mammoth

Community Health Worker (CHW) program

of Indonesia including its programmatic and

institutional background; benefits of the

program; its shortcomings and financing and

examining the role of the same in Indonesia’s

health system and speculating on the

challenges for building of a more efficient

system based on the current accomplishments

Narrative Synthesis

Primarily qualitative review of literature on Indonesian CHW

experience at National Level to examine the characteristics,

program and institutional mechanisms of a national CHW

system which is also compared with CHW experiences in

voluntary sector. The report also examines the effectiveness of

CHW system through indicators of coverage, maintenance of

the system, outcomes and impact of interventions of CHW,

costs, affordability and cost efficiency through narrative

synthesis of available studies on the above indicators

3 Community health

workers in Nepal. Nepal

Description of the evolution of CHW program

in Nepal; examination of the successes and

failures of the existing and past CHW

Programs; Problems encountered and tackling

approaches used and examination of the ways

in which the international health policies and

donor priorities have shaped the development

of the CHW Programs

Commentary and

analysis on contextual

factors pertaining to

development of health

system in Nepal and

review-synthesis of

selected literature (the

exact study

methodology is not

specified)

Narrative review of documented experiences on Nepalese

CHW experience at national level to examine the

characteristics, program and institutional mechanisms of a

national CHW system. The report attempts to draw out lessons

from past national experiences and their influence on the latest

national level CHW system (1978) and initial review of the

latest CHW system to examine the strengths and challenges of

the same.


- 16 -

4

Community health

work: India's

experience.

India

A Reflective analytical review on the

Government steps taken to universalize access

to PHC through a large cadre of Community

Health Workers (CHW)

An experiential

reflection on the

CHW program of

India which examines

the National Rural

Health Scheme, PHC

concept and practice

in India in the existent

realities of political

and social context

Narrative review of policy documents, formal and informal

evaluation of CHV scheme and other reports reviewing the

health system of India and critical reflection on the processes

of implementation and impacts of CHW scheme under

National Rural Health Scheme. The author does an

experiential reflection on the same, and examines the NRHS,

PHC concept and practice in India in the existent realities of

political and social context

5

Revisiting

Community-based

Health Workers

and Community

Health Volunteers

Thail

and

The paper examines the benefits of

community based health-workers and

volunteers in a thorough overview of the

evolution of community-based actions and

health workers in Thailand

Narrative synthesis

Narrative review of available literature and compilation of

data on CHW service utilization and data on infant and child

mortality, nutritional status and major vaccine preventable

diseases in areas covered by CHWs

6

The costs of public

primary health care

services in rural

Indonesia

Indon

esia

The study was designed to provide a large

enough sample of cost data on Indonesia’s

rural health services to obtain national and

regional estimates of the total per capita, and

unit costs of the major public health

programmes.

Cost Analysis

Cost Analysis was performed on the expenditures at 168

facilities in 41 health centers located in 41 sub-districts across

5 provinces chosen to represent various physical landscapes

and distances from major health centers. The costs

represented the expected expenditure on rural health services

in a month.

7

Increasing

contraceptive in

rural Pakistan: An

evaluation of the

Lady Health

Worker

Programme

Pakist

an

Assessing the impact of the Lady Health

Worker Program on the uptake of modern

contraceptive methods

Cross-section survey

(with control

population)

Primary quantitative data collection and analysis

8

The India Local

Initiatives

Program: a model

for expanding

reproductive and

child health

services

India

Measuring effectiveness of the India Local

initiative program (LIP) that adapted a model

used in Indonesia and Bangladesh to expand

reproductive and child health (RCH) services

to people living within 4 northern Indian states

through the efforts of 3 Indian NGOs with

significant community involvement and

partnership with Government agencies

Cross Sectional

(without control),

Case study

(comparative)

Mixed qualitative and quantitative

9

Village Family

Planning

Volunteers in

Indonesia: Their

role in the family

Indon

esia

Impact of female volunteers in villages in

Indonesia on family planning

Community based

research; Cohort

study, no control;

qualitative survey

Mixed qualitative and quantitative


- 17 -

planning program

10

Women's Health

Training

Programme: As

Assessment of the

Programme in

Karnataka

India

Evaluation of the Women’s health training

program undertaken the state of Karnataka

which was designed to empower rural, poor

women to address the broader issues of health

and to encourage informed health seeking

behavior and better access to health care

facilities

Cross-section without

control group Qualitative (Interview with multiple stakeholders)

11

An external

evaluative study of

the State Health

Resource Centre

(SHRC) and the

Mitanin

Programme- A

state wide health

sector reform

initiative and

community health

worker programme

in Chhattisgarh

State, India

India

What are the challenges of the challenges of

successfully scaling up the Community Health

Worker program from a small program

catering to a small population to a state wide

program and the necessary changes it calls for

in the health system?

Rapid evaluation

study [Cross-sectional

(without control)]

Qualitative (Review of documents, interview and focus group

discussions with multiple stakeholders including community

people)

12

An innovative

method for

longitudinal data

collection on

demographic

characteristics and

health status of

rural population

developed by

Iranian Primary

Health Care system

Iran

To describe the management information

system (MIS) developed by the PHC network

of Iran and to describe the type of longitudinal

information collected by it, with a focus on the

culturally appropriate and technically

innovative tool called “Vital Horoscope”

Quasi-experimental

Quantitative methods were used to analyze the longitudinal

data on population health status by Behvarz (CHW) of Iranian

PHC network to assess the trends in various health status

indicators in Iranian population, especially the rural

population


- 18 -

5.1.c.1.c. A third group of studies (4/25) explore the effects of reforms in national health systems

measured in terms of temporal change in health system performance and analyzing critically the short

term and long term effects of such health system reforms . Two studies examined the changing

paradigms and investment patterns in health sector reform and the question of what role the public

health system can meaningfully play, and how best to revitalize them 17;24 through critical analysis of

health sector reform efforts in Vietnam and Pakistan. While one study takes a critical look at targeting

approach of health services within national health system in Bangladesh to explore the question of

whether broad based targeting approach is sufficient to ensure effective services for the poor 1, another

study is a critical examination of the latest health sector reform efforts in Pakistan with the purpose of

informing and influencing public health policy as the country moves towards devolution 12.

All the four studies were published articles in peer reviewed journals and have case study (single)

design constructing arguments and analysis based on secondary qualitative and quantitative data. Life

expectancy, mortality rates, fertility rates, illiteracy, and financial investment on health sector reforms

make up the secondary quantitative measures while service utilization and satisfaction collected from

the community members surveys using exit interviews and project outputs and strength of PHC

components collected using local, facility based, health worker and household constitute the primary

quantitative measures. Document review, review of project reports and minutes of meetings, semi

structured and open ended key-person interviews and community focus group discussions were the

main qualitative methods used in the studies.

The ideological underpinning of health sector reform led by World Bank influence on national

health policies following the 1993 World Development Report

The monetisation of health & the use of DALYs for priority setting challenging the ethical

foundations of CPHC which was built on social justice and rights

Comprehensiveness of CPHC


- 19 -

Table.No.5. Summary of key questions/objectives, design and methods of national and sub-national CPHC studies analyzing experiences of one

aspect of CPHC practice

Sl.No.


Country Key question/Objective of the

study Design Description of the methods

1

Good governance

and sustainability:

A case study from

Pakistan

Pakistan Analysis of “family health project”

funded by World Bank in Pakistan Case Study Qualitative analysis of secondary data

2

Do essential

service packages

benefit the poor?

Preliminary

evidence from

Bangladesh

Bangladesh

An evaluation of the implementation of

“essential services package” program in

Bangladesh

Case study

Quantitative analysis of life expectancy, mortality, fertility

rates, illiteracy, spending on Essential Service Packages,

service utilization and efficiency

3

Legacies of

primary health care

in an age of health

sector reform:

Vietnam's

commune clinics in

transition

Vietnam

An evaluation of the “National Health

Support Project” approach to revitalize

local infrastructure of Primary Health

Care in a country undergoing economic

transition

Case Study

Mixed quantitative/qualitative research Vietnam National

Health Survey 2001-2002 as base and included local, facility

based, health worker and household surveys. The resulting

database allowed assessment of several indicators to measure

the change in the following indicators: project outputs,

strength of PHC components, Clinic coverage and quality

indicators eg availability, utilization; compared characteristics

of project and matching communities used in quantitative

analysis of health survey. Data collection was through

fieldwork in 4 provinces selected for regional

representativeness using semi structured and open ended

interviews with provincial and district health officers, clinic

personnel and focus group discussions with users and non-

users of clinic services in community

4

Health sector

reform in Pakistan:

future directions

Pakistan A case study of critical analysis on health

sector reform in Pakistan Case Study

Critical analysis of secondary data from special studies and

annual reports from international agencies eg World Health

Organization, Asian Development Bank, World Bank, UN

Children’s Fund, and UN Development Program and

scholarly articles on health sector reform from other countries

and national government and research reports.


- 20 -

The NGO led local CPHC programs appear to be more experimental in nature compared to the national

and sub-national studies. However, similar to national and sub-national studies, the study design and

methods seem to be closely linked to the themes/objectives addressed by the studies; based on which

we can group the studies into three broad categories.

1. Studies that examine the evolution of the understanding of the concept, principles and

implementation of CPHC in communities

2. Studies that investigate or report on the effectiveness of one particular aspect of CPHC

practice, either a principle or an operational factor

3. Miscellaneous group of studies

5.1.c.2.a. The first group of local CPHC studies (6/41) are derived from the grey literature and

examine in detail both the theoretical principles and the operational aspects of CPHC in their local

context 26-31.

Aroles in their book Jamkhed: A comprehensive rural health project distill their experiences of over

three decades of work in building up a very successful community based health program, which

contributed substantially towards the evolution of Alma Ata Declaration’s “Primary Health Care”

vision, in an impoverished community in India and examine critically the philosophy, the principles,

the operational aspects and the effectiveness of CPHC 27. Another study, that predates Alma Ata

conference by almost three decades, explores and traces the evolution of a Community Based Health

Program from an initial hospital based curative work in the Deenabandhupuram area in South India

over a period of almost four decades with a focus on the evolution of ever volatile topics of concept,

process and outcomes of their work and placing them in the local historical and situational context to

understand the varied contours of CPHC 26. While two studies examine the effectiveness and outcomes

of processes and operational mechanisms of a community based, comprehensive approach to improve

community health 29;30, another study examines the appropriateness and effectiveness of PHC

approach, as envisioned in the Alma Ata declaration, as an entry point to work with the people at a

community level for integrated action on health, education, social and economic fronts with the end

goal of developing a just society 31. The last in this group is an evaluation study that attempts to

analyze the effectiveness and sustainability (including costs) of PHC programs initiated by Aga Khan

Health Services (AKHS) in 6 different sites spread across three countries in the Indian subcontinent

(India, Pakistan and Bangladesh) covering different populations (rural, urban and tribal) to draw

lessons on implementation, that also does a comparative analysis of the programs for drawing lessons

on the effects of historical and local contextual factors and of different approaches of operation of

CPHC programs on the effectiveness of programs 28.

Five of the six studies had quasi-experimental design mixed with case study (single) design 26-30 and

two among them also had experiential reflection 26;27 in addition. Furthermore, three of them had

characteristics of Community Based Participatory Research (CBPR) incorporated in their design 26;27;29. The other study adapted a narrative review approach for capturing the effectiveness of PHC

approach towards just social development 31.

As with the study designs, all the studies adopted mix and match study methods and used both

qualitative and quantitative methods. Processes and outcomes of various components of the CPHC

project including health outcomes of individuals, health status of populations, and empowerment

indicators of individuals and communities and best practices in PHC were the main measures used to

present the effectiveness of CPHC programs.


- 21 -

All the studies analyzed the impact of CPHC initiatives in terms of improvements in health of the

people in the project area i.e. defined geographical area, both individual and population as units of

study. For quantitative data, all studies relied on a mix of primary and secondary data sources. Two of

the six studies27;28 had concurrent data collection systems and used the prospectively collected data for

effectiveness analysis and one among them featured community led data collection 27 which were

supplemented by cross section surveys to fill in the missing data as and when required. Improvements

in physical health were measured using conventional health indictors like Infant Mortality Rate (IMR),

Maternal Mortality Rate (MMR), proportion of children vaccinated, proportion of malnourished

children and such others. Two studies26;27 have attempted to measure the health of the community

under three dimensions of physical, mental and social wellbeing, especially of people from vulnerable

communities like women, people from lower castes, landless laborers and such others, by using socio-

economic empowerment indicators collected through socio-economic survey designed by the local

project staff in consultation with the community (See Box No.1 for an example of the same).

The main qualitative methods used included key person interviews using structured and semi-

structured interview guides with various stakeholders, participant observation and focus group

discussions. The diaries of CHWs and meeting minutes were also used as sources of qualitative data.

The lone narrative synthesis study primarily relied on documentary analytical perusal and on

secondary qualitative and quantitative data to capture effectiveness of CPHC 31. As mentioned earlier,

an experiential, critical-reflection narrative of program leaders and staff members was also used to

study the processes of two of these CPHC studies. Two of the studies have attempted costing of CPHC 27;28 and one among them attempted to link it with the question of sustainability by disaggregating

sources of finances into donor contribution and community contribution and matching them with

capital and recurrent expenditure of the program 28.

Box.No.1. Example of measuring social empowerment of women in Jamkhed CRHP

Criteria for women’s status:

1. Are women allowed to speak to leaders?

2. Are women allowed to come to public places?

3. Do women participate in village affairs?

4. Do women participate in literacy classes?

5. Do women participate in decision making in the family?

Each positive score is given 2 points and total possible score is 10. This is then compared

over a period of time in project villages classified into three categories of villages

depending upon the number of years of CRHP activity in a village (A: Above 5 years of

CRHP activity; B: 2-5 years and C: 1-2 years) to measure temporal progress.


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Box.No.2. An example of study design and methods for measuring CPHC initiative used by Reynolds J et all in their

study titled “Lessons Learned from Primary Health Care Programmes funded by The Aga Khan Foundation”

A mixture of various quantitative and qualitative methods was used for evaluating the PHC

experiences.

The analysis was guided by a framework that identified key quantitative and qualitative issues and

variables of interest, broken down into a hierarchy of program components.

Data from secondary sources (Data on 41 standardized indicators for monitoring and evaluating PHC

programs introduced by Aga Khan Foundation like IMR, MMR, Immunization coverage, etc. and

collected by the program staff during their routine monitoring activities) were mainly used. Primary

data collection was undertaken, after the secondary data was compiled (in the first 12-18 months of the

evaluation), only to collect remaining information that could not be obtained from secondary data

sources. This allowed adequate time for the programs to have as much time as possible to implement

their programs. Interviews with program staff, beneficiaries and other developmental agencies working

in the area provided the qualitative data for the analysis.

The data was collected and analyzed along two dimensions: planned and actual performance. The data

was analyzed on two themes- effectiveness and sustainability (including costs) - and nine sub-topics:

immunization; maternal care and family planning; diarrhoeal disease control and Oral rehydration

therapy (ORT), water, hygiene and sanitation; treatment of common diseases; community health

workers; information systems; community participation and community-based developmental

activities.

The pre-program indicator levels were compared with multiple, annual post-program indicator level to

measure the effectiveness. In addition, comparisons were made within as well as between and among

programs examining (1) similarities, (2) differences, (3) explanations and (4) implications.

Preliminary background reports were prepared on each of the 11 principal topics and these were

reviewed and discussed at a 3-day workshop with PHC program managers and Aga Khan Health

Service’s officials following which final report was prepared incorporating their suggestions.


- 23 -

Table.No.6. Summary of key questions/objectives, design and methods of local CPHC studies examining the evolution of understanding of the

concept, principles and implementation of CPHC in communities

Sl.No. Title of the

study/report Key question/Objective of the study Design

Description of the

methods

1

Jamkhed: A

Comprehensive Rural

Health Project.

How to evolve a model of a community based health program responsive to people’s

needs and aspirations towards empowering people for overall development of the

community and improving the health of the people?

Quasi-experimental, Case

study and Critical

reflection of processes

Mixed

2

We learn through our

failures: The evolution

of a community based

programme in

Deenabandhupuram

Explore and trace the development of the Community Based Health Program in the

Deenabandhupuram area with focus on the development of concept, process and

outcomes to understand the meaning of PHC


study and Critical

reflection of processes

Mixed

3 Comprehensive health

project, Rangabelia

How to evolve a health care program with emphasis on prevention of diseases and

health education in conformity to regional specific characteristics?

Case study (single) with

characteristics of

Community Based

Participatory Research

(CBPR)

Mixed

4 With the people...For

the People

To use primary health care as an entry point to work with the people, at a community

level, to provide education, health services, economic empowerment, social

awareness and disaster relief services with the end goal of developing a just society.

Narrative Synthesis

5 Vivekananda Girijana

Kalyana Kendra

Explore and trace the development of the Community Based Health Program in the

tribal area of Karnataka state of India, with focus on the development of concept,

process and outcomes of the program

Case Study (Single)

mixed with quasi-

experimental approach

Qualitative study

supplemented

with secondary

quantitative data

6

Lessons Learned from

Primary Health Care

Programmes funded

by The Aga Khan

Foundation

To analyze the effectiveness and sustainability (including costs) of PHC programs

initiated by Aga Khan Health Services (AKHS) to draw lessons on implementation

and compare programs at different sites. The specific objectives of the study are as

follows: 1. Conduct comparisons within and among programs on quantitative indices

and qualitative descriptions of the most significant and relevant variables and issues,

including all the availability, accessibility, and utilization of various PHC services;

changes in health status of the target population; the unit cost of services; and if

possible, cost effectiveness of the program; 2. Draw conclusions and make

recommendations on more effective and cost effective PHC strategies, mix of

services, mix of personnel, technologies, and operational and managerial methods; 3.

Recommend the most useful data items, definitions, classifications, analytic

procedures and indicators for monitoring and evaluating program effectiveness,

efficiency, equity and sustainability 4. To prepare a formal report on the comparative

analysis, generic lessons learned, anecdotal and other “special” lessons learned


study Mixed


- 24 -

5.1.c.2.b. The second group of local CPHC studies (25/41) concentrate on the study of one particular

aspect of CPHC practice, either a principle or an operational factor, and are mostly published in peer

reviewed journals (19 of the 25 studies) (See Table No.7.). These studies are more focused and lack the

rich textual descriptions on the interventions undertaken in the respective programs. In addition, the

contextualization of the programs is also given little, and in some cases, no importance compromising

the key lessons that can be drawn from them.

Table.No.8. CPHC aspect examined by the local CPHC studies concentrating on the study of one particular

aspect of CPHC practice, either a principle or an operational factor

CPHC Aspect No. of

studies

CPHC Principle

Community Participation 3

Health promotion and health education 1

Community Health Worker 2

Financing CPHC and sustainability 1

Community Based Rehabilitation 1

Essential Drug practice 1

CPHC Approach to a health condition

Women's health (including reproductive health) 2

Maternal & Child health 9

HIV/AIDS 2

Communicable diseases 1

Non-communicable diseases 1

Mental Health 1

Total number of studies 25

The CPHC aspects dealt by the studies are very diverse (See table no.8). The studies examining the

principles of CPHC attempt to assess the effectiveness of the field translation of the principle and in

the course attempt to identify the theoretical contours of the principles and challenges in their field

translation and identifying good practices 32-36; and a few of them attempt to describe the evolution of

novel approaches of operationalisation of CPHC principle and report on successes and challenges

faced during such a process 37-40. The most frequently employed study design are cross section design

(4/9) of which one was with control group and three without control group; and case study (3/9), of

which one was a comparative case study combined with cross section study design. The other studies

have used community based research (1/9) and retrospective cohort (1/9) as study designs. Cross

section and cohort designs are used by studies concentrating on measuring effectiveness while case

study design is preferred by studies describing evolution of novel approaches to operationalize

principles of CPHC and it seems to give more space for a narrative description of the processes and for

reporting effectiveness not just quantitatively but also qualitatively and thus identifying good practices

regarding and lessons learnt on implementation. Mixed methods (6/9) were used more frequently by

studies investigating both the processes and outcomes whereas quantitative methods (3/9) were used

by studies reporting on outcomes only.

The other set of studies in this group (16/25) assess the effectiveness of interventions based on the

CPHC approach/principles to health conditions of a particular group (women and children) (11/16) or


- 25 -

to a particular health condition (5/16) and are primarily derived from publications in peer reviewed

journals (12/16). The studies reporting on interventions with a CPHC approach to reduce the maternal

and child mortality and improve their health conditions in defined geographical areas are mostly

studies assessing the effectiveness of targeted interventions in strengthening health care access to this

particular vulnerable group through various community based activities which include training of

CHWs for providing home based or community based comprehensive health care or/and linking them

with the formal health system for referral services and support 41-44 ; developing comprehensive,

integrated maternal and child health care systems within public health systems and social marketing of

the same 45;46; and interventions mainly involving health education (some of them based on behavioral

change communication) to increase community awareness on safe practices on maternal and child

health, mobilization of the target group (pregnant women and mothers) and increasing the use of

available antenatal, postnatal and neonatal care services within the health system 47-49. Two other

studies focusing on women’s health report on the process of women empowerment approach that

enables women to review their health and environmental situation that considers health in its socio-

environmental context and does not focus only on the biomedical dimension 50;51. The studies focusing

on a particular disease report on effectiveness of an integrated, comprehensive, community based

approach to control of adverse outcomes from particular diseases. Two studies focus on CPHC

approach for HIV prevention programs, one comparing a narrow approach by a Government led

initiative to that of an ecological approach taken up by a NGO-led program 52 and another focuses on

the evolution, success and sustainability of a community based comprehensive intervention for a

targeted and stigmatized group of commercial sex workers in India 53. One study looks at effectiveness

of community based intervention for prevention and control of dengue hemorrhagic fever 54 while two

other studies are novel interventions looking at CPHC approach for health conditions not previously

integrated in the Alma Ata declaration. One study investigates the effectiveness of CPHC approach for

control of non-communicable diseases 55 in Iran, while the other study looks at effective ways of

integrating mental health program with the existing PHC system 56 in Pakistan. The studies are more

experimental in nature and as such have used controlled, experimental study design more frequently

than other groups of studies. They have mainly employed quasi-experimental with either randomized

or non-randomized controlled study designs (5/16); case study designs (5/16) of which one is a

comparative case study; mixed study designs mainly quasi-experimental mixed with other study

designs like case study, cohort study and others (3/16); cross section study with control population

(2/16) and one study has used participatory action research design. The main measures employed by

these studies to assess effectiveness have been temporal changes in health indicators of mothers and

children (usually Infant Mortality Rate (IMR), Neonatal Mortality Rate (NMR), Maternal Mortality

Rate (MMR), % of mothers availing antenatal care, % of women undergoing safe deliveries, and such

others); KAP changes of communities and individuals with regards to health practices and healthy life

style (for example pre- and post-intervention fat consumption, tobacco usage, physical activities

disaggregated on age and gender parameters in intervention and control population in non-

communicable disease control program through CPHC approach); comparison of two approaches to

same health problem in the same area with their outcomes on health equity, risk reduction, and

empowerment indictors for identifying good practices; and temporal changes in health status and KAP

of individuals and communities with reference to one single disease condition. Mixed methods (7/16)

were used most frequently by these studies especially those reporting both on the outcomes and

processes; quantitative methods (6/16) were used by experimental studies especially those employing

quasi-experimental randomized or non-randomized control trials; and qualitative methods by studies

focusing on reporting of processes and identifying good practices (3/16).


- 26 -

Table No.9. Frequency of different study designs used by the local CPHC studies concentrating on the study of

one particular aspect of CPHC practice, either a principle or an operational factor

Design No. of studies

Quasi Experimental 5

Case Study (Single) 6

Case Study (Multiple) 1

Cross-section without control 3

Cross-section with control 3

Mixed 4

Participatory Action

Research/Community Based Research 2

Cohort (Retrospective) 1

Total Number of Studies 25


- 27 -

Table.No.7. Summary of key questions/objectives, design and methods of local CPHC studies examining effectiveness of one particular aspect of CPHC

practice, either a principle or an operational factor

Sl.No. Title of the study/report Key question/Objective of the study Design Methods

Community Participation

1 Participation- A problem in a semi-urban

community health programme

Can there be an intensive implementation of health objectives while

motivating people to assume responsibility for their own problems with

laying foundation for a continued development and self reliance?

Cross-sectional without

control Mixed

2

Primary health care, community

participation and community-financing:

Experiences of two middle hill villages in

Nepal

Impact of community financing on community participation in PHC in

two villages in Nepal

Community based

research Mixed

3 A tool to stimulate community

participation

Describing a tool for community participation to improve health in

Indonesian communities

Case study (non-

research based) Mixed

Health Promotion and Health Education

4

A description of the development of a

health education programme in rural

Pakistan

Describing the evolution of a health education program in rural Pakistan Case Study Quantitative

Community Health Worker

5

Effectiveness of depot-holders introduced

in urban areas: Evidence from a pilot in

Bangladesh

Effectiveness of Depot Holders introduced in urban areas of Bangladesh Cross sectional with

control Mixed

6 Village health workers in Java, Indonesia:

coverage and equity

An evaluation of the equity and role in service provision of VHWs in

Java

Cross sectional without

control Quantitative


- 28 -

Financing CPHC and sustainability

7 Mallur health cooperative and evaluation

of primary health care.

Is it possible to organize a self-sustaining, primary health care system at

the village level by levying a health cess on an economic activity like

dairying integrated with activities directed at helping developmental

activities in the village and using the project linked to a community

oriented medical college as a training centre for interns, doctors, nurses

and para-medical staff?

Cross-sectional without

control group Mixed

Community Based Rehabilitation (CBR)

8

Community-based rehabilitation -

Outcome for the disabled in the

Philippines and Zimbabwe

Evaluate the achievements of a CBR programme initiated for individuals Retrospective cohort Quantitative

Appropriate Drug Use

9

Enhancing appropriate drug use: The

contribution of herbal medicine

promotion. A case study in rural Thailand

An exploratory study of two approaches to encourage the use of herbal

medicine as a safe and cheap alternative to pharmaceuticals

Cross sectional

comparative case study Mixed

Women's Health

10

A community health programme in rural

Tamil Nadu, India: the need for gender

justice for women

The article describes the efforts of the Community Health &

Development Program (CHAD) of Christian Medical College to address

the issues of gender discrimination and improve the status of women in

the Kanyambadi block, Vellore, Tamilnadu, India

Case Study Mixed

11

Working with women's groups to promote

health in the community using the Health

Analysis and Action Cycle within Nepal

Outcomes of a PAR health projects with Nepalese women Participatory Action

Research Qualitative

Mother and Child Health

12

Achieving the Millennium Development

Goal on Maternal Mortality.

Gonoshasthaya Kendra's Experience in

Rural Bangladesh

How GK has made significant progress towards achieving some of the

Millennium Development Goals (MDGs) over the pass three and a half

decades, specifically related to maternal and child health using

community based health care?

Cross-sectional,

Retrospective cohort

and case studies

Mixed


- 29 -

13

An intervention involving traditional birth

attendants and perinatal and maternal

mortality in Pakistan

Impact on maternal and perinatal mortality rates in a rural community in

Pakistan of training local birth attendants and coordinating with Lady

Health Worker programs

Quasi-Experimental,

cluster-randomized

controlled trial

Quantitative

14

An integrated village maternity service to

improve referral patterns in a rural area in

West-Java

A longitudinal intervention study to develop and improve a

comprehensive maternal health program

Quasi-experimental,

longitudinal controlled

trial

Quantitative

15 A Case Study of Replication of Home

Based New born Care

The key question was aimed at testing out the replicability of the home-

based neonatal care (HBNC) strategy developed by SEARCH at

Gadchiroli for the reduction of neonatal mortality in varied settings

which included urban slums, tribal and non-tribal areas

Case study (single)

Qualitative study

supplemented with

secondary

quantitative data

16

Saving new born lives in Rural

communities: Learning from the BRAC

Experience

To develop an approach to improve neonatal health status in rural

Bangladesh in the areas where BRAC or other NGOs had running

nutrition supplementation program using Behavioral Change

Communication

Quasi-experimental,

longitudinal prospective

study design with

control population

Quantitative

17 Impact of a community-based program on

early childhood development...

A controlled trial to determine the impact of an integrated community

based program in rural villages on early childhood development

Cross sectional (with

control) Mixed

18

Effect of community-based promotion of

exclusive breastfeeding on diarrhoeal

illness and growth: a cluster randomized

controlled trial

Exclusive breast feeding is recommended until age 6 months. The study

assessed the feasibility, effectiveness and safety of an educational

intervention to promote exclusive breast feeding for 6 months

Cluster Randomized

control trial Quantitative

19

Home-Based Neonatal Care: Summary

and Applications of the Field Trial in

Rural Gadchiroli, India (1993 to 2003)

The four hypotheses tested from this program are as follows:1. It is

feasible to develop an HBNC intervention package that will cover 75%

of neonates in the intervention area, and 60% of neonates with sepsis; 2.

The NMR will decrease by 25% and sepsis-specific NMR by 40% in

three years; 3. Neonatal morbidities showing strong seasonal variation

indicate inadequate protection. With the HBNC, the seasonal increase

will disappear and the incidence of morbidities will substantially

decrease; 4. Even if the incidence of LBW and preterm birth cannot be

reduced, the HBNC will increase the survival of the LBW and preterm

neonates by preventing or managing the co-morbidities.

Non-randomized

controlled

interventional study

Mixed


- 30 -

20 Women's health groups to improve

perinatal care in rural Nepal Impact on birth outcomes of participatory women's groups in Nepal

Case study (Description

and analysis of process) Qualitative

HIV/AIDS

21

An ecological framing of HIV preventive

intervention: a case study of non-

government organizational work in the

developing world

A comparison of 2 types of approaches to HIV prevention (ecological

approach addressing the root causes by Disha Foundation vs Targeted

approach by Government of India through the National AIDS Control

Organization)

Case Study

(comparative)

Qualitative

(Broadly

Ethnographic,

comparative case

study with no data)

22 The Sonagachi Project: a sustainable

community intervention program

Explains the Sonagachi project which is a community level HIV

prevention program and its growth and sustainability since it was started

in 1991

Case Study Mixed

Communicable Disease

23

Community-based approach for

prevention and control of dengue

hemorrhagic fever in Kanchanaburi

Province, Thailand

An action research approach to assessing the effectiveness of a

community based dengue fever prevention and control program

Experimental with

control, action research

methodology

Quantitative

Non-Communicable Disease

24

Isfahan healthy heart program: Evaluation

of comprehensive, community-based

interventions for non-communicable

disease prevention

A quasi-experimental study of the effectiveness of an integrated,

comprehensive approach to non-communicable diseases

Quasi-experimental,

Combined cross

sectional and cohort

design

Mixed (Only

quantitative data

reported in the

paper)

Mental Health

25 Mental health: the missing link in primary

care?

Measuring the effects on the uptake of services offered in PHC of

demonstration community mental health project in Pakistan

Cross sectional with

control Quantitative


- 31 -


- 32 -

5.1.c.2.b. The third group of four studies within the local CPHC studies is a miscellaneous group of

studies. One study describes a PHC nursing curriculum conducted in an island in the south of the

Philippines and examines the experience of nurses working as faculty and simultaneously providing

service to the local community to explore relationships between the educational and clinical issues

inherent in the unique model of CPHC practice in local communities 57 and employs an ethnographic

study method for qualitative data collection and analysis. Another study looks at gains made in a

tertiary children’s hospital upon integration of PHC principles of priority setting, appropriate

technology, referral system support, decentralization of decision making and community participation

into the day to day operation of the child health services and compares pre- and post-intervention

admission rate; mortality rate due to different diseases; quality of services and use of resources for

drawing conclusions on the effectiveness of the approach 58 primarily using quantitative measures.

Two other studies report on targeted approach for leprosy case detection using school children in the

leprosy eradication activities in India and have adapted a cross-section design without control group

for studying the effectiveness of the intervention 59;60. Another study looks at temporal changes in

population health following the provision of medical care services alone at the most peripheral level 61

and advocating for limitations of provisions of medical care alone in the population health

improvement.


- 33 -

Table.No.10. Summary of key questions/objectives, design and methods of miscellaneous group of local CPHC studies

Sl.No. Title of the study/report Key question/Objective of the study Design Methods

1 Role of target groups in integrated

leprosy programmes

Involving and using school children in Leprosy work for new case-

detection, effective monitoring, completion of MDT and coverage of

large number of individuals

Cross Sectional

(without control) Mixed

2 Leprosy case detection using

schoolchildren Can school children help in the detection of Leprosy?

Cross-Sectional

(without control) Quantitative

3

Integration of primary health care

concepts in a children's hospital with

limited resources

A review of the impact of adopting a PHC approach to a managed health

program in a Children’s Hospital Case study

Quantitative

(Analysis of

admission, cost,

mortality and

equipment data)

4

A primary health care curriculum in

action: the lived experience of primary

health care nurses in a school of

nursing in the Philippines: a

phenomenological study

Understanding the experiences of PHC nurses working as faculty within

a PHC nursing curriculum and simultaneously providing service to the

local community

Case study

Qualitative

phenomenological

research

5

A critical assessment of the health

status of population after four years of

health services provided through

medical college in villages of Mehrauli

block of Delhi

To provide medical care services at the village level and explore the

change in health status associated with such medical service provision

alone at the most peripheral level

Quasi-experimental

Quantitative


- 34 -

6. Results:

6.1. Understanding/definition of CPHC:

Analysis of the understanding of CPHC in the reviewed studies reveals a great diversity in the way it is

understood and/or defined. The understanding in most studies was not explicit and had to be inferred.

The studies from pre-Alma Ata period had an implicit understanding of CPHC and many studies from

the post-Alma Ata period explicitly mention the CPHC definition of Alma Ata declaration as their

guiding light, but with varying stress on different principles enunciated in the declaration.

Significantly, the review of the actions and processes of the post-Alma Ata programs have found a

varied understanding of CPHC despite their stated subscription Alma Ata declaration. These may be

context specific as well as related to the differing socio-political processes in the countries.

However, the understanding of the concept of CPHC can be broadly studied under the following

headings:

6.1.a. The national and sub-national CPHC programs undertaken by the national governments:

The national CPHC studies attempting a comprehensive review of national health policies and health

systems and studies attempting to capture a “slice” of the national health system are found more often

to deal with the country’s understanding of CPHC than those attempting to analyze sector reform

efforts of national health systems. None of these studies define CPHC but many of them (n=10) refer

to the Alma Ata declaration as a framework for CPHC understanding of their respective country’s

CPHC understanding.

CPHC is envisioned by these studies both as a philosophy and as an approach; first as a philosophy

with certain principles to guide national health policy formulation and health system development; and

secondly as an approach to national health system operation which, more often than not, is

conceptualized as a level of care with package of services through a defined set of activities and

programs at the most periphery of the health system. There is no clear distinction of when CPHC

ceases to be a philosophy and starts to be seen as an approach and vice versa, but the Alma Ata

declaration appears to provide a framework for both the understandings to complement each other and

strengthening each other in the process. However, the lack of clear focus on achieving “health for All”

or equity in health in terms of strategy building, implementation and evaluation of impact on health

indicators is fairly --------

Some common themes emerging out of CPHC as a philosophy/guiding principle for national health

policy formulation and health system development, at least in theory on the various documents, are as

follows:

o Structuring of health system based on certain principles like community involvement,

intersectoral coordination, social and cultural acceptability, low-cost and good quality services,

comprehensive services, economically accessible and sustainable health system

o State sponsored “universal” health care with an “equity” focus to cater to marginalized

communities like rural and tribal people; women and children; and poor people more

preferentially

o CPHC involves community based actions towards improving the health of population through

outreach activities beyond the walls of static health facilities


- 35 -

o Few country reports imply CPHC as the corner stone of social and economic development 6;7;9

The use of CPHC as an approach of operation of national health systems has many common threads as

follows:

o State sponsored “universal” health care provision encompassing preventive, promotive,

curative and rehabilitative components, albeit to varying degrees

o Organization of a multi-tiered health care system starting from health centers at the village

level to tertiary and specialized health centers in big cities

o Integration and provision of services that address biomedical and some social determinants of

health

o Use of a health team approach with most peripheral centers having a community health worker

acting as a link between community and the formal health system

Despite the understanding and statements in national health policies to the effects mentioned above, it

looks like the practice of CPHC by national governments vary very much from stated principles to

reduce CPHC to:

o The most peripheral level of care to village and tribal communities, without a comparable

system in urban areas, through village health posts and community health workers in most

cases with some form of community involvement and

o Provision of a package of services with varying combination of the eight components

incorporated in the Alma Ata declaration (education concerning prevailing health problems and

the methods of preventing and controlling them; promotion of food supply and proper nutrition;

an adequate supply of safe water and basic sanitation; maternal and child health care, including

family planning; immunization against the major infectious diseases; prevention and control of

locally endemic diseases; appropriate treatment of common diseases and injuries; and provision

of essential drugs) undertaken through various programs and activities defined nationally or

locally

Even though the timeframe for implementation was long, for almost three decades, the expected

outcomes remaining at the level of biomedical indicators is an indicator of neglect of social and

political dimensions of CPHC in its implementation by national governments. Also, inadequate

attention seems to be paid to the financing of CPHC and to the development of human resources and

infrastructure needed for effective CPHC implementation. In addition, the social, human and financial

costs of not utilizing a CPHC approach

6.1.b. The local CPHC programs undertaken by NGOs: The local CPHC programs show a

diversity of understanding of CPHC depending upon their leadership and objectives. Similar to

national and sub-national CPHC studies, the understanding was implicit in most reports. In addition,

the understanding of CPHC was more apparent from studies reporting on “whole CPHC program”

rather than studies reporting on one aspect of CPHC program. Furthermore, many local NGO led

programs are characterized by a dynamic process, where the concepts and principles of CPHC have

been and are evolving in nature. There appears to be three dominant streams of CPHC understanding

in the local CPHC programs:

o One stream of NGOs view CPHC as a community based, health care services with community

involvement as the basic principle for deciding the priorities of their program. The


- 36 -

comprehensiveness was one major feature of this understanding in that they attempt to address

social and economic determinants of health as much as the biomedical determinants of health.

Hence agriculture, education, income-generation and such other socially and economically

empowering activities are integral components of this type of CPHC approach, thus bringing

together health and development. However, these programs neither feature explicit focus on the

process of political empowerment of communities nor question the existing local and larger

power structures of society 30;32;39.

o A second stream of NGOs view CPHC as a community empowering program where, health

services are but a component of an overall program designed for putting people at the center of

decision making for their broad development agenda. Social justice and power structure

alteration for social transformation through health work are the driving forces for these CPHC

programs 26;27;31;42.

o A third stream of NGO led CPHC programs appear to concur with the CPHC definition of

Alma Ata Declaration with additional features of innovations according to the local contexts

like greater focus on community participation, especially in priority setting, as compared to

CPHC programs taken up by national governments 28;29. These programs consider CPHC both

as a philosophy and as an approach to health system organization with provision of services as

enunciated in Alma Ata PHC components similar to many National CPHC programs but differ

from them in reaching out to difficult to reach populations and superior adherence to principles

and people-centered approach. Another important distinction between these programs and

national CPHC programs is the flexibility incorporated in these programs due to their “bottom-

up” approach which results in stronger community participation and project-community

participation that in turn allows for people’s felt needs to guide and change program activities

within a broad framework of goals and objectives of the program.

o Another group of studies, mostly those reported in indexed literature, view CPHC mainly as an

approach to public health intervention targeting a certain health condition or a specific

population group through a community based approach. These studies usually focus on one

particular health condition (dengue fever, neonatal deaths, reproductive health of women,

mental health, heart diseases and such others) and apply the principles of PHC as enunciated in

the Alma Ata declaration (focused mainly on community participation; integration of primary,

secondary and tertiary prevention; and equity with little emphasis on appropriate technology

and intersectoral coordination) at the first contact of care at villages with little or no focus on

“comprehensive” principle of CPHC 43;44;47;49;54;55.

The diversity of interpretation of CPHC is a reflection of what was articulated in Alma Ata declaration

which goes on to say “PHC reflects and evolves from the economic conditions and socio-cultural and

political characteristics of the country and its communities and is based on the application of the

relevant results of social, biomedical and health services research and public health experience…”.

Hence this diversity is an expression of the evolving nature of the CPHC and also the importance of

contextual factors in the development of a CPHC programs.

However, the diversity of interpretation of CPHC concept poses a great challenge in defining the term

and hence to identify relevant experiences for effectiveness review. In addition, the diversity of

interpretation of CPHC is also an indicator of diversity and complexity in CPHC practice and

interventions and the associated complexity involved in the effectiveness measurement and in making

comparison and contrast across different programs.


- 37 -

Box.No.3. An exemplar of CPHC understanding by a local CPHC program undertaken by a NGO

We learn through our failures: The evolution of a community based programme in

Deenabandhu 26

Community based health program was defined as the presence of all the following characteristics:

1. Task

a. Community Health Approach which means care of populations and not individuals;

preventive emphasis; decentralized care; appropriate technology and use of auxiliaries and

health education aimed at behavioral change

b. Intersectoral integration which not only means integration of various programs like

agriculture, animal husbandry, etc. but also linkages with government agencies and other

voluntary agencies

2. Process a. Community Participation which means decision-making by and with the community;

participation process in planning, management and evaluation; mobilization/organization of

poorer sections in terms of funds, labor and management for improved service delivery and

utilization and mobilizing resources for self-reliance.

3. Goal a. Self-reliance means capability building in communities, including technical, managerial,

financial and organizational skills to deal with the health problems

b. Social justice which means empowerment of the powerless; a focus on the poor to health

services and resources and mobilization of the poor for awareness building and eventual

confrontation with system

6.2. Population:

The population covered by the programs was very diverse. Studies reporting national experiences

covered populations ranging from 2.5 million (Oman) to 1.2 billion (India) while those pertaining to

local initiatives taken up by NGOs covered populations ranging from 5000 people to 500,000 people.

The national CPHC programs were implemented country wide, but all with a focus on marginalized

populations of rural and tribal populations. Frequently, urban areas were either not covered or partially

covered in the national programs. Even though the sub-national programs were more experimental and

mostly pilot programs preceding nationwide up scaling of the programs, they were also limited to rural

and tribal populations except for one study 20 that included urban slum people in addition to rural

people (See Table no.11). In addition, many sub-national programs were targeted to certain groups of

people most important among them being women of reproductive age and children 20;22;25 and

economically poor people 1.

Most of the local, NGO led CPHC programs primarily served under-served populations such as rural


- 38 -

and tribal areas (See Table No.12). Very with few programs served urban areas and those that did,

served the socially and economically underprivileged populations living in slums 28;32;34;44;52;53;56;58-60 .

Many local CPHC programs concentrated their efforts on difficult to reach populations like those

living in mountainous regions, tribal populations and such others mostly with poor coverage by public

health system. Furthermore most local CPHC programs in rural areas, especially those starting in

1990s and thereafter, operated with the public health system programs in place; sometimes in parallel

and sometimes in collaboration.

Only few local CPHC programs covered entire populations living in their coverage area 27;29;35;61 while

the others preferentially focused their efforts to reach out to economically and socially marginalized

communities. Some programs restricted their activities for only such groups in their coverage area (For

example focus on dalit and poor people in Deenabhandupuram program; tribal communities by

Vivekananda Girijana Kalyana Kendra and inclusion of only people below certain income limit and

without resources in Aga Khan CPHC program in India) 26;28;30 due to the program’s explicit

objectives of reaching the unreached and also as a strategy emanating out of their local learned

experiences over a period of time. Furthermore, local programs with a narrower and targeted approach

towards addressing certain health conditions or to reach a particular group of people have restricted

coverage to certain groups within the general population in their coverage area. The most common

among the targeted group is the group of mothers and children 34;41-45;47;48;58; women 50;51 and people

living with HIV/AIDS 53 and migrant workers in a city 52. A common strategy used by some local

CPHC programs to reach a specific group of people from among the general population in their

coverage area includes providing a wider array of services preferentially to a targeted population while

providing certain services to general population of the area to not alienate the wider community from

the program or providing services at a lower cost to target population while charging “extra” from the

general population 28;30;39.


- 39 -

Table.No.11. Summary of population covered by sub-national CPHC programs

Sl.No. Title of the study/report Country Population Details of the population

covered

1 Women's Health Training Programme: As Assessment of the

Programme in Karnataka India

Women from poor

socio-economic

communities in rural

areas

6 Districts in the State of Karnataka

2

An external evaluative study of the State Health Resource

Centre (SHRC) and the Mitanin Programme- A state wide

health sector reform initiative and community health worker

programme in Chhattisgarh State, India

India Rural and Tribal

3 The costs of public primary health care services in rural

Indonesia Indonesia Rural

41 health centers in 41 sub-districts spread

across 5 provinces

4 An Iranian experience in primary health care, the West

Azerbabaijan Project Iran Rural and tribal

239 000 People(16% of West Azerbaijan

population)

5 Increasing contraceptive in rural Pakistan: An evaluation of the

Lady Health Worker Programme Pakistan Rural

6 Good governance and sustainability: A case study from Pakistan Pakistan Rural Sindh Province

7 The India Local Initiatives Program: a model for expanding

reproductive and child health services India

Rural and Urban

slum

784000 people in 4 Northern States (Slums

of Kolkata, Punjab, Himachal Pradesh and

Uttaranchal)

8 Village Family Planning Volunteers in Indonesia: Their role in

the family planning program Indonesia Rural

108 villages in West Java, Central Java &

Dl Yogyakarta


- 40 -

Table.No.12. Summary of population covered by local CPHC programs undertaken by NGO/CSOs

Sl.No. Title of the study/report Country Population Details of the population

covered 1 Jamkhed: A Comprehensive Rural Health Project. India Rural and Tribal 500000

2 We learn through our failures: The evolution of a community

based programme in Deenabandhu India

Rural people from

low socio-economic

status

1 village

3

A critical assessment of the health status of population after

four years of health services provided through medical college

in villages of Mehrauli block of Delhi

India Rural 8256 people from 5 villages

4 Mallur health cooperative and evaluation of primary health care. India Rural 4000-5000 people from 3-5 villages

5 Comprehensive health project, Rangabelia India Rural population 42 villages across 8 islands

6 Participation- A problem in a semi-urban community health

programme India Peri-urban 5 Villages

7 Lessons Learned from Primary Health Care Programmes funded

by The Aga Khan Foundation Pakistan

Rural and

mountainous 550,000 people


by The Aga Khan Foundation Pakistan Urban impoverished 57000 people


by The Aga Khan Foundation Bangladesh urban Impovershed 60,300 in 5 areas of Dhaka


by The Aga Khan Foundation Pakistan Rural 9727 people


by The Aga Khan Foundation India Rural 24000 people centred around two villages


by The Aga Khan Foundation India Rural 6036 people in 25 villages

13 With the people...For the People Bangladesh Rural

14

Acheiving the Millennium Development Goal on Maternal

Mortality. Gonoshasthaya Kendra's Experience in Rural

Bangladesh

Bangladesh Rural Women living in the areas where GK

Programs were in place.

15 A Case Study of Replication of Home Based New born Care India

Rural, Urban

impoverished and

Tribal

Totally 87,000 people spread over 7 districts

across 2 tribal villages, 4 villages and 2

urban slums

16 Vivekananda Girijana Kalyana Kendra India Tribal 20000 people across 3 districts


- 41 -

17 Home-Based Neonatal Care: Summary and Applications of the

Field Trial in Rural Gadchiroli, India (1993 to 2003) India Tribal and Rural

81,929 in 86 villages; Intervention area

(39,312 people in 39 villages) and Control

areas (42,617 people in 47 villages)

18 Saving new born lives in Rural communities: Learning from the

BRAC Experience Bangladesh Rural 126 villages spread over 4 sub-districts

19 An integrated village maternity service to improve referral

patterns in a rural area in West-Java Indonesia Rural

Intervention: 87,000 people Control: 40,000

people

20 Integration of primary health care concepts in a children's

hospital with limited resources Vietnam

Urban Hospital

Visitors

21

A primary health care curriculum in action: the lived experience

of primary health care nurses in a school of nursing in the

Philippines: a phenomenological study

Philippines Rural

22 Village health workers in Java, Indonesia: coverage and equity Indonesia Rural &

Mountainous

People from 43 villages spread over 2 sub-

districts

23

Effect of community-based promotion of exclusive

breastfeeding on diarrhoeal illness and growth: a cluster

randomised controlled trial

India Rural Intervention: 552 infants Control: 473

infants

24 Effectiveness of depot-holders introduced in urban areas:

Evidence from a pilot in Bangladesh Bangladesh Urban

All married women of reproductive age in

the 3 Urban Pilot Areas spanning different

sized cities

25

Working with women's groups to promote health in the

community using the Health Analysis and Action Cycle within

Nepal

Nepal Rural 7 groups of women with maximum of 20

per group

26 A community health programme in rural Tamil Nadu, India: the

need for gender justice for women India Rural

People living in 18 villages in the

Kanyambadi block

27 The Sonagachi Project: a sustainable community intervention

program India

Urban Occupational

Group (Sex

Workers)

Sex workers, families of sex workers,

madams (who arrange for work), fixed

clients (ongoing regular partner) in Calcutta

28 A tool to stimulate community participation Indonesia Rural People from Central Lombok and Central

Java

29 An intervention involving traditional birth attendants and

perinatal and maternal mortality in Pakistan Pakistan Rural

7 subdistricts of rural Larkana district in the

Sindh province

30 A description of the development of a health education

programme in rural Pakistan Pakistan Rural

180,000 people across 91 villages in 4

districts in 3 provinces of Pakistan over a

period of 10 years

31 Impact of a community-based program on early childhood

development... Thailand Rural

178 children from 6 villages from Phai Sali

district, Nakhon Sawan Province


- 42 -

32 Community-based rehabilitation - Outcome for the disabled in

the Philippines and Zimbabwe

Philippines &

Zimbabwe Rural

106 people in the Phillipines & 104 people

in Zimbabwe

33 Enhancing appropriate drug use: The contribution of herbal

medicine promotion. A case study in rural Thailand Thailand Rural

People from 4 villages: 2 viallages served

by Government health centre and 2 villages

served by an NGO

34 Role of target groups in integrated leprosy programmes India Urban

219000 School children who belonged to

284 schools (Government, public and

central schools) in west Delhi

35

An ecological framing of HIV preventive intervention: a case

study of non-government organizational work in the developing

world

India Urban Migrant Workers in Nasik city

36 Women's health groups to improve perinatal care in rural Nepal Nepal Rural 86 704 people in Makwanpur district

37 Leprosy case detection using schoolchildren India Urban and Local

School children within 26 schools and 5-15

student leaders within 26 urban and rural

schools in Karigiri, Gudiyatham Taluk of

Vellore

38 Mental health: the missing link in primary care? Pakistan Rural and Peri-

urban

39

Isfahan healthy heart program: Evaluation of comprehensive,

community-based interventions for non-communicable disease

prevention

Iran

Isafahan and Najaf-

Abad counties and a

reference area Arak

located in central

iran

40 Primary health care, community participation and community-

financing: Experiences of two middle hill villages in Nepal Nepal Rural 2 villages in mountainous region

41 Community-based approach for prevention and control of

dengue hemorrhagic fever in Kanchanaburi Province, Thailand Thailand Rural 2 Villages (1 Intervention & 1 Control)


- 43 -

6.3. Range of interventions:

The range of interventions taken up by various CPHC programs reflects the diversity of the

understanding of the CPHC. The spectrum of interventions range from very narrow approach of

providing basic and selective health care such as immunization of children, antenatal and postnatal

care, reproductive health services to women, etc to a target population (children under 5 years, women

of reproductive age group, etc.) using techno-centric methods with little community participation to

improve conventional health indicators (basically by reducing infant and maternal mortality and

mortality due to infectious diseases) as in CPHC programs of Aga Khan Foundation in Dhaka, Vur,

and North Pakistan 28 to that of programs with wide spectrum of activities incorporating community

based health care provision (through community health workers, etc.), community development (water

and sanitation services, economic activities like novel agriculture technique promotion, animal

husbandry promotion, arranging soft loans for starting new businesses, etc.), community mobilization

(organization of women’s clubs, farmer’s clubs, etc.) and empowerment programs (conscientization

training, etc.) towards comprehensive human and community development as in Jamkhed CRHP and

Deenabandhupuram program 26;27.

The spectrum:

Very narrow bio-medical approach only: CPHC programs where certain principles of PHC of

Alma Ata Declaration are applied for one particular health condition (dengue fever, neonatal deaths,

reproductive health of women, mental health, heart diseases and such others) at the first contact of

care at villages with little or no focus on “comprehensive” principle of CPHC 43;44;47;49;54;55.

E.g. Isfahan healthy heart program: Evaluation of comprehensive, community-based

interventions for non-communicable disease prevention 55

Integrated activities targeted to different fields of the health sector (health promotion, disease

prevention, healthcare treatment and rehabilitation) which included public education through

mass media, intersectoral cooperation and collaboration, professional education and

involvement, marketing and organizational development, legislation and coordination, policy

development as well as research and evaluation. Main factors targeted are healthy nutrition,

increased physical activity, tobacco control and stress management.

10 distinct projects each targeting different groups: women’s healthy heart project, heart health

promotion in children, health professional education, youth healthy heart project worksite

intervention project, lifestyles for high risk groups, healthy food for healthy communities,

Isfahan exercise project, NGO and volunteer intervention project and healthy lifestyle for

cardiac patients. Each project supervised by steering committee which includes stakeholders,

policy makers, health providers and academics.

Narrow bio-medical approach with small efforts towards addressing social, economic and

political determinants of health: These programs reflect a partial, limited interpretation of CPHC.

E.g. Aga Khan Community Health Program (AKCHP), Dhaka 28


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The overall objective of the program was to improve the health and nutritional status of the

target population.

Services included immunization, growth monitoring and nutrition promotion, health and

nutrition education, Vitamin A supplementation, ORT, prenatal and post-natal care including

high-risk pregnancy screening and management, training of traditional birth attendants (TBAs)

and training of women as community health organizers (CHOs), community health workers

(CHWs), community health volunteers (CHVs) and community mother volunteers (CMVs).

Services were provided through static and mobile clinics supplemented by information,

education and outreach services provided by 20 CHWs and over 260 CHVs, TBAs and

schoolteachers. The CHOs and two medical officers supervised the services.

Program with comprehensive human and community development approach:

E.g. Deenabandhupuram – Community Health Program 26

What started as a hospital model of health care delivery project has, over a period of two decades,

metamorphosed into a community based comprehensive health project incorporating economic

and social action activities along with the health interventions. The interventions adapted are as

follows:

Village health workers provide primary care and engage themselves in preventive and

promotive health activities at the village level. They are also the “social change” agents by

being groomed as the catalysts of change at the village level.

The village health workers are supported by the Village Health Committees

The referral support is provided by the clinic at the project head quarters.

Local health traditions were integrated with the “western medicine” at all levels of health care

and local herbs are used extensively.

Social and economic activities like education, income generation activities, conscientisation,

etc. were taken on a priority basis. Novel methods of agriculture were introduced. Animal

husbandry was promoted and soft loans were provided for the poor to start income generating

activities. Women’s groups were established and women’s empowerment training was

undertaken to address the gender disparities and power imbalances.

Note: While there was strong, specific focus on poorer socio-economic groups, reductions of

inequality were perhaps implicit and not measured or reviewed regularly.

CPHC programs undertaken at the national levels by governments tended to be more towards the

narrower spectrum of addressing bio-medical determinants of health where as NGO-led programs fell

at varying points on the wide spectrum of interventions ranging from the narrower approach to address

bio-medical determinants to the wider spectrum of addressing social, economical and political

determinants of health.

Also, understanding and addressing the deeper underlying politico-economic determinants of health

that would lead to the “New International Economic Order” envisaged in the Alma Ata Declaration

were largely missing.


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7. Evidence for effectiveness of CPHC:

The evidence for effectiveness of CPHC initiatives has been assessed fall under two themes of

effectiveness, first measured in terms of outcomes of health programs and second in terms of

effectiveness of processes of CPHC as follows:

1. CPHC effectiveness assessed in terms of health outcomes:

a. National and sub-national programs: Measurement of progress in national health

indicators over time has been the main measure of CPHC effectiveness. But the national

health systems and CPHC initiatives do not have enough data both overall and

especially disaggregated on class, gender, caste and ethnicity to measure and document

the health improvements in populations.

b. NGO led CPHC initiatives: Changes in health status of the target population in

defined geographical areas where CPHC programs have been operating compared either

with the control group or with national and regional average, or temporal changes in the

health status of the population under coverage

2. Health sector achievements in nation states following adoption of CPHC strategy: The

development of health systems in the countries adopting CPHC programs over a period of time

is also presented in country reports as measure of CPHC effectiveness in realizing “health for

all”.

3. Effectiveness assessed in terms of CPHC processes and principles: Both the NGO led

programs and the country wide studies gave much importance to CPHC operational process

analysis. The studies also gave varying importance to study the implementation of important

PHC principles such as equity, participation, intersectoral collaboration and integration.

7.1. CPHC effectiveness assessed in terms of health outcomes/impact of CPHC programs:

7.1.a. Country wide CPHC initiatives:

The country reviews shows an interesting range of CPHC initiatives at country level. In Iran, CPHC

concepts seem to be an integral part of political transition 5. In Indonesia, India, Pakistan, Vietnam, Sri

Lanka and Oman CPHC concepts appear to guide the national health policy and programs 2;7;11-13;16 . In

Lebanon it appear that CPHC is given a very much great lip-service but the country health systems

maintain a hospital-oriented health care models 9. The country reviews indicate that the principles of

CPHC are almost always at the core of every country’s health plans but that the degree and nature of

implementation varies widely. In addition the country reviews of Vietnam, Lebanon and Indonesia

indicate that CPHC has been neglected in terms of political will and financial allocation and resources

are usually substantially directed towards more complex and expensive hospital based care 7;9;16. The

country report of Vietnam makes a case in point for the above when it reports that the curative care

absorbs close to two thirds of public health spending while preventive care receives just around 15% 16.

In all the country reviews, there were substantial improvements in country health indicators, both


- 46 -

mortality and morbidity indicators. Most commonly measured and reported statistics include life

expectancy at birth, infant mortality rate, under five mortality rate, maternal mortality rate,

malnutrition prevalence in children and women. The highest improvements were seen in life

expectancy at birth and infant mortality rate, with less than desirable improvements in maternal

mortality rates and little improvements in nutritional status of either the children or the mothers across

various country reviews. The Vietnam report goes on to say “infant mortality and under five mortality

rates have declined considerably, beyond expectations as related to the country’s economic growth” 16. Also some gains were reported in terms of control of communicable disease (mainly tuberculosis,

malaria, diarrhea, acute respiratory infection and diarrhea in children, vaccine preventable diseases,

water and vector borne diseases and HIV-AIDS in post 1990s period) evidenced by decreasing

incidence and prevalence rates of the same (until HIV epidemic broke out). Almost all country reports

gave special attention to family planning program and reported on the Natural Population Growth

Rate, Total Fertility Rate, Couple Protection Rate and Net Reproductive Rate as indicators of success

in family planning. Most reports also reported on percentage of children vaccinated and percentage of

women receiving full antenatal care and undergoing institutional deliveries to highlight their respective

national health systems’ effective coverage, especially of rural and tribal vulnerable population. The

country report on Oman captures this sentiment when it states “…due to all these policies in Primary

health care...one of the few countries in the region with successful experience in health

development…”11.

An example of improvements in country health status embracing CPHC principles is Iran. Iran is one

of those pioneering countries which have explicitly stated and based its health system on CPHC

principles 6.

Table.No.13. Changes in health indicators over time in the country of Iran

Indicator* Rural Urban Overall

1974 1984 1988 1993 1974 1984 1988 1993 1974 1984 1988 1993

CBR (%) 48 44 40 30 35 38 32 24 42 41 36 27

CDR (%) 14 8 7 4.8 8 6 4 3.5 13 7 5 4

TFR (%) 8 7 4.4 5 5 4 2.9 6 5 3.6

Literacy among females 15v and over (%)

7 17 21 - 43 47 55 - 25 34 41 -

IMR 120 71 51 44 62 34 31 24 91 51 45 34

NMR 45 25 31 28 18 15 20 17 32 21 26 23

1-4 Child mortality

rate 14 6 4 - 5 3 2 - 10 4 3 -

MMR 370 223 138 53 120 77 41 26 140 91 40

*Note: CBR: Crude birth rated

CDR: Crude death rate


- 47 -

TFR: Total fertility rate

IMR: Infant mortality rate

NMR: Neonatal mortality rate

MMR: Maternal mortality rate

All other country reviews also show gains in health status indicators, but the momentum of gains

varies from country to country. These improvements in national level health indicators were attributed

to respective country CPHC initiatives. However, such a method cannot capture the true contribution

of the country health care systems in improving the health of the people as it is confounded by the

concurrent presence and operation of many other social and economic programs. Also, the lack of

disaggregated data introduces ecological bias and does not let us look at equitable improvements in

health status. Furthermore, most of the country reports focus on child and maternal mortality indicators

as proxy for health improvements of national populations which cannot capture the entirety of health

development/improvements in the respective countries. In addition, there is not enough information on

the real world translation of well-meaning policies into effective program implementation at the

ground level, the lack of which further complicates the process of evaluating impact of national CPHC

health systems. Many country reports state that many health policies remain in the paper without

effective translation on the ground 2;9;16. Despite these challenges, the improvements have to be

considered on the back drop of long periods of colonial exploitation of most of these countries and

almost defunct health sector for rural masses at the turn of this century. The Lebanon country report

puts this in the perspective when it observes “In the area of Primary Health Care, several equally

important developments have taken place …this is to say that the situation is markedly different from

1994. The underlying requirements for better health care have been laid down. The time has come to

build on these achievements”9.

7.1.b. NGO led local CPHC programs:

Most NGO led local CPHC programs have measured CPHC effectiveness in terms of decreasing rates

of mortality and morbidity, mostly of children and mothers. In all the programs there was

demonstrable decline in mortality and morbidity rate and in some instances, even dramatic health

indicator improvements.

For instance is the Jamkhed Comprehensive Rural Health Project (CRHP) of India 27, which covers a

population of over 0.5 million, there was dramatic decline in Infant Mortality Rate (IMR) (from 176

per 1000 live births in 1972 to 52 in 1976 to 19 in 1993), prevalence of under nutrition in under 5

children, leprosy and tuberculosis and improvements in maternal health indicators. And these

improvements have been sustained for over more than 35 years with dramatic improvements in the

initial period and slower but definitely sustained improvements in later years. These improvements are

even more impressive in the light of comparatively higher similar indicators at the state and the

national levels and by the fact that the project area in Jamkhed is subject to frequent droughts and food

insecurity.

Similar impact in terms of improved health indicators in the project area are reported by other NGO

based CPHC initiatives, even if they are not as dramatic as in Jamkhed CRHP. Deenabandhupuram’s

program is a community based health program based in South India and is in place for more than 60


- 48 -

years and reports a reduction of IMR from 127 per 1000 live births in 1973 to less than 50 in 1986 and

similar reductions in Maternal Mortality rate (MMR), Crude Birth Rate (CBR) and Crude Death Rate

(CDR) and malnutrition rates in under five children 26. Six CPHC initiatives from Aga Khan Health

services across three countries of Pakistan, India and Bangladesh and in a wide diversity of settings

including rural areas, difficult to reach tribal and mountainous region and urban slum areas also

documents impressive improvement in child and maternal health indicators (IMR, MMR, Vaccination

coverage, nutritional status of children and others) over time in all its initiatives 28. In a CPHC Program

in Mallur in South India, authors report a gradual decline in birth rate, death rate and IMR 39 and in

another CPHC program covering tribal population in South India there was substantial decline in IMR

and MMR over a period of ten years (IMR from 145 in 1980 to 28 in 1990 compared to state average

of 75 in 1990).

The programs focusing on single health conditions have also documented impressive health gains

among the target population. Many of these programs have assessed the effectiveness of CPHC

approach in terms of control or prevention of single health conditions. The SEARCH (Society for

Education, Action and Research in Community Health) in Maharashtra state of India which developed

Home Based Neonatal Care (HBNC) model based on CPHC principles documents impressive

reductions in neonatal mortality rate by 70%, neonatal morbidities rate by 60% and infant mortality

rate by 57% in the intervention areas compared to control population over a period of ten years (1993

to 2003) 43. In addition, the same project piloted in six different areas (covering rural, urban and tribal)

lends evidence for its replicability with documented reduction of infant mortality by 47% and neonatal

mortality by 51% over a period of three years 44. Gonoshasthaya Kendra also reports impressive and

equitable reductions in maternal mortality in their coverage area (MMR down from 299 during 1993-

1997 to 186 during 2001-2005 periods) in Bangladesh which was much favourable compared to

national average (570 in 1990 and 320 in 2001) 42.

However, due to paucity of base-line data, non-standardized data collection methods, absence of and

non-comparison with control areas and relatively less emphasis on research orientation at the

beginning of the program, the robustness of the effectiveness analysis of these studies, except for some

like Jamkhed CRHP 27 and Home Based Neonatal Care program in Maharashtra in India 43;44, is less

than desirable. In addition, the attribution of the improvements in health indicators to CPHC programs

alone is a tricky issue as health improvements are also dependent on various other inputs like the

environmental hygiene, general socio-economic development due to various policies outside the

purview of CPHC like agriculture, labor, industrial and such other policies of Governments which

cannot be controlled for. Additionally, there are few similar programs to be compared with, to measure

the effectiveness of CPHC programs.

7.2. Health sector achievements in nation states following adoption of CPHC strategy:

Almost all country reviews attribute Alma Ata conference as landmark in terms of its influence on the

country health policy, programs and structuring of health systems and have measured CPHC

effectiveness in influencing these in terms of formulation of national health policy and programs and

their congruence to CPHC concept and development of health sector in terms of infrastructure and

human resources to cover entire national population.

Most country reviews report that Alma Ata declaration and commitment made there after by the


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national governments has been instrumental in nation states formulating PHC congruent health policies

and expanding their health systems to reach hitherto unreached populations. The Vietnam review

found that “the wide geographical coverage of the health infrastructure, the large supply of staff at

peripheral level, the social mobilization (including the PHC steering committees) and well functioning

national vertical programmes, which have been able to reach the majority of the population, have all

contributed to the improvements of the health indicators”16. The Lebanon review concludes that “there

has been a great deal of improvement in the health situation of Lebanon over the past decade, i.e.

since the development of the National Health Strategy for Primary Health Care in July 1994. This

improvement is primarily due to the efforts expanded by the Ministry of Health officials and their

partners in development of the health care system mainly based on PHC principles”9. The Oman

country report states “…due to all these policies in Primary health care... (Oman) has achieved a

dramatic transition in its health care system over a remarkably short span of time”11.

The climate of International solidarity and thrust for health system reform with a focus on equity and

community involvement following the Alma Ata declaration resulted in wide ranging health policy and

programs in many countries in the Asian region. As a result, most countries formed committees to

formulate national CPHC strategies and/or reframe health policies in the post Alma Ata period

incorporating many aspects of the declaration 6;7;9;11;16. In fact Oman went on to constitute Ministry of

Health for the first time in early 1980s and health was included as a fundamental right of all citizens 11.

Following National Health Conference of December 1991, Lebanon with technical help from World

Health Organization (WHO) developed a ten-year strategy to strengthen and develop Primary Health

Care (PHC) in Lebanon and followed it up with the constitution of a National Joint Committee for the

implementation of the PHC strategy through the Ministerial Decree No 1/288, dated March 27th 1996,

and amended by Decree No 1/246 dated February 24th 1997 9. Indonesia followed its commitment for

Alma Ata declaration with integration of fragmented health services at village levels under one health

post; increasing the coverage of villages under health services (86% by 1988); passage of master plan

for strengthening Primary Health Care System in the country; massive expansion of health centers so

that each of the 3270 sub-districts in the country had at least one health center by 1979; and institution

of a managerial tool for efficient management of health centers 7;8. India introduced the massive

Community Health Volunteer Scheme under Rural Health Scheme in 1977 towards universalizing

access of PHC; had its first National Health Policy passed in 1982 with a focus on strengthening

Primary Health Care system; strengthening of national health system by massive creation and

improvement of health infrastructure (by 1980s India had 5430 Primary Health Centers, 38 594 sub

centres, 126 rural hospitals to cover health care needs of around 500 million people and expansion of

medical colleges from a mere 30 in 1951 producing 960 doctors annually to 109 colleges in 1978

producing over 14,000 doctors annually) and attempted decentralization of health decision making and

devolution of powers to local bodies 3. Nepal followed up Alma Ata declaration with integration of

primary health care services under one program at the village level; strengthening of the existing

community health worker program and process of decentralization of health service planning and

administration to district level 10. Vietnam, which had strong PHC characteristics within its National

health system, followed Alma Ata conference with tried enacting a National PHC policy in mid

nineties which was later toned down to become a mere circular; had a central full PHC unit to reorient

national health system with PHC principles from 1994 to 1998 that ceased to be a separate unit once

SIDA stopped funding it in 1998; undertook expansion of rural health infrastructure to universalize

health care access and passed a National Strategy for People’s Health Care and Protection in 1996 and

revised it in 2001 16.


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Iran presents an exemplary efforts on policy and planning for health system orientation front following

Alma Ata conference call of “Health for all by 2000 AD” and passed a well formulated National

Health strategy in the form a “master plan” in 1979 (developed from the experiences of previous

projects like West Azarbaijan Project started in 1972 and a review of Iran health services and status

done in 1979) for development and strengthening of the existing Public Health system to meet people’s

health needs based on the principles of PHC; creation of a powerful and unified management of health

services with decentralization of health planning and implementation to districts as the smallest

autonomous units; creation of an integrated, stratified health infrastructure at all levels with referral

support and special emphasis on rural and deprived areas (Between 1985 and 1991 over 8800 Health

Houses at village levels, 600 Rural Health Centers, 430 Urban Health Centers, 147 behvarz (village

health workers) training centers with 19468 behvarz trained by the end of 1991 covering 66% of the

rural population and 51% of urban population); local health human resource development (19468 local

boys and girls trained and deployed as behvarz); development of indigenous pharmaceutical industry

in partnership with private sector to reduce foreign dependence; regulation of private health sector with

financial supervision and application of quality-control standards; creation of new structures to over

come bureaucratic delays like “Council for expansion of PHC Network”; development of health

information system and appropriate use of surveys to aid informed decision making; working towards

community oriented radical education and continuing educational process; close coordination with

other developmental sectors and creation of opportunities for active and organized community

participation at all levels of health system.

Despite these positive developments in the country health systems following “Health for All by 2000

AD” call by Alma Ata conference, much of these developments were inadequate, inappropriate or both

in some cases. The political statements and policy documents were not matched by political and

administrative decisions and financial resources to realize the policy statements and goals. As lamented

by the reviewers of Lebanon, “…however PHC did not become the cornerstone of the social and

economic development of the country. In fact, to what extent this recommendation has been even tried

remains dubious” 9. Even though PHC approach had political and social processes at heart, much of it

was reduced to technical to-do things and the eight elements of PHC enunciated in the Alma Ata

declaration were introduced as PHC by the countries without matching it with the intersectoral

collaboration, political determination and action on social determinants of health thus stripping off the

most vital and essential elements of Alma Ata declaration. Furthermore, the changed international

environment both in health sector and economic order did not facilitate PHC implementation in

comprehensive manner in the true spirits of Alma Ata declaration. Countries invested very little

financial resources on developing PHC systems and even the little allocated financial resources were

iniquitous as hospital-based curative care was funded more preferentially and well-off people benefited

more than the truly poor and marginalized people. The cases of Vietnam and India whose annual

public health spending averages around 0.8% and 0.9% of Gross Domestic Product respectively in

decade following 1990s 16;62 are just instances of inadequate actions by the governments to fully realize

the potential of Health for All. In fact, most reports suggest that the implementation of PHC has been

limited to the physical rehabilitation of PHC centers and half-hearted attempts of seeking community

involvement in health systems.

7.3. Effectiveness assessed in terms of CPHC processes and principles:

Assessment of processes and principles of CPHC forms an important part of the assessment of


- 51 -

effectiveness of CPHC programs if we have to understand the contribution of CPHC to improved

population health and to identify good practices of successful CPHC interventions and to analyze

challenges of effective CPHC implementation. However, it is a methodological challenge to assess the

same because of the diversity and complexities of the processes and principles which do not lend

themselves for easy measurement. Even though some work has been done on assessing some of the

principles like equity and community participation the assessment process is hampered as these

methods are not applied widely. In addition, methods for assessing certain parameters of CPHC like

community empowerment also have to be drawn up locally which makes cross-program comparison

difficult. Furthermore, the concept of “effectiveness” is difficult to apply to principles and processes of

CPHC as they are both means to an end and not just ends by themselves and it is difficult to ascribe a

causal chain for changes anticipated by following the principles and processes. In spite of these

challenges, many studies have attempted to document and some times measure effectiveness of

principles and processes of CPHC.

7.3. a. Equitable access to basic health care:

All programs, either NGO led or country wide studies, indicate that equitable access to basic health

care and equitable improvements in health as one of the main principles of their health program.

Furthermore, the fact that all NGO led local CPHC programs are usually implemented with the

vulnerable population groups makes the value of health equity as their operating principle and program

goal and that they have been able to improve the health of people in their coverage area to levels better

than otherwise comparable and adjacent areas gives an indirect evidence for the effectiveness of CPHC

contributing to achieving health equity. However, few have managed to measure them.

The narrative report of Jamkhed CPHC has qualitative evidence obtained through sequential

community mapping and socio-economic surveys that shows not only an increase in equitable access

to health care but also increased social and economic status of women and people from lower castes 27.

The report from Deenabhandupram26 and Vivekananda Girijana Kalyana Kendra 30 gives anecdotal

evidence wherein hitherto completely unreached populations being reached by the CPHC programs.

The Rangabelia CPHC program also gives quantitative data on increased access to health care for the

people living the five islands covered by the program 29. Aga Khan PHC programs demonstrate

increasing rates of immunization and maternal and child care indicators in all its program areas 28.

Similar improvements in access to health care especially for women, children, poor and rural people is

reported from almost all local CPHC studies. Studies that have single disease or target population

intervention by CPHC approach also report increased equity in access to health care of the target

population 18;49;50;53.

National and sub-national studies mainly present qualitative evidence in terms of increasing coverage

of health services due to CPHC based health systems do not give evidence for increased access to

health care for marginalized populations explicitly barring few studies. The two studies of community

health workers in Indonesia does provide quantitative evidence of increased access to health care for

poor and rural women and children 8;63. A study of CHW in Indonesia concludes that CHW services

can greatly expand coverage with basic services, for both mother and child and illness care compared

to clinic based care is biased toward better off households and that CHW nutrition services clearly

show improved equity but unable to draw conclusions about equity in illness care 63. However, the


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studies looking at health sector reforms post nineties report a negative impact of introduction of user

fees, targeting and essential service package approaches and cut back of Government spending in

health sector on equity of access for health care 1;12;16;17;64.

Most CPHC programs have used the agency of community health workers for increasing the equity in

health care access and the national and sub-national programs have tried creating village health posts

towards ensuring equity in health care access 63. However, the range, quality and timing of services

provided is reported be poor through such health workers and health centers 7. In addition, the factors

that seem to affect the effectiveness of CHW and village health post programs like selection of

appropriate and acceptable health worker; training, supervision and support from formal health sector;

financial outlay and on-field translation of policies also affect greatly the equity of health care access.

The main factor that appears to promote and sustain equity in access to health care is community

participation which often distinguishes the successful local CPHC programs from partially successful

national and sub-national CPHC programs 3;27;35. Other factors promoting equity in health care access

include adequate financial investment on health sector by the governments; sustained efforts in rooting

health systems within the communities; maintenance of quality of health services in public health

systems; and decentralized health planning and decision making.

7.3.b. Explicit value of health equity (‘leveling up health status’):

The value on leveling up health inequities was not stated explicitly in most studies but was implied.

Almost all NGO led local CPHC programs had increasing health care access to marginalized

population as their aim which is closely linked with equitable health gains. However, except for few

studies 5;16;63, most studies do not report on health equity gains quantitatively and the assumption of

increasing access to health care will lead to equitable health gains appears to be implicit. One instance

where equitable health improvements have been attempted to be measured is in Iran, which has

embraced CPHC to develop its health systems and also has developed a robust health information

system 4;5.

Table. No.4. Comparison of health indicator changes in urban and rural areas in Iran

Health Indicator*

1974 1988 1991 2000

Urban Rural Urban Rural Urban Rural Urban Rural

NMR 16 39 21 31 14 24 17 21

IMR 62 120 31 58 24 43 27.7 30.2

Under 5 Mortality rate

(per 1000) 40 72 31.5 52 36.8 34.6

MMR 120 370 41 138 26 53 0 35

*Note: IMR: Infant mortality rate

NMR: Neonatal mortality rate

MMR: Maternal mortality rate

Many other NGO led CPHC programs report health equity gains. Jamkhed CRHP reports that “… it


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works with 50% of people in rural comunities who live below poverty line…health teams ensure that

the Dalits (lower caste people in India), women, widows, nomadic tribes and those shunned as

criminal tribes are sought out…” 27. Deenabhandupuram health project reports health improvements of

Dalits and women in its project area comparable and sometimes better than affluent and higher caste

people in the adjoining areas 26. Home based neonatal care program in Maharashtra report decreasing

neonatal and infant mortality rates in rural population to levels almost equal to that of high-income

country averages 43;44. Gonoshasthaya Kendra also reports impressive and equitable reductions in

maternal mortality in their coverage area (MMR down from 299 during 1993-1997 to 186 during

2001-2005 periods) in Bangladesh which was much favourable compared to national average (570 in

1990 and 320 in 2001) 42. However, all these programs do not explicitly mention health equity gains.

7.3.c . Integration of rehabilitative, curative, preventive and health promotion components:

In almost all studies, the principle of integration of rehabilitative, curative, preventive and health

promotion components was prominently stated. However, it appears that except in Jamkhed CRHP27

and to some extent in Iran6 and Lebanon9 country health systems, rehabilitative part of integration

seems to be completely sidelined. More significantly, very few programs seem to incorporate all the

four components in their program and instead focused on varying combinations of the components.

Most NGO led CPHC programs which started as community based health programs had a focus on

prevention along with basic curative care 26-32;39;42;45;47;54 and a referral link to public health system for

complicated clinical cases. The preventive efforts were broad based and included increasing access to

resources including food, education, work in addition to health education; promotion of health

promoting practices of child and mother care; improvement of water and sanitation; specific preventive

activities like vaccination and ante-natal care; and attempts towards changing health seeking behavior.

The curative efforts were limited in most programs for minor illnesses like fever, malnutrition and such

others through extension health workers with complicated cases being refereed to either base hospitals

or public hospitals. Health promotion was implicit in preventive efforts of these programs.

Rehabilitative health care including nutritional rehabilitation of malnourished children and physically

challenged people was mostly limited to few programs 26;27. The recent NGO led CPHC programs that

work with certain vulnerable groups and more concerned social determinants of health were mostly

involved in health prevention/promotion activities with little or no curative services of their own 18;48-

50;52;53.

National and sub-national health systems had a mix of all four components, at least on paper.

Preventive activities were limited to health education, vaccination and antenatal care in most country

health systems through outreach staff of health systems or through community health workers.

Institution based curative care was given the most focus and was allocated the most of financial and

human resources. Even though rehabilitative care is said to be a part of the health system, it was mostly

neglected and offered on a sporadic basis at only higher centers like district or specialized institutions.

The Lebanon country report recommends that a comprehensive and community based rehabilitation

has to be a formal part of the PHC system if it has to succeed at all levels starting from village

community level 9. One report that investigates financing of health care in Indonesia highlights the

disconnect between policy declarations and implementation where curative care is given a primacy

over prevention and promotion by highlighting the very little financial resources allocated for

preventive component 21. The Vietnam country report further reports that curative care absorbs close to


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two thirds of public health spending while preventive care receives just around 15%; and another 7%

goes to family planning 16. The comparison with NGO led local CPHC programs also highlights the

great divide between them in terms of range of and importance with which preventive health actions

are undertaken.

7.3.d. Community involvement / citizen participation:

Community involvement in CPHC is one principle which is present in all the programs that have been

reviewed and identified as the most vital element for the success of any CPHC program. However, the

extent and method of community participation varied greatly across the program. In many CPHC

programs, community participation was given much emphasis and community members were involved

in all aspects of the health program right from needs assessment to prioritization of problems to be

solved, planning, implementation and evaluation of the health programs 26;27;29;30;32;50;53. In other CPHC

programs community participation was sought once project objectives were finalized and only in

implementation of the program 28;31;39;42;47;48;51. Three of the studies exclusively focused on community

participation in CPHC health programs 32;33;37 delineating the processes of and strengths and challenges

of community participation in health programs. Community participation was usually through

formation of village health committees; committees of specific groups like women, children, farmers,

youth and also as members of program management committees and many CPHC programs undertook

great efforts towards empowering village communities and getting their full participation in the

programs as their first step. The review gives evidence that community participation is a strong focus

of all community based health actions and that programs cannot achieve much success without active

community involvement.

However, in most country wide health programs, community participation was given a lip service. In

country wide programs where community participation was sought strongly as in Iran6 and Indonesia7

and to a lesser extent as in Thailand 14, Vietnam16 and Sri Lanka 13, community participation was

limited to mobilization of resources (human and material) from local community and seeking them to

be passive beneficiaries of the programs and not getting them involved in the planning, implementation

and evaluation of health services. In many other national and sub-national CPHC programs community

participation was limited to choosing of community health workers from their communities and then

bringing their children for routine immunization and health checkups for health centers or in the

formation of mothers’ groups 3;8-10.

Comparing and contrasting the community participation in local CPHC programs and national and

sub-national programs and the primacy given for community participation by the local program for

their success calls for a radical action by the governments to undertake immediate measures for

promoting community participation and restoring decision making powers to communities. The review

shows that successful community participation is a time, resource and effort intensive process and may

often take many years for it to be active and successful. In addition, it shows that the community

participation had to be cultural and context specific and a there is no “blanket” formula for it be

successful and that the program implementers have to consciously seek and refine methods for

effective community participation. Furthermore, effective community participation demands an

informed and empowered community necessitating efforts from programs to build communities’

capacities for effective decision making and action. It was also found that community participation is

not effective when it is sought in a premeditated and targeted, top-down approach and mutual respect


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is of utmost important if we are build community partnerships. Some of the challenges identified were

regarding achieving effective participation in communities divided along caste, class and gender lines.

But with persistence; respect to community views and perceptions; treating community people as equal

partners; flexibility in program planning and implementation; and building community capacity many

programs have shown that they can build community participation and it is an effective method for

program success.

7.3.e. Collaboration with / involvement of other sectors:

In NGO led CPHC programs the collaboration with other sector meant involvement and establishing

strong linkages with the government sectors in health, water and sanitation, education, nutrition,

agriculture, animal-husbandry and banking. The extent of the collaboration in NGO CPHC programs

vary. Six CPHC programs from Aga Khan health services28, Jamkhed CRHP27, Rangabelia29, Mallur39,

Women’s health empowerment training18 exhibit strong linkages with wide ranging government social

service agencies in order to facilitate community and government service agency linkages. In programs

as in Deenabandhupuram project26 where the program staff have more fundamental view on social

justice have shown lesser collaboration with government agencies. Intersectoral collaboration was one

of the key elements in CPHC programs focusing on a particular vulnerable group like women and on

people living with HIV-AIDS 50;52;53.

All the reviews concerning country wide health programs indicate that multisectoral collaboration is

one of the principles of the country health systems. However, only Sri Lanka13 and Oman11 seem to

have given it a strong emphasis linking health system with water and sanitation services and education

departments. Vietnam country reports poor intersectoral collaboration except with education sector 16.

Lebanon country report states that “…despite its importance in attaining health for all and better

health status, intersectoral collaboration has proved difficult to achieve in practice.. the lack of it

(intersectoral collaboration) is one of the reasons of failure of PHC…”9. Similarly, lack of

intersectoral coordination were mentioned as one of the most important factors in national CPHC

systems not realizing their full potential by the reviews of CHW systems in India, Indonesia and Nepal 3;8;10.

The communities at the most peripheral level like villages have no distinction as to who delivers the

services as long get the services unlike the delivery agencies which are very vertical. In fact,

coordinated and comprehensive development has a great influence on health and effective realization

of CPHC potential is one of the findings of this review. The review also indicates that intersectoral

coordination is effective in many NGO led local CPHC programs and pilot programs but such links fall

short of expectations when tried on a bigger scale like in sub-national or national levels. However,

Frankel notes in his book on CHW that “…the challenges identified for integration of intersectoral

actions by national and sub-national health systems must lie mainly administrative structures in the

relative government departments and agencies, and the individualls’ professional aspirations and

rivalrie..”65.

7.3.f. Action on social determinants (non-medical determinants) of health

The reviews suggest that many of the NGO led local CPHC programs had a strong focus on acting on

social determinants of health18;26;27;29;31;39;50;51 and the rest of the programs also had a component to


- 56 -

address social determinants of health for a lesser degree. The primary methods of addressing the social

determinants of health seem to be through the processes of social mobilization and conscientisation to

address the systemic, class, gender, caste and ethnic factors that combine together towards affecting

health status of people.

An important feature of these NGO led CPHC initiatives strong on social determinants is the

programs’ emphasis on linking health with development, especially through empowerment of local

communities. Most NGO led local CPHC initiatives had community empowerment programs in

varying degree and many of the initiatives have explicitly stated community empowerment activities as

one of their major objectives 18;26-29;32;39;39. Most common community empowerment activities included

community involvement in planning, implementation and evaluation of health activities to varying

degrees, initiation of income generating activities, literacy education and social conscientisation

training. However, the measurement of empowerment lends itself to difficult measurement, especially

due to paucity of development of the science of CPHC. Nevertheless, some of the programs have

attempted to measure empowerment in various methods. Jamkhed CRHP provides probably the best

example for this.

In Jamkhed CRHP 27, empowerment measurement was attempted in a participatory manner. The

CRHP staff along with community members in the project area especially the representatives from

farmer’s clubs, women’s groups, village health workers and the social workers got together and

decided on the methods of evaluating non-health, developmental initiatives. They set their own criteria

for economic classification and used various methods to evaluate changes in social life (knowledge,

attitude and practice of community with reference to status and treatment of women and dalits) and

economic life (knowledge, attitude and practice of economic activities like agriculture, animal

husbandry, forestry and such other, access to income generating resources and activities). All these

activities were disaggregated into three categories of villages depending upon the number of years of

CRHP activity in a village (A: Above 5 years of CRHP activity; B: 2-5 years and C: 1-2 years) and

temporal changes were measured as indicators of empowerment.

Other programs like those in Deenabandhupuram 26, Okhla Neighorhood Comprehensive Health and

Welfare Pilot Project 32 and Women’s Health Empowerment Training Program 18 have attempted to

measure the social and economic empowerment by using indicators like change in women’s/Dalit’s

decision making capacity at family and community level, change in the proportion of women/Dalits

participation in public political arena, proportion of people in debt, proportion of people with year-

round livelihood access, literacy percentage, percentage of people with access to safe drinking water,

sanitation and year-round access to wholesome nutrition and such others.

The reviews of the country wide programs suggest that all programs do have some component on

addressing the social determinants of health. Four of the reviews (Health reforms in Chhattisgarh, Iran,

Indonesia, Sri Lanka) have a strong component of addressing social determinants including social

mobilization and conscientisation process 5-7;13;19. Other programs show a lesser degree of importance

attached to social determinants.

It looks like the spark for social transformation by program leaders in NGO led local CPHC programs

is one of the most important determinant on the range and effectiveness of action on social

determinants as most of these programs have leaders with explicit focus on social justice and with the


- 57 -

vision of health development in the most holistic sense which is difficult to be replicated in any other

programs leave alone sub-national and national programs. In addition, action on social determinants is

a very political and long drawn out process requiring some very tough decision making which may be

one of the reasons for its little emphasis in national programs. In addition, the financial requirement for

such a program is huge and requires coordinated action of many government departments further

hindering its implementation in national CPHC programs. Furthermore, the pressure of target driven

external funding has further hindered any meaningful and effective measures to address social

determinants of health by national governments.

7.3.g. Incorporation of a rights-based approach

Not many NGO led local CPHC programs seem to explicitly use the language of rights even though

many of them are following rights incorporate rights based approach in their health programs. Only

one program that addressed health needs to commercial sex workers based in India explicitly speaks of

rights based approach 53. The reviews indicate that the programs by NGOs have tried to push the idea

of entitlements into consciousness of community members and mobilize them to demand for their

rights.

The review of country studies show that almost all countries seem to state that health care and health

services are rights of their citizens. However, except for Oman11 which has guaranteed to ensure health

care as a right to all its citizens, other countries seem to be paying it a lip service without actually

following or supplementing their declarations with concrete actions.

8. Conclusions:

The literatures review of CPHC experience in Asian region demonstrates that Asian region has had a

long and rich experience in CPHC concept, strategy and has played a major role in advocating the

same. The “Health for all by 200 AD” call by Alma Ata declaration of 1978 has had a major influence

on the Asian countries in adopting and experimenting with CPHC concept and strategy to structure and

re-structure national health systems to respond to people’s health needs. The commitment to global

improvements in health by the Health Assembly in resolution WHA51.7 (1998) during which member

nations have reaffirmed their commitments to “health for all” and have “affirmed their intent to ensure

the availability of the essentials of primary health care as defined in the Declaration and have set out

in the health-for-all policy for the twenty-first century” 9 albeit with varying success. The local NGO

led CPHC programs have continued to play a significant role, following their influential role during

Alma Ata declaration, in explaining and expanding concepts and principles and developing operating

mechanisms for effective implementation of CPHC.

The review of CPHC experiences in the Asian region has shown beyond doubt that CPHC is very

effective in reducing mortality and morbidity and improving health in a sustained and equitable

manner in local and defined populations. The size of reduction of mortality, sometimes more than half

or one-third of the comparable areas, coupled with its sustenance over a long period of time provides a

very convincing evidence for CPHC effectiveness in local areas. In addition, many of the local

programs have shown a more comprehensive social and health development of communities in the

program area compared to adjacent non-program areas giving evidence for effectiveness of CPHC

strategy for overall social development and importance for health to be placed in the context of overall


- 58 -

development of the community. The number and quality of studies reflecting on national and sub-

national health systems is low as compared to local CPHC programs. Even tough the evidence coming

up from national and sub-national studies is not as rigorous and as convincing in comparison to local

CPHC studies; they do provide substantial and clear evidence that national health systems modeled on

CPHC principles have been effective in reducing mortality and bringing about basic health

improvements even in resource constrained settings.

The findings also suggest that the concepts enunciated in Alma-Ata declaration continue to influence

key aspects of health policy and health systems in all the reviewed countries and suggest that there is a

continued albeit varying degree of commitment to the principles of Alma Ata declaration. However,

the shortcomings in the implementation of CPHC are attributed to lack of technical and practical

guidance; poor leadership; insufficient political commitment; inadequate resources allocated to CPHC;

unrealistic expectations placed on CPHC for providing a blanket solution for all health sector

problems; inadequate community participation; and continued top-down approach of health planning;

neglect of social justice and equitable development goals as envisioned by “new international

economic order” of Alma Ata declaration by the current global political and economic environment.

Despite these shortcomings, it looks like many countries are re-examining CPHC in recent years to

adapt it to a range of different health and social issues in the ever changing local, national and global

context. In this direction, many countries in the region are giving emphasis on regional approach and

strengthening the local capacities (both at state and district level) in planning, finance and management

of health systems while reiterating commitment to universal and equitable health development.

Furthermore, many national health systems are coming under increasing scrutiny and pressure from

empowered communities and rights-based people’s movements with a view of effective

implementation of CPHC in its most comprehensive manner.

This review of PHC experiences also throws up more questions than answers. Some of the important

learnings and challenges for future identified by the review are as follows:

o There is a great deal of diversity of understanding of the term CPHC. Simultaneously, the

concept of “Health for All” and its implications have received scant attention.

o The components of PHC are also understood and operationalized in varied forms by varied

programs. Some of the most important “confusions” which need to be clarified are as follows:

o Maintaining “Health for All” as a societal goal.

o “Comprehensive” in Comprehensive primary health care:

Comprehensive health care vs. Selective health care

Comprehensive health program (with health care program+ social empowerment

programs+ economic & political empowerment) vs. Comprehensive health

program with health care component only (however comprehensive that health

care component is)

o “Integration” of health care services

Integration of health service components of each disease(e.g. preventive,

promotive, curative and rehabilitative) vs. Integrated health services (Provision

of health services for different diseases and health conditions under a single

program)

o Community participation

Community development without altering socio-economic power relations to

pool community resources (community being viewed as “objects” and as passive


- 59 -

recipients of technological benefits) vs. People’s participation/Empowerment

approach where community is viewed as “subject” and transfer of power takes

place

o PHC program has worked well in diverse settings ranging from national level to small local

groups level and from rural to urban area to tribal areas. However, a pre-mobilized community

seems desirable for easy implementation of PHC.

o Issue of CPHC for urban poor is still relatively neglected area that needs emphasis if equity in

health and health care is the guiding principle of Health for All.

o Given the impact of global political economy and its impact on liberalization of trade and

privatization of social services including health and raising costs makes equity in health and

health care a difficult goal to achieve.


- 60 -

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