307 health

Medical Alliance POTENTIAL CONTRIBUTION OF PRIMARY-SCHOOL TEACHERS TO THE HEALTH OF A DEVELOPING COUNTRY

SHABBIR AHMED P.O. Box 125, Kisumu,

Summary

budget-was

developing countries, Kenya gives higher priority to primary

education than to health services. Thus, in rural areas primary schools are evenly distributed, well attended, and staffed by well-qualified teachers whereas health centres are thinly scattered, inaccessible to many, and staffed largely by people of low educational attainment. The public-health knowledge of school teachers exceeds that of many health workers. It is suggested that teachers of health science, in particular, represent a valuable resource for preventive and promotive medicine which can be exploited at little cost. INTRODUCTION

POVERTY and disease afflict nearly a third of the world’s people, and they sustain each other. This unhappy balance has been altered for the worse by inflation in the developed world and a consequent rise in the cost of medical care. Confronted with serious depletion of human resources by a rising incidence of disease, and the possibility of descent into a Fourth World of absolute poverty, many governments have examined alternatives to Western-style medicine-acupucture, herbal medicine, barefoot doctors, even witch doctors. Such alternatives sometimes have considerable national appeal; but they are all retrograde. What we need is some more efficient way of applying conventional forms of preventive and promotive medicine. In this article I suggest enrolment of a new group of health workers who are already well qualified. I show how this might work in Kenya, which is typical of developing countries in being tropical, having a host of diseases, and having attained independence comparatively recently. Political stability has enabled Kenya to put considerable effort into improvement of health services, and the shortcomings of the existing system partly reflect inappropriate influences from the developed world. HEALTH-CARE IN KENYA

to

rural health services, which

92% of the population, while

teams

rather than in formal programmes. Promotive medicine

one specialist centre, Kenyatta National Hospital, consumed 15% of the health budget.Preventive health care, as practised, consists largely of immunisations, which are offered as a crisis measure by mobile

(essentially, family planning, and child/maternal health) is seldom seen outside the provincial centres. Health-education centres do exist, but they have been kept very short of funds. EDUCATION IN KENYA

Kenya

Like many other

allocated

cover

Kenya has 8095 primary schools, evenly distributed in 2650 sublocations-1 primary school for every 1667 of the population.2 The great majority offer a full seven years’ primary education, of which the first five years are free. The national coverage is 80% and rising fast; in Central Province it is already 100%. 1 in every 4-85 of the population attends a primary school, where English language and mathematics are compulsory subjects. Health science is also part of the syllabus, and every school has at least one teacher qualified in the sub-

ject. Primary schools

are well equipped, and all have at least one other than classrooms; most have adequate water and sanitation. Rural coverage of education is excellent, taking up two-thirds of the whole education budget. Rural spending on primary education is over 2ytimes the total national health budget; 90 800 teachers are engaged in primary education. School teachers enjoy tremendous respect in the community; of the 23 members of Cabinet, 15 were teachers, and most members of Parliament are former teachers or have been connected with teaching.

. room

HEALTH AND EDUCATION PROVISION IN KISUMU DISTRICT

contrast between health and education provision exemplified by the situation in Kisumu District-a typical rural area. It contains swamps, arid plains, irrigated land, and plateau, and the altitude varies from 2700 feet to 6200 feet. In 1967 the population was 400 467, and the projected population in 1980 is 600 000. Most known tropical diseases are found in Kisumu. The malarial parasite was first isolated there.

The

is

Health Services

Health care is supplied through sixteen scattered outlets-two health centres, three health subcentres, and eleven dispensaries (fig. 1). The total staff is 86, of whom 46 have only a certificate of primary education (C.P.E.) or less, 33 are enrolled nurses or clinical officers with basic education (Kenya Junior School Examination K.J.S.E. or C.P.E.) plus three years’ paramedical training (medical assistant), and 5 are educated up to 0 (ordinary) level standard and/or have been on some sort of

The population of Kenya is expected to reach 16 million by 1980, and 92% of it is rural. The gross domestic product in rural areas is C20 ($36) per head per year; in 1975, despite a economy, only 1 was available per head for the national health service, including its administration. In 1969 10 million episodes of disease were treated, of which maternal diseases constituted 5%, communicable diseases 16%, environmental diseases 29%, nutritional diseases 10%, and respiratory and gastrointestinal diseases 365%. The estimated 1976-77 figure was 16 million episodes and this was still mainly accounted for by people living within 5 miles of a health-care facility. The coverage is very poor in rural areas. Dispensaries, sub health centres, and health centres provide most of the service, and they are largely occupied with primary symptomatic treatment; they practise little preventive medicine. These centres are staffed by a small number of paramedicals assisted by personnel with no recognised training. In 1975 only C2-3 million-less than 11% of the total

healthy looking

Fig.

1-Health facilities in Kisumu.

308 There is one dispensary headed by an enrolled nurse for every 31 250 people and 65 square miles, and an average of 1 health worker, including sweepers, for every 5814 people. Fig. 2 summarises the distribution of staff and their educational attainments. Primary Education

retraining course.

TABLE I-HEALTH-SCIENCE

QUESTIONS

FOR EAST AFRICAN

CERTIFICATE OF EDUCATION

primary

The district has295 schools, of which 205 offer seven years’ teaching up to C.P.E. standard. Just over half the 2790 teachers have had three years at teacher-training college after 0 levels or A (advanced) levels. Of the remaining 1280, 452 have passed A levels or 0 levels, and the rest have the K.J.S.E. Health science is taught in all teacher-training colleges, and most of the "untrained" teachers have taken the subject at A or 0 level (fig. 3). The scope of the health-science syllabus for the East African Certificate of Education is illustrated by table i, which analyses examination papers from 1974 to 1976. The following two sample questions are

typical: Discuss how economic development of a nation may be affected by poor methods of excreta disposal. Describe the general measures taken to reduce the incidence of and death from tuberculosis in a community.

Figures in parentheses questions.

denote essay

as

opposed

to

multiple-choice

TABLE 11-PERFORMANCE OF SIX MEDICAL ASSISTANTS IN

1976

E.A.C.E. HEALTH-SCIENCE PAPER

Public-health Knowledge of Medical Assistants I have made a small study of the public-health knowl-

of existing Ministry of Health workers. The 1976 examination paper was given to six medical assistants who, after three years in medical school, were doing their resident year in preparation for running health centres. None scored over 50%, and their knowledge of public health was alarmingly poor (table II).

edge

SCHOOL TEACHERS AS PART OF THE NATIONAL HEALTH SYSTEM

valuable and under-used resource for health education. Just as literacy and numeracy are essential for national and personal welfare, so too is health knowledge. I suggest that if the principles of health care were made compulsory subjects up to C.P.E. level, this would help to remedy deficiencies (both in quality and in coverage) of existing public-health education. Furthermore, many of the teachers could be converted quickly into part-time health workers. Unlike health services, the educational infrastructure extends into the rural depths; and the potential impact of the scheme is shown by the fact that, at this moment, a fifth of the population is going through primary school. With further training, healthscience teachers might well become better at providing promotive health care than are the existing health workers. They are in close contact with their communities and can communicate freely. They command respect. These qualities should surely be exploited in any future plans for national health in Kenya-and perhaps other countries similarly placed. I believe that teachers represent

Fig. 2-Distribution and attainmentsof health-service staff.

REFERENCES

Fig. 3-Distribution and attainments of teaching staff.

1. 1976/77 Estimates and Expenditure. Kenya, 1976. 2. Primary Education annual report. Kenya, 1975.

a

Potential contribution of primary-school teachers to the health of a developing country.

307 health Medical Alliance POTENTIAL CONTRIBUTION OF PRIMARY-SCHOOL TEACHERS TO THE HEALTH OF A DEVELOPING COUNTRY SHABBIR AHMED P.O. Box 125, Kisu...
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