NEWS FROM THE REGIONS
News from the Regions—Newsletter from India
RUHSA—A Model Primary Health Care Programme by Rajaratnam Abel RUHSA Dept., Christian Medical College, Vellore, India
270
© Oxford University Press 1992
CSU. In addition, over all administrative and logistic support is also provided from the CSU. The inputs provided by this infrastructure covered the entire range of health and development. Maternal and child health services consisted of antenatal care for pregnant women, and delivery services by trained Traditional Birth Attendants or by medical staff at the Health Centre. Family planning services were also provided. For the child, the predominant service was immunization along with vitamin A supplementation. Lack of support from mothers prevented implementing a successful growth monitoring programme. For the general community, low cost effective care was provided through 16 weekly peripheral clinics and through the government Primary Health Center and RUHSA Base Health Centre. These clinics handled the routine problems of the adults which included fevers, aches, pains, respiratory infections, and chronic diseases such as asthma and rheumatic heart disease. Due to the stigma attached, patients did not support a village-based diagnosis and treatment programme for tuberculosis. Besides direct services, health and nutrition education formed an integral component. In the early stages the education focused on antenatal care and immunization. Then it shifted to nutrition education and later to educating mothers on the use of ORS in diarrhoea. While the known TBAs were all trained in conducting safe delivery, untrained relatives continue to conduct deliveries. Community participation was elicited in a number of ways. Village Advisory Committees were formed. These helped in identifying the needs and problems of the villages. The community was encouraged to provide a building for the clinic. This was invariably provided by a richer person in the community. Their expectations in the form of free services for their kith and kin often surpassed their own contribution. This forced a shift to rented or own buildings. The community also participated in the selection of the Family Care Volunteers. Besides, as time passed the FCVs themselves became vehicles of communication to express the needs of the people. The Village Advisory Committee members, Health Aides, and Family Care Volunteers meet twice a year to identify community needs and problems, and suggest ways in which RUHSA could serve the community better. Journal of Tropical Pediatrics
Vol.38
October 1992
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
Rural Unit for Health and Social Affairs (RUHSA) was started as an intersectoral Primary Health Care Programme of Christian Medical College and Hospital, Vellore, India in 1977. Right from its inception health and development activities were implemented with more or less equal budget and personnel. The target community for its health services were children and mothers, and for its development services it was the poor, youth, and women. Among children the focus was on those under 2 years old. The primary purpose of RUHSA was to provide health and development services in a defined area (a block covering approximately 100000 people). This area was to be used for the training of medical, nursing, and social sciences students. Furthermore, research was to be conducted so as to provide answers to the problems in the areas of health and development. On completing 14 years of work it can be affirmed that these broad goals have been reached. A suitable infrastructure was developed to provide the services. This consisted of a village level health volunteer serving a population of approximately 1000 persons. This volunteer is always a female and is called Family Care Volunteer. Her primary role is to educate the community, motivate the mothers to utilize the health services and provide minimum curative services, primarily traditional. Literacy is not an essential criteria for selection. The Family Care Volunteer is supported by a female Health Aide also a volunteer, and a male Rural Community Officer (RCO), a full time staff. While the Health Aide supported the FCVs in their health work, the RCO concentrated on the process of community organization and participation. Both took part in the recording and reporting of vital events. Besides support to health inputs, the RCO is also involved in the development activities. Between them, the two workers covered a population of approximately 5000-7000 people. Each such unit is called a Peripheral Service Unit (PSU), and a total of 18 such units were established for the entire block. Since 1990 one RCO is responsible for two such units. One of these units designated as the Central Service Unit (CSU) serves as the headquarters for the programme. The CSU has a 60-bed health centre, manned by various levels of personnel. The specialists in the areas of development also operate from the
NEWS FROM THE REGIONS
Journal of Tropical Pediatrics
Vol.38
October 1992
The experience of RUHSA is very effectively used for training programmes. People from throughout India, Nepal, parts of South Asia, and East Africa have utilized the training programmes. One particular training programme is the Diploma in Community Health Management Course which is of 15 months duration. Over 70 candidates have been trained in this course. Besides this, there are courses in integrated rural development and community organization and development. Popular shorter workshops include Curriculum Development, Communication, Project Formulation, Participatory Planning, Participatory Training, and Project Evaluation. Research programmes have also been encouraged right from the beginning. A few major areas of policy research have been on basal metabolism rate and human adaptation, the effectiveness of growth monitoring, home-based, growth monitoring, acute and chronic respiratory diseases, the relationship between vitamin A deficiency, and morbidity. There have been a number of evaluative studies providing valuable information. However, one of the most significant research has been on the use of killed injectable polio vaccine (IPV). Right from the beginning RUHSA has used only IPV. It has been interesting to note the steady decline in poliomyelitis reaching zero incidence in 1988 and 1990-91. Based on this initial success the research has been taken by the other co-investigators into a larger area, and they are now also comparing the efficacy of oral polio vaccine and IPV. Having titled this as a model, the final question is whether this model is replicable. Being part of a large private medical institution, and with reasonably good finance and ideal infrastructure, this is not by itself easy to replicate in its totality. However, a number of individual components of this large programme can be successfully replicated. In fact, many trainees who come here are able to replicate a number of specific activities very successfully in their own programmes. When the principles of Primary Health Care were stated at Alma Ata very few would have realized that it could have been implemented almost word for word. RUHSA stands as a successful example of the stand taken at Alma Ata. It is hoped that the experiences gained here will help in taking the next steps beyond Alma Ata.
Cost Having described such a programme it is important to indicate the costs. The total operating cost of RUHSA including all direct and indirect costs works out to about 5 million rupees. This works out to a little less than Rs. 50/- per person or about US$2.5. If the administrative costs are excluded, then the 271
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
More recently specific target groups have been invited to join in the planning of programmes for their own development. Right from the beginning the community was encouraged to pay for the services rendered. Although this did not cover the entire cost it was another way of ensuring community participation. Service coverage outputs gradually increased till at present immunization coverage for BCG, DPT and polio range between 80 and 90 per cent. Antenatal coverage is about 85 per cent. At the CSU each year over 1200 deliveries are attended. In addition, about 1400 patients undergo tubectomy. Both these services are offered to people from outside the area as well. About 60 per cent come from within the area. Couple protection rate is about 55 per cent. Approximately 20000 new out-patient visits are handled and revisits number over 55000 each year. Over 4500 patients are admitted each year. Every year about 234 new cases of tuberculosis are diagnosed and treated. A significant proportion of the population has been covered with health and nutrition education. General Health and development films are screened regularly covering about 30000 people each year. Each year about 300 cataract surgeries are performed. More recently all severe and grade III malnourished children were taken through a community-based rehabilitation programme. Simultaneously, post-polio paralytic patients were also rehabilitated with specialists visiting the Primary Health Care Centre. Sanitary latrines have been provided to about 500 families and tile roofs have been provided to about 100 poor families by RUHSA, in addition to about 200 houses provided by the Government. RUHSA works very closely with the government. Through joint planning meetings, areas of work have been identified for the Government Health Staff and RUHSA staff. There is reasonably good co-ordination among both staff. One of the major problems encountered has been heavy staff turnover. Turnover of doctors and nurses has been the highest with periods of stay averaging 1-2 years. This heavy turnover has meant difficulties in standardizing programmes. A few senior staff have stayed long enough to maintain stability. Living and working in a rural area with all its limitations can be a frustrating experience for many. Development inputs includes economic and banking support, women's education and improvement, adult literacy, vocational training, social rehabilitation, agriculture and animal husbandry, and energy in the form of biogas. The staff and budget allotted for this development side is considerable and almost equals the health infrastructure. While health services have been extensive, development activities also constitute an important component of RUHSA's intersectoral primary health care programme.
NEWS FROM THE REGIONS
TABLE 1
Overall impact of RUHSA's work in K. V. Kuppam
Central service unit (Base Health Centre) Out-patients new revisit In-patient delivery tubectomy cataract surgery case fatality rate perinatal mortality rate
1986
1990
96234
— — 8.0 — 65
103907 23.3
— — —
34
15.0 — 116
23.3
11.3 1007 9.7%
949
14.1%
9.3 —
50.8 8.57 1011 11.4%
33.04% (90/91) 62.6 (90)
— — — —
12 — 160 — 7.0 7.0 5.4 8.9 — —
— — — — —
— — — — —
— — — — —
— — — —
60% 70% 74%
>80% >80% >95%
57.1%
— — — —
12088 33094 2025
18462 47463 3081
21331 56647 4533
426
654 974
1253
26 (79) — —
26.0 26.0
7655 10932 442 179 97
27.1
total cost would be $2.00 per person. If RUHSA's training programmes are further excluded, the cost decreases to $1.5 for the direct services in health and development. RUHSA's health services alone cost around $1.00 per person while the addition of Government health services would increase it to $1.50.
272
1983
1050 17.3
4 12 31 —
8.8 (88) 2.7 2.8 4.9 — —
12.0
0(90/91) 1 (90/91) 8 (90/91) 0(90/91)
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
Demographic indicators (block) Population Crude birth rate Crude death rate Perinatal mortality rate Infant mortality rate Child mortality rate Sex ratio Proportion children under 5 Morbidity statistics (block) Polio Whooping cough Measles Tetanus neonate Severe malnutrition Ac < 12.5 cm Wt/Age
News from the Regions—Newsletter from India
RUHSA—A Model Primary Health Care Programme by Rajaratnam Abel RUHSA Dept., Christian Medical College, Vellore, India
270
© Oxford University Press 1992
CSU. In addition, over all administrative and logistic support is also provided from the CSU. The inputs provided by this infrastructure covered the entire range of health and development. Maternal and child health services consisted of antenatal care for pregnant women, and delivery services by trained Traditional Birth Attendants or by medical staff at the Health Centre. Family planning services were also provided. For the child, the predominant service was immunization along with vitamin A supplementation. Lack of support from mothers prevented implementing a successful growth monitoring programme. For the general community, low cost effective care was provided through 16 weekly peripheral clinics and through the government Primary Health Center and RUHSA Base Health Centre. These clinics handled the routine problems of the adults which included fevers, aches, pains, respiratory infections, and chronic diseases such as asthma and rheumatic heart disease. Due to the stigma attached, patients did not support a village-based diagnosis and treatment programme for tuberculosis. Besides direct services, health and nutrition education formed an integral component. In the early stages the education focused on antenatal care and immunization. Then it shifted to nutrition education and later to educating mothers on the use of ORS in diarrhoea. While the known TBAs were all trained in conducting safe delivery, untrained relatives continue to conduct deliveries. Community participation was elicited in a number of ways. Village Advisory Committees were formed. These helped in identifying the needs and problems of the villages. The community was encouraged to provide a building for the clinic. This was invariably provided by a richer person in the community. Their expectations in the form of free services for their kith and kin often surpassed their own contribution. This forced a shift to rented or own buildings. The community also participated in the selection of the Family Care Volunteers. Besides, as time passed the FCVs themselves became vehicles of communication to express the needs of the people. The Village Advisory Committee members, Health Aides, and Family Care Volunteers meet twice a year to identify community needs and problems, and suggest ways in which RUHSA could serve the community better. Journal of Tropical Pediatrics
Vol.38
October 1992
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
Rural Unit for Health and Social Affairs (RUHSA) was started as an intersectoral Primary Health Care Programme of Christian Medical College and Hospital, Vellore, India in 1977. Right from its inception health and development activities were implemented with more or less equal budget and personnel. The target community for its health services were children and mothers, and for its development services it was the poor, youth, and women. Among children the focus was on those under 2 years old. The primary purpose of RUHSA was to provide health and development services in a defined area (a block covering approximately 100000 people). This area was to be used for the training of medical, nursing, and social sciences students. Furthermore, research was to be conducted so as to provide answers to the problems in the areas of health and development. On completing 14 years of work it can be affirmed that these broad goals have been reached. A suitable infrastructure was developed to provide the services. This consisted of a village level health volunteer serving a population of approximately 1000 persons. This volunteer is always a female and is called Family Care Volunteer. Her primary role is to educate the community, motivate the mothers to utilize the health services and provide minimum curative services, primarily traditional. Literacy is not an essential criteria for selection. The Family Care Volunteer is supported by a female Health Aide also a volunteer, and a male Rural Community Officer (RCO), a full time staff. While the Health Aide supported the FCVs in their health work, the RCO concentrated on the process of community organization and participation. Both took part in the recording and reporting of vital events. Besides support to health inputs, the RCO is also involved in the development activities. Between them, the two workers covered a population of approximately 5000-7000 people. Each such unit is called a Peripheral Service Unit (PSU), and a total of 18 such units were established for the entire block. Since 1990 one RCO is responsible for two such units. One of these units designated as the Central Service Unit (CSU) serves as the headquarters for the programme. The CSU has a 60-bed health centre, manned by various levels of personnel. The specialists in the areas of development also operate from the
NEWS FROM THE REGIONS
Journal of Tropical Pediatrics
Vol.38
October 1992
The experience of RUHSA is very effectively used for training programmes. People from throughout India, Nepal, parts of South Asia, and East Africa have utilized the training programmes. One particular training programme is the Diploma in Community Health Management Course which is of 15 months duration. Over 70 candidates have been trained in this course. Besides this, there are courses in integrated rural development and community organization and development. Popular shorter workshops include Curriculum Development, Communication, Project Formulation, Participatory Planning, Participatory Training, and Project Evaluation. Research programmes have also been encouraged right from the beginning. A few major areas of policy research have been on basal metabolism rate and human adaptation, the effectiveness of growth monitoring, home-based, growth monitoring, acute and chronic respiratory diseases, the relationship between vitamin A deficiency, and morbidity. There have been a number of evaluative studies providing valuable information. However, one of the most significant research has been on the use of killed injectable polio vaccine (IPV). Right from the beginning RUHSA has used only IPV. It has been interesting to note the steady decline in poliomyelitis reaching zero incidence in 1988 and 1990-91. Based on this initial success the research has been taken by the other co-investigators into a larger area, and they are now also comparing the efficacy of oral polio vaccine and IPV. Having titled this as a model, the final question is whether this model is replicable. Being part of a large private medical institution, and with reasonably good finance and ideal infrastructure, this is not by itself easy to replicate in its totality. However, a number of individual components of this large programme can be successfully replicated. In fact, many trainees who come here are able to replicate a number of specific activities very successfully in their own programmes. When the principles of Primary Health Care were stated at Alma Ata very few would have realized that it could have been implemented almost word for word. RUHSA stands as a successful example of the stand taken at Alma Ata. It is hoped that the experiences gained here will help in taking the next steps beyond Alma Ata.
Cost Having described such a programme it is important to indicate the costs. The total operating cost of RUHSA including all direct and indirect costs works out to about 5 million rupees. This works out to a little less than Rs. 50/- per person or about US$2.5. If the administrative costs are excluded, then the 271
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
More recently specific target groups have been invited to join in the planning of programmes for their own development. Right from the beginning the community was encouraged to pay for the services rendered. Although this did not cover the entire cost it was another way of ensuring community participation. Service coverage outputs gradually increased till at present immunization coverage for BCG, DPT and polio range between 80 and 90 per cent. Antenatal coverage is about 85 per cent. At the CSU each year over 1200 deliveries are attended. In addition, about 1400 patients undergo tubectomy. Both these services are offered to people from outside the area as well. About 60 per cent come from within the area. Couple protection rate is about 55 per cent. Approximately 20000 new out-patient visits are handled and revisits number over 55000 each year. Over 4500 patients are admitted each year. Every year about 234 new cases of tuberculosis are diagnosed and treated. A significant proportion of the population has been covered with health and nutrition education. General Health and development films are screened regularly covering about 30000 people each year. Each year about 300 cataract surgeries are performed. More recently all severe and grade III malnourished children were taken through a community-based rehabilitation programme. Simultaneously, post-polio paralytic patients were also rehabilitated with specialists visiting the Primary Health Care Centre. Sanitary latrines have been provided to about 500 families and tile roofs have been provided to about 100 poor families by RUHSA, in addition to about 200 houses provided by the Government. RUHSA works very closely with the government. Through joint planning meetings, areas of work have been identified for the Government Health Staff and RUHSA staff. There is reasonably good co-ordination among both staff. One of the major problems encountered has been heavy staff turnover. Turnover of doctors and nurses has been the highest with periods of stay averaging 1-2 years. This heavy turnover has meant difficulties in standardizing programmes. A few senior staff have stayed long enough to maintain stability. Living and working in a rural area with all its limitations can be a frustrating experience for many. Development inputs includes economic and banking support, women's education and improvement, adult literacy, vocational training, social rehabilitation, agriculture and animal husbandry, and energy in the form of biogas. The staff and budget allotted for this development side is considerable and almost equals the health infrastructure. While health services have been extensive, development activities also constitute an important component of RUHSA's intersectoral primary health care programme.
NEWS FROM THE REGIONS
TABLE 1
Overall impact of RUHSA's work in K. V. Kuppam
Central service unit (Base Health Centre) Out-patients new revisit In-patient delivery tubectomy cataract surgery case fatality rate perinatal mortality rate
1986
1990
96234
— — 8.0 — 65
103907 23.3
— — —
34
15.0 — 116
23.3
11.3 1007 9.7%
949
14.1%
9.3 —
50.8 8.57 1011 11.4%
33.04% (90/91) 62.6 (90)
— — — —
12 — 160 — 7.0 7.0 5.4 8.9 — —
— — — — —
— — — — —
— — — — —
— — — —
60% 70% 74%
>80% >80% >95%
57.1%
— — — —
12088 33094 2025
18462 47463 3081
21331 56647 4533
426
654 974
1253
26 (79) — —
26.0 26.0
7655 10932 442 179 97
27.1
total cost would be $2.00 per person. If RUHSA's training programmes are further excluded, the cost decreases to $1.5 for the direct services in health and development. RUHSA's health services alone cost around $1.00 per person while the addition of Government health services would increase it to $1.50.
272
1983
1050 17.3
4 12 31 —
8.8 (88) 2.7 2.8 4.9 — —
12.0
0(90/91) 1 (90/91) 8 (90/91) 0(90/91)
Downloaded from http://tropej.oxfordjournals.org/ at UQ Library on July 29, 2015
Demographic indicators (block) Population Crude birth rate Crude death rate Perinatal mortality rate Infant mortality rate Child mortality rate Sex ratio Proportion children under 5 Morbidity statistics (block) Polio Whooping cough Measles Tetanus neonate Severe malnutrition Ac < 12.5 cm Wt/Age
![[Diabetic retinopathy screening programme in primary health care. Diagnostic concordance between family and eye care practitioners].](/assets/img/hold.png)
