Failure of ‘Health for All’ in Rural Areas: Background and Causes
The ‘Health for All’ programme was enunciated through the Declaration of Alma Ata in 1978 which stated that, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity; it is a fundamental human right; and the attainment of the highest possible level of health is the most important worldwide social goal. Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures”.
Primary Health Care is the first level of contact between individuals of the family and community, with the national health system bringing health care as close as possible to where people live and work and it constitutes the first level of a continuing health care process. Primary Health Care addresses the main health problems in the community by providing promotive, preventive, curative and rehabilitative services accordingly. The year 2013 is halfway through already and even after 13 years we have not been able to attain “Health for All”.
Some developed countries have achieved many of the targets and goals. However, the health status of people in rural areas is generally worse than in urban areas around the world. Population and environmental health issues are the critical factors in the relationship between poverty and health which tends to encourage migration from rural areas to the cities where many people live without basic facilities of life. As described by MK Rajakumar, cities are a very recent and potentially ‘unnatural’ phenomenon and there should be effective programmes to reverse the rural–urban drift.
WHO’s International Development Programme has highlighted the need to focus specifically on improving the health of people in rural and remote areas as it will help in improving basic health care for all by reducing child and maternal mortality. In rural and remote areas, poverty and lack of facilities of health services are among major causes of high rates of avoidable deaths and injuries. Lifestyle-related illnesses are also more common in the rural areas with economic downturns often placing severe pressure on these communities. In the absence of facilities like counseling, support groups and other mental health services, there are significant levels of stress, higher alcohol and tobacco consumption, and varying standards of nutrition as compared to that in the cities.
There are usually cultural differences between rural urban communities and strong feelings of ‘gemeinschaft’ and ‘geselleschaft’ among people of various communities. A sense of behavioral norms is another aspect of the sociology and psychology of rural communities. People in rural areas often value very highly self-sufficiency, self-reliance and independence, coupled with stoicism. Mostly health is given a very low priority which often translates into the view that medical services and hospitals really are the last resort.
In most developing countries, the vast majority of the people are in rural areas whereas the condition is opposite in many developed countries. In all countries, accessibility to rural and remote communities is affected by the physical topography complicated by varying climatic conditions. Consequently, in some areas, at least some of the time, there is no means of transportation, and evacuation of critically ill or injured patients is impossible. The standard and quality of communications between different rural and remote areas and between those communities and the urban centers is also very variable.
All of these issues are emphasized in the context of often serious shortages of doctors, nurses and other health service providers in rural and remote areas. Rural health services require sufficient numbers of doctors and other health care providers with necessary healthcare skills. Sustainability of these services is dependent on adequate health service infrastructure and availability of specialist support. It is necessary that the development and delivery of health services in rural areas must be specific to the rural context and different from that in the cities.
Unfortunately, urban-based policy makers and health service planners often seem to think that a country is just like a city but with a different population distribution, and that it is possible simply to transplant modified urban health services to rural areas. Keeping in view all these aspects, it has now been stressed that these issues should be focused rather than addressing health in general. The 10/90 Report on Health Research, 1999 states same as “The global community should recognize that good health is a way out of poverty. It results in a greater sense of well-being and contributes to increased social and economic productivity.”
Considering these points together, there is a particular need to focus on the health and well-being in rural and remote areas so as to break out of the poverty–ill health–low productivity downward spiral. Some problems relate to the bureaucratic context as outlined by Judith Justice in her paper: ‘the bureaucratic context of international health—a sociologist’s view’ that many primary health care programmes were ineffective because they reflect the perspective and needs of the health bureaucracies involved rather than those of the local villages receiving the services. Often primary health care is interpreted differently in different bureaucratic settings and adapted to bureaucratic needs, but not necessarily adapted to the village cultures and conditions.
Another common problem is the tendency of primary health care programmes to dismiss curative interventions and to ignore the desire some people have regarding seeking help for their immediate health problems. A programme in Nepal, “The Nutrition Education Intervention Programme” did involve some curative intervention upon evaluation. The evaluators found that the inclusion of curative activities in the programme seemed to be a key factor in increasing the motivation of participants and acceptance by the community, contributing to the success of the programme. One of the most important problems is the tendency to exclude practicing clinicians.
As the notions of primary health care were developed, a strong emphasis was placed on disease prevention and health promotion. Consequently, over the years, the development of the community health approach focused on healthy lifestyle and ‘wellness’ in the extreme sense, to the point of excluding the practitioners, the clinicians—doctors, nurses and others who are perceived to be dealing with ill health. Such dichotomy and the tension have created difficulties.
From the above discussion, it can be concluded that without consideration of ‘facts about rural areas’ and active participation of GP’s, health professionals and the community in formulating and managing policies, the objectives of ‘Health for All’ can never fully be achieved.
About the Author: Muhammad Waqas Ahmed Bhatti is a medical student at NUST, Pakistan. He can be reached at [email protected].
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