Elsevier

Social Science & Medicine

Volume 48, Issue 8, April 1999, Pages 1053-1067
Social Science & Medicine

Attaining health for all through community partnerships: principles of the census-based, impact-oriented (CBIO) approach to primary health care developed in Bolivia, South America

https://doi.org/10.1016/S0277-9536(98)00406-7Get rights and content

Abstract

This article describes a flexible primary health care methodology which was developed by Andean Rural Health Care and its colleagues in Bolivia, South America. This methodology, the census-based, impact-oriented (CBIO) approach to primary health care, involves determining local health priorities as defined both by locally acquired epidemiologic information and by the local people themselves. The CBIO approach to primary health care is now functioning successfully at seven program sites in Bolivia, which together serve 75,000 people in urban and rural communities in three distinct cultural and ecological regions of the country.

High levels of coverage of basic health services can be achieved through a system of `epidemographic' surveillance of all families and through home delivery, when needed, of priority services to those at risk. When the services provided are based on local health priorities, when they are provided in a technically effective manner, and when the community has a strong partnership in planning, implementation and evaluation, then the CBIO approach to primary health care will lead to measurable health improvements as defined by changes in population-based rates of mortality and illness in the community.

On the basis of our experience, we believe that the CBIO approach offers great potential for strengthening the effectiveness of local health programs in impoverished communities around the world in a way which fosters community ownership and, hence, long-term sustainability.

Introduction

It has been two decades since the comprehensive primary health care philosophy of Health for All by the year 2000, embodied in the Declaration of Alma Ata, was adopted in 1978 by member governments of the World Health Organization (WHO/UNICEF, 1978). It has also been two decades since the appearance of the seminal article by Walsh and Warren (1979)calling for `selective primary health care' as an `interim strategy for disease control' in low-income countries. Since then, the comprehensive versus selective debate has continued.

Unfortunately, considerable evidence exists indicating that primary health care services (either comprehensive or selective) in economically developing countries have not produced improvements in the health status of the recipients of these services (Ewbank and Gribble, 1993; Murray and Chen, 1993). Furthermore, the great majority of the world's population in low-income countries continues to lack access to a basic `package' of essential preventive and curative services (World Bank, 1994).

Thus, Health for All by the year 2000 will be a reality for only a minority of the world's population. More than 1.36 billion disability-adjusted life years (DALYs)1 are being lost annually around the world because of premature death and disability (World Bank, 1994).

The prospects in the near future for achieving global equity in levels of health and in access to basic health services also remain dim. While the low-income countries of Sub-Saharan Africa and Asia (excluding China) account for 39% of the world's population, these same countries experience 56% of the world's DALYs lost because of premature death and disability (World Bank, 1994).

Furthermore, within low-income countries at national, regional, and local levels there are major inequities in health status and health services. For instance, a third of the one million deaths which occur every year in China are among the 12% of the population who live in remote areas or who are ethnic minorities (Taylor, 1992). In urban Bangladesh, while the overall infant mortality rate is 87 deaths per 1000 live births, the infant mortality rate in urban slum populations is 180 (UNICEF, 1993). Within one District of Ethiopia (Butajira), the mortality of children under five years of age is twice as great in the rural lowlands as in the rural highlands, and even within the lowland and highland areas respectively, there are two-fold differences in under-five mortality (Shamebo et al., 1991). In a longitudinal community-based epidemiologic study in the Punjab of India, 13% of the mothers experienced multiple child deaths which accounted for 62% of the child deaths registered during the reproductive lives of all of the women in the community (Das Gupta, 1990).

Improving community-based primary health care2 services is but one of a number of interrelated approaches to health improvement in poor communities (along with improving the status of women, education, nutrition, water quality, sanitation, and other socioeconomic conditions). Over the past two decades, the merits of both the comprehensive and selective types of approaches to primary health care have continued to be recognized. Although some have viewed the two types of approaches as directly conflicting (Wisner, 1988), others have considered them to be mutually supportive and complementary (Taylor and Jolly, 1988). Technical soundness and cost-effectiveness have typically been considered as strengths of the selective approach, while community participation and sustainability have typically been viewed as strengths of the more comprehensive approach. Both approaches have their limitations as well. According to some, the selective approach tends to be highly centralized and less responsive to the felt needs of communities, while the comprehensive approach is seen as more expensive, too complicated for lower-level workers to implement, and difficult to evaluate (Gish, 1982; Unger and Killingsworth, 1986; Engelkes, 1993).

In view of the strengths which both approaches may bring to Health for All, it is appropriate to consider examples from the field in which aspects of both have been melded into a `middle way' (Mosley, 1988), by which is meant a feasible methodology for primary health care which unites the best aspects of both comprehensive and selective primary health care. This article describes one such `middle way', developed beginning in the early 1980s by Andean Rural Health Care (ARHC), a nongovernmental organization providing community-based primary health care in Bolivia.

Andean Rural Health Care and its sister organizations (Consejo de Salud Rural Andino and Asociación de Programas de Salud del Area Rural) have now been working since the early 1980s in the provision of community-based primary health care services on the Northern Altiplano, in the Cochabamba valley, and in the Santa Cruz region of Bolivia. These activities have been reported in greater detail elsewhere (Perry, 1993; Perry and Sandavold, 1993; Ofosu-Amaah, 1994; Shanklin and Perry, 1994; Wyon, 1994; Perry et al., 1998a, Perry et al., 1998b; Shanklin et al., 1998).

This `middle way' developed by ARHC has now become known as the `census-based, impact-oriented' (CBIO) approach to primary health care. The CBIO approach emerged initially as a result of efforts by ARHC staff to improve primary health care services in a rural highland area known as the northern Altiplano of Bolivia, where such services previously had been virtually nonexistent and where the communities there had maintained a tradition of lack of faith in and involvement with modern health services. The success of the CBIO approach on the northern Altiplano and the resulting enthusiasm of the local ARHC staff there led other ARHC-related projects in the Cochabamba and Santa Cruz regions of the country to also adopt the CBIO approach.

The CBIO approach is now being utilized in seven program sites throughout Bolivia which serve a total of 75,000 people. The sites range from sparsely populated remote rural communities to low-income urban neighborhoods, from Andean highland communities to tropical lowland communities, and from homogeneous traditional native-American communities to multiethnic and multicultural communities. The CBIO approach has now become the key unifying methodology for ARHC and is beginning to be applied at new ARHC projects outside of Bolivia, including one on the Texas–Mexican border and one in collaboration with FOCAS, an NGO working in Haiti. In addition, the CBIO approach and ARHC's experiences with it have been the basis of a case study in the required introductory health course at the Department of International Health at the Rollins School of Public Health at Emory University in Atlanta since 1994. Students from around the world have found this methodology to be an exciting one which they are eager to apply upon their return to their host countries. Furthermore, increasing numbers of students (including those from Emory) and health specialists are visiting ARHC's program sites in Bolivia to learn first-hand about the CBIO approach.

What follows is an attempt to synthesize the principles that have emerged over more than a decade of experience in the development and application of this new methodology for primary health care.

Section snippets

An overview of the census-based, impact-oriented approach to primary health care

The CBIO approach is a two-stage process whose overarching goal is to improve the health of geographically delineated communities. An exploratory and pilot program stage precedes the definitive program stage. During the definitive program stage, a community diagnosis derived from locally acquired information provides the basis for program planning. Then, after a predetermined period of program implementation, the findings from the program evaluation and community rediagnosis provide a basis for

Specific activities carried out during the exploratory and pilot program stage

Exploratory planning involves specifying the program's long-term goals and objectives, identifying potential sources of support and potential program sites, and negotiating preliminary agreements with the appropriate officials and community leaders (Table 2). The program leadership also gathers readily available information to guide initial project activities. We refer to these activities as reconnaissance. Two types of reconnaissance are called for: `library' reconnaissance and `field'

The tradition upon which the CBIO approach is based

The CBIO approach incorporates the previous experience of others in community-based epidemiological research and service delivery (Wyon and Gordon, 1971; Frederiksen, 1971; Gwatkin et al., 1980; Berggren et al., 1981; Kielmann et al., 1983; Taylor et al., 1983; Fauveau, 1994; Wyon, 1994; Scrimshaw, 1995; Das Gupta et al., 1997) and also upon the tradition of community-oriented primary care (Kark, 1974; Geiger, 1993). The CBIO approach shares similarities with other primary health care and

Conclusion

The CBIO approach to primary health care described here has been developed during more than a decade of practical experience in Bolivia, South America. The concepts behind this approach have been derived from several generations of innovative community-based health activities around the world. While the application of CBIO concepts has been tailored to the Bolivian context, the methodology deserves wider application and evaluation. The experience with this and similar methodologies can

Acknowledgements

The authors would like to express their deep appreciation to the many staff members of Andean Rural Health Care (ARHC), El Consejo de Salud Rural Andino (CSRA), and La Asociación de Programas de Salud del Area Rural (APSAR) who have played a key role in contributing to the concepts presented here and, more importantly, to interpreting, applying, modifying, and making workable the concepts presented here. Although these staff members are too numerous to mention individually, we would like to

Dr. Henry Perry is a physician who lived in Bolivia from 1981 to 1984 and worked with Andean Rural Health Care from 1980 until 1995. He is now an MCH Advisor in Dhaka, Bangladesh, Associate in the Department of International Health, Johns Hopkins School of Hygiene and Public Health and Visiting Professor in the Department of International Health, Emory University School of Public Health.

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    Dr. Henry Perry is a physician who lived in Bolivia from 1981 to 1984 and worked with Andean Rural Health Care from 1980 until 1995. He is now an MCH Advisor in Dhaka, Bangladesh, Associate in the Department of International Health, Johns Hopkins School of Hygiene and Public Health and Visiting Professor in the Department of International Health, Emory University School of Public Health.

    Mr. Nathan Robison is a development specialist who has provided leadership in Bolivia over the past 20 years for community-based programs, including serving since 1986 as Bolivia Country Director for the Consejo de Salud Rural Andino, Andean Rural Health Care's counterpart NGO in Bolivia.

    Dr. Dardo Chavez is a physician who has been working in public health and community medicine in the Santa Cruz area of Bolivia for the past 20 years. He has been the regional director of the Consejo de Salud Rural Andino since 1986 in Montero.

    Dr. Orlando Taja is a physician who has been working in public health and community medicine throughout Bolivia for the past 30 years. He is the founder and executive director of the Asociación de Programas de Salud del Area Rural, based in Cochabamba. He has been collaborating with Andean Rural Health Care since 1985.

    Dr. Carolina Hilari is a physician who served as regional director for the northern Altiplano and technical advisor of the Consejo de Salud Rural Andino from 1991 until 1995. She currently serves on its board of directors.

    Mr. David Shanklin is a public health nutritionist who has worked for 15 years in nutrition program evaluation and health promotion/disease prevention. He has worked since 1990 with Andean Rural Health Care, based at Lake Junaluska, NC, where he currently serves as International Program Director.

    Dr. John Wyon worked for 20 years in community-based health activities in Africa and India before coming to the Department of Population and International Health at the Harvard University School of Public Health, where he has taught since 1960. He has worked with Andean Rural Health Care since 1979.

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