primary healthcare there was defined as something that
was universally accessible to individuals, families at the
community level, right where they needed, but also
the key point is, through their full participation.
And, again, the declaration said that primary healthcare would rely
on or be delivered through formal health workers, such as physicians,
nurses, midwives, community workers of the type that we've been talking about
here, volunteer village or community health
workers, traditional practitioners and of course others.
One thing that we would hope primary health care does is respond to
the express needs of the community because these vary from place to place.
again, getting back to the point we said earlier about the training needs
diagnosis being a bit more open ended as we talked about it before.
And, this activity, this whole process of primary healthcare would
be carried out in the spirit of partnership and service.
And we will stress again the importance of partnership between health service and the
community in making sure that village health
workers are delivering services that are needed.
So ideally, as we said, primary health care
should be based on what the community wants.
It may be first aid for farm accidents.
It may be treatment of children with fever.
But again, what we're seeing in many efforts to increase coverage of basic
child, maternal health services is a package
of services that would be nationally sanctioned.
These may include something like treating
malaria, something like handing out bed nets, something like promoting
hand washing and distribution of soap, and this would be something
that would be seen as a key package of interventions
that would address the major causes of child or maternal mortality.
This issue of, of specific elements in a package is not new.
Not long after 1978, the international
community was worried that the Alma Ata Declaration was too broad, and
they came up with what they called at that time selective primary healthcare.
And a number of agencies, whether it was USA, UNICEF, other NGOs, researchers
in universities said we really can't respond to everything the community wants.
Let's develop selective primary health care that focuses on
some of the major causes of morbidity and
some of the major issues of health promotion.
So, in that package, in those days, it
was called GOBI, Growth-monitoring,
Oral re-hydration, Breastfeeding and Immunization.
And to that was added family planning and girl's education.
But the, the idea was that, of course, diarrhea is a major cause of death.
malnutrition is a major underlining factor in other causes of death.
So growth monitoring to make sure the child is
growing, would be part of these primary health care packages.
Breastfeeding promotion.
Immunization.
And again these are not necessarily things that village health workers would
deliver, but they may be things that they could do health education on.
They could definitely promote oral rehydration
therapy even if it's mixing salt,
sugar solution at home in the village
or distributing packets, or referring people to
get immunization, or mobilizing the village if
immunization was done on a mobile basis.
We have village health workers, of course.
Community-based distributors doing family planning in markets
and in villages around, around the world.
This idea of if a specific package, selected package could
be, it would be easier to implement, it would have a greater impact on mortality.
At least this was the idea.
So it was getting away from responding to the community's felt needs.
Interestingly enough, along the way around the mid 1990's we were looking at the
problem of river blindness, or onchoceriasis, and
realized that in many places, of course,
there had been aerial spraying to kill black flies along rivers.
But this would not work throughout Africa.
It was great in the Sahel region where if there was a very
marked dry season, and you could actually fly over and see the rivers.
in the forest areas in Africa you could
not necessarily see streams and rivers through the
forest canopy, it would be harder to reach
them, there were many more sources of flowing water
in the rainy season.
and so what was discovered is this drug Ivermectin, and if any of you
have dogs or cattle, you may realize that this drug and its derivatives
used for heartworms and other kinds of veterinary use, that Merck Sharp & Dohme,
the company that developed it, realized that it might be also valuable for humans,
and it went through tests.
And it was determined that what it did was it provided clearance of all the
microfilaria of onchocerciasis worms, in the body, and if this was
done prior to the transmission season, when the black flies are going around
biting people, they would have no larvae to carry to the next person.
so this, if done over a period of 15, 20 years, could potentially
eliminate transmission.
So it was an exciting finding at the time that there
was a simple drug that could help reduce transmission throughout Africa.
And the company actually donated free, until further notice,
it's still being donated free to control this problem.
What was unique about it was that it
wasn't done strictly as a health service program,
driving out and giving people medicine.
The concept was developed using village health workers.
The community would select its own village health workers, as we talked about,