Primary Health Care and Church Planting

by J. Paul Seale

In 1983, the Philippine Baptist Mission began a pilot project in primary health care to see if we could come up with a church-planting strategy.

During the past decade, mission agencies have been developing primary health care programs to train villagers how to provide their own basic health care. Guidelines for these programs are now pretty well in place, but so far we haven’t been able to figure out how to tie them into church planting. So, in 1983, the Philippine Baptist Mission began a pilot project in primary health care to see if we could come up with a church-planting strategy.

OUR PROJECT PLANS
Project development. We assigned a missionary physician and an experienced church planter to a city of 200,000 on a remote island in the Philippines. For the first five months the physician studied the language culture. At the same time, we met with mission and national church leaders, national physicians, government leaders to discuss the pros and cons of various medical church-planting models (see appendix).

We gave priority to those models that emphasized primary health care interventions, but we also tried to take into consideration the nationals’ desire for curative physician services. A two-part plan emerged: (1) weekly clinics in three villages near the project’s home base, to be carried out over 14 months; (2) two three-day medical crusades in remote villages where weekly ministry was not feasible.

We began the medical efforts with a two-month pilot project in a mountain village of 1,200 people near the city, to work out patient flow, supplies and medicines needed, and job assignments among the staff. We also experimented with integrating outpatient services, health teaching, and Bible study into a single day’s clinic. After the pilot program, we chose three towns and villages as sites.

Site selection. In light of a concentration of medical resources in larger towns cities, we chose needy towns and villages ranging from 2,000 to 12,000 people. None had physicians. All were within a two-hour drive from project headquarters, so the team could come and go the same day. We met with local government and health authorities and arranged our clinic schedules with them.

Program goal. Our long-term medical goal was to train local people in prevention-oriented basic health care. However, at each site we found that many people wanted to see the physicians at the clinics. Therefore, we decided to hold clinics the first four months (Phase I) and then train health workers the last 10 months of the project (Phase II).

At each site we wanted to organize a new church. We planned to do evangelism four months and discipleship and leadership training the last 10 months. During the last four months we would scale down and phase out our activities (Phase III).

Team composition. The church planter and the physician headed the team. We recruited a national nurse and health teacher to help in the medical program. We recruited volunteers from area Baptist churches to help in evangelism and other tasks during the clinics. Several local church members with medical skills— two dentists and three hi-lots (traditional Filipino healers who perform therapeutic massage)— also joined our team.

Patient care. Because the people wanted to be treated by a physician, we designated him as the primary care provider in the early stages. Later on, we decided to train the team nurse and government nurses and midwives to do patient care. We also trained nonmedical people to give basic health care in the villages.

We gave high priority to making this project reproducible, so we took no lab or x-ray equipment with us. We referred patients to hospitals and carried only medicines that were bought in local pharmacies. We sold medicines at cost rather than giving them away. Our medical consultations were also free, in line with government practice.

Health teaching. Based on West African models, our health education program used the storytelling method. The team made up the stories during brainstorming sessions and then had them translated. Orignally, we had planned to hire a health aide, but during our pilot project a local church member with teacher training volunteered and she did the job so successfully that we hired her to do our health teaching. She taught simple health care concepts such as proper infant nutrition, childhood immunizations, and treatment of diarrhea.

Church-planting strategy. We planned to start with home Bible studies that would later become house churches. We used self-study booklets beginning with a series of salvation studies and moving to discipleship lessons for new Christians. The studies were organized to encourage people to be baptized and to organize a church after four months.

Clinic patients would get gospel tracts, and, as much as possible, team members would go over the tract with the patients and give them an opportunity to receive Christ. Also, the physician attempted to pray briefly with each patient and the church planter, or a local church volunteer would preach a brief gospel message during a clinic break.

We hoped that after a month, one or more home Bible studies would be organized in each village, as we visited those who had made professions of faith at the clinic. The church planter would lead the studies at first and then turn them over to local church volunteers. Out of these small groups we hoped to see churches organized at each site within four to five months.

Medical crusades. Halfway through Phase I, we planned a one-week clinic break, to hold a three-day medical crusade in a remote area. We went to a mountain where there was a small Baptist mission point (eight baptized believers) with a highly committed lay leader. Medically, we intended to provide clinic services and to give lectures on immunizations. At the same time, we hoped to move the mission point toward organizing a church.

Near the beginning of Phase II, we planned to hold a second medical crusade, this time in a tribal area where we thought the people were more needy medically and more responsive spiritually than the other ethnic groups (primarily lowland Filipinos) whom we were working with. We chose an isolated mountain village with no medical services and no church of any kind. Our goal here was to provide clinic services and to help start a new church.

RESULTS: WEEKLY VILLAGE CLINICS
Medical care. During the 10 months of clinics we saw 3,797 patients suffering from problems such as respiratory infections, gastroenteritis, parasitism, abdominal pain, and tuberculosis. More people came the first one to two months. Attendance eventually stabilized at about half the daily attendance.

The clinic nearest the city was the least attended. Very few people came after the first two to three months. After four months, we dropped this clinic and moved it to another site.

We saw significant numbers of people with chronic diseases such as tuberculosis, amebiasis, and, in one place, schistosomiasis. We also encountered endemic diseases such as malaria and epidemic measles.

At the end of Phase I, we thought about discontinuing our services, but we decided to keep on because the people wanted them and we were seeing many TB patients for weekly evaluations and medicine.

Health teaching. We encountered major obstacles to effective health teaching. Few people came early or stayed late for health, so we moved them to clinic breaks. The classes consisted of people waiting to see the doctor on any given week, so continuity was minimal.

Storytelling got mixed results. Once, an elderly person told his own story about an effective home remedy for diarrhea. Health teaching and evangelistic preaching competed for break time, which often extended too long. Finally, our teacher’s other jobs— dispensing medicines, collecting fees, and maintaining supplies—limited her time for health teaching.

So, at the end of Phase I we made some changes. We relieved our teacher of all of her clinic duties and we hired part-time worker to dispense medicines and collect fees. We sent our teacher to a seminar to learn the lecture-demonstration-return demonstration technique, using simple, homemade visual aids. We got the government nurses and midwives nearby to round up people for our classes.

Since the government had just started a village health worker training program in our area, we called ours health classes, not health worker training classes. Some were actually organized by newly-appointed village health workers, and occasionally the government nurses and midwives came.

In all three villages where we held weekly clinics, we organized classes of 10 women each. In two villages we had to hold the classes on other days, so as not to conflict with clinic and Bible study times.

At two sites, we held the classes in conjunction with existing feeding programs for malnourished children. Eventually, we assumed responsibilty for the protein sources (usually inexpensive, available mung beans). With the help of government nurses, we offered immunizations as part of the classes in two villages; in the third, most children had already been immunized.

Evangelism and church planting. The people were quite open to tract evangelism. In the first month, about one out of every four non-Muslim adults made a profession of faith reading through the tract with a clinic volunteer.

Two or three home Bible studies were begun at each clinic site. Although some were small and poorly attended, one or two consistent Bible studies remained at each site at the end of Phase I, with attendance averaging from five to 30 people.

Home Bible studies progressed more slowly than we anticipated. Each one took several weeks to organize and stabilize, because of a variety of problems. Studies were interrupted by harvest times, illnesses, and so on.

Our missionary church planter went home on furlough one month after the studies started. Although we found church volunteers to lead the studies, they were not as enthusiastic about house-to-house visitation as our church planter was. In two places, political violence disrupted our Bible studies.

Nevertheless, the 16-lesson Bible study booklets were completed by four groups some seven months into the project, and one of the groups requested baptism. Ten people—one man and nine women—were baptized. Another group was undecided about baptism, but wanted to keep on studying the Bible. A nearby pastor took this group of 10 to 15 people.

The most responsive group was at our fourth clinic, where we started after dropping one of our original sites. One team member had many relatives here and from the beginning we found an enthusiastic response to Bible study. Thirty to 40 people came every week and they met outdoors. The lay leader delivered weekly sermons, rather than leading a Bible study, and after two months some people asked for baptism and regular Sunday worship.

Five months after the clinic started, an American pastor held a week of evangelistic meetings, which culminated in the baptism of 21 people and the starting of a village church.

RESULTS: MEDICAL CRUSADES
Results from our two three-day crusades differed significantly. At the first (a sparsely populated area with a mission point), we saw 103 people, including many with TB and lots of unimmunized children. Because medical follow-up was needed, during Phase II we began monthly clinics at a village on the road nearest to the area. Attendance peaked at 75 in the third month, in the wake of a diphtheria outbreak.

After four months, however, peace and order deteriorated in the area and we were not allowed to return. Consequently, we could not follow through with primary immunization and TB therapy. Our church-planting goals also fell by the wayside. Although 27 people made professions of faith during the crusade, none of them were baptized. In addition, our lay leader eventually had to leave because of threats on his life.

We held our second medical crusade in a mountainous tribal area far from our headquarters. The physician, nurse, and health teacher were joined by an American missionary and a Filipino church planter who had already begun Bible studies there.

The medical needs were more pronounced; most people had never seen a doctor and many of them suffered from malnutrition, TB, malaria, and endemic goiter. We were inundated with patients, seeing some 300 in three days. On the third day we held the clinic in a nearby lowland village.

Tract ministry didn’t work because most of the people could not read, and, besides, we didn’t have tracts in the tribal languages. Each day we had evangelistic programming and at night we held worship services in the village.

Some 150 people made professions of faith in Christ, and in three villages people started to talk about organizing a church. After the crusade, people in the primary target village began weekly worship services in an old school building.

The Filipino church planter, who had planned to counsel and train new converts, could not come back for a long time because of medical and family problems. But the self-organized church has continued to meet local lay leadership (some are Christians from other parts of the island). Another Baptist pastor in the area has also given some help.

Phase-out of project personnel Our Phase III work included weekly health classes, ongoing Bible studies, and the delivery of TB medicines to regular patients. The nurse and health teacher made weekly visits, but the physician left and no more clinics were held. After this three-month period, discipleship training was in the hands of area churches. We left enough TB medicines for completion of a 15-month protocol with a Christian physician in the region’s major city. The physician made arrangements with church volunteers to continue monthly visits for medication delivery and check-ups.

DISCUSSION
Our project demonstrated that medical efforts, even those of relatively short duration, can be successful in planting new churches. We planted two churches, one through a rather traditional three-day medical crusade with very little in the way of primary health care emphasis, and the other within the context of a primary health care (PHC) effort.

But planting churches through PHC programs faces significant challenges. Both classical primary health care approaches—church-based and community-based—must deal with special problems. Church-based programs ordinarily train workers at a training center and then send them back to their communities. The advantage here is that the trainees are Christians who can integrate PHC and evangelism. The disadvantage is that these workers quite naturally see their congregations and the surrounding neighborhoods as their primary ministry areas. While such programs may be excellent evangelistic efforts, a great deal of energy is required to orient their activities towards planting a new church in an area outside their own church’s ministry district.

On the other hand, community-based programs train workers chosen by communities, based on criteria other than their Christian commitment. While it may be possible through such a program to target numerous communities without evangelical churches, it often proves difficult to use the PHC workers themselves to plant churches, since few of them can be expected to be mature Christians with the skills and commitment necessary to do church planting.

We chose to develop a community-based program because we wanted to reach unchurched communities, but we made two key modifications: (1) we trained our workers in their own villages rather than at a training center; (2) health care team members, who visited each community once a week over 13 months, assumed major responsibility for church planting. Our approach has the advantage of placing a number of mature believers in an unchurched community for an extended time, thus giving them opportunity to do the initial work of evangelism and discipleship, organize a church, and then move on to another area.

At the end of Phase II, we had trained health workers in three of our four target communities and we had organized a church in one of the four. Two communities also had mission points that may later become churches. Although we wanted to start a church in each community, we met some difficulties. When our missionary church planter left halfway through Phase I, our aggressive house-to-house visitation declined significantly and new Bible study leaders were assigned to Bible study groups that still lacked cohesiveness and stability. Extra effort was required to recruit men for Bible studies. The decision to be baptized was difficult for many.

Both the mission points and the church that were organized did not seem to differ significantly from churches started without using medical strategies. The great advantage of our medical program, as opposed to other church-planting methods, was that we could begin work in new communities where there were no previous contacts. Traditionally, church planters in the area depended on contacts gained through friends or family of church members, and such contacts are not always easy to come by.

Prospects for future use. The weekly village clinic strategy could be used by a medical church-planting team to plant more churches over an extended time. To be effective, the team should stay long enough in each village to allow health care workers trained by the project to become comfortable with providing health care on their own, and to give enough time to start a church that can function with some independence.

We spent 13 months on the project, ending with a three-month phase-out, At the end, we were not assured that our health care workers had gained enough experience, or were closely enough tied to the government health people, to continue to work effectively. Most of the patients who had started on TB medicines had not completed their therapy.

None of the churches or mission points were ready to function independently. Three mission points were left to be maintained by local church volunteers. Later, at least one of them was abandoned within a year.

All of these results argue for a somewhat longer project. Perhaps 18 months would be more appropriate in the Philippines. In other countries, it might be longer or shorter. Obviously, we need a TB treatment program that matches the period of the project, since TB remains the leading killer of adults in the Philippines. New six-month treatment regimens are ideal but more expensive.

The weekly village clinic program could well be used in other ways. For example, our mission has many missionary nurses who, because of home or office responsibilities, cannot have a full-time medical ministry. For them a weekly village clinic could be a feasible part-time ministry. The same is true for Filipino physicians, who might be willing to give one day a week for a clinic. This kind of medical ministry need not be limited to rural areas. In many countries, it could make a strong impact in the urban slums.

In any case, it does seem critical to pair the health worker with an evangelistic worker whose primary responsibility is church planting.

If we were to continue a project like this for a longer time, we would need a training and ministry center. While initial health care worker training might still be done in the villages, health care workers and even government health people could be brought in for periodic continuing education, especially since continuing education is a great need for rural health workers in most developing countries. Such a training center could also be used for discipleship training of lay leaders and young pastors.

The success of the second medical crusade surprised some of us who doubted whether any lasting spiritual results could be obtained from such a short project with limited follow-up. Both the responsiveness of the tribal people and the resiliency of their newfound faith were quite impressive. Indeed, the church organized in this area was twice the size of the church organized through our weekly ministry. Despite the limitations of this kind of blitz, significant potential for church planting obviously exists.

We were concerned, however, about how to increase the primary health care benefits of such an effort. So, we came up with a radically different plan. Rather than center the efforts on outpatient clinic services, we suggested immunizations for TB (BCG) and measles, which can be done through single injections. We also proposed lectures on the treatment of diarrhea (using oral rehydration) and malaria (short-course oral treatment and prophylaxis). The ongoing sale of aspirin and chloroquin could be done commercial stores. We have not yet had opportunity to try a crusade of this type.

CONCLUSION
A number of successful mission-based primary health programs, both church-based and community-based, have been described in various publications (see references). While most note some evangelistic intent, and a few describe evangelistic strategies, only one gives even brief mention of a church-planting strategy (Here’s How. Health Education by Extension).

It’s still too soon to draw definitive conclusions about church planting through primary health care programs. We need to continue to publish studies, so that we can all from one another how to plant churches this way.

Past medical missionary programs show that, except for the least responsive areas, compassionate Christian medical care will bring an evangelistic harvest. Too often, however, such programs have been dominated by medical personnel with good intentions but limited training and expertise in evangelism and church planting. Tremendous opportunities for evangelism and church planting are lost because we do not devote adequate time and enough people to plan and carry out church planting.

Therefore, each health care project should designate a significant share of its time and budget for church planting. People must be assigned to evangelism and follow-up. That’s the only way we can offer our patients a truly wholistic ministry, able to meet the needs of body, soul, and spirit.

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