Primary Health Care: Words versus Deeds

by Susan Stranahan and Sandra L. Jamison

A wide discrepancy between stated ideals and commitment.

Christian missions have made major contributions to health care for over 100 years. James C. McGilvray, former director of the Christian Medical Commission, World Council of Churches, estimated that by 1969 Christian mission agencies provided up to 40 percent of all health care in some countries. Even though governments have started assuming a greater role in making health care available, S.G. Brown found that as late as 1979, Christian missions were responsible for 25 percent of all health care services in many developing countries. According to R.K.M. Sanders, 20 percent of the hospital beds in India are furnished by Christian mission agencies and two-thirds of the professional nurses are graduates of schools of nursing sponsored by missions.

Given the extensive role mission agencies have in providing health care, the nature of their services becomes an important issue in determining the success of Primary Health Care (PHC). Historically, medical missionaries introduced Western, institution-based, curative health care. Since the World Health Organization’s Alma Ata Declaration (1978), "Health for all by the year 2000," many mission agencies and medical missionaries have advocated greater emphasis on disease prevention and health promotion. But in Kenya, for example, Mark Jacobson found that whereas most mission agencies and medical missionaries supported PHC, few participated in it. They reported devoting an average of 13 percent of their work week to PHC.

The main purpose of our study was (1) to investigate the importance mission agency administrators place on preventive health care and the allocation of health professionals to public health activities, and (2) to identify major obstacles they perceive in implementing PHC in countries where their medical missionaries work. Gaining an understanding of the use of nurses in preventive health care was a secondary purpose of our study.

METHOD
We sent our questionnaire to administrators of mission agencies listed in Mission Handbook: North American Protestant Ministries Overseas, 12th Edition who identified Medicine, Dental, and Public Health as primary tasks and reported an annual budget of at least $2,000,000. Thirty-one agencies met the criteria and 20 questionnaires were returned (65 percent). The questionnaire consisted of questions on the number and type of health care facilities and medical personnel, importance of curative and preventive care and training, obstacles to involvement in PHC, and administrative policies and personnel supportive of PHC. Respondents were asked to send copies of their policy statement regarding health care.

RESULTS
All mission agency administrators reported a favorable attitude toward PHC. However, only six of the 20 respondents supplied a health care policy that included primary health care.

In comparing the importance administrators placed on curative and preventive aspects of health care, preventive care was weighted more heavily both in general and with regard to the training of national workers. (See Table 1, page 172.)

While 100 percent of the administrators were favorable to PHC, they estimated that only 65 percent of their medical missionaries favored PHC.

The large majority of mission doctors and nurses work in settings where the emphasis is curative.

While much credence is given to the importance of prevention, mission agencies report two major obstacles to providing primary health care: training and finances. Ninety percent of the administrators responding said they had an inadequate number of health professionals trained in PHC and 55 percent reported insufficient funds to support PHC projects.

COMMENT
Despite mission administrators’ reportedly strong positive attitude toward preventive health care and the provision of primary health care services, relatively few health care personnel are involved in either. The findings of this survey suggest three actions that might facilitate closing the gap between the ideal and the actual in medical missions. First, mission agencies should develop policies that include primary health care as a vital aspect of health care. Second, the allocation of the total mission health care budget should be reevaluated in light of the values placed on preventive health care, with a greater proportion given to PHC. Third, health care personnel trained for primary health care ought either to be sought or developed from within the ranks. Health care personnel currently employed should be given orientation to the concepts and practical application of PHC, so that their priorities are congruent with those of their sending agencies.

Finally, the findings of this study, consistent with those of Jacobsen (1985), demonstrate the important role missionary nurses have in the delivery of PHC. Nurses, more than any of the other health professionals, are deployed in public health activities. The need for nurses to receive advanced education in the field of public and community health prior to embarking on a career in international health is clear.

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