PRIMARY HEALTH CARE The implications for physiotherapy in South Africa Pat Bowerbank MBL, MCSP, BA, Dip Ter Ed Associate Professor and Head o f Department o f Physiotherapy, University o f Cape Town and Groote Schuur Hospital INTRODUCTION The current crisis in health care service in South Africa has lead to the emphasis on Primary Health Care (PHC) as a method of ensuring the provision of adequate health care for all people in the country. The De­ partment of Health has changed its policy over the last two years from support di­ rected at curative services to that of a com­ mitment towards PHC. A number of po­ litical parties, civic organisation s and health care delivery systems are also advo­ cating a N ational H ealth Care system which is based on the PHC approach. The concept of PHC is not a new one but rarely appears in physiotherapy literature. Considerable confusion exists as to the meaning of PHC and how it affects physio­ therapy practice. This paper attempts to clarify some of the fundamental issues which are crucial to the understanding of the PHC approach as a means of promoting a healthy popu­ lation. BACKGROUND The International conference on PHC sponsored by WHO and UNICEF and held in Alma Ata in 1978 must be seen against a b ackgroun d o f the grow in g under­ standing that causes of poor health were not necessarily the common diseases but were the product of poor socio/economic conditions. People had becom e disen­ chanted with the traditional approaches to health care which emphasised disease and curative medicine but did not address the low health status of many communities1. The conference identified a'gross inequal­ ity in the health .status of the people par­ ticularly between developed and develop­ ing countries and stated that the health status of millions of people in the world was unacceptable2. The Alma Ata declaration on Primary Health Care was made in 1978. It called for urgent action by all governments to pro­ tect and promote the health of the people of the world. The declaration led to the WHO call for "Health for all by 2000 3. The focus of this strategy was not just im­ proving medical health care, but included a multi-sectorial approach involving agri­ culture, the provision of adequate sanita­ tion, clean water, education, and housing. THE DECLARATION OF ALMA ATA The declaration of Alma Ata defined Primary Health Care as: "essential health care made universally accessible to indi­ viduals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford. It forms an integral part both of the country's health system of which it is the nucleus and of the overall social and economic devel­ opment of the community"4. PHC is a relationship between socio­ economic and health status, concerned not only with quality of life but to broader environmentaHssues5. PRIMARY HEALTH CARE APPROACH PHC in the narrow sense means first- contact care. It is the level which most people view as the entry point into the total health care practitioner, whether it is the g e n e r a l m e d ic a l p r a c titio n e r , the physiotherapist or the village health care worker from a rural community. However, the Alma Ata declaration goes beyond the simple narrow provision of first contact service, and incorporates the definition into a broader concept by referring to the Primary Health Care Ap­ proach. This concept encompasses a phi­ losophy of health into which are embed­ ded the five principles of PHC namely1: • E q u ity - H ealth s e r v ic e s m u st be equally accessible to everyone, not ne­ glecting rural and isolated populations or peri-urban dwellers • Community involvement - Communi­ ties must actively participate in their own health decisions ^ • Focus on prevention - Comprehensive services which emphasise preventive and promotive care rather than curative services should be the basis of health care • Appropriate technology - The methods and materials used in the health serv­ ices should be acceptable and relevant to the local communities • Multi-sectorial approach - Medical care must be seen as only part of total health care. The PHC approach moves away from the conventional medical model of health care which tends to place responsibility on health care professionals. It has a much broader implication and health must be part of a country's overall development strategy. Health services have to be devel­ oped alongside, and in conjunction with, other sectors such as provision of clean water, housing, education and a healthy environment. The PHC approach rests on several processes which have im portant conse­ quences for planners of health care deliv­ ery6. The following appear to be most criti­ cal to physiotherapists. COMMUNITY INVOLVEMENT Community involvement is the corner­ stone to PHC. Kasego7 states that "w hat is primary in primary health care is not the vision of health for all, nor the emphasis on basic services. Neither is it the emphasis on care as apposed to cure, but it is the imple­ mentation strategy of community involve­ ment in determining their health care and hence their health status". Health planners in South Africa have come to use the community participation approach in many programmes as it is realised that this strategy encourages com­ munities to take responsibility for their own health8. The process can be long, pro­ tracted and frustrating. Community ex­ pectations can vary considerably from those of the professionals who may have different agendas to the communities9. The process of community participation and empowerment in South Africa is likely to require profound changes in attitudes and values from many of the health care professionals. Not all their training, as yet, promotes such an approach to health care. Community involvement leads to the developm ent of p artn ersh ip s betw een com m unities, fam ilies and individuals, w ho take basic responsibility for their health, and between all the various health providers who act as resources, give sup­ port and assist in the development proc­ ess. The development of partnerships has become an essential part of the PHC ap­ proach and is an em pow ering process which may be seen as the. movement from ind iv id u al p erson al und erstand ing of health to that of group action. Rifkin10 has suggested the following definition for the development of partner­ ships: Physiotherapy, August 1994 Voi 50 No 3 Page 49 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) "Com m unity partnerships are devel­ oped through participation which is a so­ cial process whereby specific groups with shared needs living in a defined geo­ graphical area actively pursue identifica­ tion of their needs, take decisions and es­ tablish mechanisms to meet their needs". The very nature of physiotherapy train­ ing and practice which tends to focus on the individual client on the one hand and the expertise of the physiotherapist on the other is in contrast to the concept of com­ munity participation and empowerment. This is likely to be an area which many physiotherapists may struggle to under­ stand and put into practice. The need for community based reha­ bilitation has been recognised and should b e vigorously pursued by physiothera­ pists1 ,12. In consultation with local com­ munities, rehabilitation teams m ust be es­ tablished which should be based at the district level and will be part of the com­ prehensive health service. Local communi­ ties should be encouraged to participate in needs analyses to establish the rehabilita­ tio n r e q u ir e m e n ts o f th e a r e a 11. Physiotherapists m ust learn additional skills in negotiation, facilitation and group participation and attitudes will have to change and prejudices will have to be eliminated. EQUITY AND SUSTAINED DEVELOPMENT The importance o f PHC lies in its con­ cern to establish, within national strate­ gies, an inclusive democracy, equity of service and a sustainable development which will lead to significant improve­ ment in health status1 . Sustainability is a development that meets the needs of the present without compromising the ability of future generations to meet their own needs8. It is therefore important for health workers to consider the health of the future generations as well as those of the present generation. However, the concern of any govern­ ment advocating PHC should be aimed at improving the whole issue of social justice, and at bringing equal access to available resources14. Thus the aim is to extend health care beyond the privileged few to include whole communities. This socio­ political philosophy tends to be directed to the disadvantaged people, w hether in communities, or in the rapidly developing peri-urban communities burgeoning in the major cities around South Africa. The Department of Health has commit­ ted itself on a number of occasions to sup­ porting PHC in South Africa15 and has urged health professionals to become part of this process. The need for a strong na­ tional health system which can address the serious inequalities in health care in South Africa is of the utmost importance. If South Africa is intent on a social re­ construction that is based on equality and freedom then it will be necessary for it to have a considerable transform ation in terms of health care. Health care develop­ ment will be a shared responsibility be­ tween local communities and the many sectors of health provision. Physiotherapists must be challenged to take part in this reconstruction prf>cess by actively participating in the policy and de­ cision making processes at a national level and by developing structures which will bring about a more realistic physiotherapy service delivery at a local level. The princi­ ple of equity and sustained development is one which physiotherapists must accept and it should be an absolute priority for all practitioners. COMPREHENSIVE HEALTH CARE Comprehensive health care forms the foundation to the PHC approach, it reflects and evolves from the economic conditions and socio-cultural conditions of the coun­ try. Comprehensive care includes the fol­ lowing4: • integration of preventive, promotive, rehabilitative and curative care P h u s i o m e d c c ■ CK 94/10196/23 2 N e w M edica H o u s e , Cnr Pieterse & Irving Steyn S t , Southcrest, Alberton 14 4 9 P . O . B o x 1 1 8 9 3 , R a n d h a rt, Alberton 1 4 5 7 Tel: ( 0 1 1 ) 9 0 7 -9 4 5 7 , ( 0 1 1 ) 907-9458 F a x : ( 0 1 1 ) 9 0 7 - 9 6 7 7 THE VECTORSURGE 4 INTERFERENTIAL CHECK THESE FEATURES! PORTABLE — INTEGRATED STORAGE COMPARTMENT AND EASY TO HANDLE/TRANSPORT SURGE MODE — VECTORSURGE WERE ONE OF THE FIRST TO INTRODUCE THIS FEATURE. NOW GREATtY IMPROVED. CARRIER FREQUENCY — THE CHOICE OF 2,4 and 10 kHz. SIMPLICITY — ONE CONTROL KNOB — DEFAULT SETTING CONTACT CONTROL — CONSTANT CONTACT MONITORING BETWEEN PATIENT AND ELECTRODES PLUS MANY OTHER FEATURES VERY COMPETITIVELY PRICED CALL US ON (011) 907-9457/8 OR FAX (011) 907-9677 ALSO STOCKISTS OF SUCTION UNITS, ULTRASOUND, TRACTION MACHINES AND LASER UNITS. Bladsy 50 Fisioterapie, Augustus 1994 Deel 50 no 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) • optimal channels of referral between all levels of service from community clin­ ics through to academic hospitals. Serv­ ices must be made available at the ap­ propriate level of care. • a health team approach acknowledges all levels of health workers as being of equal importance, this includes the ap­ propriate role o f com m unity health workers • community-based education is advo­ cated as opposed to exclusive hospital- based education. The trend amongst physiotherapists to specialise and to w ork as independent practitioners supplying a highly skilled service product, is an obstacle to compre­ hensive care. Furthermore this trend has strongly influenced the curricular devel­ opment for undergraduate physiotherapy training, which tends to concentrate on a preponderance of manual skills and strong subject based education. If physiotherapists are to become at­ tracted to and form part of a comprehen­ sive service, the undergraduate training programmes must reflect an orientation towards the primary health care approach. This will require a shift away from institu­ tion-based education tow ards commu- nity-based education. Formal relationships will have to be es­ tablished with community services for this p u rp o se and p h y sio th e ra p y tra in in g schools will have to take part in the devel­ opment of regional health strategies. Physiotherapists in private practice need to explore ways in which they can take part in these initiatives. The role of physiotherapy in promotive and preven­ tive care has enorm ous potential and should be rigorously pursued. Channels of communication must not only be established between the private sector through all the various levels of the public sector, but also from the hospitals th r o u g h to th e co m m u n ity le v e l. Physiotherapists need to take a more pro­ active stance to develop structures which will enable them to participate in commu­ nity development projects and utilise their skills and resources in a more appropriate and significant way. The position of the disabled and the development of community-based reha­ bilitation workers are inextricably bound to comprehensive care. The World Pro­ gramme of Action Concerning Disabled Persons called on member states to ensure the provision o f rehabilitation services necessary for the elimination or reduction in disabling effects of impairment16. The lack of rehabilitation services at all levels of health care in South Africa is a disgrace which requires an urgent plan of action. Physiotherapists are as much to blame for this state of affairs as anyone else and have allowed this component of health care to slip away whilst they pursue more exciting and remunerative treatments. The opportunity to re-establish this very important aspect of health care is a challenge physiotherapists must not allow to slip by again. The role of physiotherapy in the whole rehabilitation process includ­ ing the training of mid-level workers and com m unity w orkers requires a vision which is both empowering to the disabled and the communities and, at the same tim e , in s t ills a s e n se o f w o rth in to physiotherapists. CO NCLUSIO N Primary health care presents a major challenge to us all in South Africa. It re­ quires us to make an appraisal of the effec­ tiveness and relevance of our services to all th e p e o p le o f th e c o u n tr y . If, as physiotherapists, we believe in the concept of Health for all by 2000, then we need to adopt some creative and possibly radical strategies in order to realise that aim. The Primary Health Care approach of­ fers us an opportunity to examine our val­ SMITH AND NEPHEW EDUCATIONAL TRUST The Smith and Nephew Travel Bursary has been awarded to two physiotherapists this year. Professor Pat Bowerbank of the University of Cape Town received the grant as she was presenting a paper on "Im proving the Quality of Physical Therapy" at an International Conference in June. The second recipient was Mrs Mary Riley from the Physiotherapy Department at the Johannesburg Hospital who presented a paper on hemiplegic gait at the WCPT-Europe Congress held in Copenhagen. The South African Society of Physiotherapy is most grateful for the continued support for its members by Smith and Nephew. Applications for 1995 must be submitted by members of the SASP to Head Office (P O Box 92125, Norwood 2117) together with a short CV and motivation before 31 March 1995. Criteria for this award are: • a physiotherapy paper to be presented at a local or international congress • a copy of the paper to be forwarded to the SA Journal of Physiotherapy together with permission to publish from the publishers of the Congress Proceedings The National Executive Committee will select the suitable candidate or candidates. ues, our beliefs, our lifestyles and our pro­ fession. It also offers us a challenge to bring about a radical change to the quality of life for millions of people in South Africa. REFERENCES 1. WHO; Health fo r All, Series No 4. Leadership material WHO/HLD/87.4. Geneva 1987. 2. WHO; Alma Ata 1978. Health fo r All, Series No 1. Geneva. 3. WHO; Health fo r All, Series No 2. Strategies for health for all by year 2000;1979. Geneva. 4. WHO; Report o f the International Conference on Primary Health Care. Alma Ata USSR 1978. 5. Walt G, Vaughan P. An introduction to the Primary Health Care Approach in develop­ ing countries 1981. Ross Inst o f Tropical Hy­ giene 1981; 13. 6. Rifkin SB, Walt G. Why health improves: defining the issues concerning comprehen­ sive primary health care and selective pri­ mary health care. Soc SciMed. 1986;23:(6)559- 566. 7. Kasego D. Community Empowerment. Keynote address: Namibian National Primary Health Care Workshop, February 1991;2. 8. Reynolds L, le Roux. PHC in South Africa: Developing the Vision: Discussion docu­ ment for NPPHCW, 1992. (Unpublished). 9. Philpott S. A community empowerment ap­ proach to work with the disabled. SA J Occ Th, May 1992^6-29. 10. Rifkin SB. Lessons from community partici­ pation in health programmes. Health Policy and Planning 1986;l(3)240-249. 11. Comielje H, Perrinho P. Development of a community based rehabilitation programme for a poor urban area in SA 1993. CHASA Journal 4(2)56-57. 12. Finkenflugel HJM. Help for the disabled in hospital and at home. World Health Forum 1991;12. 13. Friedman J. Empowerment 1992. Blackwell. Cambridge USA. 14. Heggenhougen HK. Will primary health care efforts be allowed to succeed? Soc Sci Med. 1984;19(3)217-223. 15. The Department of National Health & Popu­ lation Development: A new health dispensa­ tion fo r South Africa, April 1992. 16. United Nations: World Programme o f Action Concerning Disabled Persons Report. New York 1983. University of the Witwotersrand Inaugural Lecture Professor M Goodman Professor of Physiotherapy in the Faculty of Medicine will deliver her inaugural Lecture in the Dorothy Susskind Auditorium, John Moffat Building on Tuesday, 30 August 1994 at 17:30 Hie title of her address will be: : The Metamorphosis of a Profession" "Physii Members of the public are most welcome PhysiotherapyAugust 1994 Vol 50 No 3 Page 51 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )