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Connecting rural primary health care to agriculture: A comparison of interpretations of “comprehensive primary health care” and review of agricultural connections in community health worker systems Elizabeth Kelman CUNY Macaulay Honors College at The City College of New York Advisor: Professor Lee Quinby, CUNY Macaulay Honors College Faculty mentor: Dr. Heidi Jones, Epidemiology, Hunter College Spring 2013
1
ABSTRACT
This study is a critical look at the narrow implementation of the Primary Health Care
(PHC) approach to development through rural community health worker programs. I focus on
agricultural involvement as a lens through which to view the comprehensive nature of PHC
projects. In the landmark Declaration of Alma-Ata in 1978, the Primary Health Care approach to
development was set forth as the means to achieve “Health for All” by 2000. At the core of this
radical goal was the belief that health and participatory health care are human rights, and that a
basic level of health for every person on the planet is within reach if countries alter the way they
view health care—from a single sector to one that is tied to everything from education to
agriculture, and intimately linked to social justice.
I review a variety of interpretations of “Comprehensive Primary Health Care” to see how
public health scholars and policy-makers describe the scope of “comprehensive.” The range is
from truly comprehensive to quite narrow and biomedically-focused. In rural settings, primary
health care should, logically, connect to the agricultural practices of the population it exists to
serve. An examination thus far suggests that though many types of networks of community
health workers have been set up in rural areas of less developed countries, agricultural projects
have not been directly incorporated into rural Primary Health Care. At best, agriculture is
mentioned only in passing in the literature about community health workers; even those
programs with a strong agricultural component have not published articles about or evaluating
the effect of this aspect of their work. I argue that to truly address the social determinants of
health, effectively promote nutrition and hygiene, and strive toward “Health for All,” rural
primary health care as implemented through community health worker systems must embrace a
comprehensive, intersectoral approach at the heart of Primary Health Care and connect
agricultural practices to public health at the community level.
2
PREFACE
Two years ago, I had the privilege of studying at the Comprehensive Rural Health Project
(CRHP) compound in Jamkhed, India. Though I did not know it upon registering, the Jamkhed
model of comprehensive community-based primary health care was widely used as a template
for primary health care (PHC) in other resource-poor rural areas, especially through the use of
community health workers.
While at the CRHP, my classmates and I lived at the health compound, learned from its
founder, Dr. Raj Arole, and his daughter, Dr. Shobha Arole, as well as many of the village health
workers, and visited some of the villages involved in the project. As I learned about the history
of the project and how it is still functional forty years after its founding, I developed a deep-
rooted appreciation for the view of health as something intricately tied to social and
environmental conditions. Though I have studied the theory of the social foundations of disease
in multiple courses, it was my trip to Jamkhed—where social inequality had been codified by
caste and gender roles—that clarified the close relationship between these conditions and health.
My commitment to public health has always been rooted in a desire for equity, so addressing the
distal causes of illness as part of “health care” is a matter that I feel strongly about.
For my senior thesis, I researched a topic in global health that is closely connected to
food justice, which I have been involved with throughout college. In reflecting on my time at
Jamkhed, I found an excellent example of the related natures of global health and food justice.
This link seemed to be a manifestation of the principles of primary health care, and I wondered
how other implementations of rural primary health care addressed this connection. In the course
of my research, I discovered that of the many tenets of primary health care, “intersectoral
collaboration”—with the understanding that health is affected by many aspects of one’s life and
3
community—is among the least addressed. While primary health care has been widely
implemented through community health worker systems, many based on the Jamkhed model, the
connection between agriculture and health is rarely applied to the design of these programs or the
discussion of the scope of primary health care.
4
INTRODUCTION
In 1978, delegates representing 134 countries and 67 international organizations met at
Alma-Ata and declared Health for All by the year 2000.1 Health is widely accepted as a human
right and the importance of basic health care for all is hardly controversial, yet a woman dies
from pregnancy or childbirth-related conditions every two minutes,2 and in at least 15 countries
more than one in four children under five years old are malnourished.3 Primary health care
(PHC), as adopted by the World Health Organization (WHO) following the conference at Alma-
Ata, addresses the social, political, environmental and economic determinants of illness as a
means to improve public health and achieve Health for All.
The Jamked model of comprehensive PHC is community-based. It uses village health
workersa and sustainable development projects as a foundation to improve rural public health and
work toward social justice. Eight years before Alma-Ata and twenty-five years before Link and
Phelan published their theory of fundamental causes of disease,4 the CRHP founders recognized
social status (tied to gender and caste equalities) as a major determinant of health in rural Indian
villages, and implemented a unique intervention that addresses these factors.5 The scope of
CRHP’s work extends far beyond what is traditionally considered health-related—from
watershed construction to self-defense for adolescent girls. As the Aroles wrote in their chapter
of the WHO’s “Health By the People” in 1975, the project aimed to “use local resources, such as
buildings, manpower and agriculture to solve local health problems.”(p71) It would provide the
community with “total health care and not fragmented care” by blending promotive, preventive
a The CRHP uses the term “Village Health Worker” (VHW), but the more standard term is “Community Health Worker” (CHW). Other common terms are Health Auxiliaries, Barefoot Doctors, Health Agents, Health Promoters, Family Welfare Educators, Health Volunteers, Community Health Aides, Community Health Promoters and Community Health Volunteers.
5
and curative care,p71 unlike the existing rural practitioners and hospitals, which provided only
curative care and thus could not address the root causes of disease.6(p70, 73).
One of the many strengths of the Jamkhed model was strong community support, some of
which came through setting up Farmers’ Clubs. By joining the Farmers’ Club in their village,
farmers gained knowledge about irrigation and more efficient and sustainable farming practices,
built wells, and also had the opportunity to talk about other community wellbeing matters.
Farmers’ Clubs brought together landowners and landless workers, men of different castes and
economic means. The Clubs served as a point of entry for the CRHP, since the men in the
villages were initially more interested in improving yields and animal health than improving the
health of their community. Community health topics were integrated into Farmers’ Club
meetings, and members participated in general health surveys, where health-related data was
collected for each and every household in the village.
Water and sanitation projects were key both to community participation in the health
program and to preventing common illnesses. In rural India, 80% of diseases are water-borne.7
Worldwide, 88% of diarrheal disease—which accounts for 1.8 million deaths, mostly to children
under 5—is caused by unsafe water supplies.8 Projects carried out with the Farmers’ Clubs to
prevent the spread of these diseases included installing tube wells with hand pumps to provide
clean water and constructing soak pits to eliminate stagnant wastewater in the village. This fit
into the goal of a comprehensive health system, involving every member of the community in
improving health.
The success of the Comprehensive Rural Health Project9-11 and similar community-
oriented primary health care projects was a major motivator for the 1978 WHO conference in
Alma-Ata, which declared “health for all by the year 2000” and embraced a Primary Health Care
6
approach to development as the means to achieve it.1,12 “Selective primary health care” was
introduced within a year of the conference as an interim strategy. The selective PHC approach
focuses on providing targeted, vertical health care rather than the radical restructuring necessary
for PHC as adopted at Alma-Ata. By addressing the most problematic infectious diseases (with
oral rehydration salts, immunizations, antimalarial drugs, and breastfeeding promotion), Walsh
and Warren proposed a practical means of reducing morbidity due to diarrheal diseases, measles,
malaria and respiratory infections.13 This approach focused on cost-effective means of improving
public health, eschewing fundamental changes in the way health care is conceptualized or
delivered. (Since selective PHC differs substantially from the PHC of Alma-Ata and the
Jamkhed model, the latter is often referred to as “comprehensive PHC.”) Selective PHC, even as
an interim strategy, had very little to do with what was proposed at Alma-Ata.
Through PHC, WHO and the world envisioned a relatively low-cost and highly effective
means of achieving major gains in public health and development in resource-poor settings.
Primary health care systems relying upon the training and involvement of community health
workers have been adopted by local, regional and national governments around the world—
particularly in the Global South—with varying success.14,15 Despite the supposed embrace of the
primary health care approach to development, it is clear that the goal of a basic level of health for
all was not achieved by 2000. Moreover, we are not on target to achieve it (or the more modest
and measurable Millennium Development Goals to reduce maternal and under-five mortality) in
the near future.16 One conceivable reason for this failure is that the PHC approach that was set
forth and committed to at Alma-Ata was soon reduced from a truly comprehensive
understanding of health care to a version of PHC that is hardly recognizable past the biomedical
and participatory aspects of the original concept.
7
Though the Jamkhed system was used as a model, it was modified into overly simplified
systems of community health workers coordinating with local mobile health teams and regional
secondary/tertiary facilities, in lieu of the radical intersectoral approach proposed at Alma-Ata.
These programs are not supplemented by other Jamkhed-style initiatives, such as the founding of
clubs for farmers and women, helping with development projects (often agricultural in nature,
and carried out through the clubs), and modeling sustainable and profitable farming techniques.
Community health worker programs, which supposedly embody the spirit of comprehensive
primary health care, often lack CRHP’s deep-rooted connection to agriculture, despite it being a
major player in the lives of the rural poor the programs seek to serve.
Given these shifts in the concept and application of primary health care, it is important to
reexamine both what primary health care is and how it has been implemented, especially if we
are returning to the comprehensive vision of PHC that was proclaimed at Alma-Ata. In rural
areas, a primary health care approach to development should involve more than just community
involvement in health care and affordable services. Given the impact that farming practices have
on environmental, mental and physical health, as well as the complex ways in which agricultural
lifestyles and power structures affect health behaviors, truly comprehensive rural PHC programs
must interact with and influence agriculture. In the first part of my thesis, I discuss how different
conceptualizations of (comprehensive) PHC reflect upon the role of agriculture. I look at several
interpretations of the scope of PHC, chronologically from the Declaration of Alma-Ata in 1978
to the renewed focus on PHC three decades later, In the second part, I conduct a systematic
literature review to explore by a more scientifically rigorous means the ways in which agriculture
has been incorporated into rural PHC programs that involve community health workers.
8
Following review of the search results, I discuss the implications of this research for the
movement to return to the comprehensive approach.
I. Connecting agriculture to rural health: What is “comprehensive primary health care” and how comprehensive is it?
“Primary health care” seems to be interpreted in a variety of ways, despite being defined
in the Declaration of Alma-Ata. The shift of focus that came along with selective PHC has
obscured the original, comprehensive understanding of PHC as intimately tied to development
and equity. The Declaration was the culmination of a weeklong conference of health ministers
and public health experts on Primary Health Care that took place in Alma-Ata, Kazakhstan (then
part of the USSR). It called on all governments, NGOs and the “whole world community” to
strive toward “a level of health that will permit them to lead a socially and economically
productive life” by 2000 (Article V), and presented primary health care—as part of social
justice-driven development—as key to achieving that goal.
As unanimously accepted by the 134 member states and 67 organizations present at
Alma-Ata, “primary health care is essential health care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to individuals and
families in the community through their full participation and at a cost that the community and
country can afford to maintain at every stage of their development in the spirit of self-reliance
and self-determination” (Article VI). Article VII describes the scope of PHC, noting that the
areas mentioned represent the minimum of what PHC covers. Among these components,
alongside biomedical standards like immunization, disease control and appropriate treatment, are
“promotion of food supply and proper nutrition” and “an adequate supply of safe water and basic
sanitation,” neither of which is traditionally considered part of health care based on the
9
biomedical model, but clearly have direct and powerful effects on health. Additionally, the
Declaration states that PHC “involves, in addition to the health sector, all related sectors and
aspects of national and community development, in particular agriculture, animal husbandry,
food, industry, education, housing, public works, communications and other sectors; and
demands the coordinated efforts of all those sectors” (Article VII). By its definition at Alma-Ata,
it is clear that rural primary health care would necessarily involve and interact with agriculture
and farming practices.
However, PHC was judged too large, costly and unwieldy to implement immediately,
leading to the introduction of “selective primary health care.” Walsh and Warren proposed this in
1979 as an “interim strategy for disease control” in low-income countries.13 As a result of this
new iteration of PHC, the broad approach envisioned through most of the 1970s became known
as “comprehensive primary heath care.” Selective PHC eliminates the broad range of reforms
needed to achieve Health for All, and instead focuses on highly-targeted goals like increased
immunization and breastfeeding rates and available of oral rehydration therapy. These strategies
were direct solutions to some of the most pressing diseases but do not tackle larger, structural
factors like food security, social equity, and water quality and access, which are once again
relegated to the domain of development work rather than health. For example, instead of
investing money in clean water, a selective PHC program will ensure adequate supply and access
to oral rehydration salts. That is, instead of preventing diarrheal diseases (as CRHP
accomplished with soak pits, tube wells, and related health promotion through the village health
workers), many selective primary health care programs prevent deaths through treatment or
direct prevention (immunization, food supplementation), doing little to address the social and
environmental causes of the diseases. As a result of this limited “interim” strategy, the term
10
“primary health care” is used to describe both a comprehensive system like that detailed in the
Declaration of Alma-Ata and modeled by the CRHP, and to selective primary health care.
Alma-Ata laid the framework for an approach to development that was rooted in primary
health care and thoroughly intersectoral in nature—a truly comprehensive approach to both
development and public health, very much in line with the Jamkhed model. More than thirty
years later, it is clear that the implementation of these radical ideas lacked the intersectoral
cooperation that was supposed to underpin such programs, especially agriculturally. For a brief
window, however, comprehensive primary health care was hailed as the way to achieve the
extraordinary goal of Health For All in just over two decades, and the nations of the world
committed themselves to embrace its strategies. The idealism and commitment to health and
justice displayed at Alma-Ata, unfortunately, was not long-lasting, and the comprehensive PHC
approach to improving global health does not seem to be reflected in literature on PHC.
In a rare and instructive article about rural PHC and development (as a facet of a system’s
comprehensiveness) Eustace Muhondwa makes the case for integration of development and
health programs in rural areas of developing countries, using the PHC approach to development
to achieve the goals set at Alma-Ata. He writes, however, that implementation in less developed
countries (LDCs), like his native Tanzania, is often limited to preventive and curative care on the
individual level, losing the key element of community-based development work. He highlights
some of the barriers to the establishment of PHC “with its full complement of rural development
activities.” Muhondwa explains that rural development aspects of PHC have been ignored in the
rush to implement PHC. Referring to the shift toward selective primary healthcare, he argues, “If
resources available to LDCs are considered so scarce that even the application of PHC has to be
selective … the rural population should have priority in resource allocation if for no other reason
11
than their sheer proportion [compared to the urban poor in LDCs].”17 While the size of the urban
poor population worldwide has grown dramatically in the 25+ years since this article was
published, poverty remains a chiefly rural issue, with 75% of the global poor living in rural
areas.18(p12) Other articles are less specific about the flawed implementation of PHC, choosing
instead to contrast comprehensive and selective PHC in order to understand the merits of each
and find the most (cost?-)effective way forward.
In “The Origins of Primary Health Care and Selective Primary Health Care,” published in
2004, Dr. Marcos Cueto chronicles the history of PHC, from its introduction in the 1960s
through its dissemination and adoption in the 1970s and 1980s. Though his focus is on the roles
played by the WHO and United Nations Children’s Education Fund (UNICEF), Cueto writes that
the multiplicity in understandings, representations and implementations of PHC contributed to its
lack of appeal. “What was the meaning of primary health care? How was primary health care to
be financed? How was it to be implemented?” he asks, and then responds by stating, “The
different meanings, especially of comprehensive primary health care, undermined its power. In
its more radical version, primary health care was an adjunct to social revolution. For others,
however, it was naïve to expect such changes from the conservative bureaucracies of developing
countries.”19 From this perspective, the failure to commit to comprehensive primary health care
was not financial at its core, but political and semantic; the nature of comprehensive PHC was
unclear. Was it truly part of a revolution, or meant to foment one? How could “third world”
bureaucracies design and implement comprehensive primary health care?
Cueto’s argument suggests that the lack of implementation of comprehensive PHC
reflected an underestimation of the power of the rural poor to mobilize, plan, participate and
effect change in their communities, and a strong resistance to change by the medical field. The
12
Declaration of Alma Ata and comprehensive primary health care in general represented a threat
to powerful corporations and institutions (both public and private). The result, then, was a
continuation of reliance on vertical interventions, taking the potential power to improve health
holistically away from the people and entrusting medical professionals, policy makers, and
officials at government agencies to systematically tackle regional health priorities one-by-one,
through clear, targeted and measurable initiatives like selective PHC’s GOBI and GOBI-FFF
initiatives. Rather than reimagining health care and attempting an overhaul, it seemed safer to
stick to practical goals, especially when “revolution” might be involved—even if this revolution
would be brought about through water access, gender equality and sustainable farming rather
than violence.
In “Comprehensive Versus Selective Primary Health Care: Lessons For Global Health
Policy,” Magnussen et al. conceptualize comprehensive primary health care as the model
declared at Alma-Ata, and state that it was prematurely dismissed as too expensive and overly
idealistic. They write that the disease-focused, selective model (vertical interventions) failed in
both eradicating the burden of preventable diseases in developing countries and progressing
countries toward comprehensive primary health care, as intended. They claim that the major fault
of the selective model is that it does not adequately address the ties between health and
socioeconomic development. Specifically, “meeting people’s basic health needs requires
addressing the underlying social, economic, and political causes of poor health.”20 Magnussen et
al. described the basis of PHC as follows,
Primary health care as envisioned at Alma-Ata […] explicitly outlined a strategy that would respond more equitably, appropriately, and effectively to basic health needs and also address the underlying social, economic, and political causes of poor health. It was to be underpinned by universal accessibility and coverage on the basis of need, with emphasis on disease prevention and health promotion, community participation, self-reliance, and intersectoral collaboration. It acknowledged that poverty, social unrest and instability, the environment, and lack of basic resources contribute to poor health status.(p168)
13
This concept of primary health care is embodied by the Jamkhed model. Though agriculture is
not explicitly mentioned, it would be one aspect of intersectoral collaboration. It could also serve
to increase self-reliance (a key goal of the sustainable farming and food sovereignty movements),
community participation in health care (e.g. Jamkhed-style Farmers Clubs), and efforts to
prevent diseases that are affected by agriculture and environmental conditions.
Magnussen et al. reference the 1850 “Report of the Sanitary Commission of
Massachusetts,” also known as the Shattuck Report, and point out that the abysmal conditions it
describes are similar to those “in developing countries today.” Indeed, like mid-19th century
Massachusetts, infectious/communicable diseases, malnutrition and lack of access to basic
primary care remain major health concerns in many poor, rural areas of the world (along with,
increasingly, the chronic conditions like diabetes and hypertension associated with the other side
of the epidemiological transition). The Commission’s report, in addition to serving as an oft-
quoted document in public health presentations, includes a remarkable number of
recommendations that could in another context be a description of comprehensive PHC. These
recommendations include “communicable disease control, promotion of child health, housing
improvement, sanitation, training of community health workers, public health education …
mobilization of community participation through sanitary associations, and creation of
multidisciplinary boards of health to assess needs and plan programs.” The emphasis on public
health as a matter concerning many sectors and on health promotion/education, as well as the
creation of social structures to monitor community health and create and support health
interventions, is really very similar to the original vision of PHC.
Magnussen et al. point out that the Report addressed health disparities by contrasting
the starkly different life expectancies between urban and rural areas. As such, they argue that
14
much of the improvement in domestic health in the 19th and 20th centuries was a result of
political commitment to public health and social and economic interventions—an early form of
comprehensive primary health care.5 More than a century later, Alma-Ata represented a similar
call to action (or, rather, commitment), but it did not result in the same broad understanding of
the need to prevent poor health through social, environmental and sanitary means.
Perhaps, like the Shattuck Report, the Declaration should have included a section in
which the authors preemptively address objections to the proposal21—from “Your plan is too
complicated; require[s] too much”(p186) and “we cannot afford it”(p193) to “We acknowledge that
all you say is reasonable … but [s]o many other things take up our attention that we haven't time
to examine, much less to carry out your measure; our people are not up to it yet.”(p196) Many of
the answers given in the Shattuck Report reflect understandings that remain true today,
especially those justifying allocation of scarce resources and attention to the improvement of
public health through comprehensive, intersectoral reforms.
In “Alma-Ata 30 years on,” Lawn et al. reflect upon the “revolutionary principles” of
Alma-Ata and hold that the basic tenets of Alma-Ata are still highly relevant and its goals and
approach are “crucial to reach the ambitious goal of health for all in all countries, both rich and
poor.” They look at policy from Alma-Ata through the time of publication (2008), focusing on
the scaling-up of PHC that would be necessary to achieve the Millennium Development Goals.
These health-related development goals, reflect the outcome-based perspective of selective PHC,
especially with the sixth goal (to combat HIV/AIDS, malaria and other diseases). Similarly, the
Millennium Development Goals do not explicitly connect development goals like gender
equality and environmental sustainability to health, as a comprehensive PHC approach would do
quite clearly. However, a comprehensive PHC approach, as Lawn et al., WHO Director-General
15
Dr. Margaret Chan, and others have pointed out, can be a useful as a strategy that would achieve
all eight of the goals, from maternal health to food security.22,23,24,25
Lawn et al. describe the Declaration of Alma-Ata as “a vision for preventive and curative
interventions as well as increased social wellbeing, the comprehensive process of local
community involvement, and improving health and the social environment through effective
intersectoral action.” To be more specific, they state that the philosophy of comprehensive
primary health care involves “societal change and community ownership” and is a “full
intersectoral model.” This is contrasted with selective primary health care, which “focuses
primarily on supply of services.”
However, Lawn et al. also write, “the formation of links between community and primary
health care is essential and requires clearly understood protocols that indicate when the services
of one or other is required, and when patients should be referred for higher level care...”26 They
included the pyramidal diagram
shown at left. The statement above
and the accompanying
visualization both exclude from the
“primary health care” label those
aspects of PHC that address the
social foundations of disease and
anchor PHC in a deeply political
framework. The sentence
differentiates between a community and PHC, implying that they have separate roles and
responsibilities, rather than the community being an integral part of PHC itself. That is, rather
Figure 1 “PHC and the context of the wider health system, community mobilization, and intersectoral action”
16
than health improvements in a given population (geographically and socially defined) being
achieved through their own actions and according to their needs and circumstances, a distinction
here is made between primary health care and the social structures/capital and non-medical
determinants of health. According to Lawn et al.’s diagram, the components of PHC are
community health care (not defined), family care, outpatient care and inpatient care. Community
mobilization and intersectoral action are at the base of the pyramid, suggesting that these
conditions lay the groundwork for successful community health care and at-home family care,
but they are clearly separate from the section of the chart marked “Primary Health Care.”
Another chart in the article, shown at
right, lists the components of primary health
care; of the four sections, just the first one—and
not even all of its subsections—includes
components that are not part of a traditional
health system. The authors’ illustration of
primary health care resembles traditional
primary care, deemed “comprehensive” for the
breadth of services it aims to offer universally,
rather than for any real commitment to
intersectoral health policy. In lieu of attempting
to attack the social conditions that produce
differences in socioeconomic status, this
representation of PHC would presumably seek to
mitigate the effect of socioeconomic status on
Figure 2 Main components of PHC (as per Lawn et al.)
17
health outcomes, which is a pragmatic approach to take but, like selective primary health care,
lacks the social justice and equity values that lie beneath a truly comprehensive PHC system.
WHO’s 2008 World Report is dedicated entirely to review and discussion of Alma-Ata
and PHC, in recognition of the 30th anniversary of the conference. Of note for our discussion of
what PHC entails and how comprehensive it is meant to be is a comparison in the report’s
introduction of PHC “Then & Now.” For example, it says that while early PHC focused on
water, sanitation, hygiene, and village-level health education, current PHC focuses on promoting
healthy lifestyles and minimizing the effects of environmental and social hazards on human
health. Also germane to this analysis of PHC’s scope is that the report states that while early
PHC focused on “a small number of selected diseases, primarily infectious and acute,” (selective
primary health care), current PHC is working to address a full range of needs (comprehensive?).
These contrasts show that the meaning/understanding of PHC has shifted over the past three
decades, perhaps contributing to some of the lack of consensus regarding the true form of PHC.
The shift in understanding the comprehensive nature of PHC reflects the increased
prevalence of chronic conditions, which are more clearly tied to diet and other “lifestyle” factors
than infectious diseases are, and thus more difficult to address through vertical interventions. On
the other hand, the report states that “despite variations in the specific terminology [of PHC],
its characteristic features (person-centeredness, comprehensiveness and integration,
continuity of care, and participation of patients, families and communities) are well
identified.”19 Coming from the WHO, this statement is surprising. These tenets may have
been well-defined at Alma-Ata, but comprehensiveness and integration, i.e. intersectoral
action and synergy with a given community’s social structure and lifestyle, are far from
universally recognized as central to (comprehensive) PHC.
18
In 2010, Mrigesh Bhatia and Susan Rifkin co-authored “A renewed focus on primary
health care: revitalize or reframe?” a commentary on the task of promoting PHC in light of the
WHO reports in 2008 on PHC and the social determinants of health. In order for PHC to be
relevant and viable today, they argue, it must be reshaped. Namely, it must do a better job of
addressing the social determinants of health and move beyond a strictly biomedical model, and it
must clearly differentiate primary care from primary health care. Whereas primary care involves
just “first line health services,” primary health care looks at the wider set of conditions that cause
disease in a community and works toward equity and community participation in health care.
Bhatia and Rifkin posit that despite WHO’s moving stories of health as a tool for
development and means of improving the lives of the poor, those working in health care delivery
and policy were not convinced that “the socio-economic environment was as critical to health
improvements as medicine and service delivery.” 27 Thus, the implementation of PHC was about
delivering services, rather than social justice and equity, despite the intent at Alma-Ata. This
echoes the final report of the Commission on Social Determinants of Health, published in 2008,
which in several places includes a recommendation like the following,
Health-care systems have better health outcomes when built on Primary Health Care (PHC) – that is, both the PHC model that emphasizes locally appropriate action across the range of social determinants, where prevention and promotion are in balance with investment in curative interventions, and an emphasis on the primary level of care with adequate referral to higher levels of care. 28,29
Secondly, in order for PHC to succeed, Bhatia and Rifkin state there must be “an agreement for a
standard definition of PHC and the attributes it encompasses,”8 which would provide a
basis/platform for both health promotion and policy analysis. This would not only help clear the
confusion of terminology between primary care and primary health care, but also facilitate
implementation of truly comprehensive PHC.
19
Lawn et al. state that the decades of debate between Comprehensive and Selective
Primary Health Care—“between comprehensive and selective, horizontal and vertical, top-down
and bottom-up”—has evolved into a discussion of how best to combine the strengths of each into
a healthcare system. They also claim that currently, “community participation and intersectoral
engagement seem to be the weakest strands in primary health care.” These two statements reflect
the re-focusing that PHC vitally needs if it is to be truly embraced and implemented. Though I
would argue that selective PHC has very little in common with the overarching idea behind
primary health care, it has been successful in a few key areas, particularly with respect to
immunization/vaccination coverage.30 This focused approach is also helpful in addressing
specific and pressing global health challenges like HIV/AIDS, but not at the cost of tackling the
underlying social, cultural and political factors that contribute to the epidemic nature of these
diseases. The return to PHC can and should learn from the past four decades of experimentation
with varying forms of PHC implementation, while perhaps looking to the Declaration of Alma-
Ata to help frame the social justice motivation for PHC.
As seen here, the understanding of primary health care has morphed over time, from the
social justice-driven radical concept espoused at Alma-Ata to a more traditional, biomedical
concept—so similar to primary care that the two are sometimes used interchangeably. In the
three decades since Alma-Ata, economic and political factors contributed heavily to the rapid
rollback of the scope of PHC and strong emphasis on health outcomes and cost-effectiveness. In
recent years, there has been a call to “return to primary health care”—the revolutionary
comprehensive PHC of Alma-Ata—as a means to achieve today’s global health goals, whether in
the form of Millennium Development Goals or a renewed vision of Health For All.
20
II. Systematic Literature Review: How have rural CHW systems included agricultural involvement and development as a tenet of primary healthcare? Methods
Introduction
As discussed above, the implementation of primary health care has been plagued by
limited funding and political will, as well as a lack of a clear and widely-accepted understanding
of what PHC entails. One key component of PHC that has been widely discussed, implemented
and studied, however, is the community health worker model. Community health worker systems
function in the PHC framework as a means of achieving community participation in health care,
as well as serving as a low-cost means of health promotion and disease prevention. The projects
that motivated the 1978 PHC conference at Alma-Ata differed in their approaches to PHC, but
many included some kind of community health worker network—from China’s “barefoot
doctors” to the Jamkhed’s Village Health Workers. Similarly, though it was just one part of the
PHC framework envisioned in the Declaration of Alma-Ata, community health worker systems
were widely and rapidly adopted in the subsequent years, often on a national scale. Most of these
programs, however, lack the rest of the PHC “package”; regardless of how comprehensive it is,
PHC is necessarily more than just community participation and access to preventive care/health
promotion. As discussed above, PHC in rural settings should reflect and interact with the
agricultural lifestyles of the population. Non-systematic perusal of PHC literature in the early
stages of this paper yielded many publications about community health workers, and primary
care/community health clinics, and the occasional call for intersectoral collaboration, but very
little about the PHC programs’ rural/agricultural development components, which were vital to
the success of the CRHP. To see how PHC programs have implemented community health
21
worker systems alongside agricultural work, I conducted a systematic literature review of
relevant publications in journals and by the WHO.
Information Sources
To conduct this systematic literature review, I used EBSCOhost to do a combined search
of articles published in peer-reviewed journals contained in the following databases: Academic
Search Complete, Academic Search Premier, Anthropological Index Online, Anthropological
Literature, Anthropology Plus, Applied Science & Technology, CINAHL, CINAHL Complete,
CINAHL Plus, General Science, GreenFILE, Health Source: Nursing/Academic Edition,
MEDLINE, Social Sciences, and SocINDEX. I supplemented these results with a search of the
WHO’s online archives.
Search terms
The terms used to search databases for this literature review were a combination of
primary health care, agriculture (and variations thereof), rural health, and some of the most
common variations of terminology for community health worker, including outreach worker,
village health worker, community health advisor, community health advocate, community health
navigator, community health aide, lay health worker, and lay health advisor. See Appendices A
and B.
Study selection & inclusion criteria
To be included in this review, articles/studies must have been published in a peer-
reviewed journal or by the WHO between 1970 and 2013, written in English, and describe at
22
least one clear agricultural component to an implemented rural primary health care program. If
agricultural relevance was unclear in the abstract, full text was read to make this determination.
No age, gender or geographic restrictions were placed on eligibility.
Data (variables) sought
Descriptions of agricultural integration in a primary health care project, program scale,
location/region, impact.
Risk of bias across studies
No bias risk foreseen across the studies/reports, though smaller, more remote, and less
well-connected/funded projects are less likely to have been published in scholarly journals (and
thus less likely to be included in this review).
Findings
The EBSCO searches yielded 75 results and the WHO archive search yielded 113 results.
All of these articles were screened individually for inclusion criteria. In both searches, articles
were excluded first if they were duplicates of other articles in the results, then if they did not
describe an implemented rural Primary Health Care program/project, and finally if no mention
was made of any agricultural activities or tie-ins. Of the EBSCOhost results, four were deemed
eligible to be included in this review. From the WHO archives, five were eligible. Figure 3
represents this process visually.
23
These nine results are summarized in Figure 4. Each article describes a different PHC
project, and the years of publication range from 1997 to 2011. There is some overlap with
respect to the organization implementing the projects; two of the articles are about BRAC, and
two have to do with the WHO Eastern Mediterranean Region countries’ Community Based
Initiatives strategy. Just one describes a project in the Western Hemisphere. Two describe
nation-wide programs, while the rest are regional/local in scope. Of the nine total articles, one
presents evaluative data that was collected by the researchers, an additional five aggregate or cite
data from others’ studies, two have unclear/uncited data sources, and one does not include any
evaluation of the program.
Figure 3: Flow chart of systematic review process
24
Aut
hor
Ref
eren
ce
Proj
ect
Agr
icul
tura
l Tie
s Ev
alua
tion
Met
hod
Suka
ti (1
997)
Su
kati
NA. P
rimar
y hea
lth ca
re in
Swa
zilan
d: is
it
work
ing?
Jour
nal o
f Adv
ance
d Nur
sing.
1997
;25(
4):7
60-7
66.
PHC
in S
wazil
and
-“pr
omot
ion o
f foo
d sup
ply a
nd pr
oper
nutri
tion”
-in
terse
ctora
l acti
on fo
r wate
r, nu
tritio
n, fo
od &
en
viro
nmen
tal co
ncer
ns, w
ith ag
ricul
ture
liste
d as
one o
f the
majo
r sec
tors
to in
volv
e.
-liter
ature
revi
ew
Matt
son
(199
8)
Matt
son S
. Mate
rnal-
child
healt
h in Z
imba
bwe.
Heal
th C
are W
omen
Int.
1998
;19(
3): 2
31-2
42.
Mate
rnal
and C
hild
He
alth P
reve
ntiv
e Nu
tritio
n Pro
gram
(Z
imba
bwe)
-Sup
porte
d co
oper
ative
gard
enin
g effo
rts th
roug
h en
trepr
eneu
rial &
agric
ultu
ral s
kills
deve
lopm
ent
-enc
oura
ged c
hick
en- a
nd ra
bbit-
keep
ing (
for
nutri
tion &
inco
me)
-nut
ritio
n and
healt
h ass
essm
ents
of 5
1 wom
en
and t
heir
child
ren <
24 m
onth
s
Upha
m (2
004)
Up
ham
N. M
akin
g Hea
lth C
are W
ork f
or th
e Po
or: W
orld
Hea
lth O
rgan
izatio
n;20
04.
BRAC
(B
angl
ades
h), G
K (B
angl
ades
h)
-BRA
C be
gan a
s a ru
ral d
evelo
pmen
t or
gani
zatio
n the
n exp
ande
d int
o PHC
; GK
bega
n wi
th he
alth c
are a
nd gr
ew to
inclu
de su
ppor
t for
ag
ricul
ture
. -B
oth c
onsid
er th
eir m
icroc
redi
t wor
k key
to
help
ing f
arm
ers.
-no n
ew ev
aluati
on; c
ites s
tudi
es sh
owin
g % of
len
ders
lifted
out o
f pov
erty
, % lo
an
repa
ymen
t, an
d micr
o-lev
el ho
useh
old d
ata
analy
sis of
acce
ss to
healt
h ser
vice
s
Chow
dhur
y et a
l. (2
006)
Ch
owdh
ury A
MR,
Alam
MA,
Ahm
ed J.
De
velo
pmen
t kno
wled
ge an
d exp
erien
ce: f
rom
Ba
nglad
esh t
o Afg
hani
stan a
nd be
yond
. Bul
letin
of
the W
orld
Hea
lth O
rgan
izatio
n. 20
06;8
4:67
7-68
1.
BRAC
(A
fgha
nista
n)
Train
ed pa
rave
terin
arian
s, es
tablis
hed p
lant
nurse
ries,
intro
duce
d new
agric
ultu
ral t
ech.
-a
rticle
is an
over
view
of ac
tiviti
es, b
ut ci
tes
study
mea
surin
g he
alth s
ervi
ce de
liver
y fro
m
2004
-200
6
Dick
et al
. (20
07)
Dick
J, C
larke
M, v
an Z
yl H
, Dan
iels K
. Prim
ary
healt
h car
e nur
ses i
mpl
emen
t and
evalu
ate a
com
mun
ity ou
treac
h app
roac
h to h
ealth
care
in
the S
outh
Afri
can a
gricu
ltura
l sec
tor.
Inter
natio
nal N
ursin
g Rev
iew. 2
007;
54(4
):383
-39
0.
PHC
TB tr
ial in
W
ester
n Cap
e Pr
ovin
ce (
Sout
h Af
rica)
-Far
m-b
ased
-h
ealth
com
mitt
ees e
ach h
ad a
farm
wor
ker a
nd
farm
man
ager
/ own
er
-Com
petit
ions
to cr
eate
food
gard
ens
-CHW
s tra
ined
on fa
rm-re
lated
occu
patio
nal
healt
h & sa
fety
-Com
paris
on of
TB
case
-find
ing &
trea
tmen
t ou
tcom
es
-Net
cost
-Qua
litati
ve da
ta on
impa
ct to
CHW
s, fa
rm
owne
rs &
publ
ic he
alth p
erso
nnel;
colle
cted
thro
ugh i
nter
view
& fo
cus g
roup
s Ar
daka
ni &
Rizw
an
(200
8)
Arda
kani
MA,
Rizw
an H
. Com
mun
ity ow
nersh
ip
and i
nter
secto
ral a
ction
for h
ealth
as ke
y pr
incip
les fo
r ach
ievin
g "He
alth f
or A
ll". E
ast
Med
iterr
Hea
lth J.
14(S
pecia
l Iss
ue):S
57-S
66.
CBIs
in W
HO
Easte
rn
Med
iterra
nean
Re
gion
coun
tries
-CBI
s inc
lude
“agr
icultu
ral a
nd li
vesto
ck
proj
ects”
-In
Som
alia,
part
of a
mala
ria pr
even
tion p
rojec
t in
volv
ed ad
ding
larv
ivor
ous f
ish to
open
irr
igati
on w
ells.
uncle
ar
WHO
Reg
iona
l Of
fice f
or th
e Ea
stern
M
edite
rrane
an
(200
8)
Comm
unity
-bas
ed in
itiat
ives n
ewsle
tter.
Vol 4
: W
orld
Hea
lth O
rgan
izatio
n Reg
iona
l Offi
ce fo
r th
e Eas
tern M
edite
rrane
an; 2
008.
“Hea
lth V
illag
es”
CBI (
Syria
) -m
icrol
oans
avail
able
for f
arm
ing—
both
liv
esto
ck/d
airy a
nd ho
rticu
lture
-v
illag
e dev
elopm
ent s
ubco
mm
ittee
s for
ag
ricul
ture
, wate
r, sa
nitat
ion,
healt
h, an
d inc
ome-
gene
ratio
n
-liter
acy r
ate, a
cces
s to s
afe d
rinki
ng w
ater,
imm
uniza
tion/
vacc
inati
on ra
tes, a
cces
s to
“ade
quate
excr
eta di
spos
al fa
ciliti
es,”
incid
ence
of il
lnes
ses (
incl.
diar
rhea
& ac
ute
resp
. inf
ectio
n), a
nd re
turn
rate
of fe
male
sc
hool
drop
outs.
Ba
ntey
erga
(201
1)
Bant
eyer
ga H
. Eth
iopi
a's H
ealth
Ext
ensio
n Pr
ogra
m: I
mpr
ovin
g Hea
lth th
roug
h Com
mun
ity
Invo
lvem
ent.
MED
ICC
Revie
w. 20
11;1
3(3)
:46-
49.
Healt
h Ext
ensio
n Pr
ogra
m (E
thio
pia)
-D
issem
inati
ng he
alth m
essa
ges a
t agr
icultu
ral
com
mun
ity ev
ents,
thro
ugh a
g-ba
sed c
omm
unity
as
socia
tion
-Pro
mot
ed se
para
tion o
f hum
an &
anim
al qu
arter
s
- agg
rega
tion o
f data
from
3 lar
ge sc
ale
studi
es. D
ata in
clude
d:
*he
alth c
are c
over
age
*im
mun
izatio
n rate
s *
anten
atal c
over
age
*“c
ontra
cept
ive a
ccep
tance
rate”
*
HIV
prev
alenc
e *
acce
ss to
safe
drin
king
wate
r PA
HO (2
012)
Fa
ces,
Voice
s, Pl
aces
Beli
ze: P
AHO;
2012
. GA
TE (B
elize
) Or
gani
c/sus
taina
ble v
egeta
ble g
arde
ns at
scho
ols
None
inclu
ded
Figu
re 4
: Su
mm
ary
of fi
ndin
gs
25
Summary of Results
Sukati describes the PHC system implemented in Swaziland, and analyzes PHC in the
country from 1983 to 1995.35 The 1980s marked a shift from an urban, curative and hospital-
based health care system to a PHC-based preventative one that better addresses the health needs
of the rural majority. Sukati draws on Ministry of Health publications as well as
independent/academic evaluations and analyses to present an overview of PHC in Swaziland and
commentary on both its successes and the areas with little improvement. The Ministry of
Health’s 1983 PHC strategy included “promotion of food supply and proper nutrition” as well as
“clean water supplies.” Water, nutrition, food and environmental concerns were emphasized as
key areas for intersectoral action, alongside education and housing. Agriculture was included as
one the major sectors to involve in these efforts.35(p762)
In “Maternal-child health in Zimbabwe,”34 Mattson describes an Earthwatch-sponsored
maternal and infant health PHC intervention in the Masvingo Province of Zimbabwe. After
nutritional deficiencies, lack of safe water, and family planning needs were identified as three
main contributors to maternal and child morbidity and mortality in the target area, the project
focused on training existing community health workers to help families with nutritional
deficiencies, family planning, and hygiene needs.(p231-2) Nutrition education was based on a needs
assessment and drew from Zimbabwe’s nation-wide curricular materials on the topic.
Community members and leaders acknowledged that nutrition was a major issue, and worked
with the implementing team to develop solutions. The intervention also involved working with
women who were involved in cooperative food gardens to improve their agricultural and
business skills. Mattson implies that the women were taught how to better manage their farms,
26
including information on seed-saving, bartering, and dividing harvests between market and
home. They also discussed means of advertising their products to those outside the cooperative.
Goats were an ongoing problem in the cooperative gardens, so the gardeners were connected to
local NGOs that helped with fencing the gardens to keep goats out.(p240) Also, the women were
introduced to the ideas of growing citrus fruits and other crops well-suited to the climate, and of
starting poultry or rabbit cooperatives. CHWs were taught the nutritional benefits of eggs, since
some households already raised chickens but lacked coops and thus never had eggs. The CHWs
were also instructed in how to build coops.(p236)
Multiple chicken cooperatives and at least one rabbit cooperative are reported to have
successfully grown from these conversations. The nutritional assessment of 51 women around
the start of the program showed a high prevalence of undernourishment (40%) and iron-
deficiency (25-40%, depending on pregnancy/lactation status), but no post-intervention
measurements are presented for comparison. The baseline children’s health assessment, showed
high prevalence of malnutrition and underweight (“a majority were underweight … malnutrition
[was] a problem”), iron-deficiency (70%) and diarrheal disease (no statistics given). The follow-
up showed that 47% of children (n=204) had diarrhea and 42% were iron-deficient. No statistic
is given for underweight/malnourishment. As such, the data shows a reduction in iron-deficiency
in children. Additionally, Mattson notes that the children of women who were involved in a
garden cooperative had better health than the children whose mothers were not involved in a
garden cooperative.
Upham’s “Making Health Care Work for the Poor,” a background paper for WHO on
PHC in Asia, includes a section on NGOs in which she discusses Gonoshasthaya Kendra (GK)
27
and the Bangladesh Rural Advancement Committee (BRAC), two large Bangladeshi NGOs that
use a comprehensive PHC framework.38 Both utilize some form of a community health worker
network. GK is described as having grown from a health service provider into a PHC
development organization, which BRAC moved from a rural development work into the arena of
health care.(p5) The GK system has both rural and urban PHC systems, and has grown to
encompass “education, nutrition, agriculture, environment, generic drugs manufacturing,
vocational training and medicinal plant research.”(p26) The insurance mechanism, too, reflects the
realities of the varied agricultural lives of the population served; group “A” consists of families
who are very poor and not food sufficient, who pay only a symbolic amount (one taka), while the
food-sufficient families in group “B” and the farmers with surplus in group “C” pay fees on a
sliding scale.(p27) BRAC’s work is described in less detail, but Upham mentions that BRAC
mostly serves the landless rural poor (i.e. farm workers, not farm owners), and provides
“agricultural support” in addition to microcredit, health care, and health insurance.(p24) In
focusing on BRAC’s TB program, the report quotes BRAC Deputy Executive Director Alam as
saying that proper nutrition, good living and working conditions are key to “favoring the human
being over the bacilli.”17
Upham’s report does not evaluate either organization’s activities herself, but cites studies
showing the percent of borrowers/families of BRAC borrowers lifted out of poverty within four
years of participation in microcredit programs (11%), TB cure rate (89%), and micro-level
household data analysis of access to health services. There are no evaluative measures for GK,
just discussion of scale and prominence.
28
A 2006 report of BRAC’s work in Afghanistan by Chowdhury et al. examines the
application of the BRAC PHC/development model to rural Afghanistan.39 The report cites the
project’s components as “health, education, microfinance, women’s empowerment, agriculture,
capacity development and local government strengthening.”(p677) Specific agricultural
components of the program include the training of paraveterinarians and creation of new plant
nurseries, in tandem with the introduction of technologies like artificial insemination of livestock
and higher-yield seeds. Results attributed to BRAC’s programs between 2004 and 2006 in
Afghanistan include an increase from 37% to 91% in antenatal care, from 31% of births
occurring in hospitals to 55%, of births. Vaccination rates for tetanus toxoid increased from 78%
to 88%, and for DPT (three doses) from 16% to 51%.
Dick et al. conducted a farm-based PHC intervention program in an area of the Cape
Winelands (Western Cape Province) in South Africa.33 On 106 (randomly-selected) farms of the
211 participating farms, the investigators implemented a community health worker system in
which local nurses collaborated with farm laborers and their families, the farm owners/managers,
non-governmental organizations and the public health sector. On each participating farm, farm
dwellers selected a community health worker (nearly all of whom were female), who was then
trained at a central farm. The project also facilitated the formation of local health committees,
each of which consisted of farm laborers and farm owners/managers alongside representatives
from the public health sector, local schools and partner NGOs. These committees organized
health promotion events, “which took the form of community festivals and competitions to
produce food gardens.”(p386) The community health workers often created their own food gardens
after training.(p388) Additionally, the community health workers were trained on farm-related
29
occupational health and safety topics, including physical injuries and exposure to toxic
chemicals.(p388) The experiment was a randomized controlled trial, using the clinical indicators of
TB case-finding and treatment “success” as easily-measurable/available means of comparing the
effectiveness of the community health worker system. The study found that the successful TB
treatment completion rate in new smear-positive TB patients was 18.7% higher on the
intervention farms than on farms in the control group. Case-finding for new smear-positive cases
was 8% higher, but that was not statistically significant. The cost of treatment per TB case to the
District Health Authorities, however, was 74% lower on intervention farms than on control
farms. Qualitative research was simultaneously collected from those connected to the
intervention farms,33 and these results supported the idea that CHWs acted as health promoters.
Ardakani and Rizwan report on the community based initiatives (CBIs) implemented in
WHO Eastern Mediterranean Region countries since 1988.36 The CBI model integrates health
into development projects to address the “major determinants of health” in way consistent with
the Declaration of Alma-Ata, particularly in the emphasis on intersectoral action. Components of
the CBI model include “strengthening health, nutrition and environmental conditions,” as well as
“improving economic status” and ”empowering … intersectoral collaboration,” among
others.(pS58) Community-designed projects listed in the introduction include “agricultural and
livestock projects,” but of the CBIs described in the report (from Afghanistan, Iran, Morocco,
Oman, Pakistan, Somali, Sudan, Djibouti, Jordan, Saudi Arabia, Syria, Egypt and Yemen), just
one makes any specific reference to agricultural involvement. This is in the description of an
initiative in Somalia, part of which included the expansion of antimalarial measures. One of
these was the introduction of larvae-eating fish into shallow, open irrigation wells.(pS61) The
30
sources of the data cited in this report are unclear, but the authors write that the interventions in
participating villages in Somalia “helped contain frequent outbreaks of malaria.”
Another set of articles about CBIs in the Eastern Mediterranean appears in a WHO
Regional Office for the Eastern Mediterranean CBI newsletter from 2008.37 In this newsletter,
the “Healthy Villages” CBI implemented in Syria was the only one that mentioned both
community health workers (“community health volunteers”) and agriculture. The agricultural
components of the program, which was active in 613 villages at the time of publication, include
microloans for “livestock and dairy development, agriculture and fruit trees” and other non-
agricultural income-generation projects, and subcommittees (“specialist committees”) of each
village development committee for agriculture, water, sanitation, income-generation, and health,
among others. The data source and exact years of comparison are unclear, but the authors cite
increases in literacy rates, female school attendance and graduation rates, access to safe drinking
water, immunization coverage, and access to “adequate excreta disposal facilities,” and a
decrease in the incidence of acute respiratory infections, cutaneous leishmaniasis and diarrheal
disease, as a result of the Healthy Villages intervention.
Banteyerga describes Ethiopia’s Health Extension Program, which was implemented in
most rural agrarian areas of Ethiopia starting in 2004-2005. The program is based on a diffusion
model of health improvement, which assumes that health behaviors can be improved by creating
model families that others in the community will then emulate. Agricultural components of
Ethiopia’s Health Extension Program include informal sharing of health information at
agricultural community events through the existing mahber practical support community
31
association for activities like harvests and home constructions.26 Additionally, “All government
sectors, local leaders, and communities are required to collaborate in implementation of HEP
programs […] agriculture extension agents, community associations, as well as other social
structures are involved in disseminating HEP messages and promoting good health
practices.”(p47) One agricultural component of the main health promotion effort was to encourage
the separation of living quarters from animal sheds. Banteyerga cites large-scale scientifically
rigorous studies reporting that malaria, diarrhea and other water-borne diseases markedly
decreased in the participating villages.
“Faces, Voices, Places Belize,” published by the Pan American Health Organization,
describes began the GATE Project in rural, southern Belize, where there is already a nationwide
CHW network.31 This project, from the NGO Plenty Belize, establishes school gardens that
model sustainable, organic agriculture and use them to promote better nutrition and
environmental conservation. Produce from the gardens is used in school feeding programs. The
report list no means of project evaluation other than scale; 46 gardens were built between 2002
and time of publication (2012) as part of GATE.
Themes
Utilization of farmer clubs/community associations/committees (included in 5 articles)
The most common agricultural component mentioned in the nine results is their
utilization of existing social organizations for farmers, and/or their involvement in the creation of
committees or organizations. Mattson described that the program worked with the existing
farming cooperatives, and encouraged the development of others. Dick et al. explained that the
32
program staff facilitated the formation of health committees, each of which had representation
from the farm laborers, the farm owner, and the public health sector. Banteyerga noted that the
HEP made use of the community association for collective activities like harvests and home
constructions to spread health messages. The Healthy Villages project in Syria also involved a
village subcommittee on agriculture—this presumably but not necessarily was comprised of at
least some farmers. The BRAC model, as described in the report on BRAC’s work in
Afghanistan, also includes the creation of village organizations.
Improving agricultural practices/structures (included in 4 articles)
The next most common agricultural element shared by the projects included in this
review is the introduction or promotion of specific agricultural techniques or practices and
training community members in agricultural skill areas. Mattson described the Earthwatch
nutrition intervention’s various methods of improving farming practices in the women’s co-op
gardens, including fencing, seed-saving, and growing citrus fruits. The program also taught coop
construction (such that eggs may be collected) and facilitated the formation of chicken- and
rabbit-raising cooperatives. Similarly, BRAC’s programs in Afghanistan involved the training of
paraveterinarians and usage of higher-yielding seed varieties; the general BRAC model
described in that report noted that the organization usually trains select villagers in agriculture
and animal husbandry. Ethiopia’s HEP encouraged farmers to separate animal quarters from
their family homes. Finally, though the processes of implementation were not very clear, one
anti-malaria component of the CBI in Somalia involved an innovative modification of irrigation
techniques.
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Food gardening (included in 3)
Food gardening appeared in three of the articles in this review. Aside from Earthwatch’s
work with cooperative food gardeners, it formed the core of the GATE project, where food
gardening at schools served to model sustainable agricultural practices and to provide fresh
produce as ingredients for school meals. Additionally, food gardening was one of the central
health promotion messages disseminated by the health committees in Dick et al.’s CHW RCT in
South Africa. Community health workers also were reported to have started their own food
gardens after their training.
Microloans for farmers (included in 2)
Microloans were discussed as part of both the BRAC/GK models of PHC (as reported by
Upham) and the CBI model. Microlending was also a part of the BRAC program in Afghanistan,
but Chowdhury et al. did not make the connection between any of the 100,000 borrowers and
agriculture in the article.
Discussion
The nine publications included in this review describe programs that vary greatly in scale,
scope, and scientific rigor. Though all use a community health worker model (by design of the
review), identify as in line with the principles of primary health care, and include some kind of
agricultural component to the project/program, it is impossible to compare the programs—much
less the effects of their agricultural components-- on any level other than a purely descriptive
one.
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The differing goals of the agricultural components of these programs speak to the many
ways in which agriculture and health are intertwined. For projects like Swaziland’s PHC
strategy, which was closely modeled on the Declaration of Alma-Ata, promotion of food supply
and proper nutrition are presented together, recognizing the key link between the two. This same
vein of thought explains the recurring theme of food gardening promotion and support in the
articles reviewed. The Earthwatch maternal and child nutrition program in Zimbabwe, saw that
technically assisting women involved in cooperative food gardens was a way to address nutrition
and food supply. As Mattson writes, “it was clear that the team could not just educate them about
what to eat without helping them obtain the means to put the food on the table. Thus, the team
decided to assist with developing sustainable cooperatives and help others not associated with
cooperatives to begin their own.” This style of intervention speaks to the fact that in addition to
producing food, agriculture is a livelihood.
To that end, several of the projects reviewed had agricultural ties that focused on
improving farming practices so that they would be more profitable. In some cases, this was
primarily accomplished through making small loans available for farmers’ investments in their
business, like livestock, new seeds or technology. These inputs help them achieve financial
stability and, thus, better health. In other programs reviewed, increasing income-generation
through agriculture was accomplished with skills training.
Another facet of the link between agriculture and health addressed by these projects is
that of environmental and occupational health. The GATE project in Belize modeled organic,
sustainable farming techniques, presumably to demonstrate that these practices are effective and
encourage local farmers to consider them, thus reducing their exposure to health-harming
chemicals and reducing environmental health hazards associated with petroleum-based
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fertilizers, pesticides, herbicides, monoculture, etc. In a poor, rural area where malnutrition is an
enduring problem and most families rely on subsistence farming, the school gardens seem to be a
scalable local solution that to address community needs, even though it does not seem to be
closely connected to the larger PHC system. The farm-based program in South Africa addressed
farm workers’ occupational health risks through training the CHWs in those topics.
Perhaps more than the other projects reviewed here, the Bangladeshi NGOs BRAC and
GK exemplify the ways in which rural primary health care is intrinsically tied to rural
development and agriculture. Whereas BRAC began with rural development and GKb began
with health services provision, both evolved into organizations that work toward the goal of
offering truly comprehensive PHC; addressing agricultural practices (and income generation) is a
basic tenet of both organizations’ strategies to improve population health and reduce health
disparities. BRAC in particular connects health services to the rural, agricultural
cultures/lifestyles of the target population—whether it be in Bangladesh or Afghanistanc—in
ways that echo those used by the CRHP in Jamkhed.
Like the CRHP, BRAC first establishes an organization in each village, which functions
as both a social forum—useful to both organizations for promoting gender equality and
community solidarity—and a means of supporting income generation, particularly for women,
through the availability of small loans. Though the CRHP group members lend to each other
while BRAC group members receive microloans through a more centralized and formal
b At the time of publication of Upham’s report, GK had a staff of 25,000 and worked in twelve locations in addition to Dhaka and Savar, with plans to expand in 2004 to 200 districts for coverage of six million people altogether.(p16) GK shares some costs with the Bangladeshi government, especially for the CHW system; GK trains the CHWs, while the government pays their monthly stipend. c The BRAC Afghanistan project was large-scale, with a staff of 3,000+, 3,5000+ community health workers, and close to 100,000 microcredit borrowers after three years in Afghanistan.39
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structure, both aim to aid community members who would otherwise have a very difficult time
supporting themselves and their families. Small loans help women start businesses, turn their
existing businesses profitable, etc., by providing some or all of the upfront costs of the process of
earning one’s own money. Since poverty and social inequality are the root cause of many health
disparities, the value of helping community members develop sources of income generation
should not be overlooked in the consideration of the scope of a comprehensive PHC program.
Limitations
This review searched only those articles published in peer-reviewed journals and
included in the databases listed previously. Reports on Primary Health Care programs that were
published in books, policy documents, webpages, etc. were not included in the searches.
Additionally, a search of EBSCOhost using the same terms (but not specifying that any be
included as subject headings) yields several hundred results in addition to those that showed up
in the systematic review, which relied on at least one of the terms to have been tagged as a
subject heading. Though unlikely that many of these would have been eligible, it remains a
possibility that some of these journal articles were relevant, despite lacking a relevant subject
heading.
Funding
This systematic review was conducted for a thesis project over a relatively short period of
time, and was unfunded. It was done on a voluntary basis by the author.
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Conclusions
There are many “hotter” topics than farming, which seems very 20th century in the light
of ever-increasing urbanization and agricultural industrialization. But more than a billion people
continue to farm for a living, representing nearly 60% of employment in sub-Saharan Africa and
more than 50% in South Asia, many of them subsistence farmers.40 While addressing urban
concerns is of course crucial to achieve any major public health goals—whether they be MDGs
or Health for All—the rush toward quick one-size-fits-all fixes like bare-bones community health
worker systems or selective PHC programs seems to have resulted in a lack of academic material
on the less glamorous tenet of PHC. Discussing seeds, irrigation and fertilizer may not be as
buzz-worthy as trumpeting the life-saving powers of Plumpy’nut, but it is sustainable farming
and food sovereignty, not ready to use therapeutic foods, that will prevent malnutrition and the
host of other diet-related and environmental health issues worldwide.
There is a disconnect between the comprehensive PHC work that is being done and its
visibility in the academic field of public health. If this information is contained solely in books,
websites, and policy documents, or if journal articles were published but are poorly/inadequately
tagged due to the biomedical focus of the large and accessible databases used for public health
research, it will continue to be difficult to study comprehensive rural PHC, judge the efficacy of
agricultural components, and adapt successful models for implementation elsewhere. If we are
truly to refocus on PHC, it is essential that there be a body of knowledge regarding each of many
parts of the approach. While the importance of involving agriculture in PHC is not disputed, it is
against the scientific basis of the field of public health to for PHC policymakers and
implementers to be complacent with the total lack of research on how to tie a program to a
38
community’s agricultural practices, holistically address farming-related health issues, and use
agriculture as a means of improving community health.
39
APPENDICES Appendix A
Full EBSCOhost database search info:
(terms were searched in “all text” except where otherwise specified, and duplicates between searches are excluded from result number) Search 1:
1. subject term: “rural health” AND 2. “primary health care” AND 3. “farming” or “agriculture” or “farm” or “agricultural extension” AND 4. “community health worker,” “outreach worker,” “village health worker,”
“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor”
48 results, 3 eligible Search 2:
1. subject term: “community health advisors,” “community health advocates,” “community health navigators,” “community health aides,” “lay health workers” or “lay health advisors” AND
2. “primary health care” 3. “farming” or “agriculture” or “farm” or “agricultural extension” AND 4. “community health worker,” “outreach worker,” “village health worker,” 5. “rural health” or “rural population
11 additional results, 1 eligible Search 3:
6. subject term: “primary health care” 7. “farming” or “agriculture” or “farm” or “agricultural extension” AND 8. “community health worker,” “outreach worker,” “village health worker,”
“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor” AND
9. “rural health” or “rural population” 2 additional results, 0 eligible Search 4:
1. subject: “farming” or “agriculture” or “farm” or “agricultural extension” AND 2. “primary health care” AND 3. “community health worker,” “outreach worker,” “village health worker,”
“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor” AND
4. “rural health” or “rural population”
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4 additional results, 0 eligible Appendix B: Full WHO archive search info Archives accessed at search.who.int [Advanced Search] Search terms: Must contain: “Primary health care” AND “agriculture” AND at least one of: "community health worker" "outreach worker" "village health worker" "community health advisor" "community health advocate" "community health navigator" "community health aide" "lay health worker" "lay health advisor" 113 results, 5 eligible
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