THE NEW ORIENTATION OF HEALTH SERVICES WITH RESPECT TO PRIMARY HEALTH CARE WORK

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Title: THE NEW ORIENTATION OF HEALTH SERVICES WITH RESPECT TO PRIMARY HEALTH CARE WORK
extracted text: THE NEW ORIENTATION

OF

HEALTH

SERVICES

WITH RESPECT TO PRIMARY

HEALTH CARE WORK

THE PONTIFICAL COUNCIL COR UNUM
VATICAN CITY

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THE NEW ORIENTATION
OF HEALTH SERVICES, WITH RESPECT

TO

PRIMARY

HEALTH

CARE

WORK

COMMUNITY HEALTH CELL
326, V Main. I Block
Koramong'la
Bangalore-560034
India
The booklet entitled "Health Work for Human Development"
contains the conclusions reached by a Working Group set up
by the Pontifical Council COR UNUM in 1976 in order to
examine Primary Health Care.
A second group was convened in Rome from 31 March to
2 April 1977, to examine the new orientations of health services
to fit in with this Primary Health Care policy.
Experts drawn from many different areas of the medical and
health care profession put forward their viewpoints based on
their own experience and research in a very useful series of
discussions. They looked at Christians' responsibilities and
those of the religious congregations in the light of the new
orientations. Being all too aware of the way in which situations
can vary one from, another, and of the complexity of the
problems, they rejected the idea of prescribing formulae on
methods to be used. Any comments made regarding structures
at whatever level were only attempts to concretize the
problems in order to be able to search for the most suitable
solutions.
1.
1.1.

THE CHRISTIAN APPROACH

The attitudes taken by Christ

Christ took pity on people and came to their aid, whether
they were spiritually ill as a result of sin or physically sick. His

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attention was given to the sick person with whom he frequently
talked, showing his preference for the poor, but without
excluding anyone in need who appealed to him. Accounts of
his miracles have been recorded where he restored people to
health, teaching us that we also, with whatever means we have.
must be concerned for those who suffer sickness, and do what
we can to comfort and heal them.
1.2.

Populorum Progressio

Jesus considered suffering and sickness as forming part of
the 'less human" situations which the Encyclical "Populorum
Progressio" asks us to endeavour to make "more human" (cf.
Populorum Progressio. 20). If we wish to be faithful to Christ
and take up his attitudes with regard to our fellow-men, we
must work for the overall development of each man, and focus
on the sick person more than on his sickness. Since develop
ment also means solidarity, we must necessarily turn our
attention towards the human community of the patient, his
family first, but also his neighbourhood or village. This means
we must practise community medicine/] r
The "quality of life" of his environment is important to
ensure that the sick person will be restored to physical
and psychological health, so that with the aid of his human
community he can duly take charge of his own evolution towards
a more human state, thereby becoming the craftsman of his own
development.
The grassroots community responsibility for Primary Health
Care work has the advantage of following the principle of
subsidiarity. Health-care personal, following this principle,
serve at the same time, their own personnel development.
Mastering their impatience, they listen and learn before they
organize. They are more concerned with fostering action than
undertaking it themselves.
1.3.

Evangelii Nuntiandi

As Christians, we are evangelizers, as the apostolic
exhortation "Evangelii Nuntiandi" reminds us. We are bearers

2

the Good News, of the whole and jointly responsible salvation
of man in Christ. We proclaim this Good News through the
witness of our lives, and by taking up the saving attitudes
manifested by Christ towards each person, his environment and
his traditions. Through us the Church evangelizes men and
their communities. Through us and our commitment to health
care work, the Church proclaims evangelical liberation to the
millions of human beings whose physical and spiritual health
is affected.
1.4.

The need for conversion

The mission that we have been given is_a call for a true
conversion of our hearts and also of our methods. Secularization
is spreading in people's hearts from the industrialized and
technological world to the developing world countries. We
need to be converted all the time in order to bear witness as
Christians to the sick who, through our work, will discover the
love of Christ, The rapid development in the field of health
service technology has often meant installing expensive
equipment in the hospitals, requiring a large number of staff for
a relatively low number of patients, while in many of the
same countries in the world, up to 80%_ of the population
are still without health-care services. (Since Christians are 1
the leaven, we must reach out towards the masses by
providing simple, accessible and promotional health care
according to our own possibilities, modest as they are, or in
conjunction with the public services, where this is allowed^] 3
Let us ever be mindful of the fact that service to the sick
begins and continues to operate through the patient's human
environment. Community health care is therefore part of the
comprehensive pastoral work of the Church.

2.
2.1

PRIMARY HEALTH CARE IN THE LOCAL COMMUNITY

National health service policy

Any primary health-care organization in local communities
must take account of the health service policies laid down by

3

the authorities of the country in charge of the general running of
health services.
2.2.

The basic principles of W.H.O.

The organization of primary health care services must help
each individual person in his own community. The true
needs of this community must be taken into consideration and
it must be encouraged and helped into contributing to its own
development. Primary health care brings health services to the
patient and is concerned with prevention of disease as well as
early treatment where this is needed. In this respect, we
follow the basic principles laid down by the Executive Council
of the World Health Organization at the January 1975 meeting
in Geneva, ratified subsequently by the various governments
concerned.
1. Primary health care should be shaped around the life
pattern of the population it should serve.
2 The local population should be actively involved in the
formulation of health care activities, so that health care can be
brought into line with local needs and priorities.
3. Health care offered should place a maximum reliance on
available community resources, especially those which have
hitherto remained untapped, and should remain within the
stringent cost limitations that are often present.
4. Primary health care should be an integrated approach of
preventive, curative and promotive services for both the commu
nity and the individual.
5. All health interventions should be undertaken, at the
most peripheral practicable level of the health services by the
worker most simply trained for this activity.
6. Other echelons of services should be designed in
support of the needs of the peripheral level, especially as
this pertains to technical supply, supervision and referral
support.
7. Primary health care services should be fully integrated
with the services of the other sectors involved in community

4

'-'^iviiViUiNI I Y
HEALTH CELL
<526, V Main, I Block
Koramongala
Bangalore-5S0034
India

development (agriculture, education, public works, housing and
communication.)

2.3.

The local community

It is vitally important to be aware of the sociological situa
tion of the community. This includes the composition and
growth trend of the local population, its traditions and custo
mary laws, the various social and economic problems and all the
conditions on which the overall and balanced development of
the community depends, including its health—an integrating
factor which cannot be neglected.
The members of the community must be helped, where?
necessary, to become aware of their own problems and to
express them so that, here again, they become the craftsmen [
of their own development. They alone are in a position, for~
example, to explain why they are afraid of the hospital, why
they seek medical care late in the day, why the womenfolk
prefer to give birth at home, what dying with dignity means to
them, surrounded by their family, etc.
2.4.

The community health worker

These profoundly human factors make it possible to share
out the responsibilities for organizing primary health care. There
is a wide variety of different things to be done, and some of
them were brought to the attention of the Working Group. In
the examples which follow, there is no desire to impose a
specific pattern or model for the programmes which are to
be implemented. They are simply a way of illustrating what a
primary health care service in a local community can be. In
some countries, a grassroot Community Health Committee is
formed whose members are chosen by the community. They
may be dignitaries in the community, government officers, etc.,
or simply persons whose personality or capability makes them
suitable for such a task. This Committee makes known the
health care needs of the people they represent and appoints the
community health worker. Whatever be the title given to this

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person, and this varies in different countries, he or she is the
one selected by the community.
He (or she) is given the
basic training to be able to provide primary health care, usually
on a part-time basis, while still continuing his/her normal daily
work.
The health worker's tasks depend upon local conditions,
but in general they may be summed up in the words of the
WHO in "The Primary Health Worker" (Experimental edition,
1977, pp 4-5).
"1. care for the health of the inhabitants and look after
community hygiene;
2. give care and advice, in accordance with the instructions
written down in the guide or given by his supervisor, to anyone
who consults him;
3. send patients to the nearest health centre or hospital in
any case in which the guide instructs him to do so (evacuation
or referral) and in any case not covered by the guide. The
PHW should therefore confine his care and treatment to those
cases, conditions and situations described in the guide;
4. with authorization from the local authorities, visit all
dwellings and give those living in them advice on how to
prevent disease and learn good habits of hygiene;
5. make regular reports to the local authorities on the health
of the people and on conditions of hygiene in the community.
Get the local authorities and the people to give him the help and
support he needs for his work;
6. keep in as close contact as possible with his supervisor
so as to be able to give of his best in his work and to obtain
the equipment and supplies he needs;
7. promote community development activities and play an
active part in them."
The training required, which may be graded in complexity,
should initially be given on the spot by slow and gradual training
process, given while actually "on the job". Unless the individual
concerned is so talented that the training is going to be
followed up at a later stage to "professional" level, the
training should not be so advanced that the individual is pushed

6

beyond his capacity. Sometimes it is a good idea to train local
healers or traditional "doctors" to become community health
workers, if they are willing.
Although each community is called upon to look after its
own health care problems with its own means as far as it is
able, in accordance with the principle of subsidiarity, thereby
enabling it to work out its own development, it should not
be loaded with so many responsibilities that it finds it cannot
cope with. The public authorities, who have drawn up an
inventory of the immediate resources available (personnel,
drugs and medical supplies etc.) must allocate them fairly for
the benefit of the local communities as well.
3.

QUALIFIED HEALTH SERVICE PERSONNEL

Each individual country has the task of determining the
type of personnel required, and their respective role, in the
light of the training to be given. A great many experiences
and ventures undertaken in the past have shown that a unified
terminology would be very helpful and in this, assistance of
WHO would be appreciated.
We simply wish to mention certain constants that our own
experiences and generally recognized requirements have shown
to exist in the various types of personnel required, and their
respective tasks. These constantswill enable us to see in what
direction we should be moving in order to play our part,
especially since we are often numbered amongst the promoters.

3.1.

Health care auxiliaries

One of the first levels of health service personnel is that of
auxiliaries, whose responsibilities, recruitment, training and
motivation need to be examined. These are people who should
be able to undertake tasks on their own. They also have to
assist the doctor to perform many tasks in preventive and cura
tive medicine. They work both in medical centres and with the
community health workers. The latter's training may be given
by certain auxiliaries, whose supervision they will accept. This

7

supervision not only gives them security but also provides them
with on-going training, since it is not so much a question of
controlling them, as counselling them as they carry out their
work. The auxiliaries are recruited both from those who apply
for the work directly, or who are nominated by the local commu
nity, as well as from among those community health workers
who show the right sort of ability and know their human
environment sufficiently well. It must not be forgotten, how
ever, that they do not always continue their work on a long-term
basis, and this is a cause for concern.
Their training, which should be also given on an ongoing,
continual basis including the period they are actually performing
their health care work, can be at various different levels of skills
and responsibilities. It should be provided by professional per
sonnel such as the medical team that supervises them. The res
ponsibilities which are entrusted to the auxiliaries under this
new primary health care policy demand serious motivation.
They must consider their function not so much as a form of per
sonal development as a service to the community It is a service
which demands the highest moral conscience if dangerous devia
tions are to be averted. The auxiliaries must never lose sight of
their own limitations in terms of medical skills, and of their need
to be in continual training. Their professional conscientiousness
must constantly keep their spirit of service alive in their minds.

The nursing staff
On account of their qualification and skills, nurses frequently
have to aid the local people to grasp the fact that their health is
in need of attention, and to encourage them to aspire to im
proved health and a changed way of living. Since they will give
top priority to prevention and health education, they will also
devote their efforts to training community health workers and
auxiliaries. They can be helped by the qualified midwives who
can undertake some of the same tasks, and they also assist the
doctor in organizing primary health care services. This new role
for nursing staff of both sexes, and of qualified midwives,
demands the right training on a continuous basis, as well as
deep motivation. This is a need of all the health care personnel.

3.2.

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3.3.

The doctor

This new health care policy alters the role of the doctor,
but does not make it any the less essential. The doctor needs
not only new motivation, but a training that will enable him to
respond to all the demands that will be made on him as a mem
ber of a health care team. He must be capable of coping both
with the challenges of sickness and those of under-develop
ment. He must learn to consider his vocation as a doctor as a
call to be of service to the community rather than a means of
personal development. The reluctance to go out and serve in
rural areas, which is far too widespread, has to be overcome.

3.4.

The health care team

Since the health care is entrusted with the task of promoting
health in a context of true community development, and it is not
merely a means for accomplishing routine work such as distri
buting medicine, there should be a genuine team spirit among
them.
This health care team usually comprises the following mem
bers : the doctor, the nurses and the auxiliaries, and also the
community health workers and traditional midwives. The fact
that they have different educational background and training,
different tasks to perform and different degrees of commitment
to the service of the sick and their communities, sometimes in
evitably leads to tensions or psychological conflict within the
health team. It is the leader's responsibility to restore harmony,
if he is unable to prevent them occurring in the first instance.

The responsibilities of this health care team include planning
the various tasks the team has to carry out. The team must also
provide medical treatment, nursing care, hygiene education and
be sensitive to the psychological problems and comprehensive
needs of their fellow-men. This shows how important it is for
the members of the team to have a comprehensive training and
background.

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4.

THE THINKING UNDERLYING THE CHURCH'S
NEW APPROACH TO HEALTH CARE

The emphasis given to the new primary health care policy
has shown the vital importance of a whole motivational approach
on the part of those who work in the health field or for health
improvement. Unless this new approach on the part of the per
sonnel is inculcated through special courses that need thorough
planning and implementation by highly qualified staff, the new
orientation to be followed by the various health services will
simply not come about. The "Christian approach" outlined
above looked at the motivation underlying the Church's parti
cular interest in this new approach to health services for which
the Church and its personnel take on direct responsibility.
4.1;

The health care centre

The health care centre stands midway between the village
and the hospital, and must have a dispensary with a few beds
for emergency admissions. The number of emergency bedswill
depend on the population served by the centre and the distance
from the nearest hospital. The team must look after a certain
number of villages which will be using their services for more
complicated cases ; the centre is in charge of preventive, curative
and development work.
The team must also help the community health workers in
the various communities by providing them with continuous
advice, supervision and supplies.
A team motivated and oriented in this way will really partici
pate in the implementation of the new health care policy.

4.2.

The hospital

The rural hospital is the point of reference for a number of
health centres which refer the patients they cannot handle to it,
or those in need of surgery.
The hospital team is most important. It must look after all
the hospital's needs, as well as provide continuous training and

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supervision to its health care centres. It may be called upon to
make up mobile health teams. Eventually these may be nucleus
of a new health care centre.
Where the team includes a pharmacist, he or she can help in
the training of personnel and, where appropriate, can help edu
cate the local people in basic public health, hygiene and simple
nutrition, though this latter is more usually done by a nutritionist.
The category of personnel known as health inspectors can
be very valuable members of the team and provide aid both to
the health centres and the community health workers.
To the hospital team falls the responsibility of handling the
hospital administration problems. Where the hospital falls under
the responsibility of a Board of Governors or Directors, a
Management Board or a similar kind of body, the local commu
nities must be represented on it.
The doctor and one paramedical staff representative are
habitually ex officio members of such a board.
In a larger town there is usually a regional hospital to which
the rural hospitals in its catchment area refer the patients whom
they are unable to treat themselves. The medical team in these
hospitals needs to be larger and more highly qualified to be able
to meet all of its responsibilities. In order to avoid overburden
ing this hospital with the basic needs of the local population, it
may have an annexed dispensary, either adjacent to it or even in
another part of the town.
4.3.

Childbirth

new orientation could also be introduced in the case of
maternity units which would only be used for the difficult births.
Very serious difficulties would of course be referred to the hospi
tal. Childbirth could normally be organized in the mother's home
once the health care services really do cover the whole of the
local population, particularly through careful training given to
the traditional midwives. Maternity units can be independent
units or wards attached to the health centre.
The maternity units also have the task of training the mid
wives. Part of their instruction should include the teaching
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11

methods by which they can help their patients toward respon
sible parenthood using natural methods for child spacing in
the general context of the promotion of the family.
5.

5.1.

CHRISTIANS' RESPONSIBILITIES

Evangelical motivation

Christians are citizens just like anyone else, and must be
committed to the struggle against under-development. The
example and the teaching of Christ and the exhortations of the
Popes shed light on this commitment and serve as a guide and
encouragement to them in their work which they undertake for
the love of God and their fellow-men. If they work in the field
of medicine and nursing, the evangelical reflections mentioned
at the beginning will lead them to ongoing conversion of hearfT
to provide a better service on behalf of the suffering members of
Christ and to awaken the communities of men to their responsi-1
bilities in this area.
5.2.

Relations with the government

In the past, the laity or members of the religious congrega
tions have often pioneered healthcare work in many countries.
In some instances today, their work is being taken over by the
government which sees health work as a part of its duty towards
its citizens and for which it accepts responsibility. Far from feel
ing discouraged or useless as a result of this new state of
affairs, they must see it as a golden opportunity to play an active
part in the national endeavour to bring about integral and
mutually responsible human development.
The religious congregations are called to reinforce their
basic attitudes of cooperation with all organizations at whatever
level, and in particular with the governments. This cooperation,
respecting the specific role of all concerned (for example, the
vocation and constitutions of the religious) should always be
offered with the one concern of attending to the true needs of
the sick and their communities.

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I

I.

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A

The hospitals and health care centres for which the congre
gations are responsible and where they provide a Christian spirit
of service, are there for the benefit of the whole population with
out any racial or religious discrimination. They must be ready
to provide their services in those areas out of reach of the public
health network, insofar as their personnel and financial resour
ces permit.
Where they run schools for nursing or auxiliary staff, the
training curriculum, animated by the Christian spirit, must con
form to the requirements laid down by the government, so that
the personnel trained there will have a state-recognized quali
fication and can, one day, join the public health service if they
wish. Wherever religious personnel undertake tasks alongside
professional people in the public sector, they must demonstrate
their constant concern to be fully integrated into the medical
teams running the areas in which they work.
5.3.

The current situation

While this new primary health care policy is taking shape.
members of the religious congregations must take a good hard
look at the current conditions under which they are working in
order—where
necessary—to re-direct them.< It sometimes
happens that as a result of changes which not everyone is,
necessarily aware of, too many of them work in hospitals anc
health centres that have become too expensive for the majority
of the population, and are only within reach of the pockets of c
certain "elite" who can afford them. In this case the leaven is
too far removed from the loaf. J
5.4.

New orientation

The religious congregations are by no means ill-equipped
to take part in the necessary new orientation process. Although
it may happen that in some cases some of their hospital workers
are somewhat distant from the masses, so many others are work
ing closely with local communities and are in close contact with
the people in rural areas or poor urban areas.

13

i

Their experience can be profitably used by everyone,
since they really know the true needs and deep-seated aspira
tions of the local people. Before they take part in this new
health care policy, those in charge of religious congregations
must see if they have the necessary means to do so, especially
in terms of manpower, trained and suitable for the work, and
with the right motivation.
Having the right kind of training for the personnel will be
valuable to the country. Special care must be devoted to training
foreign1 personnel so that they have a good knowledge of the
environment and the psychology of the people with whom they
will work. Local and foreign1 personnel must be spread over the
various services in the local community and the hospital accord
ing to their skills and qualifications so that the population
everywhere may have increasingly free access to health care
services. They must never forget that they have the duty tp aid
everyone to develop wholly, bearing in mind that all develop
ment is a community matter, in a spirit of mutual respect and
brotherhood.
Religious congregations, therefore, have a chance here to play
a role of promoters and pioneers in the health field by educating
some of their members for the important tasks in the primary
health care field, such as public health specialists trained to im
plement this new health approach as well as skilled in planning
and running staff training courses.
CONCLUSION

By setting up a hierachy of values and a policy regarding the
means to be used on behalf of the sick people requiring care and
the human communities needing to be helped to reach their full
development, the Church has already provided a substantial con
tribution. It is ready to doeven more in order to bring health
to the sick and to awaken the conscience of the people. WorR^ \
ing on behalf of the very poorest, the Church is enabling them !
to know their essential needs and to undertake the responsibility
for their own development in a healthier existence.
/
1 {The word foreign" here refers to non-local personnel)

14

PARTICIPANTS TO THE WORKING GROUP

Fr. HENRI DE RIEDMATTEN. O.P.,
UNUM Secretary.

Pontifical

Council COR

Dr. LIESELOTTE BAUER DE BARRAGAN, Director "Fundacion
San Gabriel" (Bolivia).
Fr. NIVERSINDO A. CHERUBIN, M.I., Superintendent "Sociedade Beneficiente Sao Camilo" (Brazil).

Prof. VICTOR-ARMAND DE GROOTE, Pharmacist (Belgium).
Former Director "Institut de Medecine Tropicale du Zaire".
Fr. HENRI FOREST. S.J., Secretariat COR UNUM.

Dr. ANNE MARIE GADE, Former Regional Adviser MCA/WHO
(Denmark).

Sr SUZANNE LEURS, Director "Bureau des Oeuvres Medicales
de la Conference Episcopale" (Zaire).
Dr. URSULA LIEBRICH, Associate Director "Christian Medical
Commission" (Geneva).

Fr. ROGER DU NOYER, M.E.P., COR UNUM Under-Secretary.
Dr. ARNOLD RADTKE, Health Adviser to MISEREOR (Germany).

Dr. ELEONORA AGATHA
CEBEMO (Holland).

SCHRODER. ' Health Adviser to

Miss GHISLAINE VAN MASSENHOVE,
CIAMS (Belgium).

General

Secretary

Dr. Sr. FRANCES WEBSTER. Member. Central Team, "Medical
Missionary Sisters" (United States)
On the basis of the findings of the Group, the Secretariat
of COR UNUM is producing the present pamphlet whose text
was reviewed and approved by the Council's Plenary Assembly
(3-6 November 1977).

DEVARSONS (STYLISH PRINTING PRESS) 5, MALIK BUILDING,
PAHARGAN), NEW DELHI-110055

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