Made to measure: Data in the movement for primary health care

Posted on 15 June 2017

In the run up to the 101st Global Health Histories seminar ‘A world that counts?' Contexts of health: Information for Health, we're considering the data issues present in our work on the 'Local Bases of Global Health’ project. What was the role of data in the global movement for Primary Health Care (PHC); who was responsible for data collection; and how was data used? Dr Alexander Medcalf considers such issues below.

Global Health Histories Seminar 101: 'A world that counts?' Contexts of health: Information for Health’ will be streamed live online on Thursday, the 22nd of June starting at 12.30pm CEST (11.30am GMT).

Data and information collection was viewed as a vital component in improving health after the Second World War. It became an important issue for the nascent WHO; the first Director General Brock Chisholm recognised the ‘growing need for quantitative data, not only to provide comparable information on the health of populations, but also for the adequate planning of health programs and for the sound evaluation of results’. The Organization’s early annual reports displayed the extensive systems adopted for collecting and disseminating information and health statistics. In 1951 for instance, a conference on morbidity statistics was held in Geneva in connexion with a meeting of the Expert Committee on Health Statistics, and a training course for statistical coders was held at the WHO’s headquarters. Regional courses in vital and health statistics were held in the South-East Asia and the Eastern Mediterranean Regions, and surveys of the existing methods of collecting and compiling statistics were made in various countries.[1]

Whilst the WHO’s work priorities shifted in the 1970s to promote Primary Health Care (PHC), the interest in data remained constant. The 1978 Declaration of Alma-Ata at the International Conference on Primary Health Care outlined PHC as comprising ‘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’.[2] Information was seen as vital to success, and the gathering and analysis of data was envisaged as an integral part of PHC programs to help monitor and evaluate health programs, identify pressing health problems, and build up a comprehensible picture of the health needs within communities. A joint report by the WHO and UNICEF specified that the planning and management of PHC programs depended on the ‘right kind of information’: data collection should be kept to a minimum by identifying only relevant information. ‘Timely’ and ‘useful’ were the main watchwords.

Although this was the aspiration, the collection and usage of data played out differently in countries and communities around the world. We get a glimpse of some of the experiences and responses in a series of articles which appeared in the World Health Forum in the mid-1980s,[3] a half-decade after the start of many PHC programs.  In ‘Information for Health Development’, Paul Freund and Katele Kalumba argued that in many cases health systems data was unavailable, and that which existed was of ‘doubtful value’. One problem was that health information systems ‘imported from developed countries overemphasises the role of curative care in combating disease, reflecting little of prevention or other health maintenance inputs’. In some cases data collection was not so timely, with a lapse, as long as 4-5 years in some cases, between collection and the compilation and publication of results. In ‘Look, listen and learn : preparing the ground for primary health care’, Shirley Buzzard warned that where there were no clear objectives for data collection a ‘shotgun’ approach was used – asking a little about everything but not much about anything. Data collection had indeed become a part of PHC programs, to identify common health problems, but questionnaire replies frequently confirmed what was known already; that poor housing, low income, ineffective water supplies and sewage systems led to poor health. More damagingly, survey taking could give the impression that people were being listened to and steps taken to address their complaints, expectations which might later be dashed if the surveys were not followed by action. Logistical problems, such as the lack of stationery and questionnaires and inefficient mailing systems, also stifled efforts

More damagingly, whilst some program planners tended to overlook existing sources of data which might have helped avoid duplication of efforts, others overlooked the input of the communities they intended to help. Worryingly in the context of the wider aspirations of the Alma-Ata declaration, some surveys involved little or no participation from community members.

The articles also reflected on some of the responses developed to deliver better data for improved health, and agreed unanimously on the necessity of community involvement in planning and collecting data. In ’Gathering information for health’ Evangeline Suva reported that the ‘few and simple tools’ used in lay reporting in Manila provided a clear picture of the health scene and helped people to be self-reliant in health matters. The articles by Freund and Kalumba and Buzzard suggested that children should not be overlooked as potential data collectors as they were keen and dedicated observers. In addition to questionnaires, Buzzard advocated using anthropological approaches including participant observation, life histories and interviews, because they provided data as well as identifying community belief systems that affect behaviour. Life histories could reveal critical information for maternal, child health and family planning programs. She suggested that ‘listening may be one of the most important skills a health promoter can develop’.

Involving community did not just result in more relevant and useful data but also helped inspire a deep-seated concern for health issues. Freund and Kalumba detailed how, in Zambia although intended for monitoring and evaluation, community participation in data collection created linkages between CWS, schools and health centres united in a common purpose. Involving children in data collection was practical and logical, but also helped spark an interest in the health of the community from an early age. The overarching conclusion was that listening to local concerns and involving communities in the planning, collection and analysis of data provided a better way forward regardless of the country or region.

This is just a brief snapshot of the conclusions drawn from a small sample of programs, but sets out some interesting considerations when looking at the aims of data analysis, the problems of collection, and how these were overcome or worked to the advantage of communities in the 1970s and 1980s. Towards the end of 2016, to mark Universal Health Coverage Day the WHO launched a new data portal aimed at tracking progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services and where they need to improve information. At the launch the then WHO Director General Dr Margaret Chan said that ‘Any country seeking to achieve UHC must be able to measure it…Data on its own won’t prevent disease or save lives, but it shows where governments need to act to strengthen their health systems and protect people from the potentially devastating effects of health care costs’. (http://www.who.int/mediacentre/news/releases/2016/portal-universal-health/en/). This marked a very twentieth century response to a decades-old preoccupation.


 

[1] Work of WHO 1951, 4.

[2] The Declaration of Alma-Ata, 1978.

[3] Shirley Buzzard, ‘Look, listen and learn : preparing the ground for primary health care’, World Health Forum 6:4 (1985); Paul J. Freund & Katele Kalumba, ‘Information for health development’, World Health Forum 7:2 (1986); Evangeline Suva, ’Gathering information for health’, World Health Forum 7:4 (1986)