The Kangaroo, Milano, Dec.1994.
CLAUDIO SCHUFTAN
schuftan@gmail.com
PHC praxis has gone through painful adaptations the world over since Alma Ata in 1978; most often not successfully.
As a rule, since 1978, other than the eight technical components of PHC having been applied, decentralization and democratization of the planning and provision of health services, have been vastly forgotten or ignored.
When decentralization has been applied, it has seldom been interpreted as a ‘devolution of power’ -as intended by Alma Ata.
We have even embarked in reductionistic approaches to PHC -the most prominent of them probably having been UNICEF’s ‘GOBI FF’- that argued that being too ambitious in applying all technical elements of PHC was the real cause preventing us to reach ‘Health for All’. Ergo, concentrating efforts on a lesser number of elements was the way to go, the argument went on. Many health professionals, at the time, opposed the idea.
The evidence indicates it is rather the political elements of Alma Ata’s PHC concept that have been conveniently overlooked in the application of national PHC strategies. Technical issues of PHC interventions just do not play the leading role in PHC’s ultimate success.
II hereby want to propose yet another adaptation to PHC. But this time, one that blends the technical with the political in PHC by adding an ‘unorthodox’ component to PHC that more directly deals with the basic causes underlying the ill-health and malnutrition that characterize poverty worldwide: I am talking of making Income Generation Activities for Women the ninth (technical) essential element of PHC.
Disposable household income is known to correlate positively with health and nutrition indicators. Women’s IGAs affect that income. Income earned by women is, to a much higher degree than men’s, ploughed back into family wellbeing expenditures; women’s modest, frequent income simply affects income elasticities of demand for family consumables more directly (including basic services).
Note that I am not talking here of using IGAs’ revenue to finance community PHC activities, which is an option, but not my choice. I am talking about revenues going into women’s household expenditures -those traditionally controlled by them. Part of the cash will definitely pay for goods and services that maintain and improve health and nutrition of family members.
A women’s IGA element added to PHC has the double advantage of:
a) pegging this element to an often already existing activity and infrastructure, and
b) focusing PHC more on the basic socioeconomic determinants of ill-health and malnutrition (since simply more PHC organization and further technical interventions do not lead to perceived quantum leaps in improved health and nutrition indicators after perhaps an initial phase).
An added IGA element to PHC will certainly require new and different technical and organizational inputs. Training in credit and saving schemes and in basic management, marketing and accounting skills are just examples of some of these needed inputs.
There already exist specialized agencies with experience in launching IGAs. It is them who are to be brought in; trying to duplicate efforts is, I think, unwarranted. Let other experts increasingly work with us in health and get the job progressively done using valuable existing (or new) PHC infrastructures in the community.
Choosing the right mixture of IGAs in a given community -to avoid saturating the market with the same product(s) and to avoid the law of supply and demand working against the initiative- is important from the outset. Examples of IGAs that could be tried are, among many other: trading in the local staple food (replacing outside intermediaries), zero grazing schemes, agricultural production in communal land, crafts, pottery, sewing, knitting, weaving, selling of water, apiculture and honey refining, poultry or other small animal raising, and community shops.
Some will argue that IGAs may be imposing additional time requirements on already overburdened women. Existing experience seems not to bare out this contention.
Five dollars a week income is more reliable than trickle down:
Women’s IGAs can, in the poorest households, result in sometimes quite significant increases in disposable household income (even if the total income from the IGA is low).
A five dollars equivalent income a week can go a long way!
“The 5$/Week Element of Primary Health” can even become a good IGA launching campaign slogan.
National economic growth -when and if it trickles down- is expected to help reverting ill-health and malnutrition in the Third World. IGAs for women have the attractive that they can potentially short-cut this ‘Waiting-for-Godot or Hoping-for-Structural-Adjustment-Ever-to-Work Syndrome’ by generating some additional modest household income as a true bottom-up solution.
IGAs for women do not correct the roots of the immiserizing process of an unfair political and economic system.
But IGAs for women can:
a) be ‘sold’ as a technical PHC element attempting to address the key determinant(s) of ill-health and malnutrition, and
b) ultimately organize and empower women in a way that prepares them for taking more active roles in participating in health and other important decisions and actions in their communities.
In summary, what does the proposition made here mean?
It means accepting a significant paradigmatic break in PHC.
Are PHC agencies around the world ready for such a break, i.e. incorporating a non-health technical component to PHC?
I think Income Generation Activities for Women, as The Ninth Essential Element of PHC, is an idea whose time has come.
Claudio Schuftan MD
Saigon, Vietnam.