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

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. 1

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 deeprooted 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

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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.

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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 AlmaAta, 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

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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. 4

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 communityoriented 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

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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.

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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.

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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

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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

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“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

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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

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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)

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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 oftquoted 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

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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

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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 Figure 1 “PHC and the context of the wider health system, community mobilization, and intersectoral action”

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

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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

16 Figure 2 Main components of PHC (as per Lawn et al.)

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.

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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.

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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 AlmaAta 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.

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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

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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 peerreviewed journal or by the WHO between 1970 and 2013, written in English, and describe at

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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.

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Figure 3: Flow chart of systematic review process

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. 23

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Mattson S. Maternal-child health in Zimbabwe. Health Care Women Int. 1998;19(3): 231-242. Upham N. Making Health Care Work for the Poor: World Health Organization;2004.

Chowdhury AMR, Alam MA, Ahmed J. Development knowledge and experience: from Bangladesh to Afghanistan and beyond. Bulletin of the World Health Organization. 2006;84:677681. Dick J, Clarke M, van Zyl H, Daniels K. Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector. International Nursing Review. 2007;54(4):383390. Ardakani MA, Rizwan H. Community ownership and intersectoral action for health as key principles for achieving "Health for All". East Mediterr Health J.14(Special Issue):S57-S66.

Mattson (1998)

Upham (2004)

Chowdhury et al. (2006)

Community-based initiatives newsletter. Vol 4: World Health Organization Regional Office for the Eastern Mediterranean; 2008.

Banteyerga H. Ethiopia's Health Extension Program: Improving Health through Community Involvement. MEDICC Review. 2011;13(3):4649.

Faces, Voices, Places Belize: PAHO;2012.

WHO Regional Office for the Eastern Mediterranean (2008)

Banteyerga (2011)

PAHO (2012)

Ardakani & Rizwan (2008)

Dick et al. (2007)

Reference Sukati NA. Primary health care in Swaziland: is it working? Journal of Advanced Nursing. 1997;25(4):760-766.

Author Sukati (1997)

GATE (Belize)

Health Extension Program (Ethiopia)

“Health Villages” CBI (Syria)

CBIs in WHO Eastern Mediterranean Region countries

PHC TB trial in Western Cape Province (South Africa)

BRAC (Afghanistan)

Maternal and Child Health Preventive Nutrition Program (Zimbabwe) BRAC (Bangladesh), GK (Bangladesh)

Project PHC in Swaziland

Organic/sustainable vegetable gardens at schools

-Disseminating health messages at agricultural community events, through ag-based community association -Promoted separation of human & animal quarters

-Farm-based -health committees each had a farm worker and farm manager/ owner -Competitions to create food gardens -CHWs trained on farm-related occupational health & safety -CBIs include “agricultural and livestock projects” -In Somalia, part of a malaria prevention project involved adding larvivorous fish to open irrigation wells. -microloans available for farming—both livestock/dairy and horticulture -village development subcommittees for agriculture, water, sanitation, health, and incomegeneration

Agricultural Ties -“promotion of food supply and proper nutrition” -intersectoral action for water, nutrition, food & environmental concerns, with agriculture listed as one of the major sectors to involve. -Supported cooperative gardening efforts through entrepreneurial & agricultural skills development -encouraged chicken- and rabbit-keeping (for nutrition & income) -BRAC began as a rural development organization then expanded into PHC; GK began with health care and grew to include support for agriculture. -Both consider their microcredit work key to helping farmers. Trained paraveterinarians, established plant nurseries, introduced new agricultural tech.

-literacy rate, access to safe drinking water, immunization/ vaccination rates, access to “adequate excreta disposal facilities,” incidence of illnesses (incl. diarrhea & acute resp. infection), and return rate of female school dropouts. - aggregation of data from 3 large scale studies. Data included: *health care coverage *immunization rates *antenatal coverage *“contraceptive acceptance rate” *HIV prevalence *access to safe drinking water None included

-Comparison of TB case-finding & treatment outcomes -Net cost -Qualitative data on impact to CHWs, farm owners & public health personnel; collected through interview & focus groups unclear

-article is an overview of activities, but cites study measuring health service delivery from 2004-2006

-no new evaluation; cites studies showing % of lenders lifted out of poverty, % loan repayment, and micro-level household data analysis of access to health services

-nutrition and health assessments of 51 women and their children