RUHSA-a model primary health care programme
Background: The Rural Unit for Health and Social Affairs (RUHSA) was started as an intersectoral PHC programme of Christian Medical College and Hospital in Vellore, India, in 1977. From its inception, health and development activities (with roughly equal budgets and personnel), together with relevant research, were provided for a defined area of about 100 000 people. This article reviews progress over 14 years. The infrastructure was based on female Family Care Volunteers each serving about 1000 people. These in turn are supported by a female Health Aide (for the health aspects), and a male Rural Community Officer (for the development aspects). Each of these is also involved in work with the communities, and between them cover 5000-7000 people as a Peripheral Service Unit.
Methods: The headquarters of the programme (the Central Service Unit) has a 60-bed 5 health centre which also provides administrative support. The health service support consists of MCH services, along with low-cost care through 16-weekly peripheral clinics for the 18 Service Units, and health and nutrition education. Community participation was elicited through Village Advisory Committees, the provision (by the richer) of buildings for clinics, payment for services, and the selection of Family Care Volunteers.
Findings: Problems in participation noted were (a) lack of support from mothers for a growth-monitoring programme, (b) untrained relatives continuing to conduct deliveries, (c) expectations of free services for themselves and their friends by those who had contributed buildings, (d) lack of support for a village- based diagnosis and treatment programme for tuberculosis owing to the stigma attached. At present, immunization coverage for BCG, DPT and polio ranges between 80% and 90%. Antenatal coverage is about 85%. There are 1200 supervised deliveries each year, and 1400 tubectomies, 40% of those who attend these latter services come from outside of the area. About half (55%) of families use some form of contraception. Recently all severe grade III malnourished children were taken through a community-based rehabilitation programme. Post-polio paralysed patients were rehabilitated with the help of specialists. Latrines have been provided to 500 families, tile roofs to 100 poor families, and 200 houses have been provided by the government. A major problem has been heavy staff turnover; doctors and nurses stay on average 1-2 years. Development inputs include economic and banking support, women's education and improvement, adult literacy, vocational training, social rehabilitation, agriculture and animal husbandry, and energy in the form of biogas. The ex perience of RUHSA is used to train people from India, Nepal, parts of South Asia and East Africa. Research has been conducted on basal metabolic rates, human adaptation, effectiveness of growth-monitoring, home-based growth monitoring, respiratory disease, vitamin-A deficiency links to morbidity. The most important research carried out concerns the use of killed injectable polio vaccine (IPV), and its use to achieve zero incidence of polio in 1988 and 1990-91. Costs are worked out as about 50 rupees (US$2.50) per person covered (US$1.50 if administrative and training costs are included). A table is provided showing health statistics. Infant mortality rate decreased from 116 in 1978 to 62.6 in 1990, child mortality rate from 23.3 to 8.57 in 1986, severe malnutrition from 26 to 8.8 in 1986 6 (using MUAC<12.5 cm this went down to 2.7% from 26%). [It is unfortunate that there is no analysis of the development efforts, nor any discussion of the failure of community participation in so many areas or what the programme intended to do about it. We do not know about the range of social or economic problems in the communities, or how they relate to any continued patterns of ill-health. We do not know about the other service inputs available in the area, or other developmental changes that might have led to change.
Conclusions: The value of this article is that it might prompt some people to ask these questions if ever they pay a visit, as otherwise it is impossible to assess the value of the programme. On the surface it looks like a standard health service intervention, which of course will always have a particular value. It is unclear why this should have a particular training value, or if the training function is more of an important income-generation boost (again a valid activity for that purpose).]\NEW LINE\Tony Klouda