Reducing childhood mortality in poor countries: Implementing a community-based participatory intervention to improve essential newborn care in rural Nepal

The persistence of high perinatal and neonatal mortality rates in many developing countries make efforts to improve perinatal care in the home and at local health facilities important public health concerns. We describe a study which aims to evaluate a community-level participatory intervention in rural Nepal. The effectiveness of community-based action research interventions with mothers and other key members of the community in improving perinatal health outcomes is being examined using a cluster randomized, controlled trial covering a population of 28 000 married women of reproductive age. The unit of randomization was the village development committee (VDC): 12 VDCs receive the intervention while 12 serve as controls. The key elements of the intervention are the activities of female facilitators, each of whom works in one VDC facilitating the activities of women's groups in addressing problems in pregnancy, childbirth and the newborn period. Each group moves through a participatory planning cycle of assessment, sharing experiences, planning, action and reassessment, with the aim of improving essential maternal and newborn care. Outcomes assessed are neonatal and perinatal mortality rates, changes in patterns of home care, health care seeking and referral. The study also aims to generate programmatic information on the process of implementation in communities.     

Implementing a community-based participatory intervention to improve essential newborn care in rural Nepal

The persistence of high perinatal and neonatal mortality rates in many developing countries make efforts to improve perinatal care in the home and at local health facilities important public health concerns. We describe a study which aims to evaluate a community-level participatory intervention in rural Nepal. The effectiveness of community-based action research interventions with mothers and other key members of the community in improving perinatal health outcomes is being examined using a cluster randomized, controlled trial covering a population of 28,000 married women of reproductive age. The unit of randomization was the village development committee (VDC): 12 VDCs receive the intervention while 12 serve as controls. The key elements of the intervention are the activities of female facilitators, each of whom works in one VDC facilitating the activities of women's groups in addressing problems in pregnancy, childbirth and the newborn period. Each group moves through a participatory planning cycle of assessment, sharing experiences, planning, action and reassessment, with the aim of improving essential maternal and newborn care. Outcomes assessed are neonatal and perinatal mortality rates, changes in patterns of home care, health care seeking and referral. The study also aims to generate programmatic information on the process of implementation in communities.     

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in‐depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high‐performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd     

Community views on health sector reform and their participation in health priority setting: case of Lushoto and Muheza districts, Tanzania

BACKGROUND: Community participation (CP) is a key concept under 'primary health care' programmes and 'Health Sector Reform' (HSR) in many countries. However, international literature with current empirical evidence on CP in health priority setting and HSR in Tanzania is scanty. OBJECTIVES: To explore and describe community views on HSR and their participation in setting health priorities. METHODS: A multistage sampling of wards and villages was done, involving group discussions with members of households, Village Development Committees (VDCs) and Ward Development Committees (WDCs). RESULTS: Respondents at village and ward levels in both districts related HSR with a cost sharing system at public health facilities. Views on the advantages or disadvantages of HSR were mixed, most of the residents pointing out that user charges burden the poor, there is a shortage of drugs at peripheral health facilities, the performance of government health service staff and village health workers does not satisfy community needs, health insurance is promoted more than people actually benefit, VDC and WDC poorly function as compared to local community-participatory priority-setting structures. CONCLUSION: HSR may not meet the desired health needs unless more efforts are made to enhance the performance of the existing HSR structures and community knowledge and enhance trust and participation in the health sector programmes at all levels.     

A baseline survey of the Primary Healthcare system in south eastern Nigeria

A baseline survey to audit the PHC operations and determine community perception and expectations of PHC service delivery was conducted in 72 communities in Enugu state, southeastern Nigeria. The study was intended to facilitate the development of intermediate performance indicators for monitoring the progress of an ongoing health sector reform and to gather baseline data for planning and policy formulation. The tools used for the operations audit assessed indicators for evaluating: (a) Stewardship, (b) Service Provision and (c) Administrative and financial management; while the community survey was assessed by, (a) utilization of health services, (b) perception of service delivery and (c) health care financing. One hundred and sixteen respondents from each of the facilities in the sample frame were interviewed using a structured self-assessment questionnaire and a qualitative assessment was undertaken in 53 of the facilities using an audit guide. Focus group discussions (FGD) were conducted with the policy makers and planners in each of the 17 LGAs in the state. A total of 832 respondents were interviewed in the communities (using a structured questionnaire) and 42 community FGDs were conducted. The results indicate a lack of operational efficiency in the majority of the facilities audited. It was also observed that majority of the facilities do not provide all services required of it, are poorly maintained, do not have enough skilled health workers and operate without a budget. There appears to be no formal financial management system in place and no policy on financial resource generation. The community survey identified two major problems; low utilization of PHCs and poor service provision. The key indicator identified by the community for evaluating performance of the PHCs remains "access to essential drugs". The major prospect was the willingness of an appreciable number of respondents to invest in health financing through insurance schemes and payment of health tax among others. It was evident that poor funding, bad management practices and infrastructural decay is the bane of efficient PHC delivery. Consequently, we propose that cost determination studies, to establish the financial implication of the minimum package for provision of primary healthcare services, should be an essential prerequisite to the reform process. Some critical cross-cutting issues identified from the data obtained which could form the basis for major policy thrust include, development of strategies for sustainable promotion of public-private-partnership for enhanced community involvement in healthcare management, ensuring that interventional investment is proportional to the felt health needs of the populace and funding of healthcare through equitable integration of user fees/charges.     

Primary health care in the Philippines: banking on the barangays?

Primary health care has been hailed by some countries as the only practical means of providing any form of health care for expanding populations in poor economies. This is particularly true in Third World countries where the cost explosion of technology-oriented health care has been a major problem in extending services. Therefore, the PHC package of education, nutrition, preventive medicine and treatment of the most common diseases and injuries is sometimes regarded as the most beneficial application of scarce resources. The Philippines claims to be one of the first (perhaps the first) countries to have adopted PHC as a national strategy for health care and, since 1981, impressive achievements have been attained in this sector by contrast with reversals in many other sectors of the economy. PHC has not challenged the pre-eminence of Metro-Manila in the provision of hospital and specialist facilities but it has extended some basic care particularly to rural regions of the country. This paper reviews the background to health care in the Philippines and it then examines the implementation of PHC in Negros Oriental, where PHC has taken on the additional feature of special use of indigenous materials and resources. The administrative, financial and legal bases and some geographical facets of PHC are highlighted in this province. The campaign relies heavily on local (barangay) initiatives and community participation, in part to minimise resources which have to be devoted to health in a very troubled national economy. In spite of local skills and enthusiasm, this arguably still involves the abrogation of a degree of government responsibility for health care. As a result, the Philippines strategy may be said to be "banking on the barangays."     

Extent of utilisation of maternal care services of P.H.C. by the families of a rural area

The utilization of the maternal health care services offered by an upgraded primary health care (PHC) facility in a rural area of West Bengal, India was assessed. Information on the use of the maternal services by pregnant women over a 5-year period was collected from a house-to-house sample of 100 families living less than 1 hour away from the health facility and having at least 1 child born into the family in the previous 5-year period. Women in 58% of the families used the prenatal services of the facility, 6% received prenatal care from private practitioners, and 36% received no prenatal care. Reasons given for not using the facility were 1) using the clinic was too time consuming, 2) the staff was unfriendly, 3) a lack of interest in the services provided. There was no significant differences between prenatal service utililizers and nonuser in regard to caste differences. Utilizers were somewhat more likely to live in households with a literate household head than nonusers. The number of visits made by the utilizers ranged from 1-5, but many respondents had difficulty recalling the exact number. Utilizers were no more likely than nonusers to use the delivery services of the PHC. Among the 58 women who used either the prenatal services of the PHC or of private practitioners, 34 had their deliveries at the PHC, 23 at home and 1 in the hospital. Among the 42 women who received no prenatal care, 15 gave birth at the PHC center, 20 at home, and 4 at nursing homes. Home deliveries were conducted either by untrained midwives or by family members. 3 cases of neonatal tetanus and 1 case of maternal tetanus were reported in the community during the 5 year period. All of these births occurred at home. Only 6% of the 100 mothers used the postnatal services of the PHC center. The findings indicate that the provision of upgraded services by itself is insufficient to overcome the lack of health care motivation on the part of the target population.     

Making medicine for the poor: primary health care interpretations in Pelotas,Brazil

This paper explores the local political setting in which primary health care and community participation have been implemented in Pelotas, Brazil over the past two decades. We argue that in a medically plural setting with a mixture of private and public health care schemes, capitalist-based principles and ideals (such as the predominant role given to technology) shape generalized concepts of good clinical skills and quality of care, thereby regulating the medical system as a whole. The analysis shows that some women living in shantytowns reject the negative class-based associations made with their communities in a variety of ways, including the non-use of their local primary health care (PHC) centre which they considered to be a poor substitute for what the wealthy take for granted. Recent studies show that primary level antenatal care is of low quality when compared with other sectors. Nevertheless, local politicians and physicians often blamed various aspects of local 'culture' (folk health beliefs, low valuing of biomedicine, lack of modern concepts of community-building and altruism) for failed PHC programmes, contributing a prejudicial feedback cycle between frustrated professionals often engaging in prejudicial clinical practices and offended users. Rather than discuss community participation through vague concepts such as empowerment and citizenship, those involved in PHC reform would do well to take explicit (publicly stated) responsibility for the socio-political, financial and bureaucratic constraints to PHC.     

Community and facility-level engagement in planning and budgeting for the government health sector--a district perspective from Kenya

Health systems reform processes have increasingly recognized the essential contribution of communities to the success of health programs and development activities in general. Here we examine the experience from Kilifi district in Kenya of implementing annual health sector planning guidelines that included community participation in problem identification, priority setting, and planning. We describe challenges in the implementation of national planning guidelines, how these were met, and how they influenced final plans and budgets. The broad-based community engagement envisaged in the guidelines did not take place due to the delay in roll out of the Ministry of Health-trained community health workers. Instead, community engagement was conducted through facility management committees, though in a minority of facilities, even such committees were not involved. Some overlap was found in the priorities highlighted by facility staff, committee members and national indicators, but there were also many additional issues raised by committee members and not by other groups. The engagement of the community through committees influenced target and priority setting, but the emphasis on national health indicators left many local priorities unaddressed by the final work plans. Moreover, it appears that the final impact on budgets allocated at district and facility level was limited. The experience in Kilifi highlights the feasibility of engaging the community in the health planning process, and the challenges of ensuring that this engagement feeds into consolidated plans and future implementation.     

Health care facility vulnerability in developing nations: strengthening health care policy-making and implementation

Background

In developing countries such as India, inadequate importance and consideration given to assessment of health care facilities negatively affects progress towards achieving health targets. India has focused on developing Primary Health Centres (PHCs) for rural basic laboratory and curative services. The local decision-makers do not have any national-level framework to evaluate the vulnerability of PHCs which are not meeting national PHC standards, nor do they have resources to meet national PHC standards.

Aim

The study proposed a framework to assess the public health care facilities for vulnerability.

Methods

A cross-sectional questionnaire survey was performed. The study used PHC laboratory services of 42 PHCs of Osmanabad District, India as a case study for proposed framework. The data assessment was carried out at district level, block level, PHC cluster level, and PHC level to provide flexibility to local decision-makers in taking remedial measures.

Results

Staff workload (73.17%), physician’s need (51.22%), and organization structure (36.59%) are the most prevalent challenges across PHCs. Multiple challenges are prevalent in the PHCs across districts. The PHCs with poor medical doctor (MD) capability or many challenges have shown poor laboratory performance.

Conclusion

Governance need to be strengthened in PHCs, followed by sustained support in resources and financing. Poor health status in developing nations necessitates a public health response based on health systems. Therefore, an assessment of health facility vulnerability in the form of laboratory services is essential in primary health care facilities.

     

Cooperation in the care of the institutionalized elderly in a rural community

OBJECTIVE: To develop a method of addressing and minimizing the institutional, cultural, and regulatory barriers to the care of nursing facility residents in our community. METHODS: Nurses, administrators, and medical directors from all the nursing facilities in our community plus representatives from the community hospital participated in a monthly meeting where difficult issues in the care of nursing facility residents were discussed. The committee developed responses to these issues that were implemented throughout the community. RESULTS: This committee has provided an opportunity for the whole community to address problems in the care of the institutionalized elderly. Systems have been developed which have improved communication between nurses and physicians and between nursing facilities and the hospital. Community standards for the care of common problems in nursing facility residents have also been developed. Other unexpected benefits have included community discussion of regulatory concerns, nurse assistant education, and care at the end of life, as well as coordination of laboratory services in the nursing facilities. Other rural communities may find a similar approach useful.     

Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.     

Governance challenges in the Nepalese primary health care system: time to focus on greater community engagement?

Nepal has seen impressive recent health gains through a successful community‐based health program. However, governance challenges remain within the Nepalese primary health care system that include under‐staffing and absenteeism, limited health facility opening hours, poor supervision and monitoring, and insufficient financial management. We propose that these be addressed through expanded community engagement and a power shift towards local communities, enhancing skills of community representatives in co‐managing health facilities and of service providers to effectively engage the community, increased quality of community participation, and improved documentation of the process and impact of engagement on health outcomes. Copyright © 2015 John Wiley & Sons, Ltd.     

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.     

Organization and financing of mental health care in Poland

ORGANIZATION OF CARE: Health care is provided to patients with mental disorders by the state health care facilities as well as by social help agencies. Mental health care services are provided mostly by mental health facilities and partly by primary care units. Outpatient clinics, separate for psychiatric patients and substance abusers, are the most numerous mental health care units, amounting to a total of 1120. Intermediate care facilities include 110 day hospitals, 23 community mobile teams and ten hostels. The number of hospital beds amounts to 31913, i.e. 8.3 beds per 10000 population. 80% of beds are located in mental hospitals. TRENDS OF DEVELOPMENT: The trends in mental health care development are outlined in the Mental Health Programme and accompanying documents accepted by the Minister of Health and Social Welfare. The programme defines specific goals to be achieved by the year 2005 in the primary, secondary and tertiary prevention of mental disorders. In the domain of mental health care accessibility the most important goals are the following: a significant reduction in the number of beds in large mental hospitals, a marked (nearly threefold) rise in the number of beds in psychiatric wards at general hospitals and a significant increase in the number of community-based forms of care (e.g. a fourfold rise in the number of day hospitals). FINANCING OF CARE: Before 1999, the health care system was financed from the state budget and the health care spendings were subject to a political auction each year. Allocation of funds among hospitals and health care centres was based on the total previous year budgetary spendings of particular facilities and did not take into account a detailed cost analysis. Such a financing approach, although giving a feeling of a relative financial safety, did not encourage health care facilities to introduce an organizational flexibility and to expand the scope of their services. In psychiatry, it manifested itself in a very slow development of some community psychiatry forms (mostly day hospitals, mobile community teams and hostels). The Health Care Institutions Act has created a legal framework for the financial management of health care units in their new, independent form. Conditions for health care financing through regional sickness funds were thus created. The financing is currently based on contracts made by sickness funds with health care facilities for specific health services. Both the quantity and price of services should be mutually negotiated. Some simplified measures of services offered were used during the first insurance financing year. In mental hospitals and day hospitals it was a person-day; in out-patient care it was a visit. Both cost indicators were aggregated, including all the components present so far in the functioning a given unit.     

Out-of-pocket payments for under-five health care in rural southern Tanzania

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.     

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania

Little is known about health system equity in Tanzania, whether in terms of distribution of the health care financing burden or distribution of health care benefits. This study undertook a combined analysis of both financing and benefit incidence to explore the distribution of health care benefits and financing burden across socio-economic groups. A system-wide analysis of benefits was undertaken, including benefits from all providers irrespective of ownership. The analysis used the household budget survey (HBS) from 2001, the most recent nationally representative survey data publicly available at the time, to analyse the distribution of health care payments through user fees, health insurance contributions [from the National Health Insurance Fund (NHIF) for the formal sector and the Community Health Fund (CHF), for the rural informal sector] and taxation. Due to lack of information on NHIF and CHF contributions in the HBS, a primary survey was administered to estimate CHF enrollment and contributions; assumptions were used to estimate NHIF contributions within the HBS. Data from the same household survey, administered to 2224 households in seven districts/councils, was used to analyse the distribution of health care benefits across socio-economic groups. The health financing system was mildly progressive overall, with income taxes and NHIF contributions being the most progressive financing sources. Out-of-pocket payments and contributions to the CHF were regressive. The health benefit distribution was fairly even but the poorest received a lower share of benefits relative to their share of need for health care. Public primary care facility use was pro-poor, whereas higher level and higher cost facility use was generally pro-rich. We conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidization and greater reliance on general taxation to finance health care for the poorest.     

Participation in health planning in a decentralised health system: Experiences from facility governing committees in the Kongwa district of Tanzania

Tanzania introduced the decentralisation of its health systems in the 1990s in order to provide opportunities for community participation in health planning. Health facility governing committees (HFGCs) were then established to provide room for communities to participate in the management of health service delivery. The objective of this study was to explore the challenges and benefits for the participation of HFGCs in health planning in a decentralised health system. Data were collected using semi-structured interviews and focus group discussions (FGDs). A total of 13 key informants were interviewed from the council and lower-level health facilities. Five FGDs were conducted from five health facilities in one district. Data generated were analysed for themes and patterns. The results of the study suggest that HFGCs are instrumental organs in health planning at the community level and there are several benefits resulting from their participation including an opportunity to address community needs and mobilisation of resources. However, there are some challenges associated with the participation of HFGCs in health planning including a low level of education among committee members and late approval of funds for running health facilities. In conclusion, HFGCs potentially play a significant role in health planning. However, their participation is ineffective due to their limited capacities and disabling environment.     

Primary health care and public policy

The health problems of Ecuador are similar to those in other developing countries where the standard of living is low, and housing and sanitation are inadequate. Women, children, and those living in rural areas are those most severely affected. National policy has been to attempt to increase access to health care in rural areas through the construction of new facilities and the appointment of highly paid medical staff. However, little attention was paid to sociocultural factors, which caused the peasantry to reject the medical care system, or to problems of internal efficiency which inhibited utilization. Since the 1970s various national and international organizations have attempted to implement primary health care (PHC) through the use of trained community health workers (CHWs). The primary problems faced by the CHWs were shortages of medicines and supplies, an almost total lack of supervision, and lack of transportation available to take staff to isolated villages. The poor supervision is blamed for the 17% drop out rate among CHWs since 1980. Independent PHC programs have also been established in Ecuador by voluntary organizations. These work best when coordinated with governmental programs, in order to allow monitoring and to avoid the duplication of services. Problems with the establishment of PHC programs in Ecuador will continue, as the government has no clear cut policy, and difficulties financing on a broad national scale. Other problems include the absence of effective supervision and logistical support for even small pilot programs, and inconsistencies in the training and role definition for CHWs. These problems need to be met in the implementation of a national PHC policy.     

Primary health care progress and problems

The 1st generation of primary health care efforts were assessed in order to temper future efforts with implementation realities. With support from the US Agency for International Development (USAID), the American Public Health Association (APHA) studied 52 primary health care (PHC) projects from 1980-82, documenting the numerous lessons learned. The contrast between the ideology of PHC and field realities provides valuable insights which must be fed back into 2nd generation projects. The projects were in 33 developing countries in Asia, Latin America, Africa, and the Near East. Approximately 1/3 were national level efforts; one-half, variously sized regional efforts; and the remainder, small scale pilot efforts. The sources of information were project documents and interviews with individuals who knew field activities firsthand. All the projects had as their primary goal provision of low-cost health services to previously unserved rural communities, using community personnel, and strengthening community institutions. Regarding overall assessment, while data continue to be limited on the impact of the approach on health status, there are some positive indications, especially for the projects of longer duration. For example, in Nepal and Thailand, there were modest improvements in health status of the target population in 2 project areas. A project in Kitui, Kenya reported reductions in infant mortality rates. A PHC program in Panama was responsible for decreases in the incidence of diarrhea, parasites, and typhoid. Many of the projects have been successful in setting up a PHC structure that extends coverage for health measures such as immunizations, family planning, and prenatal care. Many new facilities are in place. Skills of health workers have been upgraded, and new categories of paraprofessionals have been trained. Additionally, sizable numbers of community health workers have been trained and deployed. There is some evidence that in a few cases projects have been instrumental in changing government attitudes. Some common implementation problems raise important issues for all PHC projects: provision of support services, project financing, community participation, and appropriate and effective use of community health workers, and balancing the perceived needs of the community with those of health professionals. By identifying some of the obstacles to PHC implementation, this study sets the agenda which the next generation of projects must address.