Health care for Tibetan villages

Introduction Primary Health Care Rural Water Supply Health Education Introduction  The Tibet Autonomous Region in the west of the People’s Republic of China is a large and sparsely populated province of 2.51 million people. It is home to approximately 45 per cent of the ethnic Tibetans in China, who are mainly subsistence farmers with low incomes. The region has poor health indicators - a maternal mortality rate of 136.9 per 10,000 live births and an infant mortality rate of 69 per 1,000; a moderately high incidence of diarrhoeal disease (3.7 episodes annually in children under 5 years of age); a high prevalence of wasting in children under 2 years of age (16% for children 1–11months and 18% for children 13–23 months); and a very high prevalence of stunting of children under 5 (47.1%), with the highest prevalence in children over 12 months of age. A trial program to address some of these health concerns was funded by the governments of Australia and People’s Republic of China and focused on Shigatse Municipality. The project, Water and Primary Health Care, was carried out by the Australian Red Cross in association with the Macfarlane Burnet Centre for Medical Research, with links to the Shigatse Municipal Government, the Shigatse City Health Bureau, Hospital and Epidemic Prevention Centre (for health care and health education) and the Municipal Water Resources Bureau (for the rural water supply). The project aimed to: improve health delivery by upgrading infrastructure and capacity (human resource development) at the village, township and city levels; improve the water supply by providing infrastructure, training and resources for maintaining and performing simple repairs on water and sanitation systems at the village level, building capacity at the Municipal Water Resources Bureau and leaving a large inventory of spare parts; develop an ongoing capacity to provide health education to health workers and villagers. Primary Health Care Primary health care emphasises preventive medicine, childbirth assistance, first aid, the use of basic drugs, nutrition, clean water, sanitation and health education. It is provided at the village level by community health providers or ‘barefoot doctors’ who, with six to nine months of intensive training, supervision and regular retraining, can handle 75 per cent of all the illnesses, health problems and needs of an individual and community. More serious health problems are referred to town health centres or county hospitals. Before the project began only one of the 71 rural counties in Shigatse had adequate primary health care. A health worker in the Taqing village clinic, Shigatse Municipality, Tibet. The project trained health care workers, built clinics, and supplied medicines and equipment. Source: Dr Rob Condon, AusAID To improve access to health care for villagers, eight rural town health clinics and 82 village clinics were constructed or rebuilt and equipped with essential diagnostic equipment (blood pressure metres, scales, stethoscopes, thermometers etc). This meant that 97 per cent of households were within one hour’s walk of a health facility. Each township clinic was provided with a Chinese two-wheel tractor and trailer for transporting patients and conveying the township doctor to neighbouring villages to support the village doctors. In villages with a clinic the local doctor was supplied with a bicycle to use for clinical, health promotion and child vaccination outreach activities. Dr Ga Li, Director of Lhasa City Health Bureau, tests school children for signs of goitre resulting from iodine deficiency. Source: Peter Davis, AusAID In the Tibet Autonomous Region a lack of iodine in the soil causes iodine deficiency, which in turn results in high levels of goitre, deafness and retarded growth and mental development. Health campaigns to encourage people to use iodised salt were initially resisted, as people had to pay for this salt, while untreated salt was freely available. The distribution of iodised salt to pregnant women and boarding school students has reduced goitre rates, and demonstrated the salt’s effectiveness, which has led to increased use. Medical understanding and skills were improved through the basic training of 35 village doctors (5 male and 31 female); refresher and additional training of 94 village doctors (75 male and 19 female), 36 town clinic staff and 4 city hospital medical specialists; and training of 10 health trainers. The health work force now has better skills in health promotion, management of childhood illness, pregnancy, general medical consultations, first aid and injection practices. The increased number of female health workers appears to have led to more women attending health clinics for the birth of their babies. Dr Pupula enters the clinic built by AusAID at Punu Meggna village. She is carrying vaccines in an ice box to maintain their effectiveness. Remote clinics with no electricity or refrigeration are unable to store vaccines for more than a few hours. Source: Peter Davis, AusAID Where there is strong support from village and township leaders for health promotion activities and ongoing financial support from the Health Bureau, the impact of these activities is likely to be maintained. Rural Water Supply In the Shigatse region, the dry season can last seven to eight months and winter weather is extreme. Before the project began the water supply systems in villages were limited. Many villagers relied on polluted surface ponds, often located far from their homes. One or more members of a household (usually women or children) could spend large parts of their day collecting water for drinking and cooking. Often little water was left for bathing, laundering, growing vegetables or providing for the needs of stock. In these conditions the provision of reliable, readily accessible, and adequate supplies of water was a priority. Tap stands providing filtered water were built in villages, greatly reducing the distances water needed to be carried. Known as the ‘back-happy’ tap stands, the resting shelf and high tap make lifting and loading water containers much easier and reduce lower back problems. Source: Dr Rob Condon, AusAID Fifty-four rural communities worked with water specialists to install water supply systems in villages. Strong community ownership developed, as villagers were involved in the design, location and building of the tap stands. Local water management committees were trained and provided with a tool box of equipment for repairing their water system. Specialist training was provided to enable the Municipal Water Resources Bureau to support the villages. Improvements in hygiene and general health were seen after the installation of water supply systems and follow-up health education, with reductions in the incidence of diarrhoea, hepatitis, skin sores and eye infections. In addition, villagers now have more time for productive work and water is available for household vegetable gardens. However, the transfer or retirement of trained Municipal Water Resources Board staff and a lack of funds threaten the sustainability of the water supply systems. Health Education Health education to change behaviours and improve health is an important aspect of the project. Training health workers improves their knowledge and effectiveness. Likewise, improving villagers’ confidence in health workers and their own ability to protect their water sources help reduce illness and enable preventative action to be taken earlier. One of the posters developed to promote better hygiene. Source: Peter Davis, AusAID The project used role-play for health promotion training (eg managing childhood diarrhoea with oral rehydration therapy) and foam rubber dummies for clinical training (eg safe motherhood and delivery). It developed a range of trilingual (Tibetan, Chinese and English) training materials and clinical reference manuals on safe motherhood, integrated management of childhood illness, rational drug use, safe injection practices and emergency first aid. Ongoing reference to the manuals in village and township health centres and their adoption in other areas of Tibet indicate their usefulness. Simple posters were developed so people could learn and remember the health care messages. Health education has resulted in changes in health-related knowledge, attitudes and practices in the areas of safe motherhood, breast-feeding, hygiene and the management of childhood diarrhoea. The results of the project were encouraging, thus the trial has been extended. Source Australian Government's Overseas Aid Program 'Water and Primary Health Care for Tibetan Villagers'. Quality Assurance Series No. 29, February 2002 http://www.ausaid.gov.au/publications/pdf/qas29.pdf