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

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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.

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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 deep-

rooted 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 Alma-

Ata, 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

a 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.

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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 community-

oriented 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 oft-

quoted 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

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

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

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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

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

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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 Alma-

Ata 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.

20

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

21

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 peer-

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

22

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.

23

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.

Figure 3: Flow chart of systematic review process

24

Aut

hor

Ref

eren

ce

Proj

ect

Agr

icul

tura

l Tie

s Ev

alua

tion

Met

hod

Suka

ti (1

997)

Su

kati

NA. P

rimar

y hea

lth ca

re in

Swa

zilan

d: is

it

work

ing?

Jour

nal o

f Adv

ance

d Nur

sing.

1997

;25(

4):7

60-7

66.

PHC

in S

wazil

and

-“pr

omot

ion o

f foo

d sup

ply a

nd pr

oper

nutri

tion”

-in

terse

ctora

l acti

on fo

r wate

r, nu

tritio

n, fo

od &

en

viro

nmen

tal co

ncer

ns, w

ith ag

ricul

ture

liste

d as

one o

f the

majo

r sec

tors

to in

volv

e.

-liter

ature

revi

ew

Matt

son

(199

8)

Matt

son S

. Mate

rnal-

child

healt

h in Z

imba

bwe.

Heal

th C

are W

omen

Int.

1998

;19(

3): 2

31-2

42.

Mate

rnal

and C

hild

He

alth P

reve

ntiv

e Nu

tritio

n Pro

gram

(Z

imba

bwe)

-Sup

porte

d co

oper

ative

gard

enin

g effo

rts th

roug

h en

trepr

eneu

rial &

agric

ultu

ral s

kills

deve

lopm

ent

-enc

oura

ged c

hick

en- a

nd ra

bbit-

keep

ing (

for

nutri

tion &

inco

me)

-nut

ritio

n and

healt

h ass

essm

ents

of 5

1 wom

en

and t

heir

child

ren <

24 m

onth

s

Upha

m (2

004)

Up

ham

N. M

akin

g Hea

lth C

are W

ork f

or th

e Po

or: W

orld

Hea

lth O

rgan

izatio

n;20

04.

BRAC

(B

angl

ades

h), G

K (B

angl

ades

h)

-BRA

C be

gan a

s a ru

ral d

evelo

pmen

t or

gani

zatio

n the

n exp

ande

d int

o PHC

; GK

bega

n wi

th he

alth c

are a

nd gr

ew to

inclu

de su

ppor

t for

ag

ricul

ture

. -B

oth c

onsid

er th

eir m

icroc

redi

t wor

k key

to

help

ing f

arm

ers.

-no n

ew ev

aluati

on; c

ites s

tudi

es sh

owin

g % of

len

ders

lifted

out o

f pov

erty

, % lo

an

repa

ymen

t, an

d micr

o-lev

el ho

useh

old d

ata

analy

sis of

acce

ss to

healt

h ser

vice

s

Chow

dhur

y et a

l. (2

006)

Ch

owdh

ury A

MR,

Alam

MA,

Ahm

ed J.

De

velo

pmen

t kno

wled

ge an

d exp

erien

ce: f

rom

Ba

nglad

esh t

o Afg

hani

stan a

nd be

yond

. Bul

letin

of

the W

orld

Hea

lth O

rgan

izatio

n. 20

06;8

4:67

7-68

1.

BRAC

(A

fgha

nista

n)

Train

ed pa

rave

terin

arian

s, es

tablis

hed p

lant

nurse

ries,

intro

duce

d new

agric

ultu

ral t

ech.

-a

rticle

is an

over

view

of ac

tiviti

es, b

ut ci

tes

study

mea

surin

g he

alth s

ervi

ce de

liver

y fro

m

2004

-200

6

Dick

et al

. (20

07)

Dick

J, C

larke

M, v

an Z

yl H

, Dan

iels K

. Prim

ary

healt

h car

e nur

ses i

mpl

emen

t and

evalu

ate a

com

mun

ity ou

treac

h app

roac

h to h

ealth

care

in

the S

outh

Afri

can a

gricu

ltura

l sec

tor.

Inter

natio

nal N

ursin

g Rev

iew. 2

007;

54(4

):383

-39

0.

PHC

TB tr

ial in

W

ester

n Cap

e Pr

ovin

ce (

Sout

h Af

rica)

-Far

m-b

ased

-h

ealth

com

mitt

ees e

ach h

ad a

farm

wor

ker a

nd

farm

man

ager

/ own

er

-Com

petit

ions

to cr

eate

food

gard

ens

-CHW

s tra

ined

on fa

rm-re

lated

occu

patio

nal

healt

h & sa

fety

-Com

paris

on of

TB

case

-find

ing &

trea

tmen

t ou

tcom

es

-Net

cost

-Qua

litati

ve da

ta on

impa

ct to

CHW

s, fa

rm

owne

rs &

publ

ic he

alth p

erso

nnel;

colle

cted

thro

ugh i

nter

view

& fo

cus g

roup

s Ar

daka

ni &

Rizw

an

(200

8)

Arda

kani

MA,

Rizw

an H

. Com

mun

ity ow

nersh

ip

and i

nter

secto

ral a

ction

for h

ealth

as ke

y pr

incip

les fo

r ach

ievin

g "He

alth f

or A

ll". E

ast

Med

iterr

Hea

lth J.

14(S

pecia

l Iss

ue):S

57-S

66.

CBIs

in W

HO

Easte

rn

Med

iterra

nean

Re

gion

coun

tries

-CBI

s inc

lude

“agr

icultu

ral a

nd li

vesto

ck

proj

ects”

-In

Som

alia,

part

of a

mala

ria pr

even

tion p

rojec

t in

volv

ed ad

ding

larv

ivor

ous f

ish to

open

irr

igati

on w

ells.

uncle

ar

WHO

Reg

iona

l Of

fice f

or th

e Ea

stern

M

edite

rrane

an

(200

8)

Comm

unity

-bas

ed in

itiat

ives n

ewsle

tter.

Vol 4

: W

orld

Hea

lth O

rgan

izatio

n Reg

iona

l Offi

ce fo

r th

e Eas

tern M

edite

rrane

an; 2

008.

“Hea

lth V

illag

es”

CBI (

Syria

) -m

icrol

oans

avail

able

for f

arm

ing—

both

liv

esto

ck/d

airy a

nd ho

rticu

lture

-v

illag

e dev

elopm

ent s

ubco

mm

ittee

s for

ag

ricul

ture

, wate

r, sa

nitat

ion,

healt

h, an

d inc

ome-

gene

ratio

n

-liter

acy r

ate, a

cces

s to s

afe d

rinki

ng w

ater,

imm

uniza

tion/

vacc

inati

on ra

tes, a

cces

s to

“ade

quate

excr

eta di

spos

al fa

ciliti

es,”

incid

ence

of il

lnes

ses (

incl.

diar

rhea

& ac

ute

resp

. inf

ectio

n), a

nd re

turn

rate

of fe

male

sc

hool

drop

outs.

Ba

ntey

erga

(201

1)

Bant

eyer

ga H

. Eth

iopi

a's H

ealth

Ext

ensio

n Pr

ogra

m: I

mpr

ovin

g Hea

lth th

roug

h Com

mun

ity

Invo

lvem

ent.

MED

ICC

Revie

w. 20

11;1

3(3)

:46-

49.

Healt

h Ext

ensio

n Pr

ogra

m (E

thio

pia)

-D

issem

inati

ng he

alth m

essa

ges a

t agr

icultu

ral

com

mun

ity ev

ents,

thro

ugh a

g-ba

sed c

omm

unity

as

socia

tion

-Pro

mot

ed se

para

tion o

f hum

an &

anim

al qu

arter

s

- agg

rega

tion o

f data

from

3 lar

ge sc

ale

studi

es. D

ata in

clude

d:

*he

alth c

are c

over

age

*im

mun

izatio

n rate

s *

anten

atal c

over

age

*“c

ontra

cept

ive a

ccep

tance

rate”

*

HIV

prev

alenc

e *

acce

ss to

safe

drin

king

wate

r PA

HO (2

012)

Fa

ces,

Voice

s, Pl

aces

Beli

ze: P

AHO;

2012

. GA

TE (B

elize

) Or

gani

c/sus

taina

ble v

egeta

ble g

arde

ns at

scho

ols

None

inclu

ded

Figu

re 4

: Su

mm

ary

of fi

ndin

gs

25

Summary of Results

Sukati describes the PHC system implemented in Swaziland, and analyzes PHC in the

country from 1983 to 1995.35 The 1980s marked a shift from an urban, curative and hospital-

based health care system to a PHC-based preventative one that better addresses the health needs

of the rural majority. Sukati draws on Ministry of Health publications as well as

independent/academic evaluations and analyses to present an overview of PHC in Swaziland and

commentary on both its successes and the areas with little improvement. The Ministry of

Health’s 1983 PHC strategy included “promotion of food supply and proper nutrition” as well as

“clean water supplies.” Water, nutrition, food and environmental concerns were emphasized as

key areas for intersectoral action, alongside education and housing. Agriculture was included as

one the major sectors to involve in these efforts.35(p762)

In “Maternal-child health in Zimbabwe,”34 Mattson describes an Earthwatch-sponsored

maternal and infant health PHC intervention in the Masvingo Province of Zimbabwe. After

nutritional deficiencies, lack of safe water, and family planning needs were identified as three

main contributors to maternal and child morbidity and mortality in the target area, the project

focused on training existing community health workers to help families with nutritional

deficiencies, family planning, and hygiene needs.(p231-2) Nutrition education was based on a needs

assessment and drew from Zimbabwe’s nation-wide curricular materials on the topic.

Community members and leaders acknowledged that nutrition was a major issue, and worked

with the implementing team to develop solutions. The intervention also involved working with

women who were involved in cooperative food gardens to improve their agricultural and

business skills. Mattson implies that the women were taught how to better manage their farms,

26

including information on seed-saving, bartering, and dividing harvests between market and

home. They also discussed means of advertising their products to those outside the cooperative.

Goats were an ongoing problem in the cooperative gardens, so the gardeners were connected to

local NGOs that helped with fencing the gardens to keep goats out.(p240) Also, the women were

introduced to the ideas of growing citrus fruits and other crops well-suited to the climate, and of

starting poultry or rabbit cooperatives. CHWs were taught the nutritional benefits of eggs, since

some households already raised chickens but lacked coops and thus never had eggs. The CHWs

were also instructed in how to build coops.(p236)

Multiple chicken cooperatives and at least one rabbit cooperative are reported to have

successfully grown from these conversations. The nutritional assessment of 51 women around

the start of the program showed a high prevalence of undernourishment (40%) and iron-

deficiency (25-40%, depending on pregnancy/lactation status), but no post-intervention

measurements are presented for comparison. The baseline children’s health assessment, showed

high prevalence of malnutrition and underweight (“a majority were underweight … malnutrition

[was] a problem”), iron-deficiency (70%) and diarrheal disease (no statistics given). The follow-

up showed that 47% of children (n=204) had diarrhea and 42% were iron-deficient. No statistic

is given for underweight/malnourishment. As such, the data shows a reduction in iron-deficiency

in children. Additionally, Mattson notes that the children of women who were involved in a

garden cooperative had better health than the children whose mothers were not involved in a

garden cooperative.

Upham’s “Making Health Care Work for the Poor,” a background paper for WHO on

PHC in Asia, includes a section on NGOs in which she discusses Gonoshasthaya Kendra (GK)

27

and the Bangladesh Rural Advancement Committee (BRAC), two large Bangladeshi NGOs that

use a comprehensive PHC framework.38 Both utilize some form of a community health worker

network. GK is described as having grown from a health service provider into a PHC

development organization, which BRAC moved from a rural development work into the arena of

health care.(p5) The GK system has both rural and urban PHC systems, and has grown to

encompass “education, nutrition, agriculture, environment, generic drugs manufacturing,

vocational training and medicinal plant research.”(p26) The insurance mechanism, too, reflects the

realities of the varied agricultural lives of the population served; group “A” consists of families

who are very poor and not food sufficient, who pay only a symbolic amount (one taka), while the

food-sufficient families in group “B” and the farmers with surplus in group “C” pay fees on a

sliding scale.(p27) BRAC’s work is described in less detail, but Upham mentions that BRAC

mostly serves the landless rural poor (i.e. farm workers, not farm owners), and provides

“agricultural support” in addition to microcredit, health care, and health insurance.(p24) In

focusing on BRAC’s TB program, the report quotes BRAC Deputy Executive Director Alam as

saying that proper nutrition, good living and working conditions are key to “favoring the human

being over the bacilli.”17

Upham’s report does not evaluate either organization’s activities herself, but cites studies

showing the percent of borrowers/families of BRAC borrowers lifted out of poverty within four

years of participation in microcredit programs (11%), TB cure rate (89%), and micro-level

household data analysis of access to health services. There are no evaluative measures for GK,

just discussion of scale and prominence.

28

A 2006 report of BRAC’s work in Afghanistan by Chowdhury et al. examines the

application of the BRAC PHC/development model to rural Afghanistan.39 The report cites the

project’s components as “health, education, microfinance, women’s empowerment, agriculture,

capacity development and local government strengthening.”(p677) Specific agricultural

components of the program include the training of paraveterinarians and creation of new plant

nurseries, in tandem with the introduction of technologies like artificial insemination of livestock

and higher-yield seeds. Results attributed to BRAC’s programs between 2004 and 2006 in

Afghanistan include an increase from 37% to 91% in antenatal care, from 31% of births

occurring in hospitals to 55%, of births. Vaccination rates for tetanus toxoid increased from 78%

to 88%, and for DPT (three doses) from 16% to 51%.

Dick et al. conducted a farm-based PHC intervention program in an area of the Cape

Winelands (Western Cape Province) in South Africa.33 On 106 (randomly-selected) farms of the

211 participating farms, the investigators implemented a community health worker system in

which local nurses collaborated with farm laborers and their families, the farm owners/managers,

non-governmental organizations and the public health sector. On each participating farm, farm

dwellers selected a community health worker (nearly all of whom were female), who was then

trained at a central farm. The project also facilitated the formation of local health committees,

each of which consisted of farm laborers and farm owners/managers alongside representatives

from the public health sector, local schools and partner NGOs. These committees organized

health promotion events, “which took the form of community festivals and competitions to

produce food gardens.”(p386) The community health workers often created their own food gardens

after training.(p388) Additionally, the community health workers were trained on farm-related

29

occupational health and safety topics, including physical injuries and exposure to toxic

chemicals.(p388) The experiment was a randomized controlled trial, using the clinical indicators of

TB case-finding and treatment “success” as easily-measurable/available means of comparing the

effectiveness of the community health worker system. The study found that the successful TB

treatment completion rate in new smear-positive TB patients was 18.7% higher on the

intervention farms than on farms in the control group. Case-finding for new smear-positive cases

was 8% higher, but that was not statistically significant. The cost of treatment per TB case to the

District Health Authorities, however, was 74% lower on intervention farms than on control

farms. Qualitative research was simultaneously collected from those connected to the

intervention farms,33 and these results supported the idea that CHWs acted as health promoters.

Ardakani and Rizwan report on the community based initiatives (CBIs) implemented in

WHO Eastern Mediterranean Region countries since 1988.36 The CBI model integrates health

into development projects to address the “major determinants of health” in way consistent with

the Declaration of Alma-Ata, particularly in the emphasis on intersectoral action. Components of

the CBI model include “strengthening health, nutrition and environmental conditions,” as well as

“improving economic status” and ”empowering … intersectoral collaboration,” among

others.(pS58) Community-designed projects listed in the introduction include “agricultural and

livestock projects,” but of the CBIs described in the report (from Afghanistan, Iran, Morocco,

Oman, Pakistan, Somali, Sudan, Djibouti, Jordan, Saudi Arabia, Syria, Egypt and Yemen), just

one makes any specific reference to agricultural involvement. This is in the description of an

initiative in Somalia, part of which included the expansion of antimalarial measures. One of

these was the introduction of larvae-eating fish into shallow, open irrigation wells.(pS61) The

30

sources of the data cited in this report are unclear, but the authors write that the interventions in

participating villages in Somalia “helped contain frequent outbreaks of malaria.”

Another set of articles about CBIs in the Eastern Mediterranean appears in a WHO

Regional Office for the Eastern Mediterranean CBI newsletter from 2008.37 In this newsletter,

the “Healthy Villages” CBI implemented in Syria was the only one that mentioned both

community health workers (“community health volunteers”) and agriculture. The agricultural

components of the program, which was active in 613 villages at the time of publication, include

microloans for “livestock and dairy development, agriculture and fruit trees” and other non-

agricultural income-generation projects, and subcommittees (“specialist committees”) of each

village development committee for agriculture, water, sanitation, income-generation, and health,

among others. The data source and exact years of comparison are unclear, but the authors cite

increases in literacy rates, female school attendance and graduation rates, access to safe drinking

water, immunization coverage, and access to “adequate excreta disposal facilities,” and a

decrease in the incidence of acute respiratory infections, cutaneous leishmaniasis and diarrheal

disease, as a result of the Healthy Villages intervention.

Banteyerga describes Ethiopia’s Health Extension Program, which was implemented in

most rural agrarian areas of Ethiopia starting in 2004-2005. The program is based on a diffusion

model of health improvement, which assumes that health behaviors can be improved by creating

model families that others in the community will then emulate. Agricultural components of

Ethiopia’s Health Extension Program include informal sharing of health information at

agricultural community events through the existing mahber practical support community

31

association for activities like harvests and home constructions.26 Additionally, “All government

sectors, local leaders, and communities are required to collaborate in implementation of HEP

programs […] agriculture extension agents, community associations, as well as other social

structures are involved in disseminating HEP messages and promoting good health

practices.”(p47) One agricultural component of the main health promotion effort was to encourage

the separation of living quarters from animal sheds. Banteyerga cites large-scale scientifically

rigorous studies reporting that malaria, diarrhea and other water-borne diseases markedly

decreased in the participating villages.

“Faces, Voices, Places Belize,” published by the Pan American Health Organization,

describes began the GATE Project in rural, southern Belize, where there is already a nationwide

CHW network.31 This project, from the NGO Plenty Belize, establishes school gardens that

model sustainable, organic agriculture and use them to promote better nutrition and

environmental conservation. Produce from the gardens is used in school feeding programs. The

report list no means of project evaluation other than scale; 46 gardens were built between 2002

and time of publication (2012) as part of GATE.

Themes

Utilization of farmer clubs/community associations/committees (included in 5 articles)

The most common agricultural component mentioned in the nine results is their

utilization of existing social organizations for farmers, and/or their involvement in the creation of

committees or organizations. Mattson described that the program worked with the existing

farming cooperatives, and encouraged the development of others. Dick et al. explained that the

32

program staff facilitated the formation of health committees, each of which had representation

from the farm laborers, the farm owner, and the public health sector. Banteyerga noted that the

HEP made use of the community association for collective activities like harvests and home

constructions to spread health messages. The Healthy Villages project in Syria also involved a

village subcommittee on agriculture—this presumably but not necessarily was comprised of at

least some farmers. The BRAC model, as described in the report on BRAC’s work in

Afghanistan, also includes the creation of village organizations.

Improving agricultural practices/structures (included in 4 articles)

The next most common agricultural element shared by the projects included in this

review is the introduction or promotion of specific agricultural techniques or practices and

training community members in agricultural skill areas. Mattson described the Earthwatch

nutrition intervention’s various methods of improving farming practices in the women’s co-op

gardens, including fencing, seed-saving, and growing citrus fruits. The program also taught coop

construction (such that eggs may be collected) and facilitated the formation of chicken- and

rabbit-raising cooperatives. Similarly, BRAC’s programs in Afghanistan involved the training of

paraveterinarians and usage of higher-yielding seed varieties; the general BRAC model

described in that report noted that the organization usually trains select villagers in agriculture

and animal husbandry. Ethiopia’s HEP encouraged farmers to separate animal quarters from

their family homes. Finally, though the processes of implementation were not very clear, one

anti-malaria component of the CBI in Somalia involved an innovative modification of irrigation

techniques.

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Food gardening (included in 3)

Food gardening appeared in three of the articles in this review. Aside from Earthwatch’s

work with cooperative food gardeners, it formed the core of the GATE project, where food

gardening at schools served to model sustainable agricultural practices and to provide fresh

produce as ingredients for school meals. Additionally, food gardening was one of the central

health promotion messages disseminated by the health committees in Dick et al.’s CHW RCT in

South Africa. Community health workers also were reported to have started their own food

gardens after their training.

Microloans for farmers (included in 2)

Microloans were discussed as part of both the BRAC/GK models of PHC (as reported by

Upham) and the CBI model. Microlending was also a part of the BRAC program in Afghanistan,

but Chowdhury et al. did not make the connection between any of the 100,000 borrowers and

agriculture in the article.

Discussion

The nine publications included in this review describe programs that vary greatly in scale,

scope, and scientific rigor. Though all use a community health worker model (by design of the

review), identify as in line with the principles of primary health care, and include some kind of

agricultural component to the project/program, it is impossible to compare the programs—much

less the effects of their agricultural components-- on any level other than a purely descriptive

one.

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The differing goals of the agricultural components of these programs speak to the many

ways in which agriculture and health are intertwined. For projects like Swaziland’s PHC

strategy, which was closely modeled on the Declaration of Alma-Ata, promotion of food supply

and proper nutrition are presented together, recognizing the key link between the two. This same

vein of thought explains the recurring theme of food gardening promotion and support in the

articles reviewed. The Earthwatch maternal and child nutrition program in Zimbabwe, saw that

technically assisting women involved in cooperative food gardens was a way to address nutrition

and food supply. As Mattson writes, “it was clear that the team could not just educate them about

what to eat without helping them obtain the means to put the food on the table. Thus, the team

decided to assist with developing sustainable cooperatives and help others not associated with

cooperatives to begin their own.” This style of intervention speaks to the fact that in addition to

producing food, agriculture is a livelihood.

To that end, several of the projects reviewed had agricultural ties that focused on

improving farming practices so that they would be more profitable. In some cases, this was

primarily accomplished through making small loans available for farmers’ investments in their

business, like livestock, new seeds or technology. These inputs help them achieve financial

stability and, thus, better health. In other programs reviewed, increasing income-generation

through agriculture was accomplished with skills training.

Another facet of the link between agriculture and health addressed by these projects is

that of environmental and occupational health. The GATE project in Belize modeled organic,

sustainable farming techniques, presumably to demonstrate that these practices are effective and

encourage local farmers to consider them, thus reducing their exposure to health-harming

chemicals and reducing environmental health hazards associated with petroleum-based

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fertilizers, pesticides, herbicides, monoculture, etc. In a poor, rural area where malnutrition is an

enduring problem and most families rely on subsistence farming, the school gardens seem to be a

scalable local solution that to address community needs, even though it does not seem to be

closely connected to the larger PHC system. The farm-based program in South Africa addressed

farm workers’ occupational health risks through training the CHWs in those topics.

Perhaps more than the other projects reviewed here, the Bangladeshi NGOs BRAC and

GK exemplify the ways in which rural primary health care is intrinsically tied to rural

development and agriculture. Whereas BRAC began with rural development and GKb began

with health services provision, both evolved into organizations that work toward the goal of

offering truly comprehensive PHC; addressing agricultural practices (and income generation) is a

basic tenet of both organizations’ strategies to improve population health and reduce health

disparities. BRAC in particular connects health services to the rural, agricultural

cultures/lifestyles of the target population—whether it be in Bangladesh or Afghanistanc—in

ways that echo those used by the CRHP in Jamkhed.

Like the CRHP, BRAC first establishes an organization in each village, which functions

as both a social forum—useful to both organizations for promoting gender equality and

community solidarity—and a means of supporting income generation, particularly for women,

through the availability of small loans. Though the CRHP group members lend to each other

while BRAC group members receive microloans through a more centralized and formal

b At the time of publication of Upham’s report, GK had a staff of 25,000 and worked in twelve locations in addition to Dhaka and Savar, with plans to expand in 2004 to 200 districts for coverage of six million people altogether.(p16) GK shares some costs with the Bangladeshi government, especially for the CHW system; GK trains the CHWs, while the government pays their monthly stipend. c The BRAC Afghanistan project was large-scale, with a staff of 3,000+, 3,5000+ community health workers, and close to 100,000 microcredit borrowers after three years in Afghanistan.39

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structure, both aim to aid community members who would otherwise have a very difficult time

supporting themselves and their families. Small loans help women start businesses, turn their

existing businesses profitable, etc., by providing some or all of the upfront costs of the process of

earning one’s own money. Since poverty and social inequality are the root cause of many health

disparities, the value of helping community members develop sources of income generation

should not be overlooked in the consideration of the scope of a comprehensive PHC program.

Limitations

This review searched only those articles published in peer-reviewed journals and

included in the databases listed previously. Reports on Primary Health Care programs that were

published in books, policy documents, webpages, etc. were not included in the searches.

Additionally, a search of EBSCOhost using the same terms (but not specifying that any be

included as subject headings) yields several hundred results in addition to those that showed up

in the systematic review, which relied on at least one of the terms to have been tagged as a

subject heading. Though unlikely that many of these would have been eligible, it remains a

possibility that some of these journal articles were relevant, despite lacking a relevant subject

heading.

Funding

This systematic review was conducted for a thesis project over a relatively short period of

time, and was unfunded. It was done on a voluntary basis by the author.

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Conclusions

There are many “hotter” topics than farming, which seems very 20th century in the light

of ever-increasing urbanization and agricultural industrialization. But more than a billion people

continue to farm for a living, representing nearly 60% of employment in sub-Saharan Africa and

more than 50% in South Asia, many of them subsistence farmers.40 While addressing urban

concerns is of course crucial to achieve any major public health goals—whether they be MDGs

or Health for All—the rush toward quick one-size-fits-all fixes like bare-bones community health

worker systems or selective PHC programs seems to have resulted in a lack of academic material

on the less glamorous tenet of PHC. Discussing seeds, irrigation and fertilizer may not be as

buzz-worthy as trumpeting the life-saving powers of Plumpy’nut, but it is sustainable farming

and food sovereignty, not ready to use therapeutic foods, that will prevent malnutrition and the

host of other diet-related and environmental health issues worldwide.

There is a disconnect between the comprehensive PHC work that is being done and its

visibility in the academic field of public health. If this information is contained solely in books,

websites, and policy documents, or if journal articles were published but are poorly/inadequately

tagged due to the biomedical focus of the large and accessible databases used for public health

research, it will continue to be difficult to study comprehensive rural PHC, judge the efficacy of

agricultural components, and adapt successful models for implementation elsewhere. If we are

truly to refocus on PHC, it is essential that there be a body of knowledge regarding each of many

parts of the approach. While the importance of involving agriculture in PHC is not disputed, it is

against the scientific basis of the field of public health to for PHC policymakers and

implementers to be complacent with the total lack of research on how to tie a program to a

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community’s agricultural practices, holistically address farming-related health issues, and use

agriculture as a means of improving community health.

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APPENDICES Appendix A

Full EBSCOhost database search info:

(terms were searched in “all text” except where otherwise specified, and duplicates between searches are excluded from result number) Search 1:

1. subject term: “rural health” AND 2. “primary health care” AND 3. “farming” or “agriculture” or “farm” or “agricultural extension” AND 4. “community health worker,” “outreach worker,” “village health worker,”

“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor”

48 results, 3 eligible Search 2:

1. subject term: “community health advisors,” “community health advocates,” “community health navigators,” “community health aides,” “lay health workers” or “lay health advisors” AND

2. “primary health care” 3. “farming” or “agriculture” or “farm” or “agricultural extension” AND 4. “community health worker,” “outreach worker,” “village health worker,” 5. “rural health” or “rural population

11 additional results, 1 eligible Search 3:

6. subject term: “primary health care” 7. “farming” or “agriculture” or “farm” or “agricultural extension” AND 8. “community health worker,” “outreach worker,” “village health worker,”

“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor” AND

9. “rural health” or “rural population” 2 additional results, 0 eligible Search 4:

1. subject: “farming” or “agriculture” or “farm” or “agricultural extension” AND 2. “primary health care” AND 3. “community health worker,” “outreach worker,” “village health worker,”

“community health advisor,” “community health advocate,” “community health navigator,” “community health aide,” “lay health worker,” or “lay health advisor” AND

4. “rural health” or “rural population”

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4 additional results, 0 eligible Appendix B: Full WHO archive search info Archives accessed at search.who.int [Advanced Search] Search terms: Must contain: “Primary health care” AND “agriculture” AND at least one of: "community health worker" "outreach worker" "village health worker" "community health advisor" "community health advocate" "community health navigator" "community health aide" "lay health worker" "lay health advisor" 113 results, 5 eligible

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