The developing world Primary care alternatives

The British form of primary care rarely exists outside the United Kingdom and a few European countries. Primary care, the point of first contact with the health service, can take place elsewhere—in hospital outpatient clinics, in private physicians' offices, in polyclinics in the community, in nurse-led rural health clinics, and with traditional or religious healers. Gater et al. (110) demonstrated this diversity in a study of 11 countries, in which the pathway to psychiatric care (levels 4 and 5 in the Goldberg-Huxley model) was charted. In the four participating European countries, between 60 per cent and 80 per cent of patients reached psychiatric services via the GP. This contrasts with the situation in India and Pakistan, where GPs had referred only 25 per cent, but referrals from hospital doctors came from a further 25 per cent and self-referral by 33 per cent; 15 per cent had seen native healers. A different pattern again was found in the Indonesian centre, where 35 per cent came from a native healer compared with 32 per cent from primary care, and 15 per cent were self-referred. Primary care research in most countries of the world would miss a large component of this activity if it were only to focus on medical officers in primary care settings.

In remote rural areas the medical officer will provide the only form of medical care available to the local community, and will be assisted in his work by multipurpose care workers, who will be responsible for such matters as immunization, malaria prevention, and treatment of diarrhoea with rehydration salt. Since psychiatric instruction in medical school may have been inadequate or non-existent, it is WHO policy to concentrate training for primary care staff on the recognition of a small number of key disorders—usually psychosis, drug dependency, epilepsy, subnormality, and depression. Case finding in the villages is done by the multipurpose care workers, and appropriate drug treatments are available.

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