Health in South Asia

Editor—In the South Asia issue Moazzem et al criticise the promotion in developing countries of a Western style of health services based on personalised curative treatment administered by doctors and hospitals regardless of the entirely different disease pattern and socioeconomic conditions of most people.¹ On these grounds they call for national community health worker programmes.

We contend that personalised curative care is pivotal because diseases generally require clinical skills for control, and patients demand alleviation of avoidable death, suffering, and anxiety related to illness.

Committed community health workers may sometimes be a useful link between communities and professional services. But in Africa, they were unable to substitute for professionals in delivering first line health care—unlike medical assistants, who with a few years' training may replace doctors in deprived areas. They generally offered solutions to problems for which communities already had an answer—for example, drugs available on markets.² Community health workers could not deal with many disease control interventions together (mass drugs administration, surveillance, health education, water and sanitation, and vector control).

We challenge the link made by the authors between reduction in infant mortality and the activities of community health workers. This indicator is sensitive to numerous social and economic factors.³ It decreased from 1970 to 2000 in all developing countries, with or without community health workers.

Community participation is pivotal in collaboratively managing publicly oriented health facilities,⁴ which are badly needed for disease control and patient centred care. Participation can enhance their responsiveness and utilisation rates. With adequate funding and managerial contracts, governments and international aid could promote such democratisation and quality health care.