Outreach programme in Kenya was based on extensive community participation

EDITOR,—Paul Johnstone and Isobel McConnan suggest that a wealth of knowledge about primary health care exists in developing countries and is now relevant to the NHS.1 I learnt much from supporting a successful community based health care programme in sub-Saharan Africa for six years.

Chogoria Hospital provides complete medical care for 350000 people in Meru district of Kenya. Having gained local credibility because of its effective curative services, the hospital developed an outreach programme for maternal and child health services, family planning, and curative medicine in the 1970s. By 1989 there were 30 village health clinics and a community network providing health education and contraceptives to villagers in their homes.2

The harnessing of the people's tradition of self help within the primary care programme was vital. The catchment area is served by 42 village health committees, 30 enrolled nurses, 500 volunteer family health workers, and 250 specially trained traditional birth attendants. The village health committees, selected by their communities, represent their constituents' interests and oversee the local clinics and volunteers. These committees and volunteers are active not only in expressing their health needs, prioritising developments, and monitoring the services but also in providing care.

The outreach programme is bound together by a careful monitoring system based on routinely collected service statistics. At all levels the workers' effectiveness at meeting preventive and curative targets is monitored, and help and retraining are given when necessary. Childhood immunisation neared 90%, child mortality decreased, and there was an appreciable decline in fertility associated with a high uptake of family planning services.3 Fully integrated services, both preventive and curative, were made available (within walking distance) to everyone in the catchment area. They were acceptable to the community and developed to meet its needs and were affordable (or given free in cases of poverty). There was a constant information and education programme in the community, which used all existing public meetings.

At Chogoria in the 1980s the time was ripe for extensive participation by the community in many aspects of their own health care. With which aspects of health care can patients, families, communities, and the wider population be involved in Britain in the 1990s? In my general practice a local community has been involved in assessing and prioritising health needs, using a method from the developing countries.4 We can learn from the many examples of good practice overseas.