#### STICHTING BAKENS VERZET

#### 1018 AM AMSTERDAM, THE NETHERLANDS

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## MODEL (PROJECT) FOR SUSTAINABLE SELF-FINANCING INTEGRATED RURAL AND POOR URBAN DEVELOPMENT FOR THE WORLD'S POOR

Incorporating innovative social, financial, economic, local administrative and productive structures, numerous renewable energy applications, with an important role for women in poverty alleviation in rural and poor urban environments.

"Money is not the key that opens the gates of the market but the bolt that bars them"

Gesell, Silvio The Natural Economic Order

Revised English edition, Peter Owen, London 1958, page 228

Edition 15: 03 January, 2006

### THE PROJECT AND HEALTH

### 05.62.01 Preventive and curative health.

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### This integrated development project covers structural measures for the prevention of health problems in the beneficiary community. Most of the necessary steps can be taken and paid for by the people themselves under the framework of the local money systems set up without causing financial leakage from the project area.

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### The social and financial structures set up in the project area during project execution also support, by their very nature and size , the formation of a mature three-level curative health system as well. Solutions to curative health problems which cause financial leakage from the project area are, however, excluded.

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### The following paragraphs describe what the project can do for public health in the project area and what it cannot.

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### 05.62.02 Introduction.

Good health is a major factor for our quality of life. However, it is a development fallacy that good health depends mostly on vaccination campaigns and medicines. Diseases are consequences, not causes. A promise by an American president to grant 18 billion dollars to the “fight against AIDS” is not in itself negative, but it has little if anything to do with local economic development for the world’s poor. Most of the money goes into the pockets of the pharmaceuticals companies who supply the medicines. Some of the rest of it goes into the hands of NGO organisations who pay their staff to organise and control their distribution. It is possible that not a single dollar of direct contribution be made to the development of the local economies in the areas where the AIDS medicines are distributed.

Mass vaccination campaigns are another example of activities where large amounts of money are invested with the declared intention of helping the poor in less-developed nations. Yet there is, with the possible exception of polio, little real evidence that the introduction of mass vaccination campaigns has reduced the rate of death amongst children either in industrialised or in developing countries. Some reports indicate that more children may have died as a result of being vaccinated than would have been the case had they not been vaccinated. The negative, wide-spread effects of the use of mercury in vaccination campaigns are only now becoming public. The continued use of mercury, now banned in many industrialised countries, is believed to be continuing in developing countries.

Had the money spent on vaccines been used for basic services such as hygiene education, the improvement of basic water management, better drainage, and improved cooking stoves, much of the poverty in the world could have been eliminated and the quality of life of children and their parents guaranteed. The problem is that such basic services do not put profits into the pockets of multinationals or supply work for expatriate “health specialists” from industrialised countries.

## 05.62.03 : Better health for all.

In reality health improvement necessary for a good quality of life in project areas in poor countries can best be achieved by following low technology, locally executed non-industrialised initiatives. Examples, all of which are brought under the Model, are hygiene education courses for women and in schools, clean drinking water supply, a varied food supply, proper sanitation facilities and recycling of wastes, proper aeration of homes and the elimination of smoke through the use of better cooking facilities, drainage and the elimination of stagnant waters, the use of simple, intelligent locally applied means to combat flies and mosquitoes.

In industrialised countries, the rate of occurrence of traditional infectious diseases had, with the possible exception of polio, decreased to present levels BEFORE mass vaccination campaigns were introduced. The improvements which had already been registered are generally attributed to better food, better quality accommodation, and better hygiene in homes and in public places. Logic would suggest similar principles be applied to rural and poor urban areas in less developed countries. This can be done locally, without the need for any financial leakage. Especially if some basic medicines can be locally prepared using locally grown medicinal plants.

## 05.62.04: Health and local development.

The Model tries to distinguish between the major, the preventive, part of health services which can be supplied within a local development area, and a second-level of specialised curative services which cannot. A local development project cannot substitute the state for construction and running of hospitals or the training and payment of medical personnel, with the exception of the salaries of doctors and trained nurses willing to work under the local money LETS systems set up during project execution.

Where residents in a given local development area must pay for medical services of any kind originating outside the development area serious financial leakage occurs, which reduces the amount of formal money in circulation available for other purposes in the project area and restricts possibility of productivity development there.

Viewed inversely, funds supplied by donor nations in the form of grants or loans for health improvement purposes is subtracted from their annual general development aid quota, thereby reducing the funds available for integrated local development in favour of the world’s poorest.

While in many industrialised countries solidarity in favour of the weakest is often reflected in health legislation, this is seldom the case in developing countries where users often have to pay directly in cash for the services they receive.

05..62.05 Health education.

The (200) health clubs for women and on-going hygiene education courses in the (40) schools in the project area are sustainably run under the local money systems set up. They include household hygiene, the need for keeping clean water clean, germ theory, water-borne diseases, skin infections, worms, malaria, the sanitation ladder and nutrition. It is the intention of the project that aspects relating to AIDS prevention, anti-conception and family planning in general also be introduced and discussed. Course material can also be extended to discussion of circumcision practices, household violence, and the physical abuse of women and children, and child labour. Some of these health related topics are taboo in some project areas. Since the local people are themselves directly involved in project planning and execution, there is little point in extending the courses to cover subjects they do not wish to discuss. Sensitive cultural issues needing very careful and patient management may be involved.

05..62.06 Health aspects relating to drinking water supply.

The organisational workshops for water supply will establish a network for the systematic control of water quality. The following are some possible indications:

01 Organising systematic water sampling to keep a close check on water quality in the wells and in the tank installations.
02 Hygiene education. Cooperation through the established Health Clubs with locally operating health workers and the Regional Department of Health to spread information and training of the users in the correct use of clean household utensils, washing of hands before eating.
03 Equipment for water testing will be supplied to one of the local clinics and paid for by the users on condition that water testing within the project area be carried out free of charge.
04 Organisation of regular water sampling.
05 Water testing programme.
06 Hygiene education courses in schools.
07 Rules concerning special industrial and medical waste products.

Special attention will be paid to keeping the clean drinking water supplied by the project clean once it leaves the dedicated water tank in a tank commission area, and in particular how to keep water recipients clean, how to store the water safely, and how to use the water without contaminating recipients and the water which is left over.

05..62.07 Health and sanitation.

The introduction of a complete ecological sanitation system in the project area should also have a profound effect on the health of the people there. Risk of contamination of surface and ground-waters is eliminated. Stagnant surface waters will be drained. Organic and inorganic waste products will be usefully recycled and pests eliminated from the environment. Relationships between (ethical and ecological) animal husbandry and humans may over time be reviewed. The review is expected to cover slaughtering practices and safe food storage and its safe conservation for local consumption.

05..62.08 Insects.

Once the local money system is in place in the project area, initiatives will be taken for the local production of mosquito nets, fly-catching devices and similar and for the natural biological elimination of harmful insects from homes and villages.

Stagnant surface waters offering breeding places for disease-bearing vectors will be eliminated by improving drainage from them.

05..62.09 Health and smoke elimination.

The adoption of high efficiency cookers and the elimination of wood- and charcoal-burning will eliminate smoke hazards in and around users’ homes. Smoke-related respiratory illnesses, the largest single cause of illness and death amongst children and women in developing countries, should be eliminated altogether. This is the first, and the most important, step towards improved housing quality.

05..62.10 Health and nutrition.

Improved nutritional sufficiency and dietary variation can be expected to increase resistance to illness throughout the project area. The fitter the people the higher their work capacity and productivity.

05..62.11 Curative Health structures.

This project is about the general improvement of the health of the inhabitants in the project area by prevention of diseases through the elimination of their main causes.

The proposed social and service structures set up by the project are also optimally sized to receive doctors and nurses willing to work within the framework of the local money systems once they are in operation. Doctors and nurses paid (reasonable) formal money salaries by regional or government health authorities may wish to return to the areas they come from and contribute to the local integrated development under way there. Where necessary and legally possible, they can supplement their formal money salaries by charging for their services under the local money systems set up. “Unemployed” or “underemployed” doctors and nurses originating in the project area may accept to work entirely within the local money systems in operation there.

The following paragraphs on possible future medical structures describe target sustainable health services for the project area. The realisation of these services is not formally a part of this project, but the services must be included in any integrated development vision for the area. It may take many years for the required services to become a reality. It remains a task of the project to use all of the social, financial, and productive structures it sets up in the project area to promote their realisation. These structures include the local money system which enables inhabitants to pay nurses and doctors fully or partly for their services without their needing to have formal money for the purpose.

A three-tiered system is foreseen. It incorporates nursing services at tank commission level, doctors’ services at well-commission level, and a hospital facility at project level. These are described in the following paragraphs.

05.62.12 Nursing services at tank commission level.

The (200) tank commission areas provided for in this project each serve 40-50 families, or about 250-350 people. In principle, each tank commission area should provide work for one (qualified) specialist nurse. Suitable accommodation and a reception area for the nurse can be organised and built by the local tank commission as soon as the local money system is in place. The project management will try to mediate with the Ministry of Health in support of each local tank commission’s efforts to identify and attract a nurse to its tank commission area.

As each tank commission organises nursing assistance, all of the members served by the tank commission will pay a small monthly formal money contribution into a Cooperative Health Fund (nursing section) run by the project along the same lines as the Cooperative Local Development Fund. The population will decide how much they pay into the Cooperative Health Fund (nursing section), taking eventual contributions by state and national Health Authorities into consideration. Where nurses are required to serve people in more than one tank commission area, the associated costs will be divided amongst the tank commission areas served and the monthly formal money contributions of families into the Cooperative Health Fund (nursing section) adapted accordingly.

Local money contributions to nursing costs will be paid by the local populations under the local money systems in the normal way. They may take the form of a monthly retainer payment debited in equal shares to all of the adults in a tank commission area; eventually together with a specific (limited) local money charge to the patient for each consultation. Formal money costs of medicines and equipment are paid out of the Cooperative Health Fund (nursing section). The sick are therefore collectively insured by all adult tank commission members for the formal money costs of their (basic) medicines. Purchases of (basic) medicines are pooled at project level to reduce costs.

One nurse for each tank commission area is a target to be reached over a number of years, and may depend on improvement in local education levels and training of nurses from the project area.

The nurse will be equipped with basic equipment and materials necessary for (her/his) nursing activities. Lists of very basic medical supplies for the nursing posts would be chosen on advice from health service specialists from the World Health Organisation's model list of essential medicines.

Special priority will be given to the treatment of (list of particularly common area-specific illnesses) which are common in the project area.

05.62.13 Doctors’ services at well commission level.

The (40) well commission areas provided for in this project each serve 350 families, or about 1750-2500 people. In principle, each well commission area should provide work for one (qualified) doctor. Suitable accommodation and a reception area for the doctor can be organised by the local well commission as soon as the local money system is in place. The project management will try to mediate with the Ministry of Health in support of each well commission’s efforts to identify and attract a doctor to the area.

As each well commission organises qualified doctor’s assistance, all of the members served by the well commission will pay a small monthly formal money contribution into a Cooperative Health Fund (doctors’ section) run by the project along the same lines as the Cooperative Local Development Fund. The population will decide how much they pay into the Cooperative Health Fund (doctors’ section), taking eventual contributions by state and national Health Authorities into consideration.

Local money contributions to doctors’ costs will be paid by the local populations under the local money systems in the normal way. They may take the form of a monthly retainer payment debited in equal shares to all of the adults in a tank commission area; eventually together with a specific (limited) local money charge to the patient for each consultation. Formal money costs of medicines and equipment are paid out of the Cooperative Health Fund (doctors’ section). The sick are therefore collectively insured by all adult well commission members for the formal money costs of the (basic) medicines prescribed by their doctor. Purchases of (basic) medicines are pooled at project level to reduce costs.

One doctor for each well commission area is a target to be reached over many years, and may depend on improvement in local education levels and training of doctors from the project area. The target ratio of doctors to inhabitants is in line with that currently widely accepted in industrialised countries.

The doctor’ post will be equipped with basic equipment and materials necessary for (her/his) professional activities. Supplies of medicines for the doctors’ posts would be chosen by the doctors themselves, where requested on advice from health service specialists, from the World Health Organisation's model list of essential medicines.

Special priority will be given to the treatment of (list of particularly common area-specific illnesses) which are common in the project area.

05.62.14 Project area hospital.

The size of the project area (50.000 inhabitants) is also designed to take a local non-specialised centrally located hospital facility with optimal access from all of the population centres in the project area. The hospital should have 1 bed for each tank commission area. This project provides for (200) tank commissions. The local hospital unit should therefore be equipped with (200-220) beds.

The hospital unit should be able to handle the medical situations most commonly arising in the project area. These include trauma and emergency services, rehabilitation, maternity issues, the treatment of infectious and water-borne diseases, and some basic surgical interventions. The hospital will provide active support for hygiene education activities, drinking water quality control, and HIV/AIDS and family planning campaigns in the project area. It will support doctors’ posts with advice on nutrition matters, child and youth care and mental health problems. It will provide a front office filter service for the diagnosis of more complex conditions, and provide liaison for their handling in specialised hospitals outside the project area.

Advanced hospital services are the responsibility of the Department of Health of (country).

The project can facilitate hospital services and activities which can be carried out under the local money system set up. These include non-specialist services, such as the supply of guards, gardeners, cleaning services, washing services, non-qualified kitchen services.

Non-specialised individual care following release from hospital is covered under the local money systems at well-commission (doctors) and tank commission (nurses) levels.

Simple hospital construction can be carried out under the local money system, once qualified design and specifications for buildings suitable for the project area are available.

05.62.15 Other specialist medical and paramedical activities.

There are many other standard specialist medical and paramedical support activities which should be made available in the project area, including dentists, physiotherapists, optometrists, psychiatrists and psychologists. The project can facilitate the introduction of such services and activities where they can be carried out under the local money system set up.

Improvements in the general quality of life of the local inhabitants over the years should gradually entice such specialists to (return to) the project area.

05.62.16 Transport of patients.

As soon as the local money system to be set up is in place and drivers willing to work under the local money system are available, the project management may attempt to obtain national government support and/or separate external seed funding for the purchase (where appropriate second hand) of up to four four-wheel drive vehicles suitable for the transport of patients to the project area hospital or from the project area to the hospitals nearest to the project area.

As the project management brings an ambulance service to each ambulance district (expressed as a cluster of well-commission areas), all of the members served by the well commissions in question will pay a small monthly formal money contribution into a Cooperative Health Fund (ambulance section) run by the project along the same lines as the Cooperative Local Development Fund. The population will decide how much they pay into the Cooperative Health Fund (ambulance section), taking eventual contributions by state and national Health Authorities into consideration. The formal money amount must be sufficient to pay for fuel, spare parts and long-term vehicle replacement. Drivers’ salaries will be paid under the local money systems. Long-term replacement reserves may be loaned to the Cooperative Local Development Fund and recycled in the form of interest-free micro-credit loans until they are needed.

05.62.17 Local manufacture of health products.

Priority will be given taken under the financial structures created in an early phase of the project to initiatives for the local manufacture for local use of devices and products for the rehabilitation of the physically handicapped. These may include basic assistance to individual mobility such as wheelchairs and artificial limbs. Steps may also be taken for the local production of elementary medicines, including those using locally available medicinal plants, and contact lenses. .

05.62.18 Mine clearance.

There are no parts in the project area which are known to be mined.

05.62.19 Ecological hazards.

There are no known ecological hazards in the project area.

05.62.20 A primary health care package.

For a general view of primary health care suitable for the project area, refer to:

The Primary Health Care Package for South Africa : a set of norms and standards.

Forward: Contributions of users and ongoing maintenance and administration costs.

Back: Institutional developments.

Complete index of the Model.

Main menu for the Model.

List of drawings and graphs.
Typical list of maps.
List of key words.
List of abbreviations used.
Documents for funding applications.

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