This is the presentation of the lecture I gave for the MPH students at the University of Birmingham on the Rural Health in Low-Middle Income Countries (LMICs) on 16th of April 2015. What is ‘Rural’? What is ‘Health’? Why and how rural health differ in LMICs? Practical aspects in planning and delivering healthcare in LMICs’ settings

1. Rural Health in Low-
Middle Income
Countries (LMICs)
Ghaiath Hussein
MBBS, MHSc. (Bioethics)
Doctoral Researcher

2. Outline
• What is ‘Rural’? What is ‘Health’?
• Why and how rural health differ in LMICs?
• Practical aspects in planning and delivering healthcare in
LMICs’ settings

3. What is ‘health’? Definitions & levels
• WHO definition of Health (1948)
“Health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity.”
The Definition has not been amended since 1948.
• Saracchi (1997) defines health as “a condition of well being, free
of disease or infirmity, and a basic and universal human right”
• Bircher (2005) defines health as “a dynamic state of well-being
characterized by a physical and mental potential, which satisfies
the demands of life commensurate with age, culture, and
personal responsibility”,
What’s right? What’s not so right?

4. What is ‘rural’?
• No global definition , of what counts as ‘rural’:
• Bosak and Perlman (1982) reviewed 178 articles on rural
mental health and sociology, and found that 43% of them
did not even include a definition of rural.
• Pong & Pitblado (2001) suggested that “there are almost
as many definitions of rural as there are researchers”
• Approaches to defining ‘rural’:
• Geographical
• Demographic
• Economic
• Healthcare provider characteristics
• Simply not urban/metropolitan!

5. What is Rural (2)?
• Rural Areas: Are sparsely or less populated
settlements that are isolated from
central facilities, goods and services by
distance or other physical barriers.
• Remote Settlements: are those rural
settlements that are far more limited in
facilities, goods and services when
compared to others in a similar
environment.
• Hamlets: Are very small villages and
settlements with fewer clusters of
dwellings and people.
An example of rural
settlement

6. Common Features in LMICs (1)
Indicator SSA
Arab
world MENA World
Population, total (million 2013) 936.1 369.8 345.4 7000.125
Rural population (% of total
population) 63% 43% 40% 47%
Improved water source, rural (% of
rural population with access) 53% 76% 83% 82%
GDP (in trillion US$, 2013) $1.613 $2.853 $1.496 $75.59
Access to electricity, rural (% of
population) 14.10% 71.80% 88.20% 70.20%

7. LMICs: Common Features
Health expenditure per capita (in US$)

8. LMICs: Common Features

9. LMICs: Common Features
14.10%
37%
53%
63%
71.80%
57%
76%
43%
88.20%
60%
83%
40%
70.20%
53%
82%
47%
Access to electricity, rural (% of population)
Urban population (% of total)
Improved water source, rural (% of rural
population with access)
Rural population (% of total population)
Comparison of selected rural development indicators in LMICs
World MENA Arab world Sub-Saharan Africa
Source: http://data.worldbank.org/region/WLD?display=graph

10. LMICs: Common Features

11. LMICs: Common Features

12. LMICs: Common Features

13. LMICs: Common Features

14. Water & Sanitation!

15. LMICs: Common Features

16. LMICs: Common Features
No. of hospital beds (per 1,000 people)
Source: http://data.worldbank.org/region/WLD?display=graph

17. LMICs: Common Features
56 61
92
282
70
30
40
0
71
21
26
40
71
34
46
126
0
25
50
75
100
125
150
175
200
225
250
275
300
Life expectancy at
birth, total (years)
Mortality rate, infant
(per 1,000 live births)
Mortality rate,
under-5 (per 1,000
live births)
Incidence of
tuberculosis (per
100,000 people)
Comparison of selected health indicators in LMICs regions (WB, 2013)
Source: http://data.worldbank.org/region/WLD?display=graph
Sub-Saharan Africa
Arab world
MENA
World

18. LMICs: Common Features
32.0%
46%
62%
32.9% 33%
26%
46.6%
30%
16%
17.9%
38%
23%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
55.0%
60.0%
65.0%
70.0%
Out-of-pocket health expenditure
(% of total expenditure on health)
Prevalence of anemia among
pregnant women (%)
Cause of death, by communicable
diseases and maternal, prenatal
and nutrition conditions (% of
total)
Comparison of selected health indicators in selected LMICs regions
(WB, 2013)
Source: http://data.worldbank.org/region/WLD?display=graph
Sub-Saharan Africa Arab world MENA World

19. LMICs: Common Features
CPIA transparency, accountability, and corruption in the public sector rating (1=low to 6=high)

20. LMICs: Common Features
Worldwide Governance Indicators: Control of Corruption (2013)

21. LMICs: Common Features
Source: www.rsf.org/index2014/en-index2014.php

22. LMICs: Common Features
THE ECONOMIST DEMOCRACY INDEX (2012)
Source: http://en.wikipedia.org/wiki/Democracy_Index#External_links

23. LMICs: Common Features
Map of the currently active armed conflicts in the world.
Source: http://www.conflictmap.org/

24. LMICs: Common Features

25. Democracy in my country…!
President phoning chief of intelligence
President: I’m missing my golden pen. Indeed, someone
stole it!
Chief of intelligence: No worries Sir, I will take care of
that.
Few hours later… President on the phone again
President: It’s OK, I’ve found my golden pen.
Chief of intelligence: Weird! we have arrested 14 –four
of them already signed confessions of stealing it
• The golden pen story

26. LMICs: Common Features
Central
• Central
government
policies
• Central
bureaucracy
Province/
State
• Province/
state level
approval
Community
leaders
• Religious
• Tribal
• Official (Gov.)
• Militias?
Community
members
• Men
• Male children
• Women
• Female
children
• Disabled

27. LMICs: Common Features
• Extended families
• Hierarchical families
• Tribal/geographical structures
• Community leaders
• Role of religion and religious leaders
• Men vs. women
• Local beliefs and ‘taboos’

28. LMICs: Common Features
Rural Health ‘System’
Centralized
Politicized
Donor-
dependent
Facilities
Poorly
situated
Poorly
equipped
Irrelevant
Service
Unaffordable
Staff
Insufficient
Poorly
trained
Poorly
paid
‘Brain
drain’

29. Typical levels of healthcare
Health
points/
workers
Health
dispensaries
Health
centres
Peripheral/
District
hospital
General/
Specialized
hospital

30. Focus on the ‘grassroots’:
What are the realitiesfor ruralcommunities?
• Too few
• Too far
• Too expensive
• Mal/Not functioning
Health
facilities
• Few in number
• Overloaded
• Not adequately qualified for their assigned roles
(TBAs?)
Health cadres
• Poverty
• Illiteracy
• Vulnerability (e.g. women & children, insecurity)
• Dominance of ‘community leaders’, usually men.
Socio-
economic
determinants

31. LMICs: Common Features
• Thoughts? How do these features impact rural health?
Low income
Poor quality of
life (e.g.
housing)
Poor nutrition
(including
obesity)
Alternative
medicine
Lack of clean
water
Diarrheal
diseases
Infections
Lack of
education
Uninformed
choices
Poorly-paid
‘jobs’
Inefficient
services
Inaccessible
Unaffordable
Unused/
abused
Under-
reporting

32. Note on Traditional healers
They usually composite mix of ‘healers’, community leaders, &
religious leaders. So they’re consulted in:
• Clinical: Conditions such as cerebral malaria, ARI, leprosy,
epilepsy, hypertension, diabetes, cancer, injuries,
impotence and infertility.
• Social: Examples are marital problems and prospects,
political and economic aspirations, job/ promotion
aspirations and associate problems.
• Mental/Spiritual: These include mental ailments and
psychological disorders; frequent infant and child morbidity

33. Focus on the ‘grassroots’ (2):
How do ruralcommunitiescopewith theserealities?
• When there is no adequate food (e.g. no money,
or not accessible, or no food)?
• Home-planted fruits/vegetables (if there is a
home!)
• Raw (wild) fruits naturally growing
• Junk food (e.g. a bottle of coke is cheaper than
water)
• Goods for food
• Work for food
• Sex for food!

34. Focus on the ‘grassroots’ (3):
How do ruralcommunitiescopewith theserealities?
• When there is no adequate education (e.g. no
accessible school, or no free school)?
• Religious classes
• Prioritize boys to girls (sometimes the opposite)
• Follow what the ‘community leaders’ say
• When there is no enough income?
• Multiple ‘jobs’ (e.g. farming, teaching, washing
clothes)
• Migrate to the ‘city’ or abroad

35. Focus on the ‘grassroots’:
What can/should be done?
Remember! Whatever you propose should be:
1. Culturally acceptable
2. Responds to the real needs of the served community
3. Inclusive of the ‘stakeholders’ – meaningfully, i.e. ‘bottom-
up’ approach
4. Gradual: start simple
5. Community-based and community-dependent
(sustainability)
6. Affordable
7. Sustainable
8. ‘Innovative’, though still bottom-up
9. What else?

36. Focus on the ‘grassroots’:
What can/should be done about?
Staff Availability
Affordability Accessibility
QA Sustainability

37. Now: your turn!
Countristan is LMIC with a population of 3 million,
mostly situated in the capital city and few other
metropolitan cities. Despite its mostly poor
economic and health indicators; it was declared free
of polio by UNICEF in 2013. however, over the last 6
months, sporadic cases of polio have been
reported, especially in the rural village of Pooristan.
This village is on the border with another country. It
has a population of 2,000 mostly women and
children, of whom an estimate of 200 children is
under 5. Most of the men left to find better jobs in
the capital or in the neighbouring country.

38. Now: your turn!
There is no rural hospital, and there was one primary
care centre that was run by one medical assistant, a
nurse a midwife. The medical assistant left the village
few months earlier as he was offered a better job in the
hospital of the nearest city to the village, which is 80 Km
away. The primary care centre is only opened once or
twice a week in the morning time; as in the afternoon
the midwife works in the village’s market, when not
called for a home delivery. Similarly, the nurse works as
an assistant in the ‘clinic’ of one of the 3 herbal healers
of the village. The village has no source of potable water
expect for 2 hand-pumps that were installed by an
international organization couple of years ago.

39. Now: your turn!
Many of the people in the village do not have access
to them and do not want to use them because the
religious leader used to warn them from drinking the
water of the pumps because the foreign organizations
added some material to the water that would
ultimately cause men’s infertility. He also warned
them from giving any immunizations to their children,
“These drops will ultimately cause infertility or the
slow death of your children” he warned repeatedly.
You were assigned by the ministry of health to
investigate the situation and to take the needed
action to re-eradicate polio in the village.

40. References
• Bircher, Johannes. "Towards a dynamic definition of health and disease." Medicine, Health
Care and Philosophy 8.3 (2005): 335-341.
• Bosak, J., & Perlman, B. (1982). A review of the definition of rural. Journal of Rural Community
Psychology, 3(1), 3–34.
• Health in developing countries, Department for International Development, 2014:
https://www.gov.uk/government/policies/improving-the-health-of-poor-people-in-
developing-countries#case-studies
• Pitblado, J. R. (2002, October 23–26). Defining “rural” and “rurality”: Commentary.
Methodological Issues of Rurality and Rural Health Conference Workshop, Halifax. Available:
www.brandonu.ca/organizations/RDI/Defining Rural.html
• Pitblado, J. Roger. "So, What Do We Mean by." CJNR (Canadian Journal of Nursing
Research) 37.1 (2005): 163-168.
• Preamble to the Constitution of the World Health Organization as adopted by the
International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the
representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100)
and entered into force on 7 April 1948.
• Saracci, Rodolfo. "The World Health Organisation needs to reconsider its definition of
health." Bmj 314.7091 (1997): 1409.
• The Millennium Challenge Corporation (MCC): http://data.mcc.gov/
• The Primary Care Innovator's Handbook: Voices from Leaders in the Field, 2015. Available for
free download from:
http://healthmarketinnovations.org/sites/default/files/Primary%20Care%20Innovators%20Ha
ndbook_CHMI.pdf
• The World Bank database: http://data.worldbank.org/ and the Worldwide Governance
Indicators (WGI) project (http://info.worldbank.org/governance/wgi/index.aspx#home)