789

Weaver, L. T., Laker, M. F. & Nelson, R. (1984a). Intestinal permeability in the newborn. Archives of Disease in Childhood, 59, 236241.

Weaver, L. T., Laker, M. F. & Nelson, R. (1984b). Enhanced intestinal permeability in preterm babies with bloody stools. Archives of Disease in Childhood, 59, 280-281.

Weaver, L. T., Chapmen, P. D., Madeley, C. R., Laker, M. F. & Nelson, R. (1985). Intestinal permeability changes and excretion of micro-organisms in stools of infants with diarrhoea and vomiting. Archives of Disease in Childhood, 60, 326-332.

Weaver, L. T., Laker, M. F., Nelson, R. & Lucas, A.

1 BookReview 1

Community Health Workers: The Tanzanian Ex- perience. H. K. Heggenhougen, J. P. Vaughan, E. P. Y. Muhonda and J. Rutabanzibwa-Ngaiza. Ox- ford: Oxford University Press, 1987. 205 pp. Paper- back. Price: E5. ISBN 0 19 261618 8.

Ten years on from Alma Ata, progress towards equity in health care is a highly topical subject and the time is ripe for genuine evaluation of well established programmes in primary health care to replace any earlier romanticism about the ‘barefoot doctor’ con- cept. Twenty years ago, it was clear to most health professionals with experience in less industrialized countries that high cost, hospital-based, high technol- ogy care, provided by expansively trained health professionals following the then current western model, was totally inappropriate to the needs of the people of the so-called Third World, most of whom were born, lived their too brief and disease beset lives, and died without benefit from any of the much vaunted advances in medical science.

Tanzania made an early commitment in 1969 to innovation in the shape of community health workers (CHWs1 for nrimarv health care. and the writer of this review remembers’suggesting to the BBC Horizon team that they would find Tanzania as exciting as China as the site for a programme about the ‘barefoot’ idea. Her advice was taken and the film, ‘A Fair Share of What Little We Have’ attracted wide international interest in the mid-70s, illustrating as it did the enormous potential of ‘health by the people’ in the run-up to the WHO/UNICEF conference in 1978 at Alma Ata. There almost all governments accepted the concept of primary health care as the way towards equity and the target of Health for All by the year 2000.

Too often, the dream bears little relation to the reality and planning and implementation need to be based on reality. This book represents a skilful assessment of the issues that have emerged as critical to the success of the Tanzanian CHW nroaramme. With special assistance from Dr M. P. M&id&a of the Department of Community Health at Muhumbili Medical Centre, Patrick Vaughan and Kris Heg- genhougen, from the Evaluation and Planning Centre of the London School of Hygiene and Tropical Medicine, have collaborated in authorshin with Eus- tace P. Y. Muhondwa, Department of Behavioural Sciences at Muhumbili Medical Centre. and with 1. Rutubanzibwa-Ngaiza, Planning Unit,’ Ministry of Health in Dar es Salaam. In his foreword, the

(1987). Milk feeding and changes in intestinal permeabil- ity and morphology in the newborn. Joumal of Pediatric Gastroenterology and Nutritti, 6, 251-358.

Whitehead, R. G., Paul, A. A. & Aluned, A. E. (1986). Weaning practices in the United Kingdom and variations in anthropometric development. Acta Paediahica Scandi- navica, 323, 11-23.

Yamanaka. K. (1975). D-Mannitol dehvdroeenase from Leucomkwc ~esekroides. In: Method; in ~Enzyrnology, Wood, W. (editor). New York: Academic Press. pp. 138-142.

Received 27 January 1988; revised I1 April 1988; accepted for publication I I May 1988

Tanzanian Minister of Health, the Honourable Dr A. D. Chiduo, sets out briefly the historical and political backeround to the CHW nroaramme which he freely adrniis has had considerable ;ps and downs over the years. He stresses the need for more and more reliable information to be gathered about such innovations in the provision of health care so that others may benefit; and he suggests that the analysis and evaluation of the Tanzanian experience contained in this book provide just such information and may act as a spur to those countries not yet committed to the use of CHWs.

There are ten chapters-eight about Tanzania, one about community health workers in southern Africa (Botswana, Lesotho, Mozambique, Zambia and Zim- babwe), and a final and fascinating chapter about critical issues, which includes such tricky matters as intersectoral relationships, co-operation with tradi- tional healers, the question of quantity versus quality, organization and management issues.. .and many other issues, all equally important. The earlier chapters are just as lucid and succinct, based on extensive surveys and interviews, and they give a highly readable account of the successes and the shortcomings of the programme and the way in which the lessons learned through making this evaluation will be applied in the future. The value of community participaGon at all levels and stages in any CHW programme is emphasized again and agairr--only thus can unmet expectations be avoided and lasting success achieved.

The final 30 pages are devoted to a useful annotated bibliography grouped under three headings: training of auxiliaries; primary health care and general socio- economic development; and CHWs and their work. This is followed by a general bibliography relating more to the overall theme of health care in Tanzania than to CHWs as such-and this also includes some references to materials about CHWs in general. The text itself is well referenced. The book orovides an excellent description of the role and effectiveness of community health workers within their village con- text in Tanzania over the last two decades. The collaboration between the Muhumbili Medical Cen- tre, the Tanzanian Ministry of Health and the London School of Hvrriene and Tronical Medicine clearly worked well and has produced a book which should be read by everyone interested in and con- cerned with primary care, and particularly with the implementation of CHW programmes on the wide scale that is now so badly needed in both rural and urban areas of the developing world.

Katherine Elliott