Revitalisation of Primary Health Care and Health System Development: the Potential of Community Health Workers. AFRICA and SOUTH ASIA S CRISIS

Transcription

1 Acknowledgements Revitalisation of Primary Health Care and Health System Development: the Potential of Community Health Workers David Sanders Director: School of Public Health University of the Western Cape Member of Global Coordinating Council, Peoples Health Movement Much of the material presented is drawn from collaborative work with Uta Lehmann, Irwin Friedman, Princess Matwa and Andy Haines. Grateful thanks are due to Dr. Sundararaman, Raman and members of the State Health Resource Centre in Chhattisgarh, India for information on the Mitanin programme. Thanks for many insights go to colleagues in the Peoples Health Movement. A WHO Collaborating Centre for Research and Training in Human Resources for Health Outline of Presentation AFRICA and SOUTH ASIA S CRISIS The current situation of health and health systems with special emphasis on Africa Primary Health Care and community participation Rationale for Community Health Workers History and evolution of CHWs Evidence of effectiveness of CHWs Factors affecting performance of CHWs CHWs as agents of social change and a current example Mortality 1-4 year olds Territory size shows the proportion of all deaths of children aged over 1 year and under 5 years old, that occurred there in Despite successes, growing inequalities in global health AFRICA and SOUTH ASIA S CRISIS TB cases Territory size shows the proportion of worldwide tuberculosis cases found there.

2 Growing inequalities in child health within countries What are the key Basic Causes of Africa s Health Crisis? HIV/AIDS Increasing poverty and inequality worsened by inequitable globalisation and selective PHC and inappropriate health sector reform.. result in slow progress and reversals. Global HIV prevalence 40 million people around the world live with HIV - more than the population of Poland. Nearly two-thirds of them live in Sub-Saharan Africa, where in the two hardest hit countries HIV prevalence is almost 40%. The AIDS debate, BBC News External debt Between 1970 and 2002, African countries borrowed $540 billion from foreign sources, paid back $550 billion (in principal and interest), but still owe $295 billion (UNCTAD 2004) Africa spends more on debt servicing each year than on health and education Unfair Trade (1) The result unequal growth of wealth between countries..drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations (G8 Communiqué, Genoa, July 22, 2001) BUT many developing countries have destroyed domestic economic sectors, such as textiles and clothing in Zambia (Jeter 2002) and poultry in Ghana (Atarah 2005), by lowering trade barriers and accepting the resulting social dislocations as the price of global integration.

3 AFRICA and SOUTH ASIA S CRISIS..and growth of poverty GDP wealth According to the World Bank s most recent figures, in sub- Saharan Africa 313 million people, or almost half the population, live below a standardized poverty line of $1/day or less (Chen and Ravallion 2004). Territory size shows the proportion of worldwide wealth, that is Gross Domestic Product based on exchange rates with the US$, that is found there. Sub-Saharan Africa is the only region of the world in which the number of people living in extreme poverty has increased indeed, almost doubling between 1981 and Why should a Japanese cow enjoy a higher income than an African citizen? Primary Health Care and the place of Community Participation US dollars Japan annual dairy subsidy, per cow EU annual dairy subsidy, per cow Per capita annual income, sub-saharan Africa Per capita cost of package of essential health interventions Per capita annual health expenditure, 63 low income countries WHO/UNICEF Alma Ata Conference PHC as a strategy Alma Ata, the capital of Kazakhstan, now called Almaty Site of the 1978 WHO/UNICEF conference Health for All by the Year 2000 The concept of PHC had strong sociopolitical implications. It explicitly outlined a strategy which would respond more equitably, appropriately and effectively to basic health care needs and ALSO address the underlying social, economic and political causes (determinants) of poor health.

4 Principles of the Primary Health Care Approach Universal accessibility and coverage on the basis of need (equity) Comprehensive care with emphasis on disease prevention and health promotion Community and individual involvement and selfreliance Intersectoral action for health Appropriate technology and cost-effectiveness in relation to available resources From Primary Medical to Primary Health Care FROM TO Focus: Illness Health Cure Prevention and Care Contents: Treatment Health promotion Episodic care Continuous care Specific problems Comprehensive care Organisation: Specialists General Practitioners Physicians Other personnel groups Single-handed Team Responsibility: Health Sector alone Intersectoral Collaboration Professional dominance Community Participation Passive reception Self-responsibility Source: Vuori Community participation in PHC Community organisation in PHC In order to make P.H.C. universally accessible to the community as quickly as possible, maximum community and individual self-reliance for health development are essential. To attain such self reliance requires full community participation in the planning, organisation and management of P.H.C... Alma Ata Declaration, 1978 It can be seen that the proper application of primary health care will have far-reaching consequences, not only throughout the health sector but also for other social and economic sectors at community level. Moreover, it will greatly influence community organisation in general. Resistance to such change is only to be expected Alma Ata Declaration, 1978

5 Health systems & personnel Health personnel vital, consume between 60 80% of recurrent public health expenditure (WB, 1994). Current health workforce data are aggregates that mask unequal distribution between rich and poor African countries and between rural and urban areas Mortality (per 1,000, log) Health Worker and Mortality Maternal Infant Under Density (workers per 1,000, log) JLI, 2004 HRH DENSITY BY REGIONS Health professional migration from Africa Sub-Saharan Africa Asia S&Central America Between 1985 and 1995, 60% of Ghana s medical graduates left Global 4.2 M iddle East Western Pacific North America During the 1990s Zimbabwe lost 840 of 1,200 medical graduates 10.3 Europe Workers (physicians, nurses and midwives) per 1,000 population 2,114 South African nurses left for the UK during 2001 Slide Date: Octo In summary: health status is stagnant or declining and public health systems in Africa and many Southern countries are weakened mainly as a result of.. Increasing poverty and failure to address health determinants resulting in poorer health status Declining per capita health spending reducing Health personnel numbers and morale Drugs availability Transport for outreach & supervision Donor funding, including Global Public-Private Partnerships, have reinforced selective and vertical approaches, fragmenting health services HIV/AIDS affecting and infecting health personnel reversing previous gains in PHC implementation Global Immunization , DTP3 coverage global coverage at 75% in Global Industrialized countries Latin America and Caribbean South Asia Central Europe, CIS East Asia and Pacific Mid-East and N Africa Sub-Saharan Africa Source: WHO/UNICEF estimates, 2003

6 The case for revitalising PHC and reintroducing CHWs A Case Study of IMCI IMCI pneumonia case management (Tanzania) Coverage: child actually receives the intervention % children receiving intervention Breastfeeding 6-11 mo Measles vaccine Vitamin A Skilled birth attendant Source: Jones et al, Lancet 2003, 362: Tetanus toxoid Antibiotics for pneumonia ORT Newborn resuscitation IMCI pneumonia case management (Tanzania) Towards population impact Coverage under actual programme conditions Population Pneumonia mortality effectiveness averted = Intervention efficacy x Intervention Health workers availability are trainedx 9% 65% 80% The HR factor Health Diagnostic workers assess accuracy child xcorrectly 63% Health workers Provider treat compliance child correctly x 65% Coverage Patient (mother compliance recognised x 40% illness, sought care and complied Coverage with treatment: child receives the intervention) Tugwell framework applied to multi-country evaluation data Source: Tugwell, J Chron Dis, 1985; 38(4): IMCI pneumonia case management (Tanzania) Towards population impact Coverage under improved programme conditions Population Pneumonia mortality effectiveness averted = Intervention efficacy x Intervention Health workers availability are trainedx 19% 65% 90% The HR factor Health Diagnostic workers assess accuracy child xcorrectly 90% Health workers Provider treat compliance child correctly x 90% Coverage Patient (mother compliance recognised x 40% illness, sought care and complied Coverage with treatment: child receives the intervention) Source: Tugwell, J Chron Dis, 1985; 38(4): Why should interventions be delivered in community settings? Many child deaths occur outside health facilities Currently the coverage of many effective interventions is low well under 50% in many cases eg only 3-12% of children born at home in 5 South Asian and Sub-Saharan African countries received a visit from a trained health worker within 3 days of birth Jones et al, Lancet 2003; 362: Children from poor families are less likely to access government health facilities than those from wealthier families Schellenberg et al, Lancet 2003; 361:

7 Why should interventions be delivered in community settings? An analysis of cost effective interventions for saving newborn lives examined three different delivery approaches outreach, familycommunity and facility-based clinical care. Outreach and family-community care in combination at 90% coverage could result in an 18-37% reduction in mortality even before facility-based care is strengthened. Darmstadt et al, Lancet 2005; 365: Definition of Community Health Workers Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers WHO 1989 Who are Community Health Workers? generic type eg village health workers, community resource persons, or workers known by local names. more specialised cadres eg community rehabilitation facilitators, community-based directly observed therapy short-course supporters, traditional birth attendants (TBAs), HIV/AIDS communicators, etc. Internationally, CHWs had and have a large number of different titles. Below are some examples (not exhaustive and do not include a range of lay health workers who now render different forms of services for people living with HIV and AIDS). All CHWs perform one or more functions related to health care delivery, or home-based care, trained in some way, but usually have no formal professional or paraprofessional certification. Table: Alternative titles for CHWs Title Country Activista Agente comunitario de salud Agente comunitário de saúde Anganwadi Animatrice Barangay health worker Basic health worker Brigadista Colaborador voluntario Community drug distributor Community health agent Community health promoter Community health representative Community health volunteer Community health worker Female community health volunteer Health promoter Kader Lady health worker Monitora Mother coordinator Mozambique Peru Brazil India Haiti Philippines India Nicaragua Guatemala Uganda Ethiopia various countries various countries Malawi Various Nepal various countries Indonesia Pakistan Honduras Ethiopia Lehmannn and Sanders, WHO, Why the renewed interest? Brain drain and continued maldistribution Increased requirements imposed by HIV/AIDS, particularly chronic care needs A renewed interest in/focus on PHC and roles of communities and community empowerment. Lehmannn and Sanders, WHO,

8 Liberator or lackey (David Werner, 1981) Past debates and new evidence with current implications The early literature emphasises the role of the CHWs as not only (and possibly not even primarily) a health care provider, but also as an advocate for the community and an agent of social change: functioning as a community mouthpiece to fight against inequities and advocate community rights and needs to government structures. This view is also reflected in the Alma Ata Declaration which identified CHWs as one of the cornerstones of comprehensive primary health care. Profiles Most CHWs are women, although there are programmes which consist primarily of men. Age and educational status are linked in many cases: mature women with little education but much practical experience, versus young people with secondary education but little experience. Lehmannn and Sanders, WHO, Which interventions can be delivered in community settings? interventions to promote healthy behaviours eg hand washing and breast feeding preventive interventions eg insecticide-treated nets for malaria and micronutrients more complex tasks eg case management of childhood illnesses such as malaria, pneumonia and neonatal sepsis active involvement and empowerment of communities through activities of CHWs eg through changing health beliefs and advocating for improved access to health and other services. Haines, Sanders et al, Lancet, 2007, Vol. 369, pages Evidence for impact and costeffectiveness of community health workers A meta-analysis of community-based trials of pneumonia case management on mortality suggested an overall reduction of 24% in neonates, infants, and preschool children Sazawal and Black, Lancet Infectious Diseases 2003; 3: A trial in Tigray, Ethiopia, of training local coordinators to teach mothers to give prompt home antimalarials showed a 40% reduction in under-5 mortality Kidane and Morrow, Lancet 2000; 356: Evidence for impact and cost-effectiveness of community health workers In a recent review of immunisation in developing countries, one of the interventions with the highest impact on coverage was the use of CHWs Pegurri et al, Vaccine 2005; 23: Use of CHWs in periodic outreach programmes in urban Mexico, and in the Amazon, Ecuador led to community involvement and improved services by ensuring that houses were located precisely, potential recipients were registered and vaccination days chosen with parents. Calderon Ortiz and Mejia-Mejia. Salud Publica de Mexico 1996; 38: Use of CHWs was more cost-effective than outreach teams of health staff in the Amazon region of Ecuador. San Sebastian et al, Tropical Doctor 2001; 31:

9 Evidence for impact and costeffectiveness of community health workers A recent systematic review of lay health workers delivery of simple interventions was conducted mainly in high-income countries (35 of 43), but nearly half of them (15 of 35) in low-income and minority populations. Benefits over usual care were shown for lay interventions to promote immunisation uptake in children and adults, and to improve outcomes for malaria and acute respiratory infections. Insufficient data exist to assess which training or intervention strategies are likely to be most effective. Lewin et al, Cochrane Database, 2005 Evidence for impact and costeffectiveness of community health workers CHW-led women s groups in Nepal provided education to reduce neonatal and maternal mortality. The programme achieved substantial reduction in both neonatal and maternal mortality rate and was very cost-effective. Manandhar et al, Lancet 2004; 364: Borghi et al, Lancet 2005; 366: Comparing the performance of doctors and nurses with other health workers in child care In Bangladesh lower level workers (family welfare visitors and nursing aides) performed much better than higher level workers (paramedics, physicians, and nurses) in rational prescription of antibiotics and provision of appropriate advice to caregivers. Arifeen et al, Bull WHO 2005; 83: In Benin much higher percentages of children with diarrhoea received ORS and were appropriately treated with an antimalarial by nursing aides compared with nurses (intermediate) and physicians (worst performance). Rowe et al, Am J Public Health 2001; 91: Factors influencing success of CHW programmes Selection Training Health system factors Community factors Political, macroeconomic and international factors Financial and non-financial incentives Factors influencing success of CHW programmes Selection Literature emphasizes that CHWs should be from communities they serve and communities should be involved in selection. Selection from local communities is internationally practised; community involvement is not. Whether and how communities are involved depends on governance and community participation; role of CHCs. Lehmannn and Sanders, WHO, 2007, Factors influencing success of CHW programmes Training Length, depth, organisation of, responsibility for, and approaches to training vary dramatically across programmes Training is in many cases conducted by members of the formal health services, or, in the case of NGO-driven programmes, by the NGOs themselves. Consensus that on-going or refresher training is as important as initial training. Several studies show that if regular refresher training is not available, acquired skills and knowledge are quickly lost; good on-going training may be more important than who is selected. Lehmannn and Sanders, WHO, 2007,

10 Factors influencing success of CHW programmes Health system factors CHWs function best in a well-functioning health system with appropriate management capacity, functioning referral channels, good hospital care and reliable supply chains. But they may also be key in poor health systems. Travis P, Lancet 2004; 364: Improving performance of community health workers Health system factors Several evaluations have documented the weakness of supervision and support in national programmes. Walt, OUP, 1992 Berman et al, Soc Sci Med 1987; 25: A recent review concluded that supportive supervision leads to benefits and that well-organised supervisory systems have the potential to improve motivation and provide professional development. Rowe et al Lancet 2005; 366: Factors influencing success of CHW programmes Political and Community factors Many CHW programmes have emerged and been sustained in situations of political transition and popular mobilisation Mobilised and well-informed communities, community-based workers and formal health services have rapidly disseminated child survival interventions and reduced mortality eg Nicaragua, Zimbabwe Sanders in Frankel (Ed) OUP 1992: Garfield and Williams, OUP Factors influencing success of CHW programmes Political and Community factors Poor accountability of local governments and politicians can lead to reward appointments eg in LHW programme in Hala, Pakistan, 20% were from different locations than their place of work Oxford Policy Management P Stronger community participation in selection and monitoring of CHWs could reduce abuse of appointment systems, although attaining this depends on general political context Chopra and Sanders, CHIP Report no 10, Save the Children, Improving performance of community health workers Financial and non-financial incentives Most CHW schemes aspire to volunteerism. But volunteer programmes show very high turnover and attrition. However, most programmes pay their CHWs a salary or an honorarium. An exciting current example Walt, HPP, 1988; 3: WHO, SHS/CIH/87.2; 1987 Sustained community financing is rare, apart from China in 60s and 70s where surplus from collective production funded barefoot doctors Even on a part-time basis, the costs entailed by lost economic opportunities may be higher than small honorarium. Other financial incentives include: small state salary, payments for attending training sessions Bhattacharyya et al, BASICS II, USAID, 2001

11 Mitanin Programme: About Women as Community level Health Volunteers To Support the Public Health System & Public Health Initiatives in Chhattisgarh Chhattisgarh, India State Health Resource Centre, Chhattisgarh, India Chhattisgarh: A Brief Profile Area : 146,361 Sq. Km. (Ninth largest State of India) Population: 20,795,956(Census 2001) Rural-80%: Urban-20%. Population Density: 154 /sq.km (National-324) Tribal Population Scheduled Castes Population 32% (Has 7 of India s tribal groups) 12 % Literacy Rate: 65% Female Literacy: 52.4% Other unique features Rice bowl of India, Museum of Mines, Forest based economy, Archeological and Natural Heritage Mitanin Programme Started in A State-Civil Society joint initiative as a result of a long consultation process. Mitanin- the best friend - derived from the friendship custom among indigenous communities Scaled up to all 146 rural development blocks of the state in 3 phases - during 2002 & About 60,000 female CHVs selected and trained - one per hamlet, covering about population Influenced design of ASHA Scheme under National Rural Health Mission - now being initiated in many states across the country. Key Objectives Improve awareness of health and spread health education Improve utilisation of existing public health care services through advocacy for equitable access Provide local curative and preventive measures for common health problems of poor Organise community, especially women and weaker sections, on health and health related issues Sensitize panchayats (the local self-governing institutions) and build their capabilities in planning and implementing health actions - placing health on panchayats agenda. Selection and Training of Mitanin Chosen by the village/hamlet supported by a trained facilitator interacting with hamlet communities and women s committees Supported by ongoing social mobilisation & communication inputs focused at local level and specially designed radio programmes Specially set-up training cascade and supporting system- 1 trainer per 20 Mitanins, 1 District Resource Person per 10 trainers, 1 Coordinator per 10 District Resource persons and the State Health Resource Centre Team Trained in various health & health related issues in 11 rounds so far, comprising 35 days of camp based training and about 150 days on-the-job training spread across 3 years : each training camp followed by further field support A continuation Phase of 12 day training per annum- to maintain the knowledge-skills and spirit-motivation levels

12 Key Activities of Mitanins Planning for the expected deliveries and facilitate for proper ANC; Prompt referral for complications and inst. delivery Day 1 visit at childbirth, delivering essential neonatal care messages Regular Health Education, awareness and initiatives for health entitlements through women's groups Identification of malnourished children- refer the severe cases and counseling for moderate cases Mobilize community for public health services - find out gaps and help the health worker to fill them Early detection, first contact care and referral- focus on common but critical childhood illnesses - fever, cough-colds, diarrhoea To act as community interfaces for health & related interventions- national health programmes, epidemic control, education, food security, water & sanitation etc. To lead the hamlet level initiatives under Panchayat Health Planning & health related development. Mitanin Drug kit Provided to all Mitanins under a special scheme declared by the Chief Minister of the State, with a total 50 million INR per annum special budget allocation Contains Paracetamol, Chloroquine, Co-trimoxazole, ORS, Metronidazole, Antacid, Albendazole, Iron-folic acid, Gentian Violet, Gamma BHC, blood slides, cotton, spirit, lancets, pregnancy detection kit, Rapid Diagnostic Kit for Malaria, Condoms, and Doctor initiated Drugs like MDT for TB. Specially designed kitbag and containers and unique drug identification system: logo for each drug, colour code, nicknames- to help less-educated Mitanins Efficient usage recorded of the drug kit- special inventory system introduced for refills Sometimes the refills are delayed Ongoing support and monitoring Ongoing training camps Supportive visit to every mitanin by Trainers to be ensured so as to improve Mitanin activity levels Cluster (Panchayats) meeting of mitanins with trainers/drps to Assess this Fortnightly Trainer meeting to Review Mitanin Status Field Visits by DRPs to assess this DRP meeting to review block/trainer status Analytical look at data and improving measures at all levels Some Health Situation indicators in Chhattisgarh & India: Comparison of 2000 & latest figures Chhattisgarh India Indicator Proportion (%) of mothers who had at least 3 ante-natal care visits for their last birth- NFHS Proportion (%) of births assisted by health personnel- NFHS Proportion (%) of children months fully immunized- NFHS Proportion (%) of children with diarrhoea in last 2 weeks who received ORS-NFHS Proportion(%) of children below one year who are breastfed within 24 hours of birth-ces 2000 Latest Change 2000 Latest Change IMR : A comparison with Madhya Pradesh, the mother state, and India What do Mitanins Get? No salaries envisaged Wages against loss of livelihood on training days- 75 INR a day Performance based incentives: 50 INR for mobilising people for immunisation/anc, 200 INR for motivating for family planning, 200 INR for institutional delivery referal, 150 INR for hospital stay with pregnant women, 175 INR to work as a TB DoTS provider But these payments not made promptly, due to systemic weaknesses - hence the average income of Mitanins is negligible But huge social recognition: more than 5000 Mitanins were elected to local village to district level bodies and also made convenors of Village Health Committees

13 Anti-Deforestation Agitation by CHWs Chhattisgarh-India They organised anti-felling demonstrations In Chhattisgarh: Mitanins led a Women s agitation to oppose state government plan of felling and selling 40,000 hectares of dense natural forests involving felling of 20 million trees for timber Mitanins mobilised women to oppose deforestation policies of state as deforestation threatens livelihoods and nutrition security of tribal (indigenous) communities especially the women They mobilised Village Assemblies and Forest Protection Committees (Formal mechanisms of local self governance) to pass resolutions demanding a stop to the felling When resolutions and demonstrations did not seem to put an immediate stop to felling, they snatched the axes and saws They chased the timber contractors away. They did not allow the contractors to take away the wood They forced Central Government to institute an Enquiry They fought against pressure from police and administration

14 Mitanin CHWs fight against deforestation Filed a Public Interest Litigation in State High Court Mitanins won the litigation, thus forcing the Government to withdraw its deforestation programmes in three districts of Chhattisgarh Followed it up with national litigation in the Supreme Court, which is now demanding an end to all state sponsored deforestation programmes Conclusions There exists accumulating and robust evidence of effectiveness of CHWs in provision of services esp. in child health. CHWs can make a valuable contribution to community development and, more specifically, can improve access to and coverage of communities with basic health services. For CHWs to be able to make an effective contribution, they need to be carefully selected, appropriately trained and, very importantly, adequately and continuously supported. Large-scale CHW programmes require substantial and reliable resources for training, management, supervision, and logistics. Conclusions CHW programmes are vulnerable unless they are driven, owned by and firmly embedded in communities themselves. Where this is not the case, they exist on the geographical and organisational periphery of the formal health system and are often fragile and unsustainable. The concept of community ownership and participation is often ill-conceived and poorly understood when programmes are initiated from the centre. Evidence suggests that CHW programmes thrive in mobilised communities but with exceptions - struggle to galvanise and mobilise communities. Conclusions CHW programmes are neither the panacea for weak health systems nor a cheap option to provide access to health care for under-served populations. Numerous programmes have failed in the past because of unrealistic expectations, poor planning and an underestimation of the effort and input required to make them work. This has unnecessarily undermined and damaged the credibility of the CHW concept It is time to advocate for careful reintroduction of CHWs in national health strategies PEOPLE S HEALTH MOVEMENT The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHO s strategy of Primary Health Care.