Systematic Review of the Effectiveness of CommunityBased Primary Health Care in Improving Child Heal

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Systematic Review of the Effectiveness of
Community-Based Primary Health Care in Improving
Child Health The Contribution of the
Faith-Based Community

• Henry Perry, Co-Chair, Review Task Force and Carl
  Taylor Professor for Equity and Empowerment
• Future Generations

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Outline

• The review itself
• Findings of the review
• Contribution of individuals and organizations
  with a strong faith-based perspective to the
  evidence base
• Conclusions

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Key Questions of the Review

• How strong is the evidence that CBPHC can improve
  child health?
• What conditions/program elements must be in place
  for CBPHC to be effective?
• How important are partnerships between
  communities and health systems?
• Does CBPHC promote equity and is it
  cost-effective?

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Definition of CBPHC

• Activities, interventions, programs that take
  place in the community outside of health
  facilities (but possibly in partnership with
  health facilities)
• Includes selective and comprehensive approaches
  as well as top-down and bottom-up approaches
• Includes non-health interventions (e.g.,
  micro-credit, education, womens empowerment,
  societal factors)

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Outline of Report

• Evidence concerning individual interventions
• Evidence concerning integrated approaches
• Cross-cutting themes
• Limits of health facilities for reducing
  mortality,
• CHWs, etc.
• Major programmatic approaches
• Selective vs comprehensive PHC Bamako
  Initiative, SEED-SCALE, Care Groups, etc.

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Evidence for Specific Interventions
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Key Interventions

• Community-based diagnosis and treatment of
  childhood pneumonia
• Insecticide-treated bednets
• Home-based neonatal care
• Handwashing (reduces rates of childhood diarrhea
  AND pneumonia)

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Key Interventions (cont.)

• Cleanliness (including handwashing and keeping
  house and yard clear of human and animal feces)
• Exclusive breastfeeding and consumption of
  potable water (at point of use)
• Immunizations, vitamin A essential, and ORT
• Family planning, womens empowerment, cash
  transfers, micro-credit, overall social/political
  environment each contribute

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Major Findings and Recommendations
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Contextual Factors Enhancing Intervention
Effectiveness

• Integrated community-based approaches are
  powerful and cost-effective strategies for
  reducing child mortality WHEN
• Proven interventions are employed
• Strong technical and professional leadership
  present
• Strong monitoring and evaluation and operations
  research present
• Strong outreach components down to the household
  level are present
• Strong supervisory systems present especially
  for lower-level workers
• Functioning health systems with referral systems
  (including referral hospital care) present
• The health system interacts with the community
  and community-level workers with respect and
  treats them as partners
• Long-term financial, technical and professional
  support (gt 5 years) present

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Overall Findings

• The evidence for the efficacy of specific CBPHC
  interventions in improving child health is
  strong, and CBPHC deserves a stronger role in
  programming
• We need a stronger evidence base for the
  mortality impact of packages of interventions at
  scale in routine field settings (effectiveness
  studies)
• There are few studies of the influence of
  community partnerships and community empowerment
  in improving outcomes, but those which do exist
  are compelling

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Overall Findings (cont.)

• The emerging evidence on the effectiveness of
  home-based neonatal care is very exciting, but
  effectiveness studies are needed at scale,
  especially when neonatal interventions are
  integrated with a broader package of
  interventions
• Lack of studies from Africa except for malaria
  interventions
• Need more effectiveness studies at scale of
  programs integrating reproductive and child health

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Overall Findings (cont.)

• More emphasis on CBPHC needed to accelerate
  progress in reaching MDG4, especially in high
  mortality settings, where health systems are weak
  (only 16 of the 68 countries with 97 of global
  under-5 deaths are on target)
• More efforts are needed to involve the community
  as a partner in order to help programs reach
  their full potential
• Ongoing rigorous monitoring and evaluation of
  impact on under-5 mortality will be critical for
  long-term effectiveness at scale

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Figure 1. A Conceptual Framework for Planning,
Implementing and Evaluating the Effectiveness of
Proven Technical Interventions in Routine Field
Situations at Scale
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Expert Review Panel Recommendations for Promoting
Community Empowerment for Improved Child Health

• Establish a foundation of values to shift power
  to the community and to support processes to
  build community capacity through giving
  communities authority to supervise or control
  certain aspects of government health services and
  through programs such as the promotion of womens
  empowerment, micro-credit, and conditional cash
  transfers.

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Expert Review Panel Recommendations (cont.)

• Create a delivery system culture which is
  respectful of and collaborative with community
  members
• Create bi-directional information and
  communication flows
• Create bi-directional linkages between the
  district health system and communities which
  can help everyone be accountable for their
  performance

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• Final report will be out at the end of the summer
  or early fall

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Sustained Impact of Integrated Programs on
Under-5 Mortality

• Matlab (Bangladesh)
• Hopital Albert Schweitzer (Haiti)
• Jamkhed (India)
• SEARCH (India)

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Significance of the Narangwal Project

• One of the few field research projects which
  treated the community as a partner and resource
  rather than a target and placed rights of
  villagers over scientific objectives
• First use of rapid breathing and chest in-drawing
  as a community-based method for diagnosing
  childhood pneumonia (suggested by the villagers)
• First demonstration of the effectiveness of
  antibiotics in reducing mortality from childhood
  pneumonia

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Significance of the Narangwal Project (cont.)

• One of the few studies systematically comparing
  sets of integrated packages of services and
  integrating family planning, nutrition and health
  interventions, and clearly showing synergism
  (increased program effectiveness and
  cost-effectiveness) arising from integration
• Provided the basis for Carl Taylors
  controversial child survival hypothesis which
  was disputed for many years but is now widely
  accepted
• Served as an inspiration to James Grant and the
  first Child Survival Revolution, to the Aroles at
  Jamkhed (India), and to the Bangs at SEARCH in
  Gadchiroli (India)

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• Carl Taylor -
• The acknowledged leader of primary health care
  over the second half of the 20th century"
• Jon Rohde, 2002

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John Wyon Pioneer in Census-Based Child Survival
Programming
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Matlab MCH-FP, Bangladesh, Field Site (100,000
people)
ICDDR,B, 1996 and 2007
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Major Early Influences on Matlab

• Henry Mosley
• Carl Taylor and Shushum Bhatia

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The Aroles at Jamkhed(rural Maharashtra, India)
with Carl Taylor
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Community Dialogue and Information System at
Jamkhed
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Jamkhed (150,000 people)
Arole and Arole, 1994
(Major external evaluation of mortality impact
compared to surrounding villages currently
underway by researchers at the London School of
Economics and at the London School of Hygiene)
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Hopital Albert Schweitzer
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Hospital Albert Schweitzer, Haiti(150,000 people)
Perry et al., American Journal of Public Health,
2007
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Dr. Albert Schweitzer in Lambarene
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Albert Schweitzer with the Mellons
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The Entrance to HAS in Deschapelles
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Hôpital Albert Schweitzer Aerial View
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Father Bringing Newborn to Tie Umbilical Cord
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Tetanus of the Newborn
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• Malnutrition and Tuberculosis

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• Tuberculosis of the Spine

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Kwashiorkor
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Kwashiorkor
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Marasmus
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Marasmus
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Pediatric Ward A MotherAdministersOral
Rehydration Treatment to Her Child
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One of 9 Original Community Health Centers
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Community Health Agents Immunizing Children in
the Community
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Gwen and Larry Mellon Surveying
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The Mellonswith the CaterpillarBuilding a
Road into the Mountains
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Community Development Bringing Water to
Villages By Capping Fresh Mountain Springs and
Piping the Water to Newly Constructed
Fountains
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Rows Of Fountains Making Clean Water
Accessible
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On The Back of This Photograph in Larry
MellonsHandwriting First To Drink From The
Public Water Fountain In Desarmes.
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Larry MellonAndNeighborsClearing
OldIrrigation Ditches
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Valley Farmers Digging New Drainage Ditches
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Dam Construction for Irrigation
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Seedlings For Reforestation ProjectsWater
From A Watering Can
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Cottage IndustriesLarry Mellon Buys Cotton
To MakeCloth And RugsAt The
HospitalsWeaving Center
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Cotton ManBringing Balls Of Seeded And Spun
Cotton To TheWeaving Center
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In Addition To WeavingCommunity DevelopmentHas
Fostered Works In CarpentryCarving Ceramics
IronworkPaintingMicro Enterprise AndSmall
Loan Programs
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Gwen And Larry Mellon At Home In Haiti
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The Flute Always Draws an AudienceBut So Does
theCelloClarinetGuitarFrench
HornandAccordion
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A Letter From Dr. Schweitzer

• Larimer Mellon Died in 1989, Buried in
  Deschapelles

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Gwen Grant MellonDied in 2000Buried in
Deschapelles
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HAS Results 1956-1999

• 18,000 lives of children lt 5 saved
• 1 million years of life saved among children lt 5
• 143 million spent (almost all Dr. Mellons own
  money)
• Estimated cost 2,775 per life saved, 77 per
  DALY saved
• Gwen Mellon We had so much fun doing it!
• Answer of Why?to Larimer Mellon To follow
  Jesus

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The Bangs at SEARCH in Gadchiroli (rural
Maharashtra, India) with Carl Taylor
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SEARCH in Gadchiroli
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Reductions in Infant Morality in Gadchiroli
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Reductions in Neonatal Mortality in Gadchiroli
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• SEARCH as a faith-based organization
• Ghandian communitarian social solidarity

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The Care Group Model of World Relief
Mozambique, Rwanda, Cambodia, Mali
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Care Group Model
WHE
WHE
WHE
WHE
WHE
A Care Group
WHE
WHE
WHE
WHE
WHE










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The total number of WHEs 2490
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Handwashing Practices
Percentage of mothers who wash their hands before
food preparation, before feeding their children
before eating, or after defecation OA Original
Project Area EA Extension Project Area
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Percentage of Children Who Received All
Immunizations
Children 12-23 months of age completely
vaccinated on day of survey
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Mortality Impact on Care Groups in Mozambique
(Edwards et al., Transactions of the Royal
Society of Medicine and Hygiene, 2007)
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The Web of Influence
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Conclusions

• Individuals with a strong Christian faith
  orientation, including individuals with an early
  experience in medical missions, have played an
  important role in the creation of the evidence
  base for CBPHC as an approach to improving child
  health
• Faith-based organizations , including Christian
  organizations, have made important contributions
  to this evidence base as well

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Full Report

• Download at
• http//www.apha.org/membergroups/sections/aphasect
  ions/intlhealth/cbphcw/news
• Or email me henry_at_future.org