Welcome everyone to, the lectures for the, 2nd week of our course.
We're going to begin with, a lecture, which is a continuation of, last weeks
lecture. And as I said before, this, was originally recorded as part of a lecture
on primary healthcare from, the course I teach here at Johns Hopkins on
Introduction to International Health. And so, this is Section B, of that
initial lecture, An Introduction to International Health, is called, What is
Primary Health Care? So as an attempt to, describe in some depth, the concept of
primary health care is, it has come to be understood in the field of global health.
And then following this lecture, we're going to have a very special experience
by listening to Carl Taylor in a lecture that he recorded prior to his death,
which is his own definition of primary health care as well and what he considers
to be the roots of primary health care. So we hope you enjoy this.
The term, primary healthcare, in reality, means many things to many different
people. Some of the meanings of this, word
primary health care, are derived on the term primary.
Primary health care has, really 2 parts, 1 is the term primary, the other is the
term health care. But by primary, to some people, it means
first contact with the health system. Which is certainly understandable.
Some people refer to it as meaning basic, very elementary, the very fundamentals of
health care, and this leads some people to sometimes say that this basic health
care is poor quality health care, inadequate health care, and therefore
isn't really appropriate if we're looking for a high quality standard for people on
the world. Some people refer to the word primary as
meaning essential. In that sense, I think we could think of
some activities that are not commonly thought of as primary health care to be
primary health care. And in that sense, essential and
emergency surgery. I think could very easily be thought of
as part of primary health care. And increasingly, people are already
using that concept of, basic and essential surgery as needing to be
considered as a part of primary health care.
And then there's the sense of primary as meaning first causes, and by that I mean
the multi-sectoral influences on health that go far beyond medical care.
We're talking about education, nutrition, water and sanitation, among other things.
And then we have this trouble understanding what we mean by health
care, the dilemma between preventive and curative services, the biomedical disease
orientation, in which the patient is the passive recipient of medical services
versus the concept of creating conditions and environments that are healthy or that
promote health, very different kinds of concepts.
And then as I mentioned before as well, health is a social phenomenon whose
determinants cannot be neatly separated from other social and other economic
determinants. And then the whole behavioral side of
health, the importance of programs to promote healthy behaviors is certainly a
fundamental part of health care. But it's not commonly thought of as part
of the health care process so much in developed countries, but it's clearly
important in very poor countries. So we have this issue in which I think
for many people primary healthcare is what I call an ambiguous mental model.
It's the unconscious concepts that flow around a set of words that we're not
always well aware of. One of the interesting parts of all this,
to me, is the, concept of the household production of health.
Which isn't widely recognized but it's the, basic notion that mothers are the
most important health care providers in the world because of the influence that
they have on the health of their children, which is very much Alma-Ata
kind of concept and opposed to the idea that it's health systems and doctors in
the hospital that produce health. And then there is a whole new flow of
activities and ideas that flow around community based primary health care that
I will get to in a minute as well. Activities that take place, outside of
health facilities, with strong engagement in the communities.
I like this slide that came from an article by a friend of mine, Jack Bryant,
in which, primary health care, is such a fundamental part of healthsystems,
thinking. But unfortunately, for a lot people
involved in health systems, they don't really see primary health care as a
fundamental basic element, of what a health system should be.
This is a set of diagrams that I put together myself, when I was living in
Bangladesh that, I think helps me and my thinking about the way we can
conceptualize where primary health care fits into the health care model.
In the top, we have on the left the various levels of curative medical
services from primary care to secondary care and tertiary care, and the term
primary care there is more the medical notion of it.
But then we have public health services to the right, which have a continuum
going from community oriented, to services oriented, to disease oriented.
And as you move towards the center on this diagram, we have an increasing
emphasis on community oriented approaches and responsiveness to local community
health needs. And that general approach is shown also
And the bottom, but not from the medical side as much as it is to the more
intersectoral approach to improving health, thinking about centralized
top-down approaches to the left, to more decentralized bottom-up approaches toward
the center, in a somewhat kind of philosophical way, but not quite as
medically oriented. When I lived in Bangladesh, I wrote a · ,
book which I am very proud, of called Health Role in Bangladesh.
Lessons in primary Health Care for the 21st century.
I was able to track down a fairly accurate notion of where the government
expenditures for health went and you can see that in Bangladesh, at that time, the
late 1990's they spent less than 20% of their budget on primary health care.
And approximatley 2/3 of it on hospital care.
I think this is typical, for many developing countries, in which primary
healthcare has not, been the, major focus on funding.
Although, many would argue that it's, got the greatest potential for imporving
health. In terms of personal expeditures for
health, you see that in Bangladesh, again similar to so many different developing
countries, the overwhelming proportion of the small amount of money that's spent on
health care is given directly to drug retail outlets for Purchases for drugs
over the counter, very small amount of money for other activities.
This is the annual World Health research from 2008 that I mentioned earlier, which
promoted primary healthcare. And, the Lancet series, on Alma-Ata, that
was published in 2008 as well. Both, in part, recognizing the importance
of Alma-Ata in the growing recognition of the, need to give more attention to the
concepts of Alma-Ata. I wanted to get into some, a little bit
of detail about exactly, how Alma-Ata defined primary health care, but I also
want to, focus briefly, on, some of the other variations of, primary health care
as you see on this slide, Community-based primary health care, what I call CBIO,
Census-based, Impact-Oriented approach, Care Groups and Participatory Women's
Groups, and Community-oriented primary health care.
The effect-relation of Ala-Ata, considered, primary healthcare to be
essential healthcare, based on practical, scientifically sound and socially
acceptable methods in technology, made university accessible to individuals in
families and the community, through their full participation And at a cost that the
community and country can afford. So in that sense, primary healthcare
addresses the main problems of the community.
It includes promotive, preventive, curative and rehabilitative services, so
it certainly has the curative element built into it, but within the context of
a whole. Range of broader activities.
But it has this intra-sectoral element that's lacking from the biomedical model,
specifically talks about the importance of food supply and nutrition.
safe water, basic sanitation, maternal and child health, family planning, the
public health approach of, prevention and control of locally endemic diseases.
Treatment of common diseases and injuries, which is a priority for local
people in provision of a central drug. Again, a local priority, but not
necessarily a disease control priority. But it talks about these other sectors;
agriculture, animal husbandry, food, education, and housing.
And it also, gives great importance to engagement with the community.
Maximum community and individual self-reliance and participation in
planning, organization, operation and control of primary health care.
Again, this is an example of the challenge to the more traditional medical
model. The declaration of Alma-Ata goes on to
say that these primary health care services need to be sustained and
integrated into a functional and mutually supportive referral system.
So it recognizes the need for hospital care, surgical services And the need for
comprehensive care. But of course, it also states that we
need to create services that countries themselves can afford.
And it talks about the various levels of workers that are required to make primary
health care work, all the way down to community workers, as well as traditional
practitioners. Again, a challenge to the modern medical
model, so to speak. But the creation of a health team.
In order to be able to respond to the health needs of communities particularly,
when resources are limited. So many people have referred to the three pillars
of Alma-Ata, which were embedded in this definition, Equity, Community
participation and Intersectoral development. Again, very different
concepts from the medical model and from the notion of primary medical care.
I want to say a few words about community based primary health care because this is
becoming such an important new direction for primary healthcare.
Of course, it was very much a part of the Alma-Ata concept, but the success of this
and the enthusiam for it now is becoming quite exciting.
And so I wanted to say a few words about this.
Again community based is a term that means different things to different
people. And when I think of it and I talk about
it, I'm talking about services that take place outside of health facilities, but.
In the eyes and the ears and the mind of many other people, they're thinking about
services in which local people are engaged, in which they're readily
accesible but they still could be facility based services, but that's not
my concept of community based priority healthcare.
I'm not saying that I'm right, and their wrong, but it's important to be clear,
what we're talking about. So, through this approach, we're talking
about provision of important services, outside of facilities, which again was
part of the Narangwal Project. They were one of the early pioneers in
this. But we are also talking about education,
health promotion at the household level, which is a fundamental part of CBPHC. So
you see here, this is a definition that I was involved in developing, it's very
long and laborious, but it tries to as clearly as possible, define what we mean
by CBPHC. And we did this because we were
developing a review of the effectiveness of.
Community based primary health care and improving child health so we needed to
define what kinds of programs and documents qualified for our view, and
which ones didn't. And so, I won't read this to you, but it
gives you a sense of the effort that we took to clearly define what community
based primary healthcare really is. But when you boil all this stand it
basically involves any activity that takes place ouside of the health
facility, that's focussed toward improving health, it could be well, very
nearly focussed to vertical activity or could be more comprehensive approach and
it could have conduction of health facility but it didn't have to, And so,
that's the basis for what our review is all about.
There's an interesting story about, integrated management of childhood
illness, and how that links to primary healthcare.
But, this started out as being almost entirely focused on facilites, and became
a community activity Because of the lack of effectiveness of simply limiting this
to facility-based services. It's very interesting that back in the
late 80's and much of the 90's, IMCI was the major focus on WHO's activities And
to a lesser degree UNICEF at improving child health, and it underwent a very
rigorous evaluation, and because of its facility orientation it was shown to have
no impact at all on mortality, and part of the reason for this is the limitation
of health facilities and the The lack of access that people have to health
facilities, because the effort that it takes to get there.
This is a slide that came back from way back in the 1966, almost 50 years ago,
which shows that The probability of a person attending a health facility drops
off exponentially with their distance away from the facility, and we're still
having trouble understanding this basic principle, that when facilities are few
and far between, it's very unlikely that people are going to be able to make use
of them, and that's still the case in very poor countries.
And so, as a result of all of this, this whole approach to, developing child
health care services in the community away from facilities, became very strong,
and showed a very dramatic impact, and I'll get into some of this as we move
along. So you see here that in 2004 the World
Health Organization summarized the, very important influences that family in
community practices again outside of heath facilities have on promoting child
survival growth and development. So this was their review of the current.
Evidence that focused on the importance of community based primary healthcare for
child health. This is the review that I helped to lead
again focusing on community based primary healthcare in child health.
And in these slides that follow you see the very very large number of very
important interventions that have been scientifically shown to improve health.It
can be delieverd outside the facilities.So i am not going to go
through these, But just for child health alone, the list is quite substantial.
The, enthusiasm with which, these community based interventions have been,
taken up, in very poor countries has been disappointing, but I think we are seeing,
more recently Expanded interest and and rapid growth now, in many of these for
instance the expansion of coverage of insecticide treated nets as making a
dramatic difference in the reduction in cases of malaria just to give one small
example. But recognizing the growing power of
community based approach's to improve health, particularly child health, but,
increasing in maternal, and I don't have time to talk about that now.
But a number of exciting interventions are coming forth that are very powerful
Can be delivered, at the community level, and I have mentioned family planning, but
that is certainly a very important one that can be delivered at the community
level. But this is a framework that came out of
some of out work in which we tried to highlight the importance of community
engagement, as well as the health care system, for impacting health and.
The four major delivery processes for providing these interventions to the
community level or home visitation participatory women's group, what we call
community case management, which is diagnosis and treatment by community
level workers. And then mobile clinics, which have been
the traditional. Way in which imunizations have, been able
to achieve their high levels of coverage. So again, I think these are all important
as we think about primary health care. And I come back to this concept of John
Wyon's that I mentioned earlier that so important.
And I mention this here to move to this next framework, which I was involved in
developing as well, which I think is a nice way of thinking about how we can use
community based primary health care for diesease control programs, for basic
services and for addressing the priority needs of communities through these 4
approaches. So, there's increasing interest in
community engagement in health systems. That's coming slowly but the global fund
to fight AIDS, Tuberculosis, and Malaria, recently has come out with a framework
that highlights the need to consider communities and their interact with
health systems as you see here. The Lancet has recently published an
article, reviewing the importance of community health workers which are
certainly a fundamental part of community based primary health care, and there's
throwing enthusiasm for building up various types of community workers.
Interestingly enough, after Alma-ata there was a strong push towards this
direction, but with the failure of Alma-ata The whole concept of community
workers fell out of favor as well, and there were many failures of community
health worker programs at that time as well, so we're entering now after several
decades a resurgence of interest in this and this slide shows a number of the
different types of community level workers that are used around the world.
Then the implementation of community based primary health care, and whether or
not we can develop these programs and make them effective is certainly one of
the key issues in global health today. The ways in which communities can be
engaged in community based primary health care is another important issue, and
again coming out of our review we see here A wide variety of different ways in
which programs have interacted with communities in a way that has led to
effective, programming for the benefit of children.
Let me turn now to a somewhat different Kind of framework which I'm passionate
about personally but is not widely known, and we call it the CBIO framework.
It's not specifically a community based framework.
it's a little more specific than the concept of primary healthcare at Alma-ata
We call it the census based impact oriented approach and it grew out of my
early days in the early 1980s working in Bolivia but with the support of John
Wyon, and I mention that to bring that link back to those early primary
healthcare concepts that permeate what we have here.
So in CBIO we have a conceptual framework in which a practitioner is working with a
population with the overarching goal to improve health and to show that we have
in fact improved health, but it also recognizes that this can't be done unless
a strong partnership between the practitioner.
And the community has been established and you can't establish a strong
partnership unless you have trust between the health system and the community, and
in order to build trust the practitioner has to respond to community priorities.
A very simple set of ideas, but often lacking so much in what we think of as
health programming and public health. So you see here some steps that are
embedded in this CBIO paradigm which involves defining the community, that is
determining who's living there, where they're living.
That's the census part of this. But making a community diagnosis, which
involves the epidemiological priorities as well as the communities priorities,
which could be very different kinds of Of things.
John Wyatt is the, person who taught me this idea about epidemiological
priorities, and I'm sure he learned it from John Gordon, if you remember from
our initial lecture about founding figures in primary health care.
John Wyatt always taught me that epidemiological priorities are the most
serious, frequent, readily preventable, or treatable conditions in the The
population where the program is being provided, and those require technical
support to define. A community can't readily define those,
but the community's priorities are what they conceive of in their own mind of
course, and they don't require technical support so much.
But by clarifying the epidemiological priorities, and the community priorities,
then the program priorities became a merged, set of activities, that arise
from those 2. And so the whole process, then builds
from that. But epidemiological priorities require
some way of contacting everybody in the community or perhaps set a minimally
represented sample of the people in the community but in the way we have
developed this we have built-in routine systematic visitation as a key action for
developing trust of the community for delivering, For delivering services, but
also for determining what the epidemiological priorities are, so I
won't go into that further, but there are lot of programmes around the world that
are increasingly using these ideas and I think it is going to continue to gain
steam and people are developing these ideas on their own, that are we are
having heard CBI or when I think through some real power, when I think the,
Concepts are worth mentioning. Another different kind of primary health
care, which is also very important now, is what I call participatory women's
groups. And there's a special type of this called
care groups that I've had engagement with that I thought I would just mention in,
in the outset here. As you see on this slide here, a care
group is a group of 10 or so women. And here, they're designated as WHE's.
WHE means Women Health Educator. From program to program, different names
are given to the women who make up a care group.
It's the idea and the principle that's important here.
But each one of the members of the care group, takes responsibility for 10 to 15
households, and the mothers and the children within that household.
And over the course of a 2-week period or a 1 month period, she visits all of her
10 households with a specific message: wash your hands, after you go to the
bathroom, for example. These are messages that have come out of
the community based IMCI experience among others.
The care group meets periodically, usually every 2 weeks or once a month
with a paid low-level supervisor who herself has been taught this message.
And then she carries it to the care group, and then the care group members
carry it to each household. So its a way of achieving very high
coverage at very subtle low cost process and the results have been very dramatic.
Another interesting element of this, which I like very much which brings it to
CBIO, is the common common practice in many of these programs to use these home
visits is a way to record vital events which is a part of CBIO.
So recording births and deaths and putting them back into the system is an
important way of determining further you are making any progress with your
program. A different approach to this use of
volunteer women is shown here in a study from the Lansen where they did a
randomized controlled trial of participatory women's groups in Nepal.
And in this case these, were just volunteers from a village who met with a
paid volunteer. And this was very empowerment-focused
process where women were encouraged to talk among themselves, to understand
their problems. And in the process, they also receive
some education about maternal health issues and neonatal healthcare issues,
which is what their study was about. But they were able to show fairly
dramatic results in terms of improvement of neonatal mortality through this and
even maternal mortality which was a big surprise to them.
And these participatory women's groups only involved about a third of the
community, and so they were spreading this information to the other people in
the community to make the impact. And of course, the health impact was determined
at the community level, not just among the people who attend these sessions.
So finally, let me very briefly mention a different approach to primary health
care, which has been very influential, particularly in the United States, but it
started in South Africa with the Karks'. Sydney Kark and his wife, as shown here
in the early publication in 1952. But it is an attempt to involve the
community in primary health care, but to a less public health oriented concept, at
least in my thinking. And this was the origin of what is in the United States
referred to as the Community Health Center movement. But it's a little bit
more of a medical model but still attempting to engage the community and
involve the community, but not so much on public health principles.